final question
Hade1113
HSA4113-IntroductiontoglobalhealthKathrynH.Jacobsenz-lib.org.pdf
GLOBAL HEALTH
THIRD EDITION
INTRODUCTION TO
Kathryn H. Jacobsen, MPH, PhD George Mason University
Fairfax, Virginia
World Headquarters Jones & Bartlett Learning 5 Wall Street Burlington, MA 01803 978-443-5000 [email protected] www.jblearning.com
Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com.
Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to [email protected].
Copyright © 2019 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner.
The content, statements, views, and opinions herein are the sole expression of the respective authors and not that of Jones & Bartlett Learning, LLC. Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not constitute or imply its endorsement or recommendation by Jones & Bartlett Learning, LLC and such reference shall not be used for advertising or product endorsement purposes. All trademarks displayed are the trademarks of the parties noted herein. Introduction to Global Health, Third Edition is an independent publication and has not been authorized, sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product.
There may be images in this book that feature models; these models do not necessarily endorse, represent, or participate in the activities represented in the images. Any screenshots in this product are for educational and instructive purposes only. Any individuals and scenarios featured in the case studies throughout this product may be real or fictitious, but are used for instructional purposes only.
This publication is designed to provide accurate and authoritative information in regard to the Subject Matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the service of a competent professional person should be sought.
12396-8
Production Credits VP, Product Management: David D. Cella Director of Product Management: Michael Brown Product Specialist: Carter McAlister Production Manager: Carolyn Rogers Pershouse Director of Vendor Management: Amy Rose Vendor Manager: Molly Hogue Senior Marketing Manager: Sophie Fleck Teague Manufacturing and Inventory Control Supervisor: Amy Bacus Composition: codeMantra U.S. LLC
Project Management: codeMantra U.S. LLC Cover Design: Scott Moden Director of Rights & Media: Joanna Gallant Rights & Media Specialist: Robert Boder Media Development Editor: Shannon Sheehan Cover Image (Title Page, Chapter Opener):
© Xinzheng. All Rights Reserved/Moment/Getty Printing and Binding: LSC Communications Cover Printing: LSC Communications
Library of Congress Cataloging-in-Publication Data Names: Jacobsen, Kathryn H., author. Title: Introduction to global health / Kathryn H. Jacobsen. Description: Third edition. | Burlington, MA: Jones & Bartlett Learning, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2017044502 | ISBN 9781284123890 (paperback: alk. paper) Subjects: | MESH: Global Health | Communicable Diseases | Health Promotion | Social Determinants of Health | Health Transition Classification: LCC RA441 | NLM WA 530.1 | DDC 362.1—dc23 LC record available at https://lccn.loc.gov/2017044502
6048
Printed in the United States of America 22 21 20 19 18 10 9 8 7 6 5 4 3 2 1
iii
© Xinzheng. All Rights Reserved/Moment/Getty
3.8 Governance and Politics . . . . . . . . . . . . . . . . . . . . .61
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63
Chapter 4 Environmental Determinants of Health . . . . . . . . . . . . . . . . . . . 65
4.1 Environmental Health and the SDGs . . . . . . . . .65
4.2 Water, Sanitation, and Hygiene . . . . . . . . . . . . . .67
4.3 Energy and Air Quality . . . . . . . . . . . . . . . . . . . . . . .75
4.4 Occupational and Industrial Health . . . . . . . . . .81
4.5 Urbanization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84
4.6 Sustainability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88
4.7 Climate Change and Health . . . . . . . . . . . . . . . . .92
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94
Chapter 5 Health and Humans Rights . . . 98 5.1 Health and Human Rights . . . . . . . . . . . . . . . . . . .98
5.2 Access to Basic Human Needs . . . . . . . . . . . . . 101
5.3 Access to Health Services . . . . . . . . . . . . . . . . . . 103
5.4 Access to Medicines . . . . . . . . . . . . . . . . . . . . . . . 106
5.5 Health and Natural Disasters . . . . . . . . . . . . . . . 108
5.6 Conflict and War . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
5.7 Bioterrorism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
5.8 Health in Prisons . . . . . . . . . . . . . . . . . . . . . . . . . . 118
5.9 People with Disabilities . . . . . . . . . . . . . . . . . . . . 119
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Chapter 6 Global Health Financing . . . . . 126 6.1 Personal and Public Health . . . . . . . . . . . . . . . . 126
6.2 Health Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
6.3 Paying for Personal Health . . . . . . . . . . . . . . . . . 131
6.4 Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 133
6.5 Paying for Global Health Interventions . . . . . 135
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii
New to This Edition . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x
Chapter 1 Global Health Transitions . . . . . . 1 1.1 Defining Global Health . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Health Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.3 Prevention Science . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.4 Health Transitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.5 World Regions and Featured Countries . . . . . .12
1.6 Global Health Security . . . . . . . . . . . . . . . . . . . . . . .17
1.7 Globalization and Health: Shared Futures . . . .18
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Chapter 2 Global Health Priorities . . . . . . 21 2.1 Global Health Achievements . . . . . . . . . . . . . . . .21
2.2 Prioritization Strategies . . . . . . . . . . . . . . . . . . . . . .23
2.3 Health Metrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
2.4 Millennium Development Goals . . . . . . . . . . . . .34
2.5 Sustainable Development Goals . . . . . . . . . . . . .36
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Chapter 3 Socioeconomic Determinants of Health . . . . . . . . . . . . . . . . . . . 42
3.1 Health Disparities and the SDGs . . . . . . . . . . . . .42
3.2 Economics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
3.3 Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51
3.4 Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54
3.5 Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
3.6 Minority Populations . . . . . . . . . . . . . . . . . . . . . . . .57
3.7 Migrant and Refugee Health . . . . . . . . . . . . . . . . .59
Contents
iv Contents
9.4 Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
9.5 Other Respiratory Infections . . . . . . . . . . . . . . . 206
9.6 Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
9.7 Immunization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
9.8 Vaccine-Preventable Infections . . . . . . . . . . . . 212
9.9 Viral Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
9.10 Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Chapter 10 Malaria and Neglected Tropical Diseases . . . . . . . . . . 224
10.1 Malaria, NTDs, and Global Health . . . . . . . . . 224
10.2 Parasites: Protozoa and Helminths . . . . . . . . 227
10.3 Malaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
10.4 Malaria Interventions . . . . . . . . . . . . . . . . . . . . . 229
10.5 Dengue and Other Arboviruses . . . . . . . . . . 233
10.6 Chagas Disease and Trypanosomiasis . . . . . 236
10.7 Leishmaniasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
10.8 Schistosomiasis . . . . . . . . . . . . . . . . . . . . . . . . . . 237
10.9 Lymphatic Filariasis . . . . . . . . . . . . . . . . . . . . . . . 238
10.10 Onchocerciasis . . . . . . . . . . . . . . . . . . . . . . . . . . 239
10.11 Leprosy, Buruli Ulcer, and Trachoma . . . . . 240
10.12 Rabies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
10.13 Soil-Transmitted Helminths . . . . . . . . . . . . . 242
10.14 Other Neglected Tropical Diseases . . . . . . 244
10.15 Eradication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
10.16 Emerging Infectious Diseases . . . . . . . . . . . 250
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Chapter 11 Reproductive Health . . . . . . 257 11.1 Reproductive Health and Global Health . . 257
11.2 The Fertility Transition . . . . . . . . . . . . . . . . . . . . 259
11.3 Population Planning. . . . . . . . . . . . . . . . . . . . . . 263
11.4 Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 264
11.5 Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
11.6 Healthy Pregnancy . . . . . . . . . . . . . . . . . . . . . . . 269
11.7 Maternal Mortality and Disability . . . . . . . . . 272
11.8 Neonatal Health . . . . . . . . . . . . . . . . . . . . . . . . . . 275
11.9 Gynecologic Health . . . . . . . . . . . . . . . . . . . . . . 279
6.6 Official Development Assistance . . . . . . . . . . . 136
6.7 Multilateral Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
6.8 Foundations and Corporate Donations . . . . 140
6.9 Personal Donations . . . . . . . . . . . . . . . . . . . . . . . . 142
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Chapter 7 Global Health Implementation . . . . . . . . . . . 148
7.1 Global Health Interventions . . . . . . . . . . . . . . . 148
7.2 Local and National Governments . . . . . . . . . . 150
7.3 International Cooperation . . . . . . . . . . . . . . . . . 151
7.4 The World Health Organization and the United Nations . . . . . . . . . . . . . . . . . . . . .153
7.5 International Health Regulations . . . . . . . . . . . 156
7.6 Global Partnerships . . . . . . . . . . . . . . . . . . . . . . . . 158
7.7 The Nonprofit Sector . . . . . . . . . . . . . . . . . . . . . . 159
7.8 The Corporate Sector . . . . . . . . . . . . . . . . . . . . . . 161
7.9 Research and the Academic Sector . . . . . . . . 162
7.10 Measuring Impact . . . . . . . . . . . . . . . . . . . . . . . . 163
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Chapter 8 HIV/AIDS and Tuberculosis . . . 167 8.1 HIV/AIDS, TB, and Global Health . . . . . . . . . . . . 167
8.2 Viruses, Bacteria, and Fungi . . . . . . . . . . . . . . . . 168
8.3 HIV and AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
8.4 HIV/AIDS Epidemiology . . . . . . . . . . . . . . . . . . . 173
8.5 HIV Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . 179
8.6 Other Sexually Transmitted Infections . . . . . . 183
8.7 Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
8.8 TB Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
8.9 Antimicrobial Resistance. . . . . . . . . . . . . . . . . . . 189
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Chapter 9 Diarrheal, Respiratory, and Other Common Infections . . . . . . . . . . . . . . . . . 195
9.1 Infectious Diseases and Global Health . . . . . 195
9.2 Diarrheal Diseases . . . . . . . . . . . . . . . . . . . . . . . . . 198
9.3 Diarrhea Interventions . . . . . . . . . . . . . . . . . . . . . 200
Contents v
14.4 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
14.5 Other Cardiovascular Diseases . . . . . . . . . . . . 348
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
Chapter 15 Other Noncommunicable Diseases . . . . . . . . . . . . . . . . . 351
15.1 The Epidemiologic Transition and Global Health . . . . . . . . . . . . . . . . . . . . . . . . .351
15.2 NCDs and Behavior Change . . . . . . . . . . . . . . 355
15.3 Chronic Respiratory Diseases . . . . . . . . . . . . . 358
15.4 Tobacco Control . . . . . . . . . . . . . . . . . . . . . . . . . . 360
15.5 Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
15.6 Chronic Kidney Disease . . . . . . . . . . . . . . . . . . 366
15.7 Liver and Digestive Diseases . . . . . . . . . . . . . . 367
15.8 Neurological Disorders . . . . . . . . . . . . . . . . . . . 368
15.9 Genetic Blood Disorders . . . . . . . . . . . . . . . . . . 369
15.10 Musculoskeletal Disorders . . . . . . . . . . . . . . . 371
15.11 Sensory Disorders . . . . . . . . . . . . . . . . . . . . . . . 372
15.12 Skin Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
15.13 Dental and Oral Health . . . . . . . . . . . . . . . . . . 374
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
Chapter 16 Mental Health . . . . . . . . . . . . 381 16.1 Mental Health and Global Health . . . . . . . . . 381
16.2 Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
16.3 Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . 383
16.4 Depressive Disorders . . . . . . . . . . . . . . . . . . . . . 383
16.5 Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 385
16.6 Alcohol and Drug Use Disorders . . . . . . . . . . 385
16.7 Other Mental Health Disorders . . . . . . . . . . . 387
16.8 Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388
16.9 Autism and Neurodevelopmental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .390
16.10 Dementia and Neurocognitive Disorders 391
16.11 Mental Health Care . . . . . . . . . . . . . . . . . . . . . 391
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
Chapter 17 Injuries . . . . . . . . . . . . . . . . . . 396 17.1 Injuries and Global Health . . . . . . . . . . . . . . . . 396
11.10 Men’s Reproductive Health . . . . . . . . . . . . . . 279
11.11 Sexual Minority Health . . . . . . . . . . . . . . . . . . 280
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Chapter 12 Nutrition . . . . . . . . . . . . . . . . 285 12.1 Nutrition and Global Health . . . . . . . . . . . . . . 285
12.2 Macronutrients . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
12.3 Protein-Energy Malnutrition . . . . . . . . . . . . . . 288
12.4 Food Security and Food Systems . . . . . . . . . 293
12.5 Micronutrients . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
12.6 Iodine Deficiency Disorders . . . . . . . . . . . . . . 297
12.7 Vitamin A Deficiency . . . . . . . . . . . . . . . . . . . . . 297
12.8 Iron Deficiency Anemia . . . . . . . . . . . . . . . . . . 298
12.9 Other Micronutrient Deficiencies . . . . . . . . . 300
12.10 Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
12.11 Overweight and Obesity . . . . . . . . . . . . . . . . 304
12.12 Food Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Chapter 13 Cancer . . . . . . . . . . . . . . . . . . . 315 13.1 Cancer and Global Health . . . . . . . . . . . . . . . . 315
13.2 Cancer Biology . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
13.3 Cancer Epidemiology . . . . . . . . . . . . . . . . . . . . 316
13.4 Cancer Risk Factors and Prevention . . . . . . . 320
13.5 Cancer Screening and Diagnosis . . . . . . . . . 324
13.6 Cancer Treatment . . . . . . . . . . . . . . . . . . . . . . . . 326
13.7 Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
13.8 Breast Cancer and Cervical Cancer . . . . . . . . 328
13.9 Prostate Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . 332
13.10 Liver Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332
13.11 Esophageal, Stomach, and Colorectal Cancers . . . . . . . . . . . . . . . . . . . . . . .333
13.12 Other Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . 334
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Chapter 14 Cardiovascular Diseases . . . . 338 14.1 Cardiovascular Disease and Global Health 338
14.2 Ischemic Heart Disease . . . . . . . . . . . . . . . . . . . 342
14.3 Cerebrovascular Disease (Strokes) . . . . . . . . 344
vi Contents
Chapter 19 Promoting Healthy Adulthood and Aging . . . . . . 425
19.1 Aging and Global Health . . . . . . . . . . . . . . . . . 425
19.2 Health Promotion in Early and Middle Adulthood . . . . . . . . . . . . . . . . . . . .428
19.3 Health Promotion for Older Adults . . . . . . . . 430
19.4 Caring for Aging Populations . . . . . . . . . . . . . 431
19.5 Health Promotion Across the Life Span . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .434
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434
Chapter 20 Global Health Careers . . . . . . 436 20.1 Career Pathways in Global Health . . . . . . . . . 436
20.2 Global Health Education . . . . . . . . . . . . . . . . . 437
20.3 Experiential Learning in Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . .439
20.4 Global Health Matters . . . . . . . . . . . . . . . . . . . . 440
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .443
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .468
17.2 Transport Injuries . . . . . . . . . . . . . . . . . . . . . . . . . 400
17.3 Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402
17.4 Drowning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
17.5 Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404
17.6 Other Unintentional Injuries . . . . . . . . . . . . . . 405
17.7 Intentional Injuries . . . . . . . . . . . . . . . . . . . . . . . 405
17.8 Interpersonal Violence . . . . . . . . . . . . . . . . . . . 406
17.9 Gender-Based Violence . . . . . . . . . . . . . . . . . . . 407
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408
Chapter 18 Promoting Neonatal, Infant, Child, and Adolescent Health . . . . . . . . . 410
18.1 Progress in Child Survival . . . . . . . . . . . . . . . . . 410
18.2 Improving Neonatal Survival . . . . . . . . . . . . . 415
18.3 Promoting Infant and Child Health . . . . . . . 417
18.4 Promoting Early Childhood Development 419
18.5 Children with Special Needs . . . . . . . . . . . . . . 419
18.6 Health Promotion for Older Children . . . . . 420
18.7 Health Promotion for Adolescents . . . . . . . . 421
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
vii
© Xinzheng. All Rights Reserved/Moment/Getty
across the income spectrum. For example, the SDGs include targets for preventing new hep- atitis B virus infections; reducing the number of adults who die from cardiovascular diseases, cancers, and other noncommunicable diseases before their 70th birthdays; reducing the suicide mortality rate; increasing access to treatment for substance use disorders; and reducing deaths from road traffic injuries and violence. These conditions affect people in every country, and all countries have the opportunity under the SDGs to track their progress toward improving health metrics related to these concerns.
This third edition of Introduction to Global Health is a book for the SDG era. The socioeconomic and environmental determi- nants of health are presented in the context of the SDGs. The shifting landscape for financ- ing and implementing global health initiatives is described in expanded chapters on payers and players. Chapters on infectious diseases, reproductive health, and nutrition are comple- mented by new chapters on noncommunica- ble diseases, mental health, and injuries. The similarities and differences in the conditions that cause illness and death in featured coun- tries representing diverse world regions and income levels are illustrated with estimates from the Global Burden of Disease (GBD) project, which now produces annually updated profiles of health status in every country. (Dis- closure: the author is a GBD collaborator.) The global health agenda has expanded to cover all of the world’s people, and this book provides a positive, forward-looking perspective on the numerous actions that are helping promote the health, well-being, and security of people across the lifespan and across the globe.
The first and second editions of Intro- duction to Global Health were written during the Millennium Development
Goals (MDG) era of global health. The MDGs spelled out an ambitious plan for significantly reducing global poverty between 2000 and 2015. They were wildly successful. The num- ber of people living on less than $1 per day dropped substantially during the first 15 years of the 21st century. As a growing number of global health partnerships set agendas for change and financed action plans, significant progress was made toward alleviating hun- ger, preventing maternal and child mortality, and controlling HIV/AIDS and malaria.
The next generation of global goals—the Sustainable Development Goals (SDGs)—were launched at the end of 2015. They spell out 17 goals for enhancing human flourishing by 2030, including targets related to poverty reduction, hunger, health, education, gender equality, clean water and sanitation, affordable and clean energy, decent work, infrastructure and tech- nology development, human rights, sustainable urbanization, responsible production and con- sumption, climate and environment, peace, and governance. The SDGs seek to promote pros- perity while upholding human rights, protect- ing the planet, and fostering peace and security. All of the goals are interdependent, and all are inextricably tied to health. Improvements in any of the 17 areas will yield benefits for popula- tion health, and improvements in public health will enable other SDGs to be achieved.
Most of the MDGs were targeted at improv- ing quality of life among the world’s poorest people. The SDGs retain those aims but add a lengthy list of objectives that apply to countries
Preface
viii
© Xinzheng. All Rights Reserved/Moment/Getty
Chapter 6 is a new chapter that describes the health system models used in various countries and explains the funding mecha- nisms used to pay for global health activities. Chapter 7 features the diversity of entities involved in implementing and evaluating global health interventions, including gov- ernmental and intergovernmental agen- cies, nonprofit organizations, and for-profit corporations.
Chapters 8 through 17 present the health conditions that account for the greatest burden of disease globally. Each chapter begins with a section that explains why the featured topic is considered to be a global health issue, and each chapter emphasizes the interventions that can reduce the impact of adverse health conditions on individuals and populations. Health met- rics from the Global Burden of Disease (GBD) collaboration are used to illustrate the popula- tions affected by each condition.
Chapter 8 describes the global threats posed by HIV/AIDS, tuberculosis, and anti- microbial resistance. Chapter 9 discusses the heavy toll that child mortality from diarrheal diseases and pneumonia takes on low-in- come countries and describes the tools that are available to contain outbreaks of influ- enza and other vaccine-preventable infections. Chapter 10 describes the burden from malaria and neglected tropical diseases in low-income countries and the global threats associated with emerging infectious diseases. Chapter 11 highlights a diversity of reproductive and sex- ual health issues, including family planning, infertility, pregnancy, maternal mortality, neo- natal health, men’s health, and sexual minority
The third edition of Introduction to Global Health has been significantly expanded to include more comprehensive coverage of the full spectrum of topics that now constitute part of the global health agenda.
Chapter 1 presents a new model for iden- tifying global health issues—one that incor- porates populations, action, cooperation, equity, and security—and it introduces the key concepts of prevention science, health transi- tions theory, globalization, and global health security.
Chapter 2 introduces the new Sustainable Development Goals (SDGs) that will guide international development efforts through 2030 and describes the most commonly used global health metrics.
Chapters 3 and 4 use the SDGs as a frame- work for exploring the social and environmen- tal determinants of health. Chapter 3 describes the connections between health and econom- ics, education, gender, employment, culture, migration, and governance. Chapter 4 exam- ines the links between health and water, san- itation, energy, air quality, occupational and industrial health, urbanization, sustainability, and climate change.
Chapter 5 uses the SDGs and the Universal Declaration of Human Rights to highlight some of the major ethical issues in global health, including questions about the right to have access to healthcare ser- vices and medicines, humanitarian respon- sibilities after natural disasters and during times of conflict, and the rights of people in prison, people with disabilities, and other special populations.
New to This Edition
New to This Edition ix
achieved under the MDGs and the opportu- nities for continued progress under the SDGs. Chapter 19 describes the emerging challenges associated with aging populations and the opportunities for promoting healthy adult- hood and aging.
Chapter 20 is a new chapter that describes the links between diverse educational and career pathways and global health, and emphasizes the opportunities for everyone to be involved in making communities and the world a healthier place for current and future generations.
More than 350 figures and tables high- light key material, and nearly all of these are new for the third edition. All of the statistics in the book have been updated. Data from eight of the world’s largest countries, which collec- tively are home to half of the world’s people, are used to illustrate the patterns of health status in high-income, middle-income, and low-income countries: Brazil, China, Ethiopia, Germany, India, Iran, Nigeria, and the United States. A new glossary provides definitions for more than 780 key terms in global health.
health. Chapter 12 describes the nutrition transition and the challenges associated with undernutrition, overnutrition, and food safety.
A series of new chapters describe the oppor- tunities for global health initiatives to address the noncommunicable diseases (NCDs), men- tal health disorders, and injuries that are among the leading causes of death worldwide. Chapter 13 focuses on cancer, Chapter 14 focuses on cardiovascular disease, and Chapter 15 focuses on chronic respiratory diseases and diabetes. The principles of behavior change, tobacco control, and other methods for prevention and management of NCDs are highlighted. Chapter 16 describes the diversity of mental health con- ditions that contribute to global disease burden and emphasizes the need for greater access to mental health services. Chapter 17 discusses injury prevention and control methods.
Two chapters synthesize the core mes- sages of the book through the lens of health promotion across the lifespan. Chapter 18 presents the major improvements in neonatal, infant, child, and adolescent health that were
x
© Xinzheng. All Rights Reserved/Moment/Getty
Kathryn H. Jacobsen, MPH, PhD, is professor of epidemiology and global health at George Mason University. She is the author of more than 150 scientific articles as well as Introduction to Health Research Methods: A Practical Guide, also published by Jones & Bartlett Learning.
She is also a contributor to the Global Burden of Disease project and frequently provides commentary for print and television media.
About the Author
© Xinzheng. All Rights Reserved/Moment/Getty
CHAPTER 1
Global Health Transitions Global health is a multidisciplinary, multisectoral field in which diverse partners from around the world act together to improve population and environmental health. Scientific advances during the last century have reduced infant and child death rates, increased the number of infectious diseases that can be prevented or cured, and provided new tools for managing the chronic diseases associated with aging. Global health activities can also be effective for promoting security, stimulating economic growth, fostering justice, and achieving other shared goals.
▸ 1.1 Defining Global Health
Health is often defined as the absence of dis- ease or injury, but this is an incomplete expla- nation because the focus is on what health is not, rather than on what health is. Some defi- nitions of health try to focus on the essence of health by emphasizing health as the ability to conduct normal daily activities. But that type of statement is also limited because the defi- nition of “normal” varies from person to per- son. For example, some people assume that it is normal for an older person to have limited mobility and forgetfulness, but that is not true. Many older people are very active and men- tally sharp, and many of those who have joint pain or memory loss could be helped by ther- apy and medication. Similarly, in many parts of the world, parents think it is normal for their children to have intestinal worms. This belief is also not true, and untreated worm infections significantly reduce the health, growth, and
school performance of millions of children worldwide.
A more comprehensive definition of health addresses both physical and mental health as well as the presence of a social system that facil- itates health. The Constitution of the World Health Organization (WHO), written in 1948, defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” This defini- tion recognizes that health is not just a function of biology. Health stems from biology, psy- chology, sociology, and a host of other factors. Although there is almost no one in the world today who would be classified as having “com- plete” health according to the WHO statement,1 this definition provides a target for medical and public health systems as they work together to promote the improved health status of individu- als and communities.
An ideal health trajectory begins with a consenting adult becoming pregnant and that pregnancy leading to an uneventful full-term delivery of a healthy newborn. After birth,
1
the ideal health trajectory continues with that healthy infant growing into adulthood without experiencing serious infections, injuries, or ill- nesses, and that adult remaining healthy and active for many decades. Because everyone eventually dies, the ideal health trajectory ends in very old age with a gentle death that is not preceded by months or years of disability and pain. However, few people achieve this ideal pathway (FIGURE 1–1A). In very low-income communities, a large proportion of children are born with low birthweight and struggle with repeated bouts of infectious diseases like pneumonia and malaria, and many young women die in childbirth (FIGURE 1–1B).
No matter where a person lives, a combina- tion of happenstance and health behaviors may reduce health status at various time periods over the life span. A healthy child may develop perma- nent physical impairments due to a serious car crash in adolescence, then have reduced health status from alcohol abuse in middle adulthood, and die from a heart attack before reaching retirement age (FIGURE 1–1C). Even when peo- ple live to be very old, they usually experience a
gradual decline in function and loss of indepen- dence prior to dying (FIGURE 1–1D). A diversity of medical, behavioral, social, economic, envi- ronmental, and other interventions and changes can help people make progress toward long, healthy life trajectories. Some of these actions are taken by individuals to improve their own health status, some are communal activities by families and neighborhoods, and some are large- scale initiatives that take place on a national or international scale.
Global health refers to the collaborative actions taken to identify and address transna- tional concerns about the exposures and dis- eases that adversely affect human populations. There are many different lenses that are used to identify global health issues (FIGURE 1–2). Epidemiologists and health economists may evaluate global health metrics and select the conditions that cause the majority of deaths, disability, and lost productivity worldwide. Phy- sicians, nurses, and other clinical practitioners may see suffering that could easily be prevented or relieved and feel compelled to find ways to scale up the delivery of cost-effective solutions
FIGURE 1–1 Examples of health trajectories.
birth
death
ideal
very old age
he al
th s
ta tu
s
A (Ideal Health Trajectory)
ideal
he al
th s
ta tu
s
birth
death
B
very old age
ideal
he al
th s
ta tu
s
birth
death
C
very old age
D
birth
death
ideal
very old age
he al
th s
ta tu
s
2 Chapter 1 Global Health Transitions
to people in need, no matter where those peo- ple live. Environmental health scientists may observe how quickly some pathogens and tox- ins cross international borders and recognize that international partnerships are necessary in order to mitigate those threats to health. Health promoters and others whose work is guided by a social justice perspective may focus on calling attention to the health needs of the most vulner- able people around the world. Security experts may zero in on the factors that contribute to instability and conflict. All of these global health lenses—ones focused on populations, action, cooperation, equity, and security (PACES)— emphasize transnational health issues, but
different global health priorities will emerge when different lenses are applied (FIGURE 1–3). These varied perspectives are why so many dif- ferent environmental concerns, a broad range of diseases, and a diversity of special populations have been targeted by global health initiatives.
▸ 1.2 Health Interventions
Etiology is the study of the causes of dis- ease, including both intrinsic (internal) causes, such as genetics and psychological factors, and extrinsic (external) causes, such as infectious disease and environmental exposures. A per- son’s health status at a given age is a function of his or her experiences throughout the life course.2 These biological, behavioral, and other exposures occur in particular natu- ral and built environments, and they are also a function of a broad set of social, political, cultural, economic, occupational, and other factors.3 The diversity of contributors to dis- ease means that a considerable diversity of changes can improve health.
Humans have long recognized the envi- ronment’s role in disease etiology. For many centuries before microscopes allowed people to observe bacteria, communities recognized that some illnesses were linked to environmen- tal exposures, and they took care to dispose of human waste, protect water sources, and bury the carcasses of diseased animals. During most of the 19th century, the term miasma was used to describe the pungent odors of poorly man- aged waste, and the prevailing theory of disease causation in Western countries was that epi- demics were spontaneously generated in places with poor sanitation.4 When cholera outbreaks occurred in England in the mid-1800s, inves- tigators found a higher infection rate in places of low altitude, especially places near marshes that had an abundance of foul-smelling gases, and they blamed the spread of cholera on contact with those offensive gases.5 This was
Populations A focus on the exposures and diseases that cause the greatest public health burden and affect large numbers of people in diverse geographic regions
Action A focus on effective, low- cost interventions that prevent illness and injury, diagnose and treat diseases, and alleviate suffering
Cooperation A focus on the health concerns that must be addressed through worldwide efforts to share knowledge, tools, and resources
Equity A focus on helping the global poor and addressing social, environmental, and health inequalities
Security A focus on addressing the health issues most likely to contribute to political and economic instability and conflict
FIGURE 1–2 PACES: Defining global health.
1.2 Health Interventions 3
crowding and its associated grime.6 Although outbreaks are no longer blamed on miasmas, good hygiene (like frequent handwashing) and the avoidance of known environmental hazards remain very important for preventing infec- tions and injuries.
By the middle of the 20th century, most medical scientists had shifted their efforts
a reasonable conclusion because the people who lived in the gassy, marshy areas were the same people who drank the bacterium- infected water that was the true cause of the outbreak. Public health efforts in the 19th century focused primarily on environmental sanita- tion, with special attention aimed at reducing epidemics thought to be associated with urban
Lens Sample Priority Sample Priority
Populations Cardiovascular disease (CVD)
CVD is the leading cause of adult mortality worldwide.
Drinking water
Unsafe drinking water causes billions of cases of severe diarrhea annually.
Action Hunger There is enough food in the world to spare children from the lifelong consequences of not having access to adequate nutrition during their early years of development.
HIV HIV medications can extend the lives of infected individuals by many years or even decades.
Cooperation Air pollution Air pollution generated by one country can cause adverse health effects for its neighbors.
Drug- resistant infections
One country with poor regulations for antibiotic use can put the whole world at risk.
Equity Neglected tropical diseases
The world’s poorest children are disabled and disfigured by parasitic diseases that do not affect children who happen to have been born in higher- income places.
Mental health
People with mental health disorders in every country face stigma that may exclude them from full participation in society.
Security Violence The violence in conflict areas can spill over into new locations and create refugee crises.
Emerging infectious diseases
Outbreaks of deadly infectious diseases threaten public safety and can cause social, economic, and political instability.
FIGURE 1–3 PACES: Examples of global health priorities.
4 Chapter 1 Global Health Transitions
Public health focuses on promoting health and preventing illnesses, injuries, and early deaths at the population level by iden- tifying and mitigating environmental haz- ards, promoting healthy behaviors, ensuring access to essential health services, and taking other actions to protect the health, safety, and well-being of groups of people (FIGURE 1–4).11 Modern public health comprises a diversity of subdisciplines. Environmental health is the study of the connections between human
from the identification of social and environ- mental risk factors for disease to the iden- tification of specific infectious agents and genes.7 But even with the emphasis on immu- nology and genetics, one of the biggest pub- lic health breakthroughs in the 20th century was a series of studies published in the 1950s that confirmed that cigarette smoking was a major cause of lung cancer, emphysema, and cardiovascular disease.8 Later studies showed that exposure to secondhand smoke was an additional risk factor for lung disease.9 Today, health scientists and clinicians agree that there are many social and behavioral, envi- ronmental, and biological contributors to dis- ease. This means that there are diverse actions that can improve health status. The particular set of interventions recommended for global health concerns tends to reflect the disci- plinary perspectives of the people designing and implementing the interventions.10 Two of the most prominent voices in global health in the 21st century are medicine and public health.
Medicine focuses on preventing, diag- nosing, and treating health problems in indi- viduals and families. For thousands of years, various types of health practitioners in cultures across the globe have cared for people with health concerns, including herbalists adept at treating fevers, midwives skilled in delivering babies, and numerous other people equipped to provide physical and spiritual comfort to people with various ailments. As modern medical science has developed, clinical pro- fessionals like physicians, surgeons, nurses, dentists, psychologists, and physical therapists have developed highly specialized methods for caring for patients. Examples of common interventions in the medical field include antibiotics to treat infections, medications to manage chronic diseases (such as insulin for people with diabetes and inhaled bronchodi- lators for people with asthma), counseling to address mental health concerns, surgery to correct traumatic injuries, and physical ther- apy to restore function after an injury.
1 Monitor health status to identify community health problems.
2 Diagnose and investigate health problems and health hazards in the community.
3 Inform, educate, and empower people about health issues.
4 Mobilize community partnerships to identify and solve health problems.
5 Develop policies and plans that support individual and community health efforts.
6 Enforce laws and regulations that protect health and ensure safety.
7 Link people to needed personal health services and ensure the provision of health care when otherwise unavailable.
8 Ensure a competent public health and personal healthcare workforce.
9 Evaluate effectiveness, accessibility, and quality of personal and population- based health services.
10 Research for new insights and innovative solutions to health problems.
FIGURE 1–4 Essential public health services. Reproduced from The public health system & the 10 essential public health services. Centers for Disease Control and Prevention website https://www .cdc.gov/stltpublichealth/publichealthservices/essentialhealthservices .html. Updated September 20, 2017.
1.2 Health Interventions 5
that promote active lifestyles for people of all ages, and school nutrition programs that ensure that children have access to the nutri- tious food they need to grow and learn.
The lines between medicine and public health are blurry (FIGURE 1–5). Medicine tends to focus on the clinical care of individuals, while public health has a focus on larger pop- ulations. Public health usually emphasizes the prevention of health problems while medicine has more of a focus on treating the existing problems. But many people trained in clinical fields work in population health and provide preventive services (including public health nurses, physicians specializing in community medicine and preventive medicine, and oth- ers), and many people trained in public health are dedicated to increasing access to treatment for individuals with critical health issues. Medi- cal research informs the design of public health interventions, and the information generated from public health research helps clinicians to make differential diagnoses, prescribe appro- priate therapies, and encourage healthy life- styles for their patients in addition to helping communities set their own public health pri- orities and design and evaluate evidence-based programs to address these issues.
In global health, an intervention is a strategic action intended to improve individ- ual and population health status. Interven- tions take many different forms: detection and treatment of physical and mental health
health and environmental exposures, such as air quality, water quality, solid and hazardous waste, unsafe food, vermin and pathogen- transmitting insects, radiation, noise, and resi- dential and industrial hazards. Epidemiology is the study of the distribution of health prob- lems in populations, the risk factors for devel- oping those conditions, and the effectiveness of interventions to address these concerns. Biostatistics is the science of analyzing health data and interpreting the results so that they can be applied to solving public health prob- lems. Health promotion is an applied social science that encourages individuals and communities to take steps to improve their own health. The Ottawa Charter for Health Promotion was an international agreement sponsored by the WHO and approved at a conference in Canada in 1986 that identified the core health promotion actions as including healthy public policies, supportive environ- ments, strong communities, skilled person- nel, and expanded access to preventive health services.12 There are also specialists in health policy and management, public health admin- istration, health communication, maternal and child health, public health nutrition, health economics, and other public health fields. Examples of common public health interven- tions include policies that ensure that food and drinking water are safe, vaccination campaigns that prevent widespread outbreaks of infec- tious diseases, health education campaigns
FIGURE 1–5 Comparing medicine and public health.
Individuals Families Communities States/provinces Nations
Prevention Treatment
Medicine
Medicine
Public health
Public health
6 Chapter 1 Global Health Transitions
health cannot on their own accomplish global health goals. People working in a diversity of fields make important contributions to the conditions that promote or inhibit the health of individuals and communities. Social workers, spiritual advisors, teachers, sanitation workers, farmers, scientists and engineers, policymakers and lawyers, a variety of government officials, and many others all have a role to play in the big-picture interventions that enable health.
▸ 1.3 Prevention Science The adage that prevention is better than a cure expresses one of the foundational prin- ciples of global health. It is usually cheaper to spend relatively small amounts of money on interventions that keep people healthy across the life span than it is to spend relatively large amounts of money helping people recover from serious health problems (FIGURE 1–7). Severe health problems, long-term disabili- ties, and untimely deaths are expensive for the affected individuals and for their fami- lies, who must pay the direct costs of medical care as well as bear the direct and indirect costs of caregiving. Health problems are also costly for the communities and nations that lose the economic and other contributions the affected individuals would have made through work productivity, tax revenue, and service if they had lived longer, healthier lives. Prevention science is the process of
conditions, counseling and social marketing to promote healthier behaviors, develop- ment and enforcement of health policies, and numerous other actions.13 Interventions tar- geted at any level from the individual to the community, the nation, and the world can be effective at improving personal and public health. For example, nutrition support pro- grams for pregnant and breastfeeding women can reduce the risk of low birthweight and malnutrition in infants, the use of antibiotics to treat childhood pneumonia soon after the onset of a cough can prevent life-threatening illness, the availability of skilled birth atten- dants can prevent women from dying during childbirth, and numerous other interventions during adulthood, such as injury prevention activities, mental health care, and lifestyle changes that reduce the risk of heart attacks, can improve both quality of life and the num- ber of years lived (FIGURE 1–6). Together, these interventions can have a strong posi- tive impact on an individual’s health, allow- ing a person who might otherwise have been in poor health in childhood and died young to instead have a healthy childhood and live to old age. When these interventions reach millions of people, they make a huge differ- ence in population health, happiness, and productivity.
Because individual and community health status is the result of a complex mix of bio- logical, socioeconomic, environmental, and other factors, the clinical disciplines and public
FIGURE 1–6 Examples of interventions that improve health trajectories across the life span.
ideal
he al
th s
ta tu
s
birth
death
Baseline scenario
old age
ideal
birth
death
Health trajectory with interventions
old age
skilled birth attendants
antibiotics nutritional support
medical therapies
1.3 Prevention Science 7
Secondary prevention interventions typically are targeted at people with early, asymptom- atic (that is, not symptomatic) disease, so that health problems can be diagnosed before they become so severe that the affected individu- als seek health services. There are numerous types of cancer screening tests that are forms of secondary prevention, such as mammogra- phy for breast cancer, Pap smears for cervical cancer, and colonoscopies that look for the polyps that are precursors to colorectal cancer. Other examples of screening tests include rou- tine HIV tests, blood pressure checks in adults, and vision tests for children, all of which are intended to detect health issues in people who might otherwise remain unaware of the pres- ence of these manageable health conditions for many years.
The aim of tertiary prevention is to reduce impairment, minimize pain and suf- fering, and prevent death in people with symptomatic health problems. Examples of tertiary prevention include treating chronic diseases with medication, alleviating the pain of people with advanced cancers, and provid- ing physical therapy and occupational therapy to people recovering from strokes.
Given the three levels of prevention, there is almost always some intervention that could improve the health of those who are vulnera- ble to a particular disease or are already sick. Primary prevention is the preferred option when a cost-effective preventive intervention is available. When primary prevention is not
determining which preventive health inter- ventions are effective in various populations, how successful the interventions are, and how well they can be scaled up for wide- spread implementation.14
There are three levels of prevention (FIGURE 1–8). When an effective intervention for preventing disease or promoting health has been identified, primary prevention actions can keep an adverse health event from ever occurring. Numerous global health ini- tiatives focus on primary prevention. Some promote health behaviors, such as vaccinat- ing children to protect them from measles and polio infections, exercising to protect against heart disease, avoiding tobacco to reduce the risk of lung disease, and using a seatbelt to reduce the risk of serious inju- ries during a motor vehicle collision. Some programs work to modify the health envi- ronment by increasing access to improved sanitation facilities to prevent diarrhea, spraying insecticides to kill the mosquitoes that spread infections, implementing clean delivery room practices to prevent infections of newborns and their mothers, and building roads that are safe for bicyclists and pedes- trians. Others use policy changes to improve access to healthcare services, essential medi- cations, and nutritious foods.
The goal of secondary prevention is to detect health problems at an early stage when they have not yet caused significant damage to the body and can be treated more easily.
FIGURE 1–7 Maintaining good health status through preventive interventions is less costly than paying for rehabilitation after health crises.
ideal he
al th
s ta
tu s
birth
death
Low cost interventions
very old age
clean water
education blood pressure medicine
psychological counseling
ideal
he al
th s
ta tu
s
birth
death
High cost interventions
very old age
rehabilitation after a life- threatening infection
rehabilitation after a stroke
8 Chapter 1 Global Health Transitions
lower birth rate, a lower death rate, longer life expectancies, and a higher burden from the chronic diseases often associated with over- nutrition. For example, in the United States, the leading causes of death in 1800 and 1900 were pneumonia (including pneumonia caused by influenza), tuberculosis, and diar- rhea, all of which are infectious diseases.15 By 1950, the death rate had dropped signifi- cantly, life expectancy had increased, and the most common causes of death had shifted to heart disease, cancer, and stroke, the same noncommunicable diseases that remain the most frequent causes of death in the United States today.16 These changes in population health status were due to a variety of factors, including new health technologies, such as new vaccines, new antibiotics, and new con- traceptives, as well as improved sanitation,
possible or health problems are already pres- ent, secondary prevention and tertiary preven- tion can improve longevity and quality of life.
▸ 1.4 Health Transitions The changing health profiles observed in high-income countries over the last century are strong evidence that large-scale health interventions are effective at improving health throughout the life course. One hun- dred years ago, most populations across the globe had similar health profiles: high birth rates, high death rates, short life expectan- cies, and a considerable number of diseases and deaths due to infections and under- nutrition. During the 20th century, most high-income nations made a transition to a
Level Also Called…
Target Population Goal Examples
Primary prevention
Prevention People without disease
Prevent disease from ever occurring
■ Vaccinating children to protect them from paralytic polio
■ Giving vitamin A capsules to at-risk children to prevent blindness
Secondary prevention
Early diagnosis
People with early, non- symptomatic disease
Reduce the severity of disease and prevent disability and death
■ Checking blood pressure routinely to detect the onset of hypertension
■ Screening with mammography to detect early-stage breast cancer
Tertiary prevention
Treatment and rehabilitation
People with symptomatic disease
Reduce impairment and minimize suffering
■ Extracting teeth with severe decay in order to alleviate pain
■ Providing physical therapy to people who have been injured in a vehicle collision in order to prevent long- term disability
FIGURE 1–8 Three levels of prevention: primary, secondary, and tertiary.
1.4 Health Transitions 9
with sedentary lifestyles, decreases in infec- tious diseases and corresponding increases in chronic diseases, reductions in infant and child mortality, and increases in life expectancy and the proportion of older adults in the popula- tion (FIGURE 1–9). Low-income countries have not experienced such dramatic changes.
Because some countries have gone through these health transitions and other countries have not, there are now signif- icant differences in health status in the highest-income and lowest- income countries (FIGURE 1–10). A diversity of health statistics
better nutrition, increased education, and economic growth.17
A health transition is a shift in the health status of a population that usually occurs in conjunction with socioeconomic development. Over the last century, high- income countries have experienced a diversity of health transitions: decreases in fertility rates, changes in population size and age structures, substantial reductions in the risk of death from pregnancy-related conditions, shifts from hun- ger to obesity as a dominant nutritional con- cern, increases in health problems associated
Type of Transition Pre-transition Populations Post-transition Populations
Fertility transition The typical woman gives birth to several children.
The typical woman gives birth to only one child or two children.
Demographic transition The total population size may be increasing due to high birth rates.
The total population size may be shrinking because birth rates are so low.
Obstetric transition Pregnancy-related conditions are a common cause of death in women of reproductive age.
The maternal mortality rate is very low.
Nutrition transition Underweight is a major concern. Obesity is a major concern.
Risk transition Environmental exposures like unsafe drinking water and polluted indoor air are major contributors to disease.
Lifestyle factors like physical inactivity and tobacco use are major contributors to disease.
Epidemiologic transition
Infectious diseases in children are a significant burden to the population.
Chronic diseases in adults are the dominant health concern in the population.
Mortality transition High death rates in children and reproductive-age adults mean that few people live to very old age.
Low mortality rates for children and reproductive-age adults allow many people to live to old age.
Aging transition Children comprise the majority of the total population.
Older adults are a growing proportion of the population.
FIGURE 1–9 Examples of health transitions.
10 Chapter 1 Global Health Transitions
Today, in Very LOW-Income Populations… Today, in Very HIGH-Income Populations…
■ There are high rates of poverty, illiteracy, and unemployment, which can have negative effects on personal, family, and community health.
■ Most people have access to the basic tools for health, although there are still health disparities based on socioeconomic status.
■ Many people do not have access to an outhouse or other type of toilet and many do not have reliable access to safe drinking water.
■ Almost everyone has indoor plumbing and safe drinking water.
■ Many infants and young children die from diarrhea, pneumonia, malaria, and other infections.
■ Almost every baby will survive to adulthood.
■ The typical woman gives birth to many children, and it is not uncommon for women to die in childbirth.
■ The typical woman gives birth to 1 or 2 children, and very few women die due to pregnancy-related conditions.
■ The median (average) age of the population is in childhood.
■ The median (average) age of the population is in adulthood.
■ A typical age at death for adults is 60 or 70 years old.
■ A typical age at death for adults is 80 or even 90 years old.
■ Visits to hospitals and clinics are usually because of infections (such as malaria or tuberculosis) or serious injuries.
■ Visits to hospitals and clinics are usually due to chronic noncommunicable diseases (such as arthritis, back pain, hypertension, and diabetes).
■ Access to effective management of chronic diseases (such as hypertension and diabetes) is very limited.
■ Screening tests (such as mammography for breast cancer) often detect emerging health problems early, when they are usually more treatable.
■ Undernutrition (including protein energy and micronutrient deficiencies) remains a significant public health concern.
■ Overweight and obesity are major public health concerns, and many people have diets that are excessively high in fat and calories.
■ Very few people with mental health disorders receive clinical care because there are so few psychiatrists and psychologists.
■ Clinical mental health services are usually available, but they are often underused.
■ Serious injuries often lead to death because no surgical services are available.
■ Serious injuries can often be treated with surgery and rehabilitation
FIGURE 1–10 Examples of significant differences in health status and access to the tools for health in low-income and high-income countries.
1.4 Health Transitions 11
illustrate the wide gaps in health status.18 A baby born in Japan in 2015 could expect to live to about 84 years old, but a newborn in Sierra Leone, in West Africa, could only expect to live to age 50. A woman giving birth in Sierra Leone in 2015 was about 450 times more likely to die of a pregnancy- related condition than a pregnant woman living in Finland, in northern Europe. A baby born in Angola, in southwestern Africa, was nearly 80 times more likely to die before his or her fifth birthday than a baby born in Iceland. A 30-year-old living in Mongolia, in central Asia, was 3.5 times more likely to die from heart disease, cancer, chronic respiratory diseases, or diabetes before age 70 than an adult of the same age living in Switzerland. Those multipliers would not have been as high 100 years ago when no one had access to neonatal intensive care units, advanced obstetric care, antibiotics, and medications for managing chronic diseases. As some pop- ulations have gained access to more tools for health, and others have not, the disparities in the health profiles of high- and low-income countries have become more extreme.
Middle-income countries tend to have inter mediate health profiles with statistics somewhere between those of high-income and low-income countries. Many middle- income countries continue to have some populations burdened by undernutrition and infectious diseases while, at the same time, other pop- ulations within the same country experience the challenges associated with obesity and chronic noncommunicable conditions. This need for the health system in middle- income countries to address both “pre- transition” and “post-transition” health problems is some- times called the “dual burden” of disease. Comparing high-, middle-, and low-income countries provides insights into how health transitions occur and insights into the types of interventions that are likely to be effective at achieving particular types of changes in popu- lation health status.
▸ 1.5 World Regions and Featured Countries
Throughout this book, data from eight large countries will be used to represent the diver- sity of the world’s health profiles, including the three countries with the largest populations— China and India, which each have more than 1 billion residents, and the United States, which has more than 320 million inhabitants—as well as five other countries that are among the 19 countries that are each home to more than 1% of the world’s population (that is, more than 75 million people).19 Together, these eight countries are home to half of the world’s peo- ple (FIGURE 1–11).
The featured countries represent a diver- sity of economic profiles (FIGURE 1–12). The World Bank divides countries into four cate- gories based on the gross national income per person. Of the eight featured countries, two are classified as high income, three as upper- middle income, two as lower-middle income, and one as low income. This classification is
FIGURE 1–11 The eight featured countries represent nearly half of the world’s population. Data from World development indicators 2016. Washington DC: World Bank; 2016.
United States
China
India Rest of the
world
Brazil Nigeria
Ethiopia Germany
Iran
12 Chapter 1 Global Health Transitions
about longevity and education.20 These catego- ries generally align with the World Bank group classifications, but one of the featured lower- middle- income countries (Nigeria) is classified as having a low rather than a medium human development level. The featured countries also represent geographic diversity (FIGURE 1–14), covering all seven World Bank analytical regions and all six of the WHO’s regions (FIGURE 1–15).
There is often considerable diversity in the socioeconomic and health profiles of countries within the same world region. There is also considerable diversity among different states or provinces within countries and between urban and rural areas. These types of within-country differences can be observed in all eight of the featured countries. For example, parts of southern Nigeria have a middle-income eco- nomic profile while some of the northern areas of Nigeria have a very low-income pro- file and are at risk of famine.21 National sta- tistical reports present the average values for various metrics, and those averages do not
similar to the distribution of the world’s popu- lation by income level, since 70% of the world’s people live in a country classified as middle income by the World Bank (FIGURE 1–13).19 Many analyses of global health compare the health status in low- and middle-income countries (LMICs), a category that includes all low-income, lower-middle- income, and upper-middle-income countries, to the health status in high-income countries (HICs). Some global health reports compare LMICs to coun- tries that are members of the Organisation for Economic Co-operation and Develop- ment (OECD), an intergovernmental orga- nization that represents about three dozen of the world’s richest countries. Six of the eight featured countries in this book are LMICs and two are OECD-member HICs.
The United Nations Development Pro- gramme (UNDP) divides countries into four groups (very high, high, medium, and low) based on a human development index calcu- lated from income per person plus statistics
Country World Bank Income Group UNDP Human Development Level
United States High Very high
Germany High Very high
Iran Upper middle High
Brazil Upper middle High
China Upper middle High
India Lower middle Medium
Nigeria Lower middle Low
Ethiopia Low Low
FIGURE 1–12 Eight featured countries by income group. The countries are listed in order from highest to lowest human development index. Data from World development indicators 2016. Washington DC: World Bank; 2016. Human development report 2016. New York: UNDP; 2016.
1.5 World Regions and Featured Countries 13
eight featured countries are sufficient to illus- trate the patterns associated with the fertility transition (women in higher- income countries have fewer babies), the obstetric transition (higher-income countries have lower rates of maternal mortality), and the aging transition (higher-income countries have older popula- tions) (FIGURE 1–17).20 Similar trends can be observed for a great diversity of indicators.
express the wide range of values that may be present within diverse regions of the country. Despite that limitation, general patterns can be observed by comparing statistics from large countries. The differences between higher- income (high- and upper- middle-income) countries and lower- income ( lower-middle and low-income) countries are often notable ( FIGURE 1–16). For example, data from just the
FIGURE 1–13 Most of the world’s people live in a country classified as middle income by the World Bank. Data from World development indicators 2016. Washington DC: World Bank; 2016; Human development report 2016. New York: UNDP; 2016.
World bank income group
High
Upper middle
Low
Lower middle
Very high Low
High Medium
UNDP human development level
Ethiopia
India
Nigeria
Featured countries
United States
Germany
Iran
Brazil China
14 Chapter 1 Global Health Transitions
Country Geographic Location World Bank Region WHO Region
United States North America North America Americas
Germany Europe Europe and Central Asia Europe
Iran Middle East Middle East and North Africa Eastern Mediterranean
Brazil South America Latin America and the Caribbean
Americas
China East Asia East Asia and Pacific Western Pacific
India South Asia South Asia South-East Asia
Nigeria West Africa Sub-Saharan Africa Africa
Ethiopia East Africa Sub-Saharan Africa Africa
FIGURE 1–15 Eight featured countries by geographic location. World development indicators 2016. Washington DC: World Bank; 2016; World health statistics 2016: Monitoring health for the SDGs. Geneva: WHO; 2016.
FIGURE 1–14 Eight featured countries representing nearly half of the world’s population. Data from World development indicators 2016. Washington DC: World Bank; 2016.
USA
Germany
Iran
Brazil
China
India
Nigeria
Ethiopia
1.5 World Regions and Featured Countries 15
FIGURE 1–16 Income-level terminology.
FIGURE 1–17 Examples of socioeconomic and health trends. Data from Human development report 2016. New York: UNDP; 2016.
UPPER MIDDLE income
LOWER income
LOWER MIDDLE income
LOW income
HIGHER income
HIGH income
OECD
USA
Germany
Iran
Brazil
China
India
Nigeria
Ethiopia
Human development index (HDI)
0 1 0
Average number of births per woman
USA
Germany
Iran
Brazil
China
India
Nigeria
Ethiopia
6
0 814
Number of women who die of pregnancy-related conditions
per 100,000 live births
USA
Germany
Iran
Brazil
China
India
Nigeria
Ethiopia
0 50
Median age
USA
Germany
Iran
Brazil
China
India
Nigeria
Ethiopia
16 Chapter 1 Global Health Transitions
matter which geographic region they happen to be located in.27 While many international health programs are humanitarian, they also enable workers and consumers in the recipi- ent countries to remain active participants in the global economy.
Human security was defined in the 1994 Human Development Report as the freedom from fear and want that results from having health security as well as food security (free- dom from hunger), personal security (free- dom from violence), environmental security (freedom from preventable environmental vulnerabilities), economic security (freedom from extreme poverty), community security (freedom from discrimination), and political security (freedom from human rights viola- tions).28 Human security focuses on individ- ual and community well-being, while national security focuses on the protection of the col- lective interests of people living within a coun- try’s borders. For many countries, promoting health security and other aspects of human security in other countries is a core component of national security plans.29 The investment in global health activities by high-income countries generates major returns through expanded markets for international trade, strengthened diplomatic relationships, and fortified homeland security.30
The nascent field of global health security seeks to protect populations from threats to health and safety by engaging a diversity of stakeholders, including govern- mental and military personnel, in public health interventions.31 The current concept of global health security is an extension of the historic international health policies and practices that aimed to stem the spread of epidemics as international travel and trade became more common.32 Communities and countries suffering from widespread health problems are more likely to have political and economic instability, and poverty and unrest can further exacerbate public health prob- lems that might spill over into other parts of the world. International and global health
▸ 1.6 Global Health Security
The goal of the first international health ini- tiatives was to prevent widespread outbreaks of infectious diseases. For example, a series of International Sanitary Conferences held in various European cities starting in 1851 assembled representatives from several coun- tries to address concerns about travel and trade spreading cholera to new ports.22 Sig- natories of the resulting agreements agreed to notify other countries about outbreaks of chol- era, plague, yellow fever, and other epidemic diseases, and they pledged to monitor health at ports and impose quarantines on disease- carrying ships.23 These treaties set the stage for the International Sanitary Regulations (later renamed the International Health Reg- ulations) that were approved by the WHO 100 years later in 1951 and are still in force today. By the early 1900s, international regulations addressed several other cross-border health issues, including drugs and alcohol sales, occupational health and safety, and water pol- lution,24 but the initial impetus for these delib- erations was the recognition that countries had to collaborate with their neighbors to keep dangerous pathogens at bay.
A second set of early international health concerns focused on threats to economic and political interests. The field of tropical medicine blossomed in the late 1800s and early 1900s as more European (and American) military personnel, businessmen, and their families relocated to colonies in tropical cli- mates.25 Tropical medicine specialists aimed not only to protect settlers from parasitic and infectious diseases—a role similar to that of travel medicine specialists today—but also to ensure that the workforce in these areas could be productive.26 Today, tropical medicine has expanded to become international health,10 a term that now typically refers to initiatives targeted toward addressing poverty-related health conditions in lower-income areas, no
1.6 Global Health Security 17
other part of the world within hours rather than weeks or months. Concerns about global- ization and health also encompass a diversity of other emerging health issues, like bioter- rorism, drug resistance, food safety, and the health effects of climate change.
Globalization is not a uniformly good or bad process, but one that yields a mix of pos- itive and negative outcomes.36 For example, globalization has allowed more goods to be manufactured in middle-income countries and then sold in high-income countries where higher salaries for workers make manufac- turing comparatively expensive. In middle- income countries, globalization often means more job opportunities, but there may also be pressures to increase productivity even if that causes environmental damage or creates unsafe working conditions. In high-income areas, international trade reduces the cost of consumer products but it also means that there are fewer local jobs in the manufacturing sector. Cheaper products created in middle- income countries also make it harder for the lowest-income countries to participate in the global economy because the poorest countries do not have educational systems geared toward producing a technologically skilled workforce. Globalization tends to create greater inequal- ities in income between countries and within countries.
Concerns about the adverse impacts of globalization have led in many countries to the rise of nationalistic political movements that call for greater self-reliance and less engagement with other nations. However, even if countries implement isolationist pol- icies, it is not possible to eliminate the need for involvement in global health activities. The threat from emerging infectious dis- eases is an ancient one that will continue to exist for future generations, and environ- mental hazards can easily cross international borders when they are carried by air, water, or animals. Whether a country has pro- or anti- globalization policies, it is in every country’s best interests to actively engage in
initiatives can help to break this cycle, facili- tating peace and productivity. Global health security recognizes that countries participat- ing in global health activities reap the benefits of self-protection in addition to the humani- tarian gains and goodwill that these actions may generate.33
▸ 1.7 Globalization and Health: Shared Futures
Globalization is the process of countries around the world becoming more integrated and interdependent across economic, polit- ical, cultural, and other domains. Global- ization contributes to the health transitions that are occurring in many parts of the world by increasing access to health technologies, encouraging urbanization, changing social and cultural practices, and accelerating envi- ronmental changes.34 Globalization can also be observed in the increasing number of global governmental and nongovernmental organi- zations, the proliferation of multilateral trade agreements, and increases in global supply chains, foreign direct investment, population mobility, communication, data sharing, and cultural diffusion.
The concept of globalization is not new to the field of public health. Infectious diseases like plague and smallpox spread across Asia and Europe more than a 1000 years ago, when sea and land trade routes like the Silk Road linked China, India, and the Mediterranean. The pathogens carried by the Europeans who explored the Americas in the 15th century caused the decimation of many indigenous American populations, while some infections indigenous to the Western hemisphere (such as syphilis) made their way back to Europe and sparked mass epidemics.35 Pathogens have never stopped at national boundaries, and modern transportation allows for a new infectious disease that emerges in any part of the world to be transported by aircraft to any
18 Chapter 1 Global Health Transitions
10. Packard RM. A history of global health: Interventions into the lives of other peoples. Baltimore MD: Johns Hopkins University Press; 2016.
11. Harrell JA, Baker EL; Essential Services Work Group. The essential services of public health. Leadersh Public Health. 1994;3:27–30.
12. The Ottawa Charter for Health Promotion. Ottawa: 1st International Conference on Health Promotion; 1986.
13. Keller LO, Strohschein S, Lia-Hoagberg B, Schaffer MA. Population-based public health interventions: Practice-based and evidence-supported. Public Health Nurs. 2004;21:453–68.
14. Flay BR, Biglan A, Boruch RF, et al. Standards of evidence: Criteria for efficacy, effectiveness and dissemination. Prev Sci. 2005;6:151–75.
15. Jones DS, Podolsky SH, Greene JA. The burden of disease and the changing task of medicine. New Engl J Med. 2012;366:2333–8.
16. Guyer B, Freedman MA, Strobino DM, Sondik EJ. Annual summary of vital statistics: Trends in the health of Americans during the 20th century. Pediatrics. 2000;106:1307–17.
17. Martens P. Health transitions in a globalising world: Towards more disease or sustained health? Futures. 2002;34:635–48.
18. World health statistics 2016: Monitoring health for the SDGs. Geneva: WHO; 2016.
19. World development indicators 2016. Washington DC: World Bank; 2016.
20. Human development report 2016. New York: UNDP; 2016.
21. National human development report 2015: Human security and human development in Nigeria. Abuja: UNDP Nigeria; 2015.
22. Huber V. The unification of the globe by disease? The International Sanitary Conferences on cholera, 1951–1894. Historical J. 2006;49:453–76.
23. Fidler DP. From International Sanitary Conventions to global health security: The new International Health Regulations. Chinese J Int Law. 2005;4:325–92.
24. Fidler DP. The globalization of public health: The first 100 years of international health diplomacy. Bull World Health Organ. 2001;79:842–9.
25. Gibson AD. Miasma revisited: The intellectual history of tropical medicine. Aust Fam Physician. 2009;38:57–9.
26. Brown ER. Public health in imperialism: Early Rockefeller programs at home and abroad. Am J Public Health. 1976;66:897–903.
27. Koplan JP, Bond TC, Merson MH, et al. Consortium of Universities for Global Health Executive Board. Towards a common definition of global health. Lancet. 2009;373:1993–5.
28. Human development report 1994. New York: UNDP; 1994.
communicating about transnational health concerns, sharing the scientific discoveries that enable populations to fortify themselves against threats to health, and collaborating on health interventions that promote peace, prosperity, and security.
Global health offers a proactive way to prevent outbreaks (and to respond to them when they happen), to protect economic and political interests at home and abroad, to pro- mote goodwill and humanitarian values, and to achieve shared health and development goals.37 Global health is a dynamic field. The health patterns that exist today are not the same as the patterns from 100 years ago, and new health transitions will occur in the com- ing decades. Global health provides an oppor- tunity to use prevention strategies and other interventions to shape a healthier, safer future for the world’s people.
▸ References 1. Huber M, Knottnerus JA, Green L, et al. How should
we define health? BMJ. 2011;343:d4163. 2. Kuh D, Ben-Shlomo Y, Lynch J, Hallqvist J, Power
C. Life course epidemiology. J Epidemiol Community Health. 2003;57:778–83.
3. Committee on Assuring the Health of the Public in the 21st Century. The future of the public’s health in the 21st century. Washington DC: National Academies Press; 2002.
4. Susser M, Susser E. Choosing a future for epidemiology: I. Eras and paradigms. Am J Public Health. 1996;86:668–73.
5. Bingham P, Verlander NQ, Cheal MJ. John Snow, William Farr and the 1849 outbreak of cholera that affected London: A reworking of the data highlights the importance of the water supply. Public Health. 2004;118:387–94.
6. Shryock RH. The early American public health movement. Am J Public Health. 1937;27:965–71.
7. Pearce N. Traditional epidemiology, modern epide- miology, and public health. Am J Public Health. 1996;86:678–83.
8. Doll R, Hill AB. Lung cancer and other causes of death in relation to smoking. Br Med J. 1956;2:1071–81.
9. Hackshaw AK, Law MR, Wald NJ. The accumulated evidence on lung cancer and environmental tobacco smoke. BMJ. 1997;315:980–8.
References 19
33. Lakoff A. Two regimes of global health. Humanity. 2010;1:59–79.
34. McMichael AJ. Globalization, climate change, and human health. N Engl J Med. 2013;368:1335–43.
35. Morens DM, Folkers GK, Fauci AS. Emerging infections: A perpetual challenge. Lancet Infect Dis. 2008;8:710–19.
36. Osland JS. Broadening the debate: The pros and cons of globalization. J Manage Inquiry. 2003;12:137–54.
37. Global health works: Maximizing U.S. investments for healthier and stronger communities. Washington DC: Global Health Council; 2017.
29. Oslo Ministerial Declaration: Global health: A pressing foreign policy issue of our time. Lancet. 2007;369:1373–8.
30. The Case for U.S. Investment in the Global Fund and Global Health. Washington DC: Friends of the Global Fight against AIDS, Tuberculosis and Malaria; 2017.
31. Aldis W. Health security as a public health concept: A critical analysis. Health Policy Plan. 2008;23:369–75.
32. Hoffman SJ. The evolution, etiology and eventualities of the global health security regime. Health Policy Plan. 2010;25:510–22.
20 Chapter 1 Global Health Transitions
© Xinzheng. All Rights Reserved/Moment/Getty
CHAPTER 2
Global Health Priorities Global health priorities are established based on population needs assessments, economic evaluations of the tools that are available to deploy as interventions, donor values, and security considerations. Health metrics provide valuable information for priority-setting, decision-making, and monitoring of progress toward achieving global health targets. Global partnerships for development like the Sustainable Development Goals also shape the global health agenda and encourage transnational cooperation to address shared priorities.
▸ 2.1 Global Health Achievements
Innovations in health technology during the last century have created an incredible set of tools for global health work. New antibiotics were discovered along with a host of medica- tions for treating noncommunicable diseases (NCDs) like heart disease and cancer. Life- saving vaccines were developed. Smallpox was eradicated. Oral contraceptives trans- formed family planning, and assisted repro- ductive technologies enabled many couples with infertility problems to have biologi- cal children. New diagnostic tools, such as electrocardiographs and MRIs, increased the quality of medical care, as did new therapies, like insulin for diabetes, dialysis for kidney disease, and contact lenses for vision impair- ments. Modern surgical techniques made joint replacements, open heart surgery, and organ transplants routine in some parts of
the world. These technological advances enabled many of the top 10 public health achievements of the 20th century that were highlighted by the U.S. Centers for Disease Control and Prevention (CDC) at the start of the new millennium (FIGURE 2–1)1 as well as many of the leading global health achieve- ments during the first years of the 21st century (FIGURE 2–2).2
While these health technologies are indisputably beneficial, the uneven distri- bution of access to them has generated a massive intensification of health disparities. People living in the world’s richest coun- tries now have access to an array of tools for health that would have been unimag- inable 100 years ago, while children living in the world’s poorest areas continue to succumb to easily preventable conditions like starvation and vaccine-preventable and antibiotic-treatable infectious diseases. At the same time that the health profiles of populations worldwide were becoming more
21
disparate, the 20th century brought potent reminders that all people around the world are at risk from a shared set of hazards. The emergence of HIV, virulent new strains of influenza, and drug-resistant patho- gens prompted truly global research and response efforts. The goals of global health in the 21st century are to continue to create innovative solutions to public health prob- lems; to increase access to health, healthcare services, and health technologies around the world; and to expand global commu- nication and action about shared health concerns.
In an ideal world, there would be enough resources for all worthy global health goals to receive the funding they need to be achieved.
In the real world, the amount of funding available for health interventions is limited. Advocates for various health problems and solutions must compete for attention and support, and only the proposals that garner buy-in from well-resourced groups are able to move forward. The gap between commend- able ideas and the resources to implement them has created a demand for prioritization strategies that allow funders to make informed decisions about where and how to invest in global health. When future generations com- pile lists celebrating the major global health accomplishments of the 21st century, those lists will reflect the decisions today’s global health leaders make about which projects to prioritize.
FIGURE 2–1 The U.S. CDC’s top 10 public health achievements of the 20th century (1900–1999). Reproduced from Ten great public health achievements: United States, 1990–1999. MMWR Morb Mort Wkly Rev 1999;48:241–3.
1 Reductions in child mortality
2 Vaccine-preventable diseases
3 Access to safe water and sanitation
4 Malaria prevention and control
5 Prevention and control of HIV/AIDS
6 Tuberculosis control
7 Control of neglected tropical diseases
8 Tobacco control
9 Increased awareness and response for improving global road safety
10 Improved preparedness and response to global health threats
1 Vaccination
2 Motor-vehicle safety
3 Safer workplaces
4 Control of infectious diseases
5 Decline in deaths from ischemic heart disease and stroke
6 Safer and healthier foods
7 Healthier mothers and babies
8 Family planning
9 Fluoridation of drinking water
10 Recognition of tobacco as a health hazard
FIGURE 2–2 The U.S. CDC’s top 10 global health achievements in the first decade of the 21st century (2001–2010). Data from CDC, Ten great public health achievements: Worldwide, 2001–2010. MMWR Morb Mort Wkly Rev 2011; 60:814-8.
22 Chapter 2 Global Health Priorities
▸ 2.2 Prioritization Strategies
Funding agencies and planning committees use a variety of strategies to prioritize the types of activities that they will support.3 For example, some focus specifically on health and nutrition interventions, while others support broader education and economic development activities that enable healthier communities. Some give priority to prevention activities, and some prioritize treatment of existing health issues. Some prepare primary health facili- ties to address a diversity of health issues, and some focus on increasing access to advanced disease-specific care at tertiary hospitals. The priorities identified by groups viewing global health with different lenses provide insight into the common health challenges of nations and
populations around the world, and they point toward solutions for shared concerns. The PACES definition of global health—one that considers populations, action, cooperation, equity, and security to be identifiers of global health issues—also provides a framework for prioritizing items for the global health agenda (FIGURE 2–3).
One approach is to establish priorities based on the health concerns that affect the most people. The term burden of disease (BOD) refers to the adverse impact of a par- ticular health condition (or group of con- ditions) on a population. Disease burden can be measured using health metrics (like the number of deaths from a particular dis- ease) and economic indicators (like the total direct costs of medical care for a disease plus the indirect costs of absences from work or school due to the condition). Groups that
Lens Key Questions
Populations What are the health issues that cause the greatest number of deaths, illnesses, and disability worldwide?
Which populations have the greatest need?
Action What are the “best buys” among the available interventions?
How do we allocate resources to do the greatest good for the greatest number of people?
Cooperation What are the goals of the partners?
What problem is the partnership best equipped to solve?
Equity What actions will do the most to improve the lives of children and other vulnerable populations?
How will the intervention reduce health disparities?
Security What are the greatest threats to peace?
How will the intervention help to achieve the national interests of sponsoring governments?
FIGURE 2–3 PACES: strategies for prioritizing global health issues.
2.2 Prioritization Strategies 23
women, taxing tobacco products to reduce use, expanding the use of cardiovascular med- ications to prevent heart attacks and strokes, and enforcing traffic laws to reduce injuries as some of the highest-impact global health interventions (FIGURE 2–4).7
Some groups make decisions based on the special interests and capabilities of the collaborators. For example, the 14 Grand Challenges in Global Health identified by the Bill & Melinda Gates Foundation in 2003 highlighted critical needs for new health technologies (FIGURE 2–5),8 and the Gates Foundation subsequently used that list as part of selecting proposals to fund. Because the Gates Foundation is led by people with expertise in computers and information tech- nology, the foundation is uniquely prepared to support the development and dissemina- tion of new tech products. When funding and implementation agencies have particular areas of expertise, they can maximize their impact by applying their existing knowledge and experience toward new projects that build on past successes.
Groups focused on equity prioritize projects that will address perceived injustices and reduce health disparities. Many equity- oriented programs focus on the health of infants and children because of the nearly universal belief that no child anywhere should suffer from abuse, hunger, or preventable dis- eases.9 Equity-focused initiatives may also focus on the health of other vulnerable pop- ulations, like refugees and other migrants, people in prison, people with disabilities, and older adults, or they may advocate for human rights.
Another common approach is to make prioritization decisions based on the security interests of sponsoring governments, including direct and indirect threats to national, regional, and global peace and stability. For exam- ple, the top public health challenges that the U.S. CDC has identified for the United States
prioritize global health spending based on a population lens make their decisions after looking at statistics about the conditions that cause the greatest BOD. For example, the Global Burden of Disease (GBD) project, a massive collaborative effort to quantify the epidemiologic profiles of every country in the world that was initiated by the World Health Organization (WHO) in the 1990s and is now housed at the Institute for Health Metrics and Evaluation (IHME) in Seattle has identified unhealthy diets, child and maternal under- nutrition, untreated high blood pressure, tobacco smoke, and indoor and outdoor air pollution as some of the most common mod- ifiable exposures that cause poor health and early death globally.4 The evidence that these risk factors cause a substantial BOD can be used to support proposals for interventions that will enable a large number of people to live longer, healthier lives. The GBD collab- orators also release annual estimates of the causes of death, illness, and disability world- wide and for each country. These numbers inform the development of policy recommen- dations that can be acted on by governmental bodies and other public health funders and implementers.
Prioritization based on an action orien- tation often gives the highest ratings to the cost-effective interventions that have been identified as “best buys” because they help many people make meaningful gains in health status at a low cost per person (or at a low cost per adverse event averted by the inter- vention).5 In general, low-cost primary pre- vention activities are the most cost- effective interventions.6 The Disease Control Priori- ties (DCP) project has identified vaccinating children, preventing malaria and HIV infec- tions, treating tuberculosis and common communicable childhood diseases to prevent them from spreading to other people, improv- ing the basic care of newborns, distributing micronutrients to children and pregnant
24 Chapter 2 Global Health Priorities
Target Action
1 Child health Vaccinate children against major childhood killers, including measles, polio, tetanus, whooping cough, and diphtheria.
2 Child health Monitor children’s health to prevent or, if necessary, treat childhood pneumonia, diarrhea, and malaria.
3 Tobacco use Tax tobacco products to increase consumers’ costs by at least one-third to curb smoking and reduce the prevalence of cardiovascular disease, cancer, and respiratory disease.
4 HIV/AIDS Attack the spread of HIV through a coordinated approach that includes promoting 100% condom use among populations at high risk; treating other sexually transmitted infections; providing antiretroviral medications, especially for pregnant women; and offering voluntary HIV counseling and testing.
5 Maternal and child health Give children and pregnant women essential nutrients, including vitamin A, iron, and iodine, to prevent maternal anemia, infant deaths, and long-term health problems.
6 Malaria Provide insecticide-treated bednets in malaria-endemic areas to drastically reduce malaria.
7 Injury prevention Enforce traffic regulations and install speed bumps at dangerous intersections to reduce traffic-related injuries.
8 TB Treat TB patients with short-course chemotherapy to cure infected people and prevent new infections.
9 Child health Teach mothers and train birth attendants to keep newborns warm and clean to reduce illness and death.
10 Cardiovascular disease Promote use of aspirin and other inexpensive medications to treat and prevent heart attack and stroke.
FIGURE 2–4 Ten “best buys” in global health from the Disease Control Priorities Project. Reproduced from Pathways to global health research: strategic plan 2008–2012. Bethesda MD: The John E. Fogarty International Center, National Institutes of Health (NIH); 2008, p. 22.
2.2 Prioritization Strategies 25
alleviated by any one country working in iso- lation. Once a country has identified its own strategic global health priorities, that country is prepared to advocate for those priorities in conversations with potential partners. Work- ing with partner nations on achieving shared aims will then advance health security at home and abroad.
include protecting the environment, respond- ing to emerging infectious diseases (including pandemic influenza and drug-resistant patho- gens), and reducing the burden from violence (including the physical and psychological trau- mas sustained by military personnel deployed to conflict areas) (FIGURE 2–6).10 These types of threats to health and security cannot be
Improve childhood vaccines
1 Create effective single-dose vaccines.
2 Prepare vaccines that do not require refrigeration.
3 Develop needle-free vaccine delivery systems.
Create new vaccines
4 Devise testing systems for new vaccines.
5 Design antigens for protective immunity.
6 Learn about immunological responses.
Control insects that transmit agents of disease
7 Develop genetic strategy to control insects.
8 Develop chemical strategy to control insects.
Improve nutrition to promote health 9 Create a nutrient-rich staple plant species.
Improve drug treatment of infectious diseases
10 Find medications and delivery systems to limit drug resistance.
Cure latent and chronic infection
11 Create therapies that can cure latent infection.
12 Create immunological methods to cure latent infection.
Measure health status accurately and economically in developing countries
13 Develop technologies to assess population health.
14 Develop versatile diagnostic tools.
FIGURE 2–5 Grand Challenges in Global Health. Data from Varmus H, Klausner R, Zerhouni E, Acharya T, Daar AS, Singer PA. Grand challenges in global health. Science 2003; 302:398-9.
26 Chapter 2 Global Health Priorities
patient files and insurance claims.12 Many types of health data are disseminated through the websites and annual reports of major governmental and nongovernmental health organizations and through academic journal articles. The websites of the WHO, the U.S. CDC, the U.S. National Institutes of Health (NIH), and other health agencies provide easy- to-read and regularly updated information about hundreds of diseases. For example, the WHO’s Weekly Epidemiological Record and the CDC’s Morbidity and Mortality Weekly Report (MMWR) provide timely information about emerging health issues, such as new outbreaks of serious infections.
For comparative global health statistics, the best sources are often the appendices of the annual reports of UN agencies, such as the WHO’s annual World Health Statistics report and UNICEF’s annual State of the World’s Children report. For disease-specific statistics, the reports of specialty organizations can be
▸ 2.3 Health Metrics As more resources have been devoted to global health efforts, it has become increasingly important to quantify the health needs in var- ious parts of the world, identify major modifi- able risk factors for common diseases, assess the impact of new public health interventions, and monitor changes in the health status of populations over time. The key measures of health and disease in populations include information about population size, the birth rates and death rates, the causes of death, the frequency and causes of various illnesses and disabilities, and the rate at which members of the population engage in risky behaviors. All of these measures provide an evidence base for making policy and funding decisions.11
Health information comes from a wide variety of sources, including census data, regis- tries, surveillance systems, household surveys, and health services records, such as hospital
1 Institute a rational healthcare system (balance equity, cost, and quality).
2 Eliminate health disparities.
3 Focus on children’s emotional and intellectual development.
4 Achieve a longer “healthspan” (healthy aging).
5 Integrate physical activity and healthy eating into daily lives.
6 Clean up and protect the environment.
7 Prepare to respond to emerging infectious diseases.
8 Recognize and address the contributions of mental health to overall health and well-being.
9 Reduce the toll of violence in society.
10 Use new scientific knowledge and technological advances wisely.
FIGURE 2–6 The U.S. CDC’s top public health challenges for the early 21st century. Data from Koplan JP, Fleming DW. Current and future public health challenges. JAMA 2000; 284:1696-8.
2.3 Health Metrics 27
mortality rates are higher for older adults than for younger people. Age-adjusted rates that account for differences in population age struc- tures are usually used to compare mortality rates in two or more populations. While the crude (unadjusted) all-cause mortality rates are typi- cally highest in high-income countries that have a large proportion of older adults, the age- standardized (adjusted) mortality rates are usually highest in low-income countries (FIGURE 2–8).
Measuring mortality (death) at the pop- ulation level can be challenging for two prin- cipal reasons. The first is that in many parts of the world there is no system for reliably reg- istering vital statistics. In places where most births and deaths occur in homes instead of in hospitals, few births and deaths are docu- mented by government officials. The most dis- advantaged populations—often the ones with the highest mortality rates—are the least likely to have their life events accurately counted. Thus, while very precise mortality statistics are available from high-income countries, death rates in low-income countries often must be estimated based on limited data. The second key challenge is assigning one cause of death to each deceased individual. Should a person with HIV/AIDS who dies of tuber- culosis be recorded as an HIV death or a TB death? Should a person with advanced-stage
helpful references. For example, some global cancer statistics are reported every year by the American Cancer Society and by the Interna- tional Agency for Research on Cancer (IARC), which is part of the UN system.
For detailed information about par- ticular research methods and findings, the best sources are academic and professional journals articles that have undergone peer review, which means that before the papers were published, the manuscripts were sent to experts in the field who scrutinized the methodology and evaluated the validity of the results. An abstract is a one-paragraph summary of the methods, results, and con- clusions of a scientific investigation. Abstract databases like MEDLINE can be used to search for abstracts summarizing journal articles on selected topics. The full reports can then be found online or in a library. These various types of high-quality resources provide an evidence-based foundation for those who seek to create, implement, evalu- ate, or improve global public health policies and practices.
Most countries maintain vital statistics on their residents, population-level metrics about births, deaths, and other life events. Vital statis- tics are compiled from birth and death certifi- cates, marriage and divorce certificates, census records, and other sources. Demographers use these statistics to understand the current popu- lation distribution and predict the size and char- acteristics of the population in future years. The birth rate is the annual number of births per 1000 people in the total population. The birth rate is usually highest in the lowest-income countries (FIGURE 2–7). The death rate, also called the mortality rate, is the annual number of deaths per 1000 people (or other units, such as per 100,000 people). Mortality rates can be presented for all-cause mortality and for specific causes of death. The all-cause death rate is usually higher in populations with a large percentage of older adults than in populations with an abundance of school-aged children because age- specific
0 5
10 15 20 25 30 35 40
USA
Ger m
an y
Ira n
Bra zil
Chin a
B irt
h ra
te p
er 1
00 0
In dia
Nige ria
Eth iop
ia
FIGURE 2–7 Birth rate per 1000 people in 2015 in featured countries. Data from World development indicators 2016. Washington: World Bank; 2016.
28 Chapter 2 Global Health Priorities
median expected age at death of all babies born alive. Life expectancy captures the bur- den from infant and child deaths in addition to the average age at death of adults. In places with high infant mortality rates, the median age at death is often in middle adulthood, which represents an age somewhere between a large number of child deaths and an even larger number of deaths in older adults. Life expectancies have increased over time in most countries, but they remain much higher in high-income countries than in low-income countries (FIGURE 2–10).13 Some estimates of life expectancy instead focus on healthy life expectancy (HALE), which is the number of years the average individual born into the
cancer who dies of pneumonia be counted as a cancer death or an infectious disease death? These decisions about how to assign causes of death can have a significant impact on which diseases appear to be the most com- mon causes of mortality in a population. Even with these limitations, epidemiologists using standardized estimation methods and the best available data can make reasonably accurate assessments of the annual number and causes of death by age group and sex in every region of the world.
Another common way of examining mortality and survival at the population level is through the estimation of life expectancy (FIGURE 2–9). Life expectancy at birth is the
FIGURE 2–8 Crude and age-standardized all-cause mortality rates per 100,000 people in 2015 in featured countries. Data from GBD Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388:1459-544.
USA Germany Iran Brazil China
India Nigeria Ethiopia Global average
Crude death rate
D ea
th r
at e
pe r
10 0,
00 p
eo pl
e
Age-standardized death rate 0
200
400
600
800
1000
1200
1400
2.3 Health Metrics 29
0
10
20
30
Li fe
e xp
ec ta
nc y
at b
irt h
40
50
60
70
80
90
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015
USA Germany Brazil China
Iran NigeriaIndia Ethiopia
FIGURE 2–10 Life expectancy has increased over time. Data from United Nations Department of Economic and Social Affairs. World population prospects: the 2017 revision. New York: UN; 2017.
Missing/Excluded
Less than 60
60 to 70
70 to 75
75 to 80
80 and above
FIGURE 2–9 Life expectancy at birth (2015). Data from World development indicators 2016. Washington: World Bank; 2016.
30 Chapter 2 Global Health Priorities
cases of the disease occurring in a time period divided by the total number of people at risk for that disease in that time period. Incidence is usually used to study infectious diseases, acute diseases (diseases that occur suddenly), and outbreaks. Prevalence is the number of total existing cases, whether newly diagnosed or long-established, divided by the total num- ber of people in the population at the time the prevalence is measured. Prevalence is usually used to describe the frequency of chronic (long-lasting) exposures and diseases in a pop- ulation, such as the percentage of adults in a country who have diabetes or asthma or who smoke tobacco products.
population can expect to live without disabil- ity (FIGURE 2–11).14 In most countries, adults experience about 10 years in poor health before dying. Global health aims to increase life expectancies and increase HALEs, so that people live to older ages without experienc- ing extended periods of disability prior to death.
Morbidity refers to the presence of illness or disease, whether that disease is relatively mild, like the common cold, or quite severe. The two most common terms used to describe the morbidity rate for a particular disease in a population are incidence and prevalence (FIGURE 2–12). Incidence is the number of new
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
0 20 40 60 80
U S
A G
er m
an y
Ir an
B ra
zi l
C hi
na In
di a
N ig
er ia
E th
io pi
a
HALE at birth
Life expectancy at birth
Total LE at birth
FIGURE 2–11 Life expectancy and healthy life expectancy (HALE) at birth. Data from GBD 2015 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388:1603-58.
2.3 Health Metrics 31
is age 80, someone who dies at 60 years of age would contribute 20 YLLs to the population total. Diseases that kill children, who would have had decades of productive life remaining if they had survived, generate more YLLs per case than diseases that primarily affect older adults. An intervention that keeps one 5-year- old from dying will prevent the loss of up to 75 YLLs in a population that has a target sur- vival age of 80 years, while an intervention that keeps a 75-year-old alive for at least 5 more years will generate only 5 averted YLLs. An intervention for people who are already older than the target survival age will not help reduce the number of YLLs in the population because only premature deaths count toward the total.
In the models created for the GBD proj- ect, the term disability refers to any short- or long-term reduction in health status.15 Weights are assigned to the level of disability caused by each type of physical or mental health con- dition. Years lived with disability (YLDs) quantify the burden to a population from
Epidemiologists measuring incidence and prevalence must establish a clear case defini- tion that spells out exactly which characteristics indicate that a person has (or does not have) the conditions of interest. They must also have a system in place for ascertaining the total num- ber of people in the population being studied, especially if changes in the health status of a population are being tracked over time and the population might be growing or shrinking or aging. Age-adjustment can be used to standard- ize two populations with different age struc- tures before their morbidity rates are compared.
A variety of more complex health metrics also are used to examine the disease burden at the population level. Years of life lost (YLLs) quantify the burden from premature mortal- ity in a population. Premature mortality is any death before a selected target survival age. For example, if the goal is for everyone in a pop- ulation to live to age 70, someone who dies at 60 years of age would contribute 10 YLLs to the population total. If the target for survival
December 31, 2017
At the end of 2017, there were 100 adult residents of Villagetown and 20 of them had HIV infection.
The prevalence of HIV infection was 20/100 = 20%.
December 31, 2018
At the start of 2018, there were 80 susceptible adults in Villagetown. During 2018, 8 became newly infected with HIV.
The one-year incidence rate of HIV infection was 8/80 = 1/10. One in 10 susceptible adults became infected.
Assuming that all of the adults survived to the end of 2018, there were 100 adult residents of Villagetown and 28 of them had HIV infection.
The prevalence of HIV infection was 28/100 = 28%
FIGURE 2–12 An example of incidence and prevalence.
32 Chapter 2 Global Health Priorities
be considered fully disabled for that time period, contributing about one full YLD to the population total. Someone who is unable to work or go to school for 1 week due to a bout of influenza or a severely sprained ankle would contribute a tiny fraction of 1 YLD to the tally. The typical person contributes a small portion of one YLD to the population total each year. However, many small contributions from a particular cause can add up to a large number of YLDs across a population. Some of the most common causes of YLDs are back pain, depres- sion, iron deficiency anemia, age- related hear- ing loss, diabetes, and migraine headaches.17
A disability-adjusted life year (DALY) is a measure of the total burden of disease in a pop- ulation from both premature deaths and disabil- ity. The total number of DALYs in a population is the sum of YLLs and YLDs. One of the key ben- efits of using DALYs is that it highlights the high burden of disability caused by mental health dis- orders, pain, and other causes of reduced health status that are usually not fatal (FIGURE 2–14).17 The main criticism of DALYs is the difficulty in assigning weights to the amount of disability caused by various illnesses and impairments. It will never be possible to assign an accurate weight to the decrease in quality of life caused by blindness, loss of a limb, depression, a brain tumor, or asthma, because the experience of dis- ability varies so much based on the individual,
nonfatal health conditions that cause signif- icant impairment and distress (FIGURE 2–13). The total number of YLDs in a population is a function of how often a condition occurs, how much disability the condition causes (that is, the weight associated with the disability), and how long the condition typically persists.16 A person who spends a year in a coma would
A
birth
death
ideal
very old age
he al
th s
ta tu
s
FIGURE 2–13 Examples of years lived with disability (YLDs) and years of life lost (YLLs) to premature mortality for different health trajectories.
B
birth
death
ideal
very old age
YLDs YLLs
0%
20%
40%
60%
80%
100% YLLs YLDs DALYs+ = Other
Injuries
Sense organ disorders (such as age- related vision and hearing loss) Musculoskeletal disorders (such as back pain and arthritis) Mental health
Cardiovascular disease, cancer, chronic respiratory diseases, and diabetes Infectious diseases
FIGURE 2–14 Global distribution of YLLs, YLDs, and DALYs in 2015. Data from GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388:1545-602.
2.3 Health Metrics 33
when they were calculated based on similar methods and assumptions. Health metrics computed using the same methods allow dif- ferent populations (or the same population at two points in time) to be compared.
▸ 2.4 Millennium Development Goals
The Millennium Development Goals (MDGs) that were adopted by the United Nations in 2000 and endorsed by nearly 200 countries worldwide were a major contribu- tor to the global health successes thus far in the 21st century. The MDGs spelled out eight major goals for significantly reducing global poverty by 2015 (FIGURE 2–15).20 While the MDGs overall were about general socioeco- nomic development, most of the goals had direct links to health: eradicating extreme pov- erty and hunger (MDG 1); reducing child mor- tality (MDG 4); improving maternal health (MDG 5); combatting HIV/AIDS, malaria, and other diseases (MDG 6); and ensuring environ- mental sustainability (MDG 7). Each signatory country was committed to working toward these
living conditions, the level of community sup- port, access to health care, and other individual factors. For example, the amount of disability caused by an amputated foot would be much higher for a manual laborer in a low-resource setting where prosthetics are not available than it would be for an office worker in a place where high-tech prosthetics are common.
Economists frequently use health- adjusted life year estimates similar to the DALY as part of cost-effectiveness analyses. A quality-adjusted life year (QALY) quan- tifies the additional duration of life and quality of life conferred to populations by successful public health interventions.18 A DALY is a bad thing to be avoided (the loss of a healthy year of life), while a QALY is a good thing to save.19 While vital statistics and simple measures of morbidity (like incidence and prevalence) can be directly measured, more complicated health metrics like DALYs and QALYs are estimated using complex equations. The results of these types of computational models are dependent on the assumptions of the modelers, such as assumptions about the target survival age in a population and the disability weights assigned to various conditions. Health metrics from dif- ferent populations should only be compared
Eradicate extreme poverty and hunger
Achieve universal primary education
Promote gender equality and
empower women Reduce child mortality
Improve maternal health
Combat HIV/ AIDS, malaria and other
diseases
Ensure environmental sustainability
Develop a global partnership for development
1 2 3 4
5 6 7 8
FIGURE 2–15 Millennium Development Goals (MDGs) (2000–2015). Reproduced from United Nations. United Nations millennium development goals. http://www.un.org/millenniumgoals/. Reproduced with permission from UNDP Brazil.
34 Chapter 2 Global Health Priorities
The MDGs facilitated remarkable improvements in health status and quality of life for the world’s lowest-income populations. Globally, there was a 44% reduction in hun- ger between 1990 and 2015, a 53% reduction in the mortality rate among children between birth and their fifth birthdays between 1990 and 2015, a 44% reduction in pregnancy- related deaths during that time period, a 45% reduction in new cases of HIV compared to the rate in 2000, and a 62% reduction in the percentage of people without reliable access to safe drinking water sources.22 Although not all of the goals were achieved, most lower-income countries had healthier populations in 2015 than they had when the MDGs were launched in 2000.20 The success of the MDGs was the impetus to create a follow-up set of goals, called the Sustainable Development Goals (SDGs). Many of the MDG targets that were not reached are now included among the SDG targets along with a host of new targets and indicators covering a broader diversity of socioeconomic, health, and environmental issues (FIGURE 2–16).
goals, so the MDGs provided a blueprint for national- and international-level priority setting.
One of the main reasons the MDGs were so influential is that they provided a clear strategy for evaluation. When the eight MDGs were launched in 2000, they were accompa- nied by 18 targets that spelled out benchmarks for success (many of which used 1990 as the baseline year for comparison) and 48 specific indicators that were used to evaluate progress toward achieving those targets. These were later expanded to 21 targets and 60 indicators. Data about each of the 60 indicators were col- lected annually from most participating coun- tries and were used to determine how much progress had been made toward reaching the goals at national, regional, and global levels. While some concerns were raised about how well the MDGs promoted equity, sustainabil- ity, local ownership of priorities, and holistic development (rather than relatively narrow, single-sector silos of focus), the general con- sensus was that the MDGs provided a help- ful framework for global cooperation toward international development.21
© 2018 United Nations.
2.4 Millennium Development Goals 35
“to protect the planet from degradation,” “to ensure that all human beings can enjoy prosperous and fulfilling lives,” and “to foster peaceful, just, and inclusive societies which are free from fear and violence.”23
Like the MDGs, the SDGs consider health to be both a necessary prerequisite to and an outcome of economic growth. Two of the 17 SDGs focus specifically on health (SDG 3) and nutrition (SDG 2). Several of the SDGs address the socioeconomic determinants of health: poverty (SDG 1), education (SDG 4), gender equality (SDG 5), employment (SDG 8), equal opportunities for all peo- ple (SDG 10), peace (SDG 16), and good governance (SDG 17). The remaining SDGs address the environmental determi- nants of health: water and sanitation (SDG 6), affordable clean energy (SDG 7), safe work environments (SDG 9), healthy urban areas (SDG 11), sustainable consump- tion and production practices (SDG 12), and healthy climates (SDG 13), including healthy oceans (SDG 14) and land (SDG 15).
Unlike the MDGs, the SDGs are not singularly focused on the world’s poor- est billion people. While the SDGs remain “focused in particular on the needs of the poorest and most vulnerable,” the SDGs mix goals for poverty reduction with a lengthy list of other targets that apply to countries across the economic spectrum, noting that “if we realize our ambitions across the full extent of the Agenda, the lives of all will be profoundly improved and our world will be transformed for the better.”23 The goal is to improve “the lives of all” and not just some countries and some stakeholders. For exam- ple, although there is only one SDG focused specifically on health, SDG 3 includes a much greater diversity of targets and indi- cators than were encompassed by the three MDGs that aimed to reduce the burden from child mortality, maternal mortality, and infectious diseases (primarily HIV, malaria,
▸ 2.5 Sustainable Development Goals
The Sustainable Development Goals (SDGs) are 17 goals established by the mem- ber countries of the United Nations at the end of 2015 that aim, by 2030, to end pov- erty, protect the planet, and promote prosper- ity and peace (FIGURE 2–17).23 The 17 SDGs are operationalized through 169 targets and more than 230 indicators.24 The preamble of the 2030 Agenda for Sustainable Development that guides the SDG process states that the goals are “a plan of action for people, planet, and prosperity” that aim “to end poverty and hunger” in order to “ensure that all human beings can fulfill their potential in dignity and equality and in a healthy environment,”
MDGs 8 goals
21 targets 60 indicators
1 Poverty & hunger
2 Education
3 Gender equality
4 Child mortality
5 Maternal health
6 Infectious diseases
7 Environmental sustainability
8 Global partnership
SDGs 17 goals
169 targets >230 indicators
1 Poverty
2 Hunger
4 Education
5 Gender equality
10 Inequality
8 Work
16 Peace
3 Health
6 Water & sanitation
7 Energy
11 Cities
12 Sustainability
13 Climate
9 Industry
14 Sea
15 Land
17 Global partnership
FIGURE 2–16 Transitioning from the MDGs to the SDGs.
36 Chapter 2 Global Health Priorities
SDG Theme Goal
No poverty
Good health and well-being
Quality education
Gender equality
Clean water and sanitation
Affordable and clean energy
Decent work and economic growth
Industry, innovation, and infrastructure
Reduced inequalities
End poverty in all its forms everywhere
Ensure healthy lives and promote well-being for all at all ages
Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all
Achieve gender equality and empower all women and girls
Ensure availability and sustainable management of water and sanitation for all
Ensure access to affordable, reliable, sustainable, and modern energy for all
Promote sustained, inclusive, and sustainable economic growth, full and productive employment, and decent work for all
Build resilient infrastructure, promote inclusive and sustainable industrialization, and foster innovation
Reduce inequality within and among countries
1
Zero hunger End hunger, achieve food security and improved nutrition, and promote sustainable agriculture
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Sustainable cities and communities
Make cities and human settlements inclusive, safe, resilient, and sustainable
Responsible consumption and production
Ensure sustainable consumption and production practices
Climate action Take urgent action to combat climate change and its impacts
Life below water Conserve and sustainably use oceans, seas, and marine resources for sustainable development
Life on land Protect, restore, and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat deserti�cation, and halt and reverse land degradation and halt biodiversity loss
Peace, justice, and strong institutions
Promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build effective, accountable, and inclusive institutions at all levels
Partnership for the goals
Strengthen the means of implementation and revitalize the global partnership for sustainable development
FIGURE 2–17 Sustainable Development Goals (SDGs) (2016–2030). Reproduced from United Nations. Transforming our world: The 2030 agenda for sustainable development. New York: UN; 2015, p. 14.
2.5 Sustainable Development Goals 37
FIGURE 2–18 Examples of Sustainable Development Goals targets related to health. Data from World health statistics 2016: monitoring health for the SDGs. Geneva: WHO; 2016.
and tuberculosis). The health-focused SDG targets include ambitious aims for further reducing maternal and child mortality, alle- viating the burden from a diversity of infec- tious diseases (including hepatitis B virus and neglected tropical diseases), reduc- ing the number of adults who die before their 70th birthdays from common NCDs (cardiovascular disease, cancer, diabetes, and chronic respiratory diseases), improv- ing treatment of substance use disorders and other mental health conditions, pre- venting transportation-related deaths, and
increasing the accessibility of health services, medications, and vaccines (FIGURE 2–18).25
Because all of these health conditions and the socioeconomic and environmental condi- tions that influence them are now among the priorities for global action for the next decade, the SDGs are deployed as a framework for the outline of this book. The links between all of the SDGs and health are described in the next two chapters (FIGURE 2–19). The specific health topics and conditions included among the SDG targets are described in the remaining chapters (FIGURE 2–20).
Target Theme
2.2 Child nutrition
3.1 Maternal mortality
3.2 Child mortality
3.3 HIV
3.3 Tuberculosis
3.3 Malaria
3.3 Hepatitis
3.3 Neglected tropical diseases
3.4 Noncommunicable diseases
3.4 Suicide
3.5 Substance abuse
3.6 Road traffic injuries
3.7 Sexual and reproductive health
16.1 Homicide
16.1 Conflicts
Target Theme
3.8 Universal health coverage
3.9 Mortality due to air pollution
3.9 Mortality due to unsafe water and sanitation
3.9 Mortality due to unintentional poisoning
3.a Tobacco use
3.b Access to essential medicines and vaccines
3.c Health workers
3.d Emergency preparedness
6.1 Drinking water
6.2 Sanitation
7.1 Clean household energy
11.6 Air pollution
13.1 Natural disasters
38 Chapter 2 Global Health Priorities
SDG Theme Section
1 No poverty 3.2
4 Quality education 3.3
5 Gender equality 3.4
8 Decent work 3.5
10 Reduced inequalities 3.6, 3.7
16 Peace and good governance 3.8
6 Clean water and sanitation 4.2
7 Affordable and clean energy 4.3
9 Industry and infrastructure 4.4
11 Sustainable cities 4.5
12 Responsible consumption and production 4.6
13 Climate action 4.7
FIGURE 2–19 Where in this book to find information about the Sustainable Development Goals as determinants of health.
SDG Target Theme Chapter
(Many) Socioeconomic determinants of health 3
(Many) Environmental determinants of health 4
3.c Health workforce 5
3.b Access to affordable medicines and vaccines 5
3.b Official development assistance for health 6
3.d Health emergency preparedness 7
(continues)
2.5 Sustainable Development Goals 39
FIGURE 2–20 Where in this book to find information about the health issues featured as Sustainable Development Goals targets.
SDG Target Theme Chapter
3.3 HIV 8
3.3 Tuberculosis 8
3.2 Child mortality 9
3.3 Hepatitis 9
3.3 Malaria 10
3.3 Neglected tropical diseases 10
3.7 Sexual and reproductive health 11
3.1 Maternal mortality 11
2.1, 2.2 Nutrition 12
3.4
Cancer 13
Cardiovascular disease 14
Diabetes and chronic respiratory diseases 15
3.a Tobacco use 15
3.5 Substance abuse 16
3.4 Suicide 16
3.6 Road traffic injuries 17
16.1 Violence 17
(Many) Child health 18
(Many) Adult health 19
40 Chapter 2 Global Health Priorities
(DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1603–58.
15. Chen A, Jacobsen KH, Deshmukh AA, Cantor SB. The evolution of the disability-adjusted life year (DALY). Socioecon Plann Sci. 2015;49:10–15.
16. Prüss-Üstün A, Mathers C, Corvalán C, Woodward A. Assessing the environmental burden of disease at national and local levels: Introduction and methods. Geneva: WHO; 2003.
17. GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1545–602.
18. Gold MR, Stevenson D, Fryback DG. HALYs and QALYs and DALYs, oh my: Similarities and differences in summary measures of population health. Annu Rev Public Health. 2002;23:115–34.
19. Sassi F. Calculating QALYs, comparing QALY and DALY calculations. Health Policy Plan. 2006;21;402–8.
20. The Millennium Development Goals report 2015. New York: United Nations; 2015.
21. Waage J, Banerji R, Campbell O, et al. The Millennium Development Goals: A cross-sectoral analysis and principles for goal setting after 2015. Lancet. 2010;376:991–1023.
22. Health in 2015: From MDGs, Millennium Development Goals to SDGs, Sustainable Development Goals. Geneva: WHO; 2015.
23. United Nations. Transforming our world: The 2030 Agenda for Sustainable Development. New York: UN; 2015.
24. Tier classification for global SDG indicators (20 April 2017). New York: Inter-agency Expert Group on SDG Indicators (IAEG-SDGs); 2017.
25. United Nations Economic and Social Council. Report of the Inter-Agency and Expert Group on Sustainable Development Goal Indicators (E/CN.3/2016/2 /Rev.1). New York: UN; 2016.
▸ References 1. Ten great public health achievements: United States,
1990–1999. MMWR Morb Mort Wkly Rev 1999; 48:241–3.
2. Ten great public health achievements: worldwide, 2001–2010. MMWR Morb Mort Wkly Rev 2011; 60:814–8.
3. Yazbeck AS. An idiot’s guide to prioritization in the health sector. Washington DC: World Bank; 2002.
4. GBD 2015 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1649–724.
5. Glassman A, Chalkidou K, editors. Priority-setting in health: Building institutions for smarter public spending. Washington DC: Center for Global Development; 2012.
6. The case for investing in public health: A public health summary report for EPHO 8. Copenhagen: WHO Regional Office for Europe; 2014.
7. Pathways to global health research: Strategic plan 2008–2012. Bethesda MD: The John E. Fogarty International Center, National Institutes of Health (NIH); 2008.
8. Varmus H, Klausner R, Zerhouni E, Acharya T, Daar AS, Singer PA. Grand challenge in global health. Science. 2003;302:398–9.
9. Convention on the Rights of the Child. New York: United Nations; 1989.
10. Koplan JP, Fleming DW. Current and future public health challenges. JAMA. 2000;284:1696–8.
11. Murray CJ, Frenk J. Health metrics and evaluation: Strengthening the science. Lancet. 2008;371:1191–9.
12. AbouZahr C, Boerma T. Health information systems: The foundations of public health. Bull World Health Organ. 2005;83:578–83.
13. UN Department of Economic and Social Affairs. World population prospects: The 2017 revision. New York: UN; 2017.
14. GBD 2015 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life years
References 41
© Xinzheng. All Rights Reserved/Moment/Getty
CHAPTER 3
Socioeconomic Determinants of Health
The disparities in health status between populations are largely due to gaps in economic development rather than differences in biology. People tend to have worse health profiles when they are poor, have low levels of education, are unemployed, experience discrimination, and have limited opportunities to participate in social and political processes. Increases in socioeconomic status are associated with improved health status, and better health enables further advancement in quality of life for individuals and communities.
▸ 3.1 Health Disparities and the SDGs
Socioeconomic status (SES), also called socioeconomic position (SEP), describes an individual’s standing in a society based on individual and household income, educa- tion, gender, occupation, ethnicity and race, and other characteristics that exist within a broader cultural, social, political, and policy environment.1 There is no one measure of SES, but proxies, such as ownership of var- ious assets (like a house, car, bicycle, televi- sion, radio, or livestock), amount and type of education, type of job, residential area, and other characteristics, can be used to evaluate a person’s relative position in a community or larger population group. These socioeco- nomic characteristics have a significant impact on an individual’s health status and ability to
access healthcare services. The personal fac- tors and community conditions that enable or hinder access to health are collectively called the social determinants of health.2 Many of these social determinants of health can be summarized using the acronym PROGRESS: place of residence, race and ethnicity, occupa- tion and employment status, gender and sex, religion, education, social capital, and other socioeconomic indicators (FIGURE 3–1).3
Children and adults who have low SES, in terms of either absolute poverty or relative poverty compared to their neighbors, tend to have significantly reduced health status com- pared to people from wealthier socioeconomic groups.4 The reduced health status in popu- lations with lower SES is largely a function of economic, social, and political environments, and it is not caused by innate biological dif- ferences. An avoidable difference in health status between population groups is called a
42
health disparity or an inequality.5 When a health inequality is considered to be unfair and unjust, the difference is classified as an inequity.6 Social justice is the principle that moving toward greater equality in the dis- tribution of income and wealth, opportuni- ties for education and employment, access to health and security, and involvement in civic and political activities is valuable for human flourishing.7 One of the key goals of global public health is to reduce health disparities by increasing the health status of disadvantaged populations.8 (Reducing health disparities by reducing the health status of the advantaged population would not be a global health gain.)
SES usually refers to individual character- istics. A related set of metrics can be used to compare the development status of different countries. The Human Development Index (HDI) is an estimate of national development calculated from composite data on longevity (life expectancy at birth), knowledge (such as the mean and expected years of schooling), and income (gross national income per capita
in purchasing power parity dollars).9 The HDI has increased in most countries over the past 25 years as life expectancies, school enroll- ment, and incomes have risen (FIGURE 3–2), but there are still significant gaps between the richest countries and the poorest countries (FIGURE 3–3).9 These disparities are evident in the health metrics from high-income and low-income countries. Objective measures of socioeconomic development in a country, such as the components of the HDI, gener- ally align with subjective measures of quality of life reported by the country’s residents. A higher HDI is correlated with better health status and also with greater levels of happi- ness (FIGURE 3–4).10 Making progress toward achieving the socioeconomic Sustainable Development Goals (SDGs) of ending pov- erty (SDG 1), ensuring quality education for all (SDG 4), achieving gender equality (SDG 5), promoting employment and decent work for all (SDG 8), reducing inequalities within and among countries (SDG 10), and promot- ing peaceful societies and good governance
P Place of residence (rural/urban; particular state or province; housing characteristics)
R Race, ethnicity, culture, and language
O Occupation and employment status
G Gender and sex
R Religion
E Education
S Socioeconomic position (income, wealth, and other measures)
S Social capital (neighborhood, community, and family support and other aspects of social relationships and networks)
Plus Age, disability, sexual orientation, and other characteristics
FIGURE 3–1 The PROGRESS-Plus framework for the social determinants of health. Data from Kavanagh J, Oliver S, Lorenc T. Reflections on developing and using PROGRESS-Plus. Equity Update 2008;2:1–3.
3.1 Health Disparities and the SDGs 43
(SDG 16) will improve the quality of life and the quality of health for billions of people.
▸ 3.2 Economics SDG 1 sets an ambitious goal of “ending poverty in all its forms everywhere.”11 Extreme poverty is defined as surviving on less income than an international poverty line, typically set at an income of less than $1 or $2 per person per day.12
Many of the world’s poorest people live in remote rural areas, where they try to grow enough as subsistence farmers with a small plot of land to feed all household members. Others are the urban poor, who often live in informal settlements that have no trash
removal, running water, electricity, or other utilities. The percentage of the world’s peo- ple living in extreme poverty decreased from approximately 35% in 1990 to 10% in 2015,
0.0
0.2
0.4
0.6
0.8
1.0
EthiopiaNigeriaIndiaChinaBrazilIranGermany
H um
an D
ev el
op m
en t I
nd ex
( H
D I)
USA
Data are not available for Nigeria in 1990 and 2000 Data are not available for Ethiopia in 1990
1990 2000 2010 2015
FIGURE 3–2 The Human Development Index (HDI) is increasing as people live longer, spend more years in school, and earn more. Data from Human development report 2016. New York: UNDP; 2015.
© Sam DCruz/Shutterstock
44 Chapter 3 Socioeconomic Determinants of Health
poverty, living on less than the nationally defined poverty line in their own countries.
Poverty is about more than income and consumption. Economic factors are inter- twined with a variety of sociocultural, politi- cal, and environmental conditions that enable some people to thrive and cause others to struggle. The United Nations Development Programme (UNDP) calculates a Multidimen- sional Poverty Index (MPI) that combines data regarding health (including hunger and child mortality), education (including total years of school for adults and enrollment of children in school), and standard of living (including access to electricity, drinking water, and toi- lets, whether the floors in the home are dirt or some other material, the type of cooking fuel used, and the presence of economic assets). When the MPI is used as a measure of poverty rather than income alone, a large proportion of people living in lower-income countries are classified as living in poverty (FIGURE 3–7).9 Poverty is not uniformly distributed within low-income countries, and there are often sub- stantial variations in the poverty rate within
and the SDGs aim to further reduce that percentage to 0% by 2030 (FIGURE 3–5).12 As of 2015, however, the majority of people in many low-income countries (the lowest of the four country income level groupings) were living below international thresholds for pov- erty (FIGURE 3–6). An even higher percentage of people are considered to live in relative
Missing/Excluded Less then 0.5 0.5 to 0.65 0.65 to 0.75 0.75 to 0.85 0.85 and above
FIGURE 3–3 Human Development Index (2015). Data from Human development report 2016. New York: UNDP; 2015.
1 2 3 4 5 6 7 8 109
Ethiopia
1= worst possible life 10 = best possible life
Nigeria
India
China
Brazil
Iran
Germany
USA
low high
FIGURE 3–4 A higher proportion of people in countries with higher HDIs report being happy. Data from Helliwell J, Layard R, Sachs J, editors. World happiness report 2017. New York: Sustainable Development Solutions Network; 2017.
3.2 Economics 45
and cultural activities, and limited engagement in civic and political processes.14 Poverty is also inextricably tied to health: living in pov- erty causes ill health, and ill health can cause poverty. Similarly, economic growth facilitates improvements in population health status, and investments in public health stimulate eco- nomic growth.15
national borders. For example, in Nigeria the proportion of people with an MPI indicating poverty or severe poverty is higher in rural areas than in cities and is much higher in the north than in the south.13 No matter where they are located, people living in poverty may have limited opportunities for education and employment, limited participation in social
0%
20%
40%
60%
80%
100%
(2010)(2009)(2011)(2010)(2013)
IranGermanyUSA
(2013) (2013) (2013)
Brazil China India Nigeria Ethiopia
> $3.10 per day
$1.91 to $3.09 per day
< $1.90 per day
FIGURE 3–6 A large proportion of residents of lower-income countries live in poverty. Data from World development indicators 2016. Washington: World Bank; 2016.
1980 1990 2000 2010 2020 2030 0
1
2
3
4
5
6
7
8
9
Percent living in extreme poverty
0
10
20
30
40
50
% li
vi ng
in e
xt re
m e
po ve
rt y
N um
be r
of p
eo pl
e (
in b
ill io
ns )
Number of people who are not living on <$1.90 (in current dollars)
Projection
Goal
Number of people living in extreme poverty
FIGURE 3–5 The percentage of the world’s population living in poverty has decreased significantly. Data from World development indicators 2016 (Table 2.8.2). Washington: World Bank; 2016.
46 Chapter 3 Socioeconomic Determinants of Health
and payment for medications and supplies like bandages (which often are not provided by healthcare facilities and must be purchased by the patient). There are also indirect costs asso- ciated with lost wages for patients and caregiv- ers, especially when outpatients must sit in a waiting area for a full day before seeing a clini- cian and when families of hospitalized patients must provide all food and most personal care for inpatients. The facilities where poor peo- ple can access health services are often under- funded, understaffed, and understocked, and they rarely have the clinical specialists, support staff, and equipment necessary to be able to offer advanced care.16 These disparities in access to health services contribute to the significant gaps in health status between the average person from a high-income household and the average person living in a low-income household.
Just as the health status of individuals and families is related to their SES, the health status of communities and nations is linked to their economic status. Health economists use a vari- ety of macroeconomic indicators to measure the amount of economic activity in a country. To distinguish between these measures, consider the way the GNI, GDP, and GNP of Germany would be calculated. The gross national income (GNI) is the total income from the sell- ing of goods and services produced in Germany, including consumer spending, government spending, investments, and exports. The gross domestic product (GDP) is the total amount of goods and services produced in Germany by both German and foreign companies. The gross national product (GNP) is the total amount of goods and services produced by German com- panies in Germany and by German companies operating in other countries. All three of these metrics can be recorded in per capita (per per- son) terms by dividing the total monetary value by the population of the country.
It is impossible to accurately measure all economic transactions in a country, so macro- economic metrics are estimated using the best available data. There are a variety of methods that can be used for the estimation process. The World Bank often uses an “Atlas method” to estimate
The economic status of a household is a function of both income and wealth. Income is the amount of take-home pay earned by house- hold members in a week, year, or other time period. Wealth is the accumulated worth of the household’s resources and can include a house, car, television or radio, livestock, and other con- sumer goods. When someone in a high-income or wealthy household has a health concern, that person usually has the resources to immediately access high-quality medical care, accurate diag- nostic tests, and effective therapies. Attending to health issues early usually prevents mild issues from becoming severe problems. By contrast, low-income households generally have very lit- tle wealth, so they have few resources to draw on when someone in the household develops a severe illness or is seriously injured. People living in low-resource households may not be able to afford to seek care for health problems that are not immediately life-threatening or dis- abling. The direct costs of medical care add up quickly when they include transportation to a healthcare facility, fees for clinical consultations,
0%
20%
40%
60%
80%
100%
EthiopiaNigeriaIndiaChinaBrazil
(2012) (2006)(2013) (2013) (2011)
Not poor
Near poverty (MPI 20-33.2)
Poverty (MPI 33.3-49.9)
Severe poverty (MPI > 50)
FIGURE 3–7 The Multidimensional Poverty Index (MPI). Data from Human development report 2016: Work for human development. New York: UNDP; 2016.
3.2 Economics 47
twice as high in the $4-per-hamburger country. Workers in the higher-priced country will have to earn a much higher salary to stay above the local poverty line than workers in the $2-per-burger country. In high-income countries, the Atlas and PPP methods generate similar values for the GNI, but in low- and middle- income countries (LMICs), the PPP GNI is usually much higher than the Atlas GNI (FIGURE 3–8).18
Summary values like the GNI have some major limitations as indicators of development. They do not count unpaid labor like caring for children and growing food to feed a family. They ignore issues of sustainability, environ- mental damage, and the distribution of wealth in a country. These values show the economic experience of the “average” person living in each country, but the “average” economic measure may be misleading if most people in a given country are very poor and some are extremely rich and there is almost no middle class. Even when a large proportion of the pop- ulation experiences something near the average
the GNI. The Atlas method calculates the GNI by adding together the value of product sales and taxes (minus subsidies) within the country plus salaries and property income from abroad and then adjusting the total to account for inflation.12 Because the amount of goods and services that can be purchased with a given amount of money varies from place to place—for example, it costs less to rent an apartment in Addis Ababa than to rent an apartment in New York City—it can be helpful for economic indicators to account for cost of living differences. GNI can be estimated in terms of purchasing power parity (PPP), which adjusts the economic metric based on how many goods, services, and other products can be purchased in each country with a fixed amount of money, such as $1000 U.S. dollars. A clever exam- ple of PPP is the “Big Mac Index” that determines the relative price of a McDonald’s hamburger in different countries and uses that exchange rate to determine the relative value of other items.17 If a Big Mac costs $4 in one country and $2 in another, it is likely that the cost of living is about
10 20 30 40 50
USA
GER
IND
BRA
NIG
ETH
CHI
IRAN
60 70 80 90
G N
I p er
c ap
ita : P
P P
m et
ho d
(in th
ou sa
nd s)
GNI per capita: Atlas method (in thousands)
High income
Upper middle income
Lower middle income
Low income
0
10
20
30
40
50
60
70
80
90
FIGURE 3–8 The GNI can be calculated in different ways, such as using an Atlas method or purchasing power parity (PPP). (The dots represent the 100 most populous countries.) Data from World development indicators 2016 (Table 2.1). Washington: World Bank; 2016.
48 Chapter 3 Socioeconomic Determinants of Health
However, at the population level, these met- rics reveal important trends. For example, even small increases in the GNI per capita are associ- ated with significant decreases in child mortal- ity rates (FIGURE 3–9) and significant increases in life expectancy at birth (FIGURE 3–10).19
reported for the country, there will still be vari- ability in the experiences of individuals. There are millionaires in every country, even the countries with the poorest “average” person, and there are people in every country, even the wealthiest ones, who live on almost nothing.
0
20
40
60
80
100
120
140
160
100 1,000
NIG
ETH
IND
BRA IRAN USAGER
CHI
GNI per capita (Atlas method, logarithmic scale)
U nd
er -5
m or
ta lit
y ra
te p
er 1
00 0
10,000 10,0000
FIGURE 3–9 Small increases in GNI per capita in lower-income countries are associated with significant decreases in the rate of death for children between birth and their fifth birthdays. (The dots represent the 100 most populous countries. Note the use of the logarithmic scale on the x-axis.) Data from World development indicators 2016 (Table 2.21). Washington: World Bank; 2016.
40
50
60
70
80
90
100
100 1,000
GNI per capita (Atlas method, logarithmic scale)
10,000 100,000
NIG
ETH IND BRA
IRAN USA
GER
CHI
Li fe
e xp
ec ta
nc y
at b
irt h
FIGURE 3–10 Small increases in GNI per capita in lower-income countries are associated with significant increases in life expectancy at birth. (The dots represent the 100 most populous countries. Note the use of the logarithmic scale on the x-axis.) Data from World development indicators 2016 (Table 2.21). Washington DC: World Bank; 2016.
3.2 Economics 49
SDG 1 is necessary for sustained progress toward achieving the health-specific SDGs. The specific targets for ending poverty include eradicating extreme poverty, defined as living on less than $1.25 per day (SDG 1.1); reduc- ing by half the proportion of people living in poverty according to national definitions (SDG 1.2); and implementing social protec- tions for vulnerable populations, such as chil- dren, older adults, and people with disabilities (SDG 1.3).23
The Gini Index is a measure of the inequality in the distribution of incomes within a particular country. A country in which everyone has exactly the same income has an index of 0 (perfect equality) and a coun- try in which one person has all the income and everyone else has zero income has an index of 100 (perfect inequality). Brazil has a Gini Index of about 40, and the richest 10% earn more than forty times more than the poorest 10%. Germany has a Gini Index of about 30, and the richest 10% earn about seven times more than the poorest 10%.20 However, the income level of a country is not a good predic- tor of Gini Index values (FIGURE 3–11).21 Some high-income countries have relatively unequal income distributions, and some low-income countries have relatively equal income dis- tributions. When two countries have similar economic profiles, the country with greater income inequality tends to have a less favor- able health profile.22
Because economic status is so strongly tied to health status, progress toward achieving
0%
20%
40%
60%
80%
100%
0
10
20
30
40
50
60
Highest 20%
Second highest 20%
Middle 20%
Second lowest 20%
Lowest 20%
USA Germany Iran Brazil China India Nigeria Ethiopia
% S
ha re
o f i
nc om
e
G in
i i nd
ex
Gini Index
More equal
Less equal
FIGURE 3–11 The Gini Index and the percentage share of income by income quintile. In a completely equal country, each of the quintiles would have a 20% share of income. In countries with a higher Gini Index (more inequality), the richest people have a higher percentage of income. Data from World development indicators 2016 (Table 2.9). Washington: World Bank; 2016.
© punghi/Shutterstock
50 Chapter 3 Socioeconomic Determinants of Health
offered by employers and the government, apply for aid and benefits, read brochures about their health conditions, use signs to navigate hospitals, and seek out additional information online or at libraries. People who cannot read will have difficulty with all of these health-related activities. They may delay seeking care for a health problem because they worry about being unable to complete paper- work at a doctor’s office or being ridiculed for not knowing how to read or write. They may have difficulty taking their prescribed medications properly if their healthcare pro- viders have not fully explained dosage and timing and they cannot read the instructions on the label. They may not be able to read the safety information provided by a pharma- cist or know when to return for a follow-up examination.
▸ 3.3 Education Both the ability to read and a higher number of years of formal education are correlated with higher health status for adults and their chil- dren.24 SDG 4 aims to “ensure inclusive and equitable quality education and promote life- long learning opportunities for all,” starting with access to early childhood education (SDG 4.2), and continuing with access for all girls and boys to primary and secondary education (SDG 4.1) and then to technical, vocational, or university education (SDG 4.3).11 Most high- and upper- middle- income countries have strong enroll- ment in early childhood education and primary education, but in most lower-income countries, there is limited access to preschool education, and many school-aged children do not attend primary or secondary school (FIGURE 3–12).25 Since many schools in lower-income coun- tries have school health programs that provide hygiene and health education, nutritional sup- port, treatment for common intestinal worm infections, and other health services, children who are not in school miss critical opportunities for both learning and healthy development.26
Literacy is the ability to read and write and apply those communication skills. Lit- eracy exists along a spectrum from minimal recognition of written words to the advanced fluency gained through higher education. Functional literacy is the ability to under- stand written words well enough to com- plete normal daily tasks.27 Functional literacy allows readers to acquire health information, navigate health systems, and attain other benefits associated with health literacy, the ability to access, understand, and apply health information.28 Readers can learn about food preparation and exercise programs in news- papers and magazines, comprehend health and safety warnings on consumer products, access air and water quality reports, read posters advertising immunization and screen- ing campaigns, follow directions on medicine containers and hospital discharge orders, understand the health benefits packages
0
20
40
60
80
100
EthiopiaNigeriaIndiaChinaBrazilIran
% of preschool-aged children enrolled in pre-primary education
% of primary school-aged children attending school
% of secondary school-aged adolescents attending school
FIGURE 3–12 Many children and adolescents in low- and middle-income countries are not enrolled in early childhood, primary, or secondary education (2014). Data from The state of the world’s children 2016: A fair chance for every child. New York: UNICEF; 2016.
3.3 Education 51
of formal education are equipped to access the information they need to keep their chil- dren healthy and nourished, their children are more likely to survive past their fifth birthdays (FIGURE 3–14C). Increasing the proportion of girls and boys worldwide who complete at least a basic education (typically about seven years of primary school) will generate significant long- term benefits for the economic status and qual- ity of life of those individuals and their families and communities. Reaching the target that “all youth and a substantial proportion of adults, both men and women, achieve both literacy and numeracy” by 2030 (SDG 4.6)11 will also yield major benefits for the health and well- being of those individuals’ future children.
Adult literacy in most LMICs increased between 2000 and 2015, but literacy rates among men and women remain low in many lower-income countries (FIGURE 3–13).29 Female literacy and education are especially important for family and child health.30 Women with more formal schooling are more likely to give birth at a healthcare facility (FIGURE 3–14A), which means that both mothers and newborns have an improved likelihood of survival if there are complications during or after delivery. The children of women with more education are also more likely to receive preventive medi- cal services, such as vaccines (FIGURE 3–14B), and to receive professional clinical care for ill- nesses. Because women who have several years
2000 2010 2015
0%
10%
20%
30%
50%
70%
90%
100%
40%
60%
80%
goal=100%
EthiopiaNigeriaIndiaChinaBrazilIran
Male Male Male Male Male MaleFemale Female Female Female Female Female
FIGURE 3–13 Literacy rates among adults (aged 15+ years) have increased in LMICs, but in many countries women lag behind men. Data from Education for all 2000–2015: Achievements and challenges. Paris: United Nations Educational, Scientific and Cultural Organization (UNESCO); 2015.
52 Chapter 3 Socioeconomic Determinants of Health
0
20
40
60
80
100
0
20
40
60
80
100
0
20
40
60
80
100
0 1-4 5-7 8-9 10-11 12+ years
India (2006)
Nigeria (2013)
1-6 7-12 13+ years
0 0 1-8 9-12 13+ years
Ethiopia (2011)
% of babies born at a healthcare facilityA
FIGURE 3–14 Women with more years of education (x-axis) have more interactions with the healthcare system, and their children are more likely to survive. Data from National Family Health Survey (NFHS-3) 2005–2006. Mumbai: International Institute for Population Sciences (IIPS)/Macro International; 2007; Demographic and Health Survey 2013. Abuja: National Population Commission/ICF International; 2014; Demographic and Health Survey 2011. Addis Ababa: Central Statistical Agency/ICF International; 2012.
0
20
40
60
80
100
0
20
40
60
80
100
0
20
40
60
80
100
0 1-4 5-7 8-9 10-11 12+ years
India (2006)
Nigeria (2013)
0 1-6 7-12 13+ years
Ethiopia (2011)
1-80 9-12 13+ years
% of toddlers (12-23 months) who have received all basic vaccinationsB
0
40
80
120
160
200
0
40
80
120
160
200
0
40
80
120
160
200
India (2006)
Nigeria (2013)
Ethiopia (2011)
1-40 5-7 8-9 10-11 12+ years
0 1-6 7-12 13+ years
0 1-8 9-12 13+ years
Number of children who die before their 5th birthdays per 1000 live birthsC
3.3 Education 53
physiology, and brain function. These differ- ences mean that men and women sometimes have different symptoms for the same disease and different prognoses and pathways to recov- ery. For example, men are more likely to have dramatic heart attacks with crushing chest pain, while women often have subtle symptoms like feeling more tired than normal. This difference is a key reason why heart disease in women has traditionally been underdiagnosed.33 There are many significant differences in the burden of disease from particular health conditions for females and males that must be considered when planning for and implementing health education and preventive, diagnostic, and ther- apeutic health services (FIGURE 3–16).34
Gender refers to social, cultural, and psy- chological aspects of being male or female, and gender is shaped by the sociocultural
▸ 3.4 Gender When the HDI is calculated separately by sex, females often lag behind males. A Gender Devel- opment Index (GDI) that compares the values of the HDI for females and males has a value of 1 when males and females have equal HDI values. In higher-income countries, the GDI is often near 1, but in lower-income countries, there is often a significant gap between males and females (FIGURE 3–15).31 Women and girls face different health challenges than men and boys because of both biological characteristics related to sex and social structures related to gender.32
Sex refers to the biological classification of people as male or female based on genetics (such as the presence of XX or XY sex chromosomes) and reproductive anatomy. Males and females also have different body chemistry, hormones,
0.0
0.2
0.4
0.6
0.8
1.0
USA
H D
I
Germany Iran Brazil China India Nigeria Ethiopia
Male HDI
Female HDI
Gender Development Index (GDI)
G D
I
0.0
0.2
0.4
0.6
0.8
1.0
FIGURE 3–15 The Human Development Index (HDI) for females lags behind the HDI for males in many lower-income countries (2015). Data from Human development report 2015: Work for human development. New York: UNDP; 2015.
54 Chapter 3 Socioeconomic Determinants of Health
FEMALES have a higher proportion of DALYs than males from…
MALES have a higher proportion of DALYs than females from…
■ Iron-deficiency anemia ■ Cancers of the reproductive system (such as
breast cancer) ■ Depressive disorders, anxiety disorders, and
migraine headaches ■ Musculoskeletal disorders (such as
osteoarthritis and rheumatoid arthritis) ■ Alzheimer’s disease and other dementias
■ Tuberculosis ■ Cancers of the lung, liver, stomach, and
esophagus ■ Cirrhosis and other chronic liver diseases ■ Alcohol and drug use disorders ■ Autism spectrum disorders ■ Unintentional injuries (such as road traffic
injuries and drowning) ■ Intentional injuries (such as violence and
self-harm)
FIGURE 3–16 Examples of differences in the disability-adjusted life years (DALYs) attributed to various health risks for females and males. Data from GBD Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1980–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1545–602.
environment and experience in addition to biology. There is tremendous variability in the ways that individuals express their gender and in the ways that cultures define gender roles. Gender roles describe how a culture believes men and women should behave. For example, gender roles may indicate what tasks women are expected to do, such as cooking, cleaning, and taking care of children. They may also define what tasks women should not do, which might include working with heavy machinery or serv- ing as religious leaders. Some cultures consider women to be under the authority of their fathers or other male relatives until marriage and under the authority of their husbands after marriage. In these places, laws may restrict women’s ability to own property or manage their own finances. Some cultures have strict rules about what women can wear in public and whether they can be in public spaces unaccompanied by a male. This can limit the ability of women to partici- pate in the marketplace and government, attend school and religious meetings, and acquire med- ical attention and information. Gender roles also define the social and behavioral norms for men. For example, young men may feel pressure to engage in risky behaviors like reckless driving or tobacco use in order to demonstrate their
masculinity. Men may also be expected to take on hazardous jobs.35
SDG 5 aims to “achieve gender equality and empower all women and girls.” The par- ticular targets include eliminating “all forms of violence against all women and girls in the public and private spheres, including traffick- ing and sexual and other types of exploitation” (SDG 5.2) and ending harmful practices “such as child, early, and forced marriage and female genital mutilation” (SGD 5.3).11 Achieving gender equity will require identifying and addressing the numerous preventable health issues that disproportionately affect women and girls and, at the same time, addressing the avoidable health conditions that dispro- portionately burden men and boys. Ideally, integrating gender-equity perspectives into new health policies, strategies, and plans will reduce within-country health disparities and improve overall population health status.36
▸ 3.5 Employment Employment of at least one wage earner per household is generally critical for keeping a household out of poverty. In addition to the
3.5 Employment 55
monetary income from working, employment often provides healthcare coverage, compen- sation for on-the-job injuries, and sometimes housing, food allowances, and schooling for employees and their children. These benefits can have a significant, positive impact on the health of workers and their families. SDG 8 aims to “promote sustained, inclusive, and sustainable economic growth, full and produc- tive employment, and decent work for all.”11 Decent work for all means eradicating forced labor and ending child labor (SDG 8.7) as well as protecting labor rights and promoting safe working environments (SDG 8.8).
Unemployment occurs when a person who is not working for pay is unable to secure a position despite actively seeking a paid job. People who are retired, have opted not to work outside the home, or are not seeking employment for other reasons are not consid- ered to be unemployed. Underemployment occurs when a person is involuntarily working part-time rather than full-time or is a low- wage worker whose earnings are below the local poverty level even after working long hours.37 (In this usage, underemployment does not refer to people who are employed full- time and earning a living wage but who are underutilizing their education and training in their current positions.) Being unemployed or underemployed can be detrimental to men- tal and physical health status,38 and so can precarious employment conditions.39 People who have lost their jobs are more likely than working peers to develop depression and other mental health disorders.40 Suicide rates are higher among people who are unemployed.41 Unemployed people are more like to adopt unhealthy behaviors like smoking and harmful use of alcohol.42 All-cause mortality rates are higher among unemployed men and women than employed people of the same age.43
Not all jobs are equally beneficial for health. People working as manual laborers have higher all-cause mortality rates, cardio- vascular mortality rates, and cancer mortal- ity rates than people of the same age who are
working in nonmanual professional jobs.44 Men and women who work in manual jobs also report lower self-rated health than same- age peers who work as managers or in other professional positions.45 Among people doing manual labor, unskilled workers have higher mortality rates and lower self-rated health than skilled workers. People with limited job skills often have the most dangerous jobs, receive little compensation for their labor, and have little or no job security. Low-skilled workers who are injured or ill may not receive adequate treatment for their health problems when they cannot afford to take time off to consult with a medical professional and recuperate at home or they cannot afford to pay for health care.
Three of the key components that contribute to the SES of an individual or household—employment and occupational category, economic security, and educa- tional level—are inextricably linked to each other and to health status (FIGURE 3–17). Any
HEALTH
Education/ literacy
Employment/ occupation
Income/ wealth
FIGURE 3–17 Employment, economics, and education are interrelated.
© Ari N/Shutterstock
56 Chapter 3 Socioeconomic Determinants of Health
own experience of having an adverse health condition) and sickness (how a person with poor physical or mental health relates to and is regarded by the community).47 Culture plays a role in how health and disease are experienced across the life span, from the way childbirth is approached to decisions about end-of-life care. Culture influences health beliefs, affects health behaviors, and shapes decisions about when and where to seek healthcare services. Different cultures may have distinct explana- tions about what causes disease. A mechanis- tic approach views disease as a dysfunction or breakdown of the human body, which is expected to function like a well-oiled machine. A moralistic perspective considers health to be the result of clean living and disease to be a type of punishment for wrongdoing. A super- natural viewpoint blames illness on demonic possession, evil eye, or the anger of God or the gods or ancestors. A disequilibrium approach considers disease to be caused by imbalances within the body, such as an imbalance between hot and cold, yin and yang, or the four humors. Disease may also be attributed to energy or qi imbalances; to emotions like fright or grief or jealously; or to stress, weather, food, germs, sex, genes, or age. These beliefs about health and illness may influence the way people inter- pret symptoms and diagnoses, the timeline for seeking treatment, the type of healer who is consulted (such as a physician or nurse, a counselor, a religious advisor, a massage ther- apist, or an acupuncturist), and the type of therapy that will be effective.
Celebrations of the various cultural tradi- tions that exist within a nation or community can bring together people with diverse back- grounds. However, these differences can also be used to divide people. At worst, these divi- sions can lead to abuse, violence, hate crimes, war, and genocide. On a day-to-day basis, people who belong to minority racial, ethnic, tribal, or religious groups may encounter prej- udice and discrimination along with language, cultural, and belief barriers. These obstacles may exist in the workplace and marketplace,
intervention aimed at one of these three cat- egories may positively impact the others. For example, new reading skills may lead to a bet- ter job, increased job skills may lead to a higher hourly wage, and extra income may be used to pay for additional training. An improvement in any one of these dimensions of SES can lead to increased health.
▸ 3.6 Minority Populations
Major differences in health status exist between countries and also between different popula- tion groups within countries.5 Some of these health disparities are a product of differences in SES, and some are a function of prejudice and discrimination against people from partic- ular groups.46 Prejudice is a perception about an individual based solely on preconceived notions about a sociocultural group to which that person belongs. Common forms of preju- dice include racism, sexism, classism, ageism, and ableism (prejudice against people with disabilities). Discrimination encompasses the actions taken against an individual because of that person’s membership in a sociocultural group. Unfair hiring and pay practices, restric- tions on access to housing, and harassing jokes and insults are examples of discriminatory practices. Prejudice is a set of beliefs and atti- tudes. Discrimination is a set of practices and behaviors. Prejudiced thoughts lead to dis- crimination, but not all people who hold prej- udicial beliefs act on them.
Culture is a way of living, believing, behaving, communicating, and understanding the world that is shared by members of a social unit. Culture encompasses a group’s norms, values, morals, rules, and customs as well as the foods people eat, the clothes they wear, the language they use, the ways they inter- act with those inside and outside the cultural group, and how they describe and experience illness (how a person perceives his or her
3.6 Minority Populations 57
Significant differences in health status often exist between different racial and ethnic groups. An assortment of explanations each partly explains the reasons for these health disparities.49 Racial and ethnic categories may capture some genetic differences between population groups, including some differential risks for heritable genetic disorders. Ethnic- ity may be a marker for some health-related behaviors. If members of a population group tend to have similar dietary preferences and favorite foods, alcohol and tobacco use habits, and physical activity routines, these practices may account for some of the health differences observed between populations. Race and ethnicity may also be associated with socio- economic factors. Members of marginalized population groups may have lower SES than other people in their town or city, and poverty is known to be associated with reduced health status. Additionally, discrimination because of race or ethnicity (or other characteristics) may cause chronic psychosocial stress that contrib- utes to poor health outcomes.50
Members of indigenous communities tend to have especially low health status com- pared to other residents of their countries. About 370 million people worldwide iden- tify as members of indigenous population groups that have maintained unique cultural traditions (and often also languages) for many generations after the colonization or domina- tion of their traditional homeland by another group.51 These populations include, among many others, the Cherokee and Navajo (and many other groups) of the United States, the Sami of Scandinavia, the Torres Strait Islanders of Australia, the Tangata Whenua (Māori) of New Zealand, the Quichua of Ecuador, the Maasai of Kenya, and the Hmong of Southeast Asia.52 Members of indigenous people groups are more likely to be poor than their nonindig- enous neighbors, and they usually have higher rates of morbidity and premature mortality.53
SDG 10 aims to “reduce inequality within and among countries” by taking steps to reduce poverty (SDG 10.1), ensure equal opportunities
and they may also be present within the healthcare system. Medical practitioners may be unfamiliar with the special health needs of patients from other backgrounds, in part because many population groups remain understudied by health researchers. Patients may be uncomfortable discussing health con- cerns and being examined by a medical pro- fessional who is not a member of their group or who is not sensitive to their cultural beliefs and practices. For example, women from some cultural and religious groups may be unwill- ing to be examined by a male clinician. Some barriers to healthcare access are legally sanc- tioned, such as when proof of legal residency is required before health care can be offered. Because of these obstacles to accessing health care, the health status of minority popula- tions tends to be worse than that of majority populations.
Prejudice and discrimination are often related to race and ethnicity. Ethnicity is a social grouping based on many dimensions of cultural heritage, nationality, language, religion, tribal affiliation, and other factors. Race refers to superficial categories that group individuals based primarily on physical attri- butes like skin color. Significant cultural and genetic diversity is present within most racial groups. For example, the U.S. government typ- ically collects and reports data for five racial categories and one ethnic category.48 The five racial categories are American Indian or Alas- kan Native, Asian, Black or African American, Native Hawaiian or other Pacific Islander, and White. The “Asian” category groups people with ancestors from countries as diverse as China, India, the Philippines, and Thailand. The “White” category includes most people whose ancestors were Europeans, North Afri- cans, or Middle Easterners, and many with ancestors from other countries in the Ameri- cas. The only ethnic category classifies people as “Hispanic or Latino” versus “Not Hispanic or Latino.” People who identify as “Hispanic or Latino” might have ancestry in places as diverse as Cuba, Ecuador, Mexico, and Spain.
58 Chapter 3 Socioeconomic Determinants of Health
settled in a new country and intends to stay there permanently. A person who is tempo- rarily living in another country and intends to return to his or her home country is called an expatriate. For example, people working in a foreign country for their home government, a business, the press corps, a nongovernmen- tal organization, or another entity are usually considered to be “expats” rather than immi- grants. Most migrants voluntarily move from one country to another to be closer to family, start a new job, or pursue educational opportu- nities. The majority of international migrants have moved from middle-income countries to high-income destination countries where their prospects for economic prosperity are greater (FIGURE 3–18).55
However, not all migration is voluntary. Some migrants are forced to move because of violence, persecution, or natural disas- ters. Some are involved in trafficking, which occurs when a migrant is forced into sex work, debt bondage, slavery, or other types of forced labor by the people who arranged the reloca- tion. The experience of being an involuntary migrant is often accompanied by adverse health effects.56 Smuggled migrants, victims of trafficking, and people fleeing conflict and persecution may experience violence and nutritional deprivation as well as other trau- mas during their travels. While some migrants gain greater access to healthcare services when they move from a country with poor health infrastructure to a country with an easily accessible healthcare system, many migrants encounter new health challenges as they settle into their new places of residence.57
A refugee is a person who has been forced to move across an international bor- der because of security concerns like war, civil conflict, political strife, or persecution based on race, tribe, religion, political affiliation, or membership in some other group. Refugees typically secure permission to move to a new country prior to arriving in that country. An asylum seeker is an involuntary migrant who asks for protection from a host country after
through the elimination of discriminatory laws (SDG 10.3), and “empower and promote the social, economic, and political inclusion of all, irrespective of age, sex, disability, race, eth- nicity, origin, religion, or economic or other status” (SDG 10.2).11 Actions to increase equity across these domains are expected to reduce health disparities by increasing the health sta- tus of currently disadvantaged groups.
▸ 3.7 Migrant and Refugee Health
A migrant is a person who has moved across an international border and has taken up res- idence in the new country.54 By 2015, there were nearly 250 million people worldwide who were living in a country that was not their original homeland.55 Some migrants intend to settle permanently in their new host country, while others are temporary residents or guest workers. An immigrant is a person who has
© Knumina Studios/Shutterstock
3.7 Migrant and Refugee Health 59
In 2015, there were more than 21 mil- lion refugees and more than 3 million asy- lum seekers worldwide.58 Half of all refugees were less than 18 years old.58 The Office of the United Nations High Commissioner for Refugees (UNHCR) and other humanitarian
arriving in that country rather than waiting for a refugee application to be processed prior to traveling. Asylum seekers are often included in the refugee category in reports about involun- tary international migration because the lived experiences of refugees and asylum seekers are similar. The primary difference between the groups is the status of their legal documents.
To be classified as a refugee or asylum seeker, an involuntary migrant must cross an international border. Nearly all refu- gees and asylum seekers originate in LMICs, and most move to middle-income countries (FIGURE 3–19).58 An internally displaced per- son (IDP) is a person who fled his or her home community because of civil war, famine, natural disaster, or another crisis, but did not cross into another country and is, therefore, not afforded the same protection and assistance as a refugee.
Low-income countries
Middle-income countries
High-income countries
0%
20%
40%
60%
80%
100%
Origination Destination
FIGURE 3–18 Most migrants were born in middle-income countries and most move to high- income countries (2015). Data from International migration report 2015. New York: UN Department of Economic and Social Affairs; 2016.
Low-income countries
Middle-income countries
High-income countries
Origination Destination 0%
20%
40%
60%
80%
100%
FIGURE 3–19 Most refugees and asylum seekers were born in low- and middle-income countries and relocate to middle-income countries (2015). Data from Global trends: Forced displacement in 2015. Geneva: UNHCR; 2016.
© Thomas Koch/Shutterstock
60 Chapter 3 Socioeconomic Determinants of Health
and to hazards like unexploded ordnance; and the displacement of their family mem- bers, neighbors, and other members of their community. Those who settle in new areas often face challenges associated with learning new cultural practices and adapting to them, overcoming language and communication barriers, having limited occupational options, and potentially having limited access to health care. Acculturation is the complex process of adopting the practices, traditions, values, and identity of a new community after migrat- ing.61 Acculturation may be correlated with improved ability to navigate healthcare sys- tems and access the tools for health.
Several of the SDGs specifically address the well-being of migrants. One of the SDG tar- gets for reducing inequality is to “facilitate the orderly, safe, regular, and responsible migra- tion and mobility of people, including through the implementation of planned and well- managed migration policies” (SDG 10.7).11 Other SDG targets aim to protect migrants from being trafficked (SDG 5.2), forced into slavery (SDG 8.7), and working in unsafe envi- ronments (SDG 8.8). Policies and practices that address these issues and the other aspects of inequality covered by SDG 10 will improve the health of refugees and other migrants as well as the health of their neighbors.
▸ 3.8 Governance and Politics
SDG 16 focuses on peace, justice, and strong institutions, and aims to “promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build effec- tive, accountable, and inclusive institutions at all levels.”11 The core of this goal is the need for good governance, the processes and structures that enable governments to set policies, provide services, and protect human rights. Good gov- ernance provides the policies, strategies, and resources that enable public agencies and other
organizations, both governmental and private, help provide for the basic needs of refugees, including water, food, sanitation, shelter, fuel, and health care for sick, pregnant, and vulner- able individuals. When possible, these organi- zations also offer treatment for malnutrition, address violence and security issues, and provide therapy for mental health problems, such as posttraumatic stress disorder. Fewer than half of refugees access these services in “camps” that provide long-term shelter. Most refugee camp residents are children, women, and the elderly. The rest are displaced to cities or rural areas, where they live alongside local residents (and other types of migrants) and rely on local social services for health care and other types of assistance.59
There were estimated to be about 28 million new IDPs worldwide in 2015, including about 8.6 million people displaced by conflict and vio- lence and 19.2 million displaced by disasters.60 More than 40 million people worldwide had IDP status after adding new IDPs to those who had been displaced in previous years and had not yet found a permanent residence.60 IDPs and refugees share the experience of having lost their homes, jobs, social support networks, and some of their independence and sense of secu- rity. However, because IDPs have remained in their home countries, they are often not eligible for assistance from UNHCR and other inter- national groups. IDPs usually do not live in camps. Most move to new rural areas or cities.
The services provided to involuntary migrants early in the cycle of displacement are not intended to be long-term solutions. The ultimate goal is for involuntary migrants (and IDPs) to secure permanent living situa- tions and become self-sufficient by integrat- ing into their host countries, resettling in a new host country, or returning to their home communities. Refugees and IDPs who return to their home communities after a period of displacement may face challenges related to the destruction of homes, healthcare facilities, schools, and other community buildings; the loss of farmland to environmental damage
3.8 Governance and Politics 61
conferred by cultural systems. A tribal or reli- gious leader may have the power to mobilize people and resources at will. A husband may have the power to control his wife’s movements and activities. Powerful people can choose to limit or grant access to goods and resources like property, technology, social networks, and health care. Corruption occurs when politically powerful people abuse their positions for per- sonal gain. LMICs tend to have less functional governance structures and more fraud, theft, bribery, kickbacks, and other types of corruption than high-income countries (FIGURE 3–20).62
In many countries, some people have the power to secure health for themselves and their families while others without power have limited or no access to the resources they need to be safe and healthy. Ethnic, racial, religious, and tribal minorities; immigrants, refugees, and internally displaced people; prisoners; people with mental health disorders or phys- ical impairments; older persons; and members of other potentially vulnerable groups may not have the power to demand access to an equita- ble level of health care. An inclusive society is one in which all people have equitable access to governmental institutions and services, including health-related services.
organizations to be well managed, and sound management ensures that health and social ser- vices are reliably delivered to the people who need them. Countries with good governance have low rates of violence (SDG 16.1), child abuse and human trafficking (SDG 16.2), orga- nized crime (SDG 16.3), corruption and bribery (SDG 16.4), and discrimination (SDG 16.b); they have freedom of the press (SDG 16.10); they have justice systems that quickly and fairly enforce laws (SDG 16.3); and they are transpar- ent (SDG 16.6) and allow diverse representatives to participate in decision-making (SDG 16.7). None of the other SDGs can be achieved when functioning governance systems are not in place to ensure that everyone has access to health services, education, clean drinking water, and other tools for health.
Access to health care and other services is associated with wealth, education, and employ- ment, and it is also related to power. Power is the authority to control or influence the actions of others. Power can be conferred by political posi- tion and by socioeconomic advantages. Govern- ment officials may have the authority to demand certain services for themselves. Business leaders may have the money and connections to access care that is denied to others. Power can also be
0
20
40
60
80
100
USA Germany
C or
ru pt
io n
pe rc
ep tio
n in
de x
Iran Brazil China India Nigeria Ethiopia
Very clean
Highly corrupt
global average
FIGURE 3–20 Low- and middle-income countries tend to have more corruption than high-income countries (2016). Data from Corruption perceptions index 2016. Berlin: Transparency International; 2017.
62 Chapter 3 Socioeconomic Determinants of Health
21. World development indicators 2016 (Table 2.9). Washington DC: World Bank; 2016.
22. Wilkinson RG, Pickett KE. Income inequality and population health: A review and explanation of the evidence. Soc Sci Med. 2006;62:1768–84.
23. United Nations Economic and Social Council. Report of the Inter-Agency and Expert Group on Sustainable Development Goal Indicators (E/CN.3/2016/2/ Rev.1). New York: UN; 2016.
24. Kickbusch IS. Health literacy: Addressing the health and education divide. Health Promot Int. 2001;16:289–97.
25. The state of the world’s children 2016: A fair chance for every child. New York: UNICEF; 2016.
26. Bundy D, Schultz L, Sarr B. Platforms to reach school-age children (Chapter 20). Disease control priorities. 3rd ed. Child and adolescent health and development (Volume 8). Washington DC: IBRD/ World Bank; 2017.
27. Education for All (EFA) global monitoring report 2006: Literacy for life. Paris: United Nations Educational, Scientific and Cultural Organization (UNESCO); 2005.
28. Nutbeam D. Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century. Health Promot Int. 2000;15:259–67.
29. Education for All 2000–2015: Achievements and challenges. Paris: UNESCO; 2015.
30. King EH, Hill MA. Women’s education in developing countries: Barriers, benefits, and policies. Baltimore MD: Johns Hopkins University Press; 1993.
31. Human development report 2016. New York: UNDP; 2016.
32. Johnson JL, Greaves L, Repta R. Better science with sex and gender: Facilitating the use of a sex and gender-based analysis in health research. Int J Equity Health. 2009;8:14.
33. Arslanian-Engoren C, Engoren M. Physiological and anatomical bases for sex differences in pain and nausea as presenting symptoms of acute coronary syndromes. Heart Lung. 2010;39:386–93.
34. GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1980–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1545–602.
35. Gender equality, work and health: A review of the evidence. Geneva: WHO; 2006.
36. Integrating equity, gender, humans rights and social determinants into the work of WHO: Roadmap for action (2014–2019). Geneva: WHO; 2015.
37. Dooley D. Unemployment, underemployment, and mental health: Conceptualizing employment status as a continuum. Am J Community Psychol. 2003;32:9–20.
▸ References 1. WHO Commission on Social Determinants of
Health. Health equity through action on the social determinants of health. Geneva: WHO; 2008.
2. Marmot M. Social determinants of health. Lancet. 2005;365:1099–104.
3. Kavanagh J, Oliver S, Lorenc T. Reflections on developing and using PROGRESS-Plus. Equity Update. 2008;2:1–3.
4. Wilkinson R, Marmot M. Social determinants of health: The solid facts. Copenhagen: WHO; 2003.
5. Braveman P, Tarimo E. Social inequalities in health within countries: Not only an issue for affluent nations. Soc Sci Med. 2002;54:1621–35.
6. Gwatkin DR. Health inequalities and the health of the poor: What do we know? What can we do? Bull World Health Organ. 2000;78:3–18.
7. Social justice in an open world: The role of the United Nations. New York: UN Department of Economic and Social Affairs; 2006.
8. Innov8 approach for reviewing national health programmes to leave no one behind: Technical handbook. Geneva: WHO; 2016.
9. Human development report 2015: Work for human development. New York: UNDP; 2015.
10. Helliwell J, Layard R, Sachs J, editors. World happiness report 2017. New York: Sustainable Development Solutions Network; 2017.
11. United Nations. Transforming Our World: The 2030 Agenda for Sustainable Development. New York: UN; 2015.
12. World development indicators 2016. Washington DC: World Bank; 2016.
13. National human development report 2015: Human security and human development in Nigeria. Abuja: UNDP Nigeria; 2015.
14. Report on the world social situation 2016: Leaving no one behind: The imperative of inclusive development. New York: UN Department of Economic and Social Affairs; 2016.
15. Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: A world converging within a generation. Lancet. 2013;382:1898–955.
16. Berendes S, Heywood P, Oliver S, Garner P. Quality of private and public ambulatory health care in low and middle income countries: Systematic review of comparative studies. PLoS Med. 2011;8:e1000433.
17. Ong LL. Burgernomics: The economics of the Big Mac standard. J Int Money Finance. 1997;16:865–78.
18. World development indicators 2016 (Table 2.1). Washington DC: World Bank; 2016.
19. World development indicators 2016 (Table 2.21). Washington DC: World Bank; 2016.
20. World development indicators 2016 (Table 2.9). Washington DC: World Bank; 2016.
References 63
50. Pascoe EA, Smart Richman L. Perceived discrimination and health: A meta-analytic review. Psychol Bull. 2009;135:531–54.
51. Gracey M, King M. Indigenous health part 1: Determinants and disease patterns. Lancet. 2009;374:65–75.
52. Bartlett JG, Madariaga-Vignudo L, O’Neil JD, Kuhnlein HV. Identifying indigenous peoples for health research in a global context: A review of perspectives and challenges. Int J Circumpolar Health. 2007;66:287–307.
53. King M, Smith A, Gracey M. Indigenous health part 2: The underlying causes of the health gap. Lancet. 2009;374:76–85.
54. World migration report 2015. Geneva: International Organization for Migration (IOM); 2015.
55. International migration report 2015. New York: UN Department of Economic and Social Affairs; 2016.
56. International migration, health and human rights. Geneva: IOM; 2013.
57. Gushulak BD, MacPherson DW. The basic principles of migration health: Population mobility and gaps in disease prevalence. Emerg Themes Epidemiol. 2006;3:3.
58. Global trends: Forced displacement in 2015. Geneva: UNHCR; 2016.
59. Spiegel PB, Checchi F, Colombo S, Paik E. Health-care needs of people affected by conflict: Future trends and changing frameworks. Lancet. 2010;375:341–5.
60. Global report on internal displacement 2016. Geneva: Internal Displacement Monitoring Centre (IDMC), Norwegian Refugee Council; 2016.
61. Fox M, Thayer Z, Wadhwa PD. Assessment of acculturation in minority health research. Soc Sci Med. 2017;176:123–32.
62. Corruption perceptions index 2016. Berlin: Transparency International; 2017.
38. Wilson SH, Walker GM. Unemployment and health: A review. Public Health. 1993;107:153–62.
39. Benach J, Vives A, Amable M, Vanroelen C, Tarafa G, Muntaner C. Precarious employment: Understanding an emerging social determinant of health. Annu Rev Public Health. 2014;35:229–53.
40. Paul KI, Moser K. Unemployment impairs mental health: Meta-analyses. J Vocational Behav. 2019; 74:264–82.
41. Wanberg CR. The individual experience of unemployment. Annu Rev Psychol. 2012;63:369–96.
42. Dooley D, Fielding J, Levi L. Health and unemployment. Annu Rev Public Health. 1996;17:449–65.
43. Roelfs DJ, Shor E, Davidson KW, Schwartz JE. Losing life and livelihood: A systematic review and meta- analysis of unemployment and all-cause mortality. Soc Sci Med. 2011;72:840–54.
44. Toch-Marquardt M, Menvielle G, Eikemo TA, et al. Occupational class inequalities in all-cause and cause-specific mortality among middle-aged men in 14 European populations during the early 2000s. PLoS One. 2014;9:e108072.
45. Aldabe B, Anderson R, Lyly-Yrjänäinen M, et al. Contribution of material, occupational, and psychosocial factors in the explanation of social inequalities in health in 28 countries in Europe. J Epidemiol Community Health. 2011;65:1123–31.
46. Stuber J, Meyer I, Link B. Stigma, prejudice, discrimination and health. Soc Sci Med. 2008;67:315–7.
47. Boyd KM. Disease, illness, sickness, health, healing and wholeness: Exploring some elusive concepts. Med Humanities. 2000;26:9–17.
48. Revisions to the standards for the classification of federal data on race and ethnicity. Washington DC: Office of Management and Budget (OMB); 1997.
49. Dressler WW, Oths KS, Gravlee CC. Race and ethnicity in public health research: Models to explain health disparities. Ann Rev Anthropol. 2005;34:231–52.
64 Chapter 3 Socioeconomic Determinants of Health
© Xinzheng. All Rights Reserved/Moment/Getty
▸ 4.1 Environmental Health and the SDGs
The most fundamental necessities for life are water, food, shelter, and fuel for heat and cook- ing. Where people live and work, the materials used to construct these buildings, what people eat and where that food comes from, the source and quality of drinking water, the quality of the air that is breathed, whether hazardous substances like cleaning agents, fertilizers, and motor oil are stored in or near the home, and numerous other components of the home envi- ronment play a role in health status. A broader set of environmental factors outside the home and workplace also contribute to health status, including geography, geology (such as the pres- ence of earthquake fault lines or volcanoes), and climate (including whether the location is desert, tropical, arctic, or something more moderate, the types of vegetation and animals
CHAPTER 4
Environmental Determinants of Health
Human health is dependent on clean water, clean air, and other features of a healthy environment. Households, workplaces, communities, and cities can take steps to promote sustainable access to utilities, prevent hazardous exposures to toxins, support ecosystem vitality, and build resilience to withstand natural disasters. Combatting climate change and other large-scale threats to planetary health requires global cooperation.
that are native to the location, and the usual weather and temperature patterns in the area).
Approximately 23% of deaths worldwide and 22% of disability-adjusted life years (DALYs) lost each year are attributable to water pollution, air pollution, occupational hazards, unsafe build- ings and roads, and other modifiable environ- mental and occupational exposures (FIGURE 4–1).1 These burdens fall on both adults and children.2 Lack of access to safe drinking water, sanita- tion, and hygiene causes many cases of diarrheal diseases. Air pollution contributes to asthma, strokes, heart disease, respiratory infections, chronic obstructive pulmonary disease (COPD), and lung cancer. Failure to control insects and other pests enables the spread of malaria. The built environment contributes to the burden from drowning, road traffic accidents, falls, and other injuries. Occupational hazards cause low back pain and hearing loss. Numerous other factors contribute to other types of infections, noncom- municable diseases, and injuries ( FIGURE 4–2).1
65
FIGURE 4–1 About one in four deaths and one in five disability-adjusted life years (DALYs) lost worldwide are attributable to environmental exposures. Data from Prüss-Ustün A, Wolf J, Corvalán C, Bos, R, Neira M. Preventing disease through healthy environments: A global assessment of the burden of disease from environmental risks. Geneva: WHO; 2016.
Disease
Population Attributable Fraction (%) Major Environmental Contributor(s)
Drowning 73 Safety of home and community environments, occupational risks
Diarrheal diseases 57 Water, sanitation, and hygiene
Asthma 44 Air pollution and occupational risks
Stroke 42 Air pollution
Malaria 42 Environmental vector management
Road traffic accidents 40 Occupational risks, built environment, traffic regulation, and land use
Ischemic heart disease 35 Air pollution
Acute lower respiratory infections 35 Air pollution
Chronic obstructive pulmonary disease 35 Air pollution and occupational risks
Falls 30 Built environment and occupational risks
Low back pain 26 Occupational risks
Hearing loss 22 Occupational noise
Self-harm 21 Chemicals, built environment, gun control, home and community safety
Cancers 20 Air pollution and many other factors
FIGURE 4–2 Percentage of disability-adjusted life years from selected conditions attributable to environmental risk factors. Data from Prüss-Ustün A, Wolf J Corvalán C, Bos, R, Neira M. Preventing disease through healthy environments: A global assessment of the burden of disease from environmental risks. Geneva: WHO; 2016.
Deaths
DALYs
USA Germany Iran Brazil China India Nigeria Ethiopia
66 Chapter 4 Environmental Determinants of Health
Public health requires safe home, work, and community environments. Public health is also dependent on healthy ecosystems at grander national, regional, and global scales.
Poverty is often linked to unhealthy liv- ing and occupational environments. Poverty impacts the type of dwelling a household lives in (which can be unstable, unventilated, and built with harmful materials), how crowded the home is (which can facilitate the spread of infec- tious diseases like tuberculosis), and whether it is in proximity to schools, healthcare facilities, public transportation, and waste dumps. Many poor communities do not have consistently safe drinking water, toilets, or enough water to prac- tice good hygiene, so the risk of contracting an infection is greatly increased. In some places, the dwindling availability of wood for fuel lim- its the ability of households to boil water and cook food. Without electricity for refrigeration, it is difficult to store food safely. In rural areas, the lack of infrastructure for communication and transportation makes it difficult to access health education and healthcare services. Fur- thermore, low- income households may not have the money to purchase tools for disease prevention, because they must dedicate all income to immediate survival needs like food, housing, clothing, and emergency medical care. As a result of these challenges, environmental hazards place a particularly high burden on
residents of low- and middle- income countries (FIGURE 4–3).3
One of the health-specific Sustainable Development Goals (SDGs) targets focuses specifically on environmental health, aiming to “substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution, and contamina- tion” (SDG 3.9).4 Numerous additional SDG targets are related to environmental health (FIGURE 4–4), and making progress toward the environmental SDGs of ensuring drinking water and sanitation for all (SDG 6), ensuring modern energy for all (SDG 7), building resil- ient infrastructure (SDG 9), making cities safe and sustainable (SDG 11), ensuring responsible consumption and production patterns (SDG 12), and taking action to combat climate change and its impacts (SDG 12), along with the related goals of ocean conservation (SDG 14) and eco- system restoration (SDG 15), will be necessary for achieving and maintaining poverty reduc- tions and improvements in global health status.5
▸ 4.2 Water, Sanitation, and Hygiene
Everyone needs access to an adequate daily supply of water for drinking, cooking, hygiene,
FIGURE 4–3 The age-standardized rates of deaths and DALYs attributable to environmental risk factors are highest in lower-income countries.
0 50
100 150 200 250 300 350
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
USA
Deaths (age standardized per 100,000 people)
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
USA
DALYs (age standardized per 100,000 people)
0
5,000
10,000
15,000
20,000
Data from Prüss-Ustün A, Wolf J, Corvalán C, Bos, R, Neira M. Preventing disease through healthy environments: A global assessment of the burden of disease from environmental risks. Geneva: WHO; 2016.
4.2 Water, Sanitation, and Hygiene 67
FIGURE 4–4 Examples of sustainable development goals targets related to environmental health. Data from United Nations Economic and Social Council. Report of the Inter-Agency and Expert Group on Sustainable Development Goal Indicators (E/CN.3/2016/2 /Rev.1). New York: UN; 2016.
1.5.3 Number of countries with national and local disaster risk reduction strategies
2.4.1 Proportion of agricultural area under productive and sustainable agriculture
3.9.1 Mortality rate attributable to household (indoor) and ambient (outdoor) air pollution
3.9.2 Mortality rate attributed to unsafe water, unsafe sanitation, and lack of hygiene
6.1.1 Percentage of the population using safely managed drinking water sources
6.2.1 Percentage of the population using safely managed sanitation services, including a handwashing facility with soap and water
6.3.1 Percentage of wastewater safely treated
6.b.1 Percentage of local administrative units with established and operational policies and procedures for participation of local communities in water and sanitation management
7.1.1 Percentage of the population with access to electricity
7.1.2 Percentage of the population with primary reliance on clean fuels and technology
7.2.1 Renewable energy share in the total final energy consumption
8.4.1 Material footprint, material footprint per capita, and material footprint per GDP
12.2.1
11.6.1 Proportion of urban solid waste regularly collected and with adequate final discharge out of total urban solid waste generated by cities
11.6.2 Annual mean levels of fine particulate matter in cities
12.4.1 Number of parties to international multilateral environmental agreements on hazardous and other chemicals and waste that meet their commitments and obligations
12.4.2 Hazardous waste generated per capita and proportion of hazardous waste treated
12.5.1 National recycling rate, tons of material recycled
12.7.1 Number of countries implementing sustainable public procurement policies and action plans
13.2.1 Number of countries that have communicated the establishment or operationalization of an integrated policy/strategy/plan that increases their ability to adapt to the adverse impacts of climate change
68 Chapter 4 Environmental Determinants of Health
water source, the water must be protected, which means that people should not wash clothes or bathe in the vicinity where drinking water is collected, and animals, sewage, and garbage should be kept away from the water source. The water source must be available and functioning all the time, or the household must have access to adequate water storage and water treatment methods, such as filter- ing, boiling, and using chemicals like chlorine.
Hygiene is the practice of maintaining cleanliness in order to prevent disease. Personal hygiene behaviors include handwashing (hand hygiene), tooth brushing (oral hygiene), and bathing (body hygiene). Enough water must be available each day so people can stay hydrated
and cleaning tasks, such as washing clothes, scrubbing cooking pots, and cleaning homes. Water access is a function of water quality, reliability, quantity, proximity, and cost.6 A household has access to safe drinking water when there is an adequate supply of afford- able clean drinking water in or near the home ( FIGURE 4–5).6 The water needs to be free of bacteria, viruses, and parasites that can cause diarrhea and other infectious diseases, and it must also be free of harmful chemicals and sediments. The water should not appear cloudy, dirty, or strangely colored, so that it does not cause problems with cooking (such as giving food a strange flavor, color, or texture) or washing.7 To be classified as an improved
FIGURE 4–5 Water service level (quality, reliability, quantity, and proximity) and health effects.
Service Level
Quality and Reliability
Quantity per Person per Day Proximity
Hygiene Needs Met?
Level of Health Concern
No access Neither quantity nor quality ensured
May be less than 5 liters
More than 1 kilometer or 30 minutes round trip
No because only available at source
Very high
Basic access Quantity ensured but quality not ensured
About 20 liters
Between 100 and 1000 meters or 5–30 minutes round trip
Yes for handwashing and food hygiene; no for laundry and bathing
High
Intermediate access
Quantity and quality usually assured
About 50 liters
Water delivered through one tap that is within 100 meters or 5 minutes round trip
Yes Low
Optimal access Quantity and quality ensured
About 100 liters
Continuous supply through multiple taps
Yes Very low
Data from Howard G, Bartram J. Domestic water quantity, service level and health. Geneva: WHO; 2003.
4.2 Water, Sanitation, and Hygiene 69
home. In some places, it is possible for house- holds to supplement their water access by col- lecting and storing rainwater for drinking and domestic use.
Water must be affordable enough that people have access to at least the minimum amount of water necessary for healthy living. This does not mean that water must be free. Households using a community water system may be asked to pay a reasonable fee so that the system can be maintained. These fees also promote water conservation if they are tied to the amount of water drawn from the pump by a household. However, it is problematic for public health when public water supplies are
and clean. The average minimum amount of water needed by one person each day just in order to survive is about 15–20 liters (about 4–5 gallons): about 1–3 liters for drinking, 2–3 liters for food preparation and cleanup, 6–7 liters for personal cleanliness, and 4–6 liters for laun- dry.8 For healthy living, rather than mere sur- vival, a minimum of about 50 liters (13 gallons) of water per person per day is recommended.6 (As a comparison, the typical American uses about 90 gallons daily at his or her residence for indoor and outdoor purposes.9)
To be considered accessible, the water source must be close enough to the home so that distance does not prevent people from using the water they need for health. At best, water is piped directly into an individual house. Public water taps, boreholes, and pro- tected (and lined) dug wells that bring water near to homes, but not inside them, are also considered to be improved water sources ( FIGURE 4–6).10 Ideally, every person should live within 1 kilometer (about 0.6 miles) of a safe drinking water source.6 When water sources are farther from the home, women and children may have to spend several hours each day walking to a water source, waiting for their turn to fill a container, and walking
Surface water from a river, dam, lake, pond, stream, canal, irrigation channel, or other water body
Unprotected dug well
• •
•
•
•
•
•
•
•
•
•
Unprotected spring
Water from mobile vendors, such as tanker trucks or carts with a small tank or drum
Bottled water (when used as a primary source of water)
Public tap or standpipe
Tube well or borehole
Protected dug well
Protected spring
Rainwater collection
Piped water into the user’s home or yard
Unimproved Improved
FIGURE 4–6 Examples of improved and unimproved drinking water sources. Data from Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF/WHO Joint Monitoring Programme for Water Supply and Sanitation; 2015.
© punghi/Shutterstock
70 Chapter 4 Environmental Determinants of Health
sanitation when there is a toilet in the home or a latrine near the home that can be used with- out a per-use payment (FIGURE 4–7).10 One of the most basic sanitation systems is a simple pit latrine, which is a hole in the ground cov- ered by an outhouse or encircled by a privacy blind. An improved toilet facility provides greater comfort, privacy, cleanliness, safety, and protection from dangers at night and from snakes and pests. For example, a ventilation- improved pit (VIP) latrine vents fumes away from the outhouse and keeps flies out of it. Pour-flush systems require some water for washing away the waste. Septic tanks and sewer connections are more advanced sani- tation technologies that use water to remove waste from indoor toilets.
Open defecation occurs when people defecate in a field, a street, or another place that is not a toilet facility. Rural residents without access to sanitation systems may be able to go to an outdoor defecation site away from their living areas. Urban resi- dents without access to a latrine often have no choice but to defecate at the side of a road or into a bag that is thrown outside, a waste disposal method that is sometimes called a “flying toilet.” A desire for privacy means that many people without an improved
not available and the prices charged for water are exorbitant.
Water used for drinking, hygiene, and other purposes must be free of toxins like arse- nic, which can leak into wells when ground- water flows through fluvial deposits that contain arsenopyrites.11 Arsenic in the water has long been a problem in Bangladesh,12 where millions of residents remain at risk of arsenicosis, chronic arsenic poisoning from being exposed to contaminated water over a long period of time. The most visible symp- toms are a change in skin color (hyperpigmen- tation) and the formation of hard skin patches ( keratosis). Arsenicosis can also cause skin cancer and cancers of the lung, kidney, and bladder as well as liver damage and peripheral vascular disease. Low-cost filter systems can remove arsenic from drinking water, but even a very low-cost filter is more expensive than many Bangladeshi families can afford. Because the filters produce toxic waste, they are at best only a temporary solution. Deeper wells that bypass the geologic formations that contain arsenic might solve the problem, but digging a deeper well is an expensive solution in low- income communities.13
Sanitation is the safe disposal of human excreta (feces). A household has access to
FIGURE 4–7 Examples of improved and unimproved sanitation facilities. Data from Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF/WHO Joint Monitoring Programme for Water Supply and Sanitation; 2015.
Unimproved Improved
Open defecation (using a field, forest, bush, open body of water, beach, or other open space as a toilet)
• • •
•
•
•
•
•
•
•
Pit latrine without a slab or platform
Hanging latrine
Bucket (or bag) latrine
Flush or pour toilet that drains into a street, yard, open sewer, ditch, or drainage way
Shared or public sanitation facilities
Flush or pour toilet that diverts waste to a piped sewer system, a septic tank, or a pit latrine
Ventilated improved pit (VIP) latrine
Pit latrine with slab
Composting toilet
4.2 Water, Sanitation, and Hygiene 71
than 650 million people—still did not have access to a reliable source of safe drink- ing water in 2015 (FIGURE 4–9). Access to an improved sanitation facility increased from 54% of the world’s people in 1990 to 68% in 2015 (FIGURE 4–10).10 However, in 2015 about 1 in 3 people worldwide—2.4 billion people— still did not have access to an improved toilet (FIGURE 4–11). Even though the proportion of people worldwide who practice open defe- cation has decreased, about 950 million peo- ple still practiced open defecation in 2015 (FIGURE 4–12). Rates of water and sanitation access are often especially low in rural areas (FIGURE 4–13). In 2015, 96% of urban residents had an improved water source and 82% had an improved sanitation facility. In rural areas, the rates were 84% for water and only 51% for sanitation.10
People who do not have access to improved water and sanitation are at increased risk for infectious diseases that are spread through contact with fecal matter.15 In lower-income countries where few people have reliable access to water and sanitation, there is a substantial mortality rate associated with lack of access to these tools for health ( FIGURE 4–14).16 The presence of feces in or near homes significantly increases the risk of bacterial, viral, and protozoal diarrheal dis- eases and helminthic (worm) infections. Intes- tinal worm infections can be treated through the periodic distribution of de-worming med- icines to school-age children and other at-risk population groups, but improved sanitation is a necessity for preventing new infections and reinfections. The best interventions for reduc- ing the public health burden from diarrheal diseases and intestinal parasites are water, sanitation, and hygiene (WASH) programs that combine improved water and sanitation systems with health education to promote frequent handwashing and consistent use of toilets.17
Millennium Development Goal 7 aimed to reduce the proportion of people with- out access to water and sanitation by half between 1990 and 2015. The target for water
sanitation facility, especially women, wait until dark to defecate, even though it is often dangerous for them to be out at night. A community is open defecation free (ODF) when all members are using designated toi- let facilities and no one is defecating outside. Becoming an ODF community requires toi- lets to be present and used consistently by all community members. Community-led total sanitation (CLTS) programs are often implemented to encourage toilet use in places where residents are accustomed to open defecation and have not yet adopted new sanitation behaviors.14
The percentage of the world’s people with an improved water source increased from 76% in 1990 to 91% in 2015 (FIGURE 4–8).10 While nearly everyone in high-income countries has access to water, more than 1 in 10 people living in low- and middle-income countries—more
0
10
20
30
40
50
60
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
W A
S H
-a ss
oc ia
te d
m or
ta lit
y pe
r 10
0, 00
0 pe
op le
p er
y ea
r
USA
FIGURE 4–8 Mortality attributed to exposure to unsafe water, sanitation, and hygiene services per 100,000 people. Data from World health statistics 2016. Geneva: WHO; 2016.
72 Chapter 4 Environmental Determinants of Health
FIGURE 4–10 Proportion of the total population with access to an improved water source (2015). Data from Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF/WHO Joint Monitoring Programme for Water Supply and Sanitation; 2015.
FIGURE 4–9 Improvement in access to improved drinking water sources, 1990–2015. Data from Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF/WHO Joint Monitoring Programme for Water Supply and Sanitation; 2015.
0
20
40
60
80
100
USA Germany Iran Brazil China India Nigeria Ethiopia
1990 2015
global average 2015
global average 1990
Missing/Excluded
Less than 60
60 to 80
80 to 95
95 to 99
99 and above
4.2 Water, Sanitation, and Hygiene 73
Missing/Excluded Less then 50 50 to 75 75 to 90 90 to 99 99 and above
FIGURE 4–12 Proportion of the total population with access to an improved sanitation facility (2015). Data from Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF/WHO Joint Monitoring Programme for Water Supply and Sanitation; 2015.
FIGURE 4–11 Improvement in access to improved sanitation facilities, 1990–2015. Data from Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF/ World Health Organization; 2015.
0
20
40
60
80
100
EthiopiaNigeriaIndiaChinaBrazilIranGermanyUSA
global average 2015
global average 1990
1990 2015
74 Chapter 4 Environmental Determinants of Health
income per person in lower-income coun- tries are associated with significantly greater levels of access to an improved drinking water source and sanitation (FIGURE 4–17).18 Both economic growth and access to water and sanitation are associated with improve- ments in population health status.19 WASH interventions are cost-effective means for reducing the preventable burden of water- and sanitation-related diseases in low- and middle-income countries.20
▸ 4.3 Energy and Air Quality
Energy is necessary for at least three import- ant purposes: cooking food and boiling water for safe consumption, providing a source of heat when outdoor temperatures are low, and providing a source of light at night. The per- centage of the world’s people with electricity in their homes increased from about 75% in 1990 to about 85% by 2015 (FIGURE 4–18).21 Nearly all of the 1.1 billion people without electricity at home live in lower-income countries.
Having electricity does not mean that electricity is the only source of household energy. About 40% of people worldwide— about 2.9 billion people who live in low- and middle-income countries—use solid fuels like wood, charcoal, coal, dung, and
was met, but the target for sanitation was not, despite good progress toward achieving it (FIGURE 4–15).10 SDG 6 has the even more ambitious goal of “ensuring available and sustainable management of water and sanita- tion for all.”4 A series of targets spell out how universal access to WASH can be achieved (FIGURE 4–16). There is a synergy between economic growth, WASH, and health. Eco- nomic development improves access to utili- ties, and increased access to utilities enables economic growth. Even small increases in © Svetlana Eremina/Shutterstock
1990 2015
India
Nigeria
Ethiopia
World
75%
24%
92%
24%
29%
13%
25%
44%
650 million 560 million
22 million
44 million
1.3 billion
45 million
946 million
29 million
FIGURE 4–13 Open defecation is still practiced by nearly 1 billion people worldwide. Data from Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF/WHO Joint Monitoring Programme for Water Supply and Sanitation; 2015.
4.3 Energy and Air Quality 75
crop waste as their primary source of energy for cooking (FIGURE 4–19).21 House- hold air pollution, also called indoor air pollution, occurs when the air in or near
buildings is of poor quality. All fuels that are burned for energy release air pollutants, but biomass (fuel from organic materials like wood, vegetation, or animal waste) and
FIGURE 4–14 Rural areas often have less access to improved drinking water sources and sanitation facilities than urban areas. Data from Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF/WHO Joint Monitoring Programme for Water Supply and Sanitation; 2015.
FIGURE 4–15 The Millennium Development Goal (MDG) target for water was met, but progress for sanitation was not met. Data from Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF/WHO Joint Monitoring Programme for Water Supply and Sanitation; 2015.
40%
30%
20%
10%
0%
60%
50%
80%
70%
100%
90%
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
USA
20%
40%
60%
80%
100%
90%
70%
50%
30%
10%
0%
Urban water Rural water Urban sanitation Rural sanitation
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
USA
100%
1990 19901995 19952000 20002005 20052010 20102015 20152020 20202025 20252030 2030
100%
90% 90%
80% 80%
70% 70%
60% 60%
50% 50%
40% 40%
30% 30%
20% 20%
10% 10%
0% 0%
MDG target met
MDG target
not met
Water Sanitation
76 Chapter 4 Environmental Determinants of Health
other solid fuels are particularly unhealthy because they are usually burned in open fires or in simple stoves that release most of the smoke from burning into the home or cooking shelter.22
The health risks associated with indoor air pollution levels are particularly high for women and young children who spend sev- eral hours a day near fires while cooking.23 Use of solid fuels for cooking and other energy needs can have adverse effects on respiratory health as well as other negative health outcomes.24 Children are at risk of burns from falling into open fires or knock- ing over pots of boiling water. Women and children often spend hours each week col- lecting sticks and brush to use as fuel, and they are susceptible to injuries related to carrying heavy loads over uneven terrain. As sources of biomass close to the home are used up, fuel- gatherers must travel further distances to find fuel. There are also envi- ronmental consequences. Burning of solid fuels contributes to outdoor air pollution, and the demand for wood and charcoal con- tributes to deforestation.
Having electricity in the home and being able to cook without solid fuels has numerous benefits, including cleaner indoor air, safer food storage because of access to refrigeration, and greater access to health and safety messages delivered through radios or televisions. However, electric- ity is not a pollution-free form of energy when the energy is generated by burning coal or oil. Power plants, the exhaust from motor vehicles, and the wastes produced by industrial processes, forest fires, and the dis- posal of solid waste can all create ambient air pollution, also called outdoor air pollution, which is the presence of harm- ful chemicals or other substances in the air at concentrations above the thresholds established for human safety. People in higher-income countries use more energy than people in lower-income countries, and they also generate more emissions per person
6.1 Achieve universal and equitable access to safe and affordable drinking water for all.
6.2 Achieve access to adequate and equitable sanitation and hygiene for all (including a handwashing facility with soap and water) and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations.
6.3 Improve water quality by reducing pollution, eliminating dumping and minimizing release of hazardous chemicals and materials, halving the proportion of untreated wastewater and substantially increasing recycling and safe reuse globally.
6.4 Substantially increase water-use efficiency across all sectors and ensure sustainable withdrawals and supply of freshwater to address water scarcity and substantially reduce the number of people suffering from water scarcity.
6.5 Implement integrated water resources management at all levels, including through transboundary cooperation as appropriate.
6.6 Protect and restore water-related ecosystems, including mountains, forests, wetlands, rivers, aquifers, and lakes.
6.a Expand international cooperation and capacity-building support to developing countries in water- and sanitation-related activities and programs, including water harvesting, desalination, water efficiency, wastewater treatment, recycling, and reuse technologies.
6.b Support and strengthen the participation of local communities in improving water and sanitation management.
FIGURE 4–16 Targets for Sustainable Development Goal 6, which focuses on water and sanitation. Data from United Nations. Transforming our world: The 2030 Agenda for Sustainable Development. New York: UN; 2015.
4.3 Energy and Air Quality 77
suspended in the air for long periods of time and can travel deep into the lungs.26 Air pollutants can cause lung disease by triggering inflamma- tion, damaging the cells that line the respiratory tract, and impairing immune response. They increase the risk of numerous respiratory dis- eases, including pneumonia, asthma, lung cancer, and other chronic respiratory diseases, and they exacerbate cardiovascular disorders.27
than less-industrialized lower- income coun- tries (FIGURE 4–20).25
Both indoor and outdoor air pollution are hazards to human health. The substances in pol- luted air include carbon monoxide (CO), nitro- gen oxides (NOx), sulfur dioxide (SO2), ozone (O3), volatile organic compounds, and partic- ulate matter. Particulate matter describes substances that are small enough to remain
FIGURE 4–17 Small increases in income per person in low-income countries are associated with significant increases in access to an improved drinking water source and an improved sanitation facility. (The dots represent the 100 most populous countries. Note the use of the logarithmic scale on the x-axis.) Data from World development indicators 2016 (Table 2.9). Washington DC: World Bank; 2016.
NIG
NIG
ETH
ETH
IND
IND
BRA
BRA
IRAN
IRAN
USA
USA
GER
GER
CHI
CHI
GNI per capita (Atlas method, logarithmic scale)
GNI per capita (Atlas method, logarithmic scale)
P er
ce nt
ag e
of th
e po
pu la
tio n
w ith
ac
ce ss
to a
n im
pr ov
ed w
at er
s ou
rc e
P er
ce nt
ag e
of th
e po
pu la
tio n
w ith
ac
ce ss
to a
n im
pr ov
ed s
an it
at io
n fa
ci lit
y
100 1000 10000 100000
0
10
20
30
40
50
60
70
80
90
100
100
0
10
20
30
40
50
60
70
80
90
100
1000 10000 100000
78 Chapter 4 Environmental Determinants of Health
SDG 7 is focused on “ensuring access to affordable, reliable, sustainable, and modern energy for all” (FIGURE 4–22).4 In lower- income countries, progress toward this goal will be met by increasing the proportion of households with electricity, since indoor air pollution lev- els will be reduced when fewer people cook with solid fuels. There are also interventions that can reduce exposure to indoor air pollu- tion among people without electricity.28 Using a cook stove with a flue that diverts pollutants out of the home improves indoor air quality. When it is not possible to increase ventilation inside the home, moving the kitchen to the outside of the home reduces smoke inhalation (if the outside cooking area has a good venti- lation system). Improved cooking devices such as those that use solar panels or other alterna- tive energy sources generally create less smoke than biomass. It is also helpful to change behaviors to reduce the health risks associated with cooking, such as keeping children away
1990 2000 2010
0%
20%
40%
60%
80%
100%
EthiopiaNigeriaIndiaChinaBrazilIranGermanyUSA
FIGURE 4–18 Many homes in lower-income countries do not have electricity. Data from Progress toward sustainable energy 2017: Global tracking framework report. Washington DC: World Bank/IEA; 2017.
0
20
10
40
30
60
50
80
70
90
100
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
USA
% w
ith ou
t n on
-s ol
id fu
el s
global average
FIGURE 4–19 Most residents of low-income countries burn solid fuels to cook food rather than using clean fuels and technologies. Data from Progress toward sustainable energy 2017: Global tracking framework report. Washington DC: World Bank/IEA; 2017.
In many low- and middle-income countries, a sizeable proportion of deaths are attributed to the combined effects of indoor and outdoor air pollution (FIGURE 4–21).16
4.3 Energy and Air Quality 79
from smoke and using pot lids to conserve heat.
In higher-income countries, progress toward achieving SDG 7 will require gener- ating a higher proportion of electricity from renewable sources that release fewer emissions into the air. Renewable energy is energy derived from a source like wind or solar power that is not depleted when it is used. Wind,
180
160
140
120
100
80
60
40
20
0
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
A ir
po llu
tio n-
re la
te d
m or
ta lit
y pe
r 10
0, 00
0 pe
op le
p er
y ea
r
USA
FIGURE 4–21 Mortality attributed to household and ambient air pollution per 100,000 people. Data from World health statistics 2016. Geneva: WHO; 2016.
FIGURE 4–22 Targets for Sustainable Development Goal 7, which focuses on energy. Data from United Nations. Transforming our world: The 2030 agenda for sustainable development. New York: UN; 2015.
7.1 Ensure universal access to affordable, reliable, and modern energy services.
7.2 Increase substantially the share of renewable energy in the global energy mix.
7.3 Double the global rate of improvement in energy efficiency.
7.a Enhance international cooperation to facilitate access to clean energy research and technology, including renewable energy, energy efficiency, and advanced and cleaner fossil-fuel technology, and promote investment in energy infrastructure and clean energy technology.
7.b Expand infrastructure and upgrade technology for supplying modern and sustainable energy services for all in developing countries, in particular, least developed countries, small island developing states, and landlocked developing countries.
0
1000
2000
3000
4000
5000
6000
7000
8000
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
USA
E ne
rg y
us e
pe r
pe rs
on (
kg o
il eq
ui va
le nt
)
global average
0
18
16
14
12
10
8
6
4
2
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
USA
global average
C O
2 em
is si
on s
pe r
ca pi
ta (
m et
ric to
ns )
FIGURE 4–20 People in higher-income countries use more energy and generate more carbon dioxide emissions than people in low-income countries. Data from The little green data book 2016. Washington DC: World Bank; 2016.
80 Chapter 4 Environmental Determinants of Health
solar, ocean, geothermal, and other renewable sources of energy produce less environmental damage than combustible fossil fuel sources like oil and coal ( FIGURE 4–23).29 Countries with high rates of electrification generally have small shares of energy consumption from renewable energy sources (FIGURE 4–24),21 and
SDG 7 can only be met if the proportion of energy generated from renewable sources in those countries increases significantly.
▸ 4.4 Occupational and Industrial Health
The field of occupational health, also called occupational safety and health and workplace health and safety, focuses on primary preven- tion of injuries and other work-related health problems. Occupational health was one of the first public health specialty fields.30 In 1713, Bernardino Ramazzini published Diseases of Workers, a book that detailed the environmen- tal hazards encountered in 52 occupations, list- ing poisoning, respiratory diseases, problems related to prolonged postures and repetitive tasks, and psychological stress as some of many on-the-job threats to health. In 1753, James Lind published the results of an experiment that supported the hypothesis that sailors could prevent scurvy if they carried citrus fruit with them on long journeys.31 (After this discovery, sailors were sometimes called “limeys” for the citrus fruit carried on ships.) In 1775, Perci- vall Pott identified chimney soot as the cause of elevated rates of scrotal cancer in chimney sweeps, which was the result of constant expo- sure to coal tar due to sweeps rarely bathing or changing their trousers.32 New occupational risks continue to be identified today.
Many workers are exposed to a mix of biological, chemical, physical, mechanical, and psychosocial challenges at work.33 Some occupations carry specific risks.34 Workers exposed to loud noises are at risk of perma- nently impaired hearing. Office and factory workers have an increased risk of repetitive strain injuries, such as carpal tunnel syndrome, that can develop after repeatedly performing the same tasks. Some workers who have long- term exposure to industrial chemicals are at increased risk of developing certain types of cancers. Those who work in the manufactur- ing industry may be at risk of crush wounds
Wind
Hydroelectric
Biomass
Solar photovoltaic
Natural gas
Oil
Coal
Lignite coal
Fossil fuels Renewable fuels
Tons of CO2 emissions per GWh
FIGURE 4–23 Renewable sources emit fewer greenhouse gases (CO2 emissions per GWh) than nonrenewable energy sources. Data from Comparison of lifecycle greenhouse gas emissions of various electricity generation sources. London: World Nuclear Association (WNA); 2011.
0
20
10
40
30
60
50
80
100
90
70
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
% s
ha re
o f r
en ew
ab le
e ne
rg y
in to
ta l f
in al
e ne
rg y
co ns
um pt
io n
USA
global average
FIGURE 4–24 Countries with high rates of electrification generally have small shares of energy consumption from renewable energy sources (including biofuels, hydro, wind, solar, geothermal, and other renewable sources). Data from Progress toward sustainable energy 2017: Global tracking framework report. Washington DC: World Bank/IEA; 2017.
4.4 Occupational and Industrial Health 81
health risks to people exposed to them.40 Haz- ardous exposures in the workplace may include radiation, chemical pollutants, and toxic sub- stances like polychlorinated biphenyls (PCBs), dioxins, asbestos, lead, mercury, cadmium, organic solvents, and pesticides. Many of these are released into the environment through industrial activities (FIGURE 4–25).41 Toxicol- ogists study the effect of exposure frequency (how often a person is exposed), duration (the length of exposure at a given time), and dose (the amount of hazardous substance contacted) on health. They also assess the various exposure routes (like inhalation, ingestion, and absorp- tion through the skin) and pathways (through air, water, food, soil, or other mechanisms) related to hazardous exposures. Carcinogens (substances that can cause genetic mutations that lead to cancer), teratogens (substances that can cause birth defects), and other hazards can be regulated or banned.
Hazardous substances cause more than 500,000 deaths worldwide each year, including about 180,000 deaths attributable to asbestos, 120,000 attributable to diesel engine exhaust, 85,000 attributable to silica exposure, and several thousand deaths due to poisonings.37 Although these hazardous substances are used and produced in indus- trial settings in countries across the income spectrum, workers in lower-income countries have greater risks from occupational expo- sure. Many highly toxic agents that are heavily
from moving parts. Medical workers are at risk of contracting infectious diseases from needle sticks and contact with body fluids. All workers may be subject to stress that can impair men- tal health.35 Specialists in industrial hygiene (also called occupational hygiene) assess and mitigate workplace hazards,36 such as issuing ear protection to workers in factories with high noise levels, making sure that people who spend their days in front of a computer have ergonomically designed chairs and are taking steps to minimize repetitive motion injuries, providing education about proper use of heavy machinery and hazardous materials, equipping healthcare workers with personal protective equipment, and providing wellness coaching.
Each year, at least 1.1 million people die from on-the-job injuries and job-related dis- eases, including about 490,000 people who die from lung cancer, bladder cancer, and other cancers attributed to workplace exposure to harmful chemicals or radiation; 400,000 who die from work-related respiratory diseases, such as COPD, asthma, and pneumoconi- osis, which is caused by inhalation of silica, asbestos, coal dust, and other substances; and 200,000 people who die from occupational injuries.37 Occupational risks are estimated to be responsible for 31% of years of life lived with low back pain, 27% of hearing loss, 15% of COPD, 8% of asthma, 8% of injuries, and 2% of leukemia cases worldwide.37 Every year there are more than 300 million occupational accidents that are severe enough to keep the injured person away from work for at least 4 days.38 Most occupational injuries, diseases, and deaths could be prevented if worksite managers and government officials enforced compliance with safety regulations.39
Toxicology is the study of the harmful effects that chemicals and other environmen- tal materials can have on living things. Chem- icals and other substances produced, handled, stored, transported, or disposed of at work and chemicals released from work activities can pose both acute (immediate) and long-term
© hedgehog94/Shutterstock
82 Chapter 4 Environmental Determinants of Health
industrial and municipal dumping, chemi- cal and product manufacturing, and the dye industry.42
Ecotoxicology examines the impact of toxic exposures on populations, communi- ties, and ecosystems. When industrial acci- dents occur, they often affect people who do not work at the site of an incident. The pol- lutants, toxins, and other substances released into air or water as a result of an accident can affect the local community and may spread to a larger area. The radioactivity released during the meltdown of the nuclear reactor at Cher- nobyl in Ukraine (then part of the USSR) in
regulated or banned in high- income countries are still used in lower-income countries, and most workers in low-income countries where occupational regulations are rarely enforced do not have access to protective gear and safety training.42 Furthermore, in some places where paid jobs are scarce, work that requires repeated exposure to dangerous chemicals may be seen as the only alternative to unem- ployment. The industries producing the most pollution-related health problems worldwide include used lead acid battery recycling, min- ing and ore processing, lead smelting, tannery operating, artisanal small-scale gold mining,
FIGURE 4–25 Harmful substances commonly found at worksites (ATSDR 2015 Substance Priority List). Data from 2015 ATSDR Substance Priority List. Atlanta GA: U.S. Agency for Toxic Substances and Disease Registry (ATSDR); 2015.
Substance Uses
Arsenic Used to make “pressure-treated” lumber, as a pesticide for cotton plants, and in copper and lead smelting
Lead Used in the production of batteries, ammunition, metal products (solder and pipes), and devices to shield X-rays; released from the burning of fossil fuels and during mining and manufacturing; used in some gasoline, paints, caulks, and ceramic products
Mercury Used in thermometers, dental fillings, batteries, and some antiseptic creams and ointments
Vinyl chloride Used to make polyvinyl chloride (PVC), plastic products like pipes, wire and cable coatings, and packaging materials
Polychlorinated biphenyls (PCBs)
Used as coolants and lubricants in transformers, capacitors, and other electrical equipment
Benzene Used to make other chemicals that form plastics, resins, nylon and synthetic fibers, rubbers, lubricants, dyes, detergents, drugs, and pesticides
Cadmium Extracted during the production of metals like zinc, lead, and copper for use in batteries, pigments, metal coatings, and plastics
Polycyclic aromatic hydrocarbons (PAHs)
A group of more than 100 different chemicals that are formed during incomplete burning of coal, oil, gas, garbage, tobacco, charbroiled meat, and other organic substances; also found in coal tar, crude oil, creosote, roofing tar, some medicines and dyes, plastics, and pesticides
4.4 Occupational and Industrial Health 83
engaged in child labor, about 245,000 children total. By 2012, the rate had dropped to about 10.6% of children, but there were still about 170,000 children engaged in child labor. That number included about 8.5% of children aged 5–11 years, 13.1% of children aged 12–14 years, and 13.0% of children aged 15–17 years.46 The proportion of children between 5 and 17 years old who were engaged in hazardous work dropped by half between 2000 and 2012, from 11% to 5.4%, but in 2012 about 85,000 children were still doing hazardous work.46
Two of the SDGs have targets that focus on occupational health, aiming to end child labor (SDG 8.7), to “promote safe and secure work- ing environments for all workers” (SDG 8.8), and to “build resilient infrastructure, promote inclusive and sustainable industrialization, and foster innovation” (SDG 9) with “increased resource-use efficiency and greater adoption of clean and environmentally sound technologies and industrial processes” (SDG 9.4).4 Many countries from all income levels have passed occupational and environmental health and safety laws,47 but meeting the SDG targets will require more attention on occupational health and safety, including protecting children from harmful labor, preventing workplace injuries and work-related diseases and disabilities, and safeguarding the health and safety of commu- nities located near industrial sites.
▸ 4.5 Urbanization Urbanicity is the degree to which a partic- ular location is urban, and it is a function of total population size, population density, pop- ulation diversity, and access to city services like retail facilities and public transportation (FIGURE 4–26).48 Urbanicity is the opposite of rurality, the degree to which a particular loca- tion is rural. In 1950, about 30% of the world’s people lived in urban areas. That percentage increased to more than 50% by 2010 and is projected to further rise to more than 65% by 2050 (FIGURE 4–27).49 Most higher- income
April 1986 spread a radioactive cloud across most of Europe. One health-related outcome of the meltdown was an increase in the inci- dence of thyroid cancer among children in the most contaminated regions.43 An accident at a chemical plant in Bhopal, India, in December 1984 released liquid and vapor methyl isocya- nate. Several thousand people died when they were exposed to the fumes, some in their beds and others in the street after they staggered out of their homes to try to escape from the chemical. Hundreds of thousands of people sustained lung injuries.44 Routine industrial practices may also put entire communities at risk, especially in lower-income countries with few regulations to prevent environmental contamination.42
Chemical hazards in the home and com- munity and at worksites can be especially dan- gerous for children who are still developing and growing. The risk of exposure to hazard- ous materials and other dangerous conditions is especially high for children who are sent to work at an early age. Some types of work, such as when rural children work alongside their parents on the family farm, can be a positive experience. But some children develop lasting physical and psychological scars from long hours doing domestic labor, agricultural work, or factory work. The International Labor Orga- nization (ILO) makes a distinction between children participating in economic activity— working (whether for pay or not) for a few hours or full time doing activities other than household chores or schooling—and children who are involved in child labor.45 It is permissi- ble for children aged 12 years and older to spend a few hours a week doing light work that is not hazardous. It is a child labor violation when a child has an excessive workload, unsafe work conditions, or extreme work intensity. Any of these conditions may harm a child’s physical health, mental health, or moral development. At worst, a child may be sold by his or her fam- ily into bonded labor, forced into sex work, or forced into armed conflict. In 2000, about 16% of all children between 5 and 17 years old were
84 Chapter 4 Environmental Determinants of Health
that lives in cities is increasing and is expected to continue to rise (FIGURE 4–29).49 SDG 11 has an aim of “making cities and human set- tlements inclusive, safe, resilient, and sus- tainable” through targets related to housing (SDG 11.1), transportation (SDG 11.2), air quality and waste management (SDG 11.6), and open public spaces (SDG 11.7).4 Because the majority of the world’s people live in cit- ies, urban health is a core component of global public health.50
© Stephane Bidouze/Shutterstock
Missing/Excluded Less then 30 30 to 50 50 to 75 75 to 85 85 and above
FIGURE 4–26 Proportion of people living in urban areas (2015). Data from United Nations Department of Economic and Social Affairs. World urbanization prospects: The 2014 revision. New York: UN; 2014.
FIGURE 4–27 The global urban population will continue to grow. Data from United Nations Department of Economic and Social Affairs. World urbanization prospects: The 2014 revision. New York: UN; 2014.
10
9
8
7
6
5
4
3
2
1
0
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050
B ill
io ns
Rural population Urban population
countries have highly urban populations, while most lower-income countries continue to have mostly rural populations ( FIGURE 4–28). How- ever, in nearly every country across the income spectrum, the proportion of the population
4.5 Urbanization 85
of better jobs, higher incomes, more social opportunities, and greater conveniences. Urbanization is occurring in nearly every part of the world, but this transition is happening
Urbanization is a shift toward more people living in cities and fewer people living in rural areas.51 Each day, thousands of peo- ple move from rural areas to cities in search
FIGURE 4–29 The proportion of the population living in an urban area is increasing in nearly every country and is projected to continue to increase. Data from United Nations Department of Economic and Social Affairs. World urbanization prospects: The 2014 revision. New York: UN; 2014.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0% EthiopiaNigeriaIndiaChinaBrazilIranGermanyUSA
1950 1975 2000 2025 2050
FIGURE 4–28 Percentage of each country living in an urban area (2015). Data from United Nations Department of Economic and Social Affairs. World urbanization prospects: The 2014 revision. New York: UN; 2014.
UrbanRural
EthiopiaNigeriaIndiaChinaBrazilIranGermanyUSA
86 Chapter 4 Environmental Determinants of Health
burden when their husbands move to cities to find wage employment, leaving the women with the responsibility of completing all household chores. Parents who move to a city may have to leave their children in the care of rural- dwelling grandparents, which puts a strain on three generations.
On average, urban residents have greater access than rural residents to water and san- itation, to a relatively reliable public trans- portation system, and to healthcare providers and health technologies. Electricity in cities
most dramatically in low- and middle-income countries ( FIGURE 4–30).49 In upper-middle- income countries, birth rates are relatively low and rapid rates of rural-to-urban migra- tion are causing rural populations to shrink as cities grow. In lower-income countries, the birth rates remain high, but rural-to-urban migration is causing the urban population to grow much faster than the rural population. This process of urbanization affects both urban and rural residents. Rural women, for example, may bear a particularly heavy
-3
-2
-1
0
1
2
3
4
5
EthiopiaNigeriaIndiaChinaBrazilIranGermanyUSA
Urban
% c
ha ng
e (2
01 5–
20 20
)
Rural
FIGURE 4–30 Urban areas are growing faster than rural areas (2015–2020). Data from United Nations Department of Economic and Social Affairs. World urbanization prospects: The 2014 revision. New York: UN; 2014.
4.5 Urbanization 87
Violence related to crowding and road- traffic accidents (often of the motor vehicle ver- sus pedestrian variety) might be common. It might be difficult to grow or purchase nutri- tious foods, and there may be little time or space for exercising.
There are numerous public health respon- sibilities that are common to all large popula- tion centers globally, including maintaining a safe built environment, managing water and sanitation services, disposing of waste, mini- mizing pollutants, and addressing other infra- structure issues.53 The similarities are especially prominent among megacities. A megacity is a metropolitan area with 10 million or more inhabitants. The number of megacities increased from 10 in 1990 to 29 in 2015, and that count is expected to rise to 41 by 2030 ( FIGURE 4–32).49 As the world urbanizes, the ability to achieve public health goals will depend on cities being safe, resilient, and sustainable. This will require cities in low- and middle-income countries to address the health-related challenges associated with poverty, socioeconomic inequalities, and environmental hazards.54
▸ 4.6 Sustainability A sustainable system is one that is able to be maintained at a particular level. When the term is used as part of the SDGs, the word sustainability emphasizes the need to pro- vide for current human needs without com- promising the ability of future generations to meet their needs.55 Sustainability has been described as a combination of “3 Es”: ethics (or equity), environment, and economics.56 These concepts have been expanded in the SDGs to include “5 Ps”: people, planet, pros- perity (or profit), peace, and partnership.4 SDG 12 has an aim of “ensuring sustain- able consumption and production patterns” through targets related to management of natural resources (SDG 12.2), reduction of food waste (SDG 12.3), management of haz- ardous waste (SDG 12.4), and improvements
reduces cooking time and makes it easier to store food safely. Communications systems broadcast news and entertainment shows as well as emergency warnings and health mes- sages. Urban women have more opportuni- ties to pursue additional education and find employment outside the home. Pregnancy in cities is safer because of greater access to ante- natal care and assistance by medical profes- sionals during delivery.
However, the benefits of urbanicity are not available to all urban residents (FIGURE 4–31). Many people who move to cities end up living in unplanned settlements (sometimes called shantytowns, slums, or squatter camps) where the quality of life is generally worse than rural life.52 In low- and middle-income countries, clusters of temporary structures are often quickly erected at the outskirts of large cities to accommodate rural-to-urban migrants. The structures are often built with cardboard or scraps of metal, wood, or other found objects, and they may provide little comfort or privacy and only minimal protection from the sun, rain, wind, and other elements. These dwell- ings may eventually be replaced with shacks built from blocks or bricks with a tin or asbes- tos roof, or they may be replaced with sturdier houses constructed from cement. Many years may pass before these growing communities have access to critical utilities. Residents might not have access to toilets. Informal dwellings are often built in floodplains or on other vul- nerable lands, and lack of drainage systems means that floods carry feces and other waste into homes. Trash and human waste might collect near the home and attract rodents and insects, increasing the risk of infectious dis- eases. Cooking indoors with solid fuels gen- erates high levels of air pollution. Unplanned communities in urbanizing cities are often located in undesirable locations near noisy and polluted highways or industrial centers that exacerbate asthma and cardiovascular condi- tions. Urban workers may face new occupa- tional hazards, and they might not have access to affordable emergency healthcare services.
88 Chapter 4 Environmental Determinants of Health
FI GU
RE 4–
31 C
om pa
ris on
o f h
ea lth
ri sk
s a ss
oc ia
te d
w ith
liv in
g in
ru ra
l, u np
la nn
ed u
rb an
, a nd
p la
nn ed
u rb
an a
re as
.
Se ct
or Ru
ra l
Un pl
an ne
d Ur
ba n
Pl an
ne d
Ur ba
n
W at
er
■ M
ay h
av e
m in
im al
a cc
es s t
o im
pr ov
ed
w at
er so
ur ce
s
■ Ri
sk o
f m ic
ro bi
al c
on ta
m in
at io
n
■
M ay
h av
e m
in im
al a
cc es
s t o
af fo
rd ab
le c
le an
w at
er
■ Ri
sk o
f m ic
ro bi
al e
xp os
ur e
an d
in du
st ria
l a nd
a gr
ic ul
tu ra
l c he
m ic
al
co nt
am in
at io
n
■
Re lia
bl e
ac ce
ss to
sa fe
, c le
an d
rin ki
ng
w at
er
Sa ni
ta tio
n
■ M
ay h
av e
in ad
eq ua
te sa
ni ta
tio n
fa ci
lit ie
s
■ O
pe n
de fe
ca tio
n in
a fi
el d
aw ay
fr om
th e
ho us
e m
ay b
e co
m m
on
■
M ay
h av
e in
ad eq
ua te
sa ni
ta tio
n fa
ci lit
ie s
■
O pe
n de
fe ca
tio n
in th
e st
re et
m ay
be
c om
m on
■
Se w
ag e
sy st
em
Tr as
h di
sp os
al
■ So
lid w
as te
is b
ur ne
d or
b ur
ie d
■
N o
co lle
ct io
n of
so lid
w as
te
■ Tr
as h
he ap
s c re
at e
a ha
bi ta
t f or
in
se ct
a nd
ro de
nt v
ec to
rs
■
So lid
w as
te is
c ol
le ct
ed a
nd re
m ov
ed
Ch em
ic al
ha
za rd
s
■ Po
te nt
ia l e
xp os
ur e
to a
gr oc
he m
ic al
s l ik
e fe
rt ili
ze r a
nd p
es tic
id es
■
Po te
nt ia
l e xp
os ur
e to
in du
st ria
l w
as te
■
Li ttl
e ex
po su
re to
in du
st ria
l o r
ag ric
ul tu
ra l h
az ar
ds
Fu el
■
So lid
fu el
s, w
hi ch
m ay
b e
ab le
to b
e co
lle ct
ed lo
ca lly
■
So lid
fu el
s, w
hi ch
m ay
b e
ex pe
ns iv
e
■ El
ec tr
ic ity
Ai r q
ua lit
y
■ In
do or
a ir
po llu
tio n
fro m
b ur
ni ng
bi
om as
s
■ Bo
th in
do or
a nd
o ut
do or
a ir
po llu
tio n
■
N oi
se p
ol lu
tio n
■
So m
e ou
td oo
r a ir
po llu
tio n
■
So m
e in
do or
a ir
po llu
tio n
fro m
bu
ild in
g m
at er
ia ls
N ut
rit io
n
■ M
ay h
av e
lim ite
d ab
ili ty
to p
ur ch
as e
fo od
■
Ca n
us ua
lly g
ro w
, g at
he r,
or h
un t f
or fo
od
■ M
ay h
av e
lim ite
d ac
ce ss
to
af fo
rd ab
le , h
ea lth
y fo
od s
■
M ay
n ot
h av
e sp
ac e
fo r a
g ar
de n
■
Ad eq
ua te
a cc
es s t
o he
al th
y an
d sa
fe
di et
ar y
ch oi
ce s
H ea
lth
fa ci
lit ie
s
■ Fa
ci lit
ie s m
ay b
e fa
r f ro
m h
om e
an d
m ay
pr
ov id
e on
ly b
as ic
c ar
e
■ Fa
ci lit
ie s m
ay b
e cr
ow de
d an
d un
de rs
ta ffe
d
■ Ba
sic , e
m er
ge nc
y, an
d sp
ec ia
lty
he al
th ca
re (i
nc lu
di ng
m en
ta l h
ea lth
an
d re
ha bi
lit at
io n)
fa ci
lit ie
s a re
a va
ila bl
e
4.6 Sustainability 89
Sustainability has grown in prominence as a global priority in recent decades because of the rapid increase in the size of the human population. The dangers of overpopulation can be illustrated by comparing Earth to an island. Picture a small island in the middle of an ocean. It is arable (that is, it can grow food) and it has a variety of plant and animal species. At first, ten people settle on the island. They build homes, develop a system for collecting freshwater (because ocean water is too salty to drink or use for irrigation), and begin to farm the land. They also begin to have children, and eventually those children have children. Soon, the population has reached 100, and then it grows to 1000. The amount of land avail- able for farming decreases as more homes are built, but the need for food is greater because there are more people to feed. Getting rid of waste products and finding energy sources are increasingly difficult. The limited amount of freshwater available is becoming a source of stress as the demand for water increases, but water quality is becoming poorer as waste pol- lutes water sources. Some plants and animals are threatened and at risk of extinction. Crime is increasing as resources become scarce. These challenges could be expected to become even worse as the population continues to grow.
in recycling and reuse (SDG 12.5).4 The con- cept of sustainability is also integrated into all of the other SDGs. The SDGs are intended to reduce poverty and disease for today’s people while ensuring that future generations inherit a healthy planet that allows them to enjoy long, healthy lives.57
Courtesy of United Nations Information Centre
FIGURE 4–32 The world’s megacities (urban areas of 10 million or more inhabitants). Data from United Nations Department of Economic and Social Affairs. World urbanization prospects: The 2014 revision. New York: UN; 2014.
Rank Metropolitan area Country Population (2015)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
Tokyo
Delhi
Shanghal
São Paul
Mumbai
Mexico city
Beijing
Osaka
Cairo
New York
Dhaka
Karachi
Buenos Aires
Kolkata
Istanbul
Chongqing
Lagos
Manila
Rio de Janeiro
Guangzhou
Los Angeles
Moscow
Kinshasa
Tianjin
Paris
Shenzhen
Jakarta
London
Bangalore
Japan
India
China
Brazil
India
Mexico
China
Japan
Egypt
USA
Bangladesh
Pakistan
Argentina
India
Turkey
China
Nigeria
Philippines
Brazil
China
USA
Russia
DR Congo
China
France
China
Indonesia
UK
India
38.0 million
25.7 million
23.7 million
21.1 million
21.0 million
21.0 million
20.4 million
20.2 million
18.8 million
18.6 million
17.6 million
16.6 million
15.2 million
14.9 million
14.2 million
13.3 million
13.1 million
13.0 million
19.9 million
12.5 million
12.3 million
12.2 million
11.6 million
11.2 million
10.8 million
10.8 million
10.3 million
10.3 million
10.1 million
90 Chapter 4 Environmental Determinants of Health
facing water scarcity crises, especially small island nations and desert countries where internal freshwater resources are extremely limited, and water wars are seen as a possibility in the coming decades as more people compete for control over the world’s finite supply of the freshwater that is essential for survival.61
Carrying capacity is the maximum human population the Earth can sustain. There is no easy way to calculate the carry- ing capacity, because it depends on the stan- dard of living and cultural factors in addition to population density (measured as land area per person or as arable land area per person), climate, and the land and natural resources that are available. However, carrying capac- ity can be approximated based on estimations of the per capita area of land needed to meet a population’s consumption patterns. The ecological footprint is a measure of how much burden human consumption places on the biosphere. People in high-income coun- tries have large ecological footprints and use many more resources per person than peo- ple in low- income countries (FIGURE 4–34).62 Earth likely could not support the current world population if everyone had the current ecological footprint of high-income countries, but most people in low- and middle- income countries aspire to the higher standards of liv- ing that come with larger ecological footprints. As countries’ economies grow, their residents tend to use more resources per person. Sus- tainable development promotes economic growth while simultaneously protecting the environment from the adverse effects that typically accompany industrialization.63
Sustainable global health programs aim to generate long-term health benefits that endure even after specific projects end. A program that depletes natural resources and promotes overconsumption is not sustainable.64 A pro- gram that is fully dependent on outside donors and does not involve recipients in planning, decision-making, and evaluation is not sus- tainable. Ideally, global health programs should foster capacity building and encourage the
Overpopulation occurs when a popula- tion becomes so large that the amount of food and other environmental resources available are insufficient to support all members of the popu- lation. The size of the Earth’s human population remained relatively steady for millennia, but recent growth has been exponential. A plot of the world’s population shows a “J-shaped” growth pattern (FIGURE 4–33).58 The doubling time, the number of years it takes for the world’s popula- tion to double in number, is getting shorter. It took only 40 years—from 1950 until 1990—for the number of humans to double from 2.5 bil- lion to 5 billion. The current world population is more than 7 billion, and demographers proj- ect that the global population may rise to 11 billion by 2100.59 The population might stabilize after that time, but it might also grow or shrink depending on numerous socioeconomic and environmental factors that will unfold over the coming decades.
In 1798, Thomas Malthus hypothesized that overpopulation leads to catastrophes like famines, epidemics, and wars.60 In the 21st century, this idea is expressed in terms of con- cerns about the unequal distribution of food and natural resources, the risks associated with the increased pollution and congestion that will occur with continued population growth, and the likelihood of increased crime and conflict as resources in some regions of the world become scarce. For example, many countries are already
FIGURE 4–33 The “J-shaped curve” for world population growth. Data from United Nations Department of Economic and Social Affairs. World population to 2300. New York: UN; 2004.
8
7
6
5
4
3
2
1
0
0 200 400 600 800 1000
Years
12001400 160018002000
B ill
io ns
4.6 Sustainability 91
include habitat loss and degradation, species overexploitation, pollution, invasive plant and animal species that crowd out native species in a location, the dissemination of pathogens in new areas due to human transportation systems, and climate change.68 Humans can promote planetary health by preserving and restoring natural resources, producing energy and goods more efficiently and less wastefully, and consuming resources more wisely.68
▸ 4.7 Climate Change and Health
Three of the SDGs address macro-level con- cerns about global environmental health. SDG 13 aims to “take urgent action to combat climate change and its impacts,” with a focus on strengthening resilience to respond to “climate-related hazards and natural disasters” (SDG 13.1). SDG 14 aims to “conserve and sustainably use the oceans, seas, and marine resources.” SDG 15 aims to “protect, restore, and promote sustainable use of terrestrial eco- systems, sustainably manage forests, combat desertification, and halt and reverse land deg- radation and halt biodiversity loss.”4
At the local level, it can be easy to observe the health effects of human actions that alter the environment. Infrastructural development like building permanent structures, convert- ing forests to farms, terracing slopes for agri- cultural use, paving streets, installing electrical lines and sewers, building dams, extracting fos- sil fuels to make oil and other petroleum prod- ucts, and a host of other activities has increased the quality of life for billions of people. But any intentional change to the local environment may have some unintended side effects that adversely affect human health.69 For exam- ple, building a dam may prevent flooding and improve agricultural productivity, but having a larger body of water nearby may increase the risk of some insect-transmitted infections and intestinal worm infestations.70
self-sufficiency of participating communities, such as by facilitating the integration of suc- cessful externally funded healthcare programs into the routine services offered by internally funded national healthcare systems.65
Sustainability applies to human behav- ior and also to larger ecological processes. Biodiversity is the presence of a wide variety of plant and animal species within a particu- lar environment. An ecosystem is sustainable when it can maintain its biodiversity and level of productivity indefinitely. The One Health concept emphasizes the interconnectedness of human health, animal health, and ecological health.66 Humans are dependent on plants and animals for food, and human lives are threat- ened when domestic animals, wildlife, agri- cultural crops, and other biological entities are harmed by environmental degradation and dis- ease. The emerging field of planetary health emphasizes the dependence of human health on the Earth, and seeks to understand the dam- age that human actions can impose on ecosys- tem health.67 Threats to the health of the planet
FIGURE 4–34 Ecological footprints are higher in high-income countries than in lower-income countries (2012). Data from National footprint accounts 2016. Oakland CA: Global Footprint Network; 2016.
0
2
4
6
8
10
9
7
5
3
1
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
USA
E co
lo gi
ca l f
oo tp
rin t
(g lo
ba l h
ec ta
re s
pe r
ca pi
ta )
92 Chapter 4 Environmental Determinants of Health
to be contributing to global climate change. The Intergovernmental Panel on Climate Change (IPCC), a scientific board that reviews and synthesizes scientific data about climate and weather under the auspices of the United Nations, has expressed certainty that global climate changes are occurring and will continue to occur for centuries to come.73 The impacts of global climate change include land degradation, water and air quality issues, bio- diversity loss, and temperature and precipita- tion extremes. The IPCC has also concluded that the observed changes are very likely due to human activity.74 While cycles of climate change have occurred throughout history, there is growing concern about the pace of climate variability.75 The IPCC predicts that climate change will mean more frequent hot days and nights, fewer cold days and nights, an increasing frequency of heat waves, an increase in the frequency of heavy precip- itation events in some areas and an increase in droughts in others, an increase in tropical cyclone (hurricane) activity, and an increase in the incidence of extremely high sea levels.76
Many of these expected climate changes could have significant adverse impacts on human health (FIGURE 4–35).77 Extreme heat increases the rate of cardiovascular disease
The immediate effects of most human activities are local, but the distinction between local and global environmental change is get- ting blurrier. In a globalized world, the choices any person makes about where to live, work, and travel and what to purchase can have an impact on people who live in distant lands. The air pollution created by millions of com- muters driving to work each day in one city does not just damage their airspace, but that of their neighbors. When electronic waste (e-waste) and other types of garbage are dis- carded by people in high-income countries, the potentially toxic materials may be shipped to dumps in lower-income countries.71 Defor- estation and habitat destruction, soil erosion and salinization, water management problems, overhunting and overfishing, invasive species (which may crowd out local flora and fauna), human population growth, and increasing use of resources per capita all can have local and global impacts.72
Climate change is a long-term shift in weather patterns and average tempera- tures. One component of climate change is global warming, a gradual increase in the temperature of the Earth’s atmosphere. The cumulative effect of the intensified use of natural resources across the planet appears
FIGURE 4–35 Examples of observed climate change trends and their likely impacts on human health. Data from Smith KR, Woodward A, Campbell-Lendrum D, et al. Human health: Impacts, adaptation, and co-benefits. In Climate change 2014: Impacts, adaptation, and vulnerability. Contribution of Working Group II to the 5th Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge UK: Cambridge University Press; 2014.
Climate Change Health Impact
Hot days become hotter and more frequent Increased rate of heat-related mortality from cardiovascular, respiratory, and kidney diseases exacerbated by heat
Precipitation events become more frequent and more intense, with more extreme floods in some places and more extreme droughts in others
Increased risks of undernutrition and of waterborne and vectorborne (insect-transmitted) infectious diseases
High sea levels become more extreme Increased risk of drowning
4.7 Climate Change and Health 93
in 1992 at the UN Conference on Environment and Development, colloquially called the Earth Summit, which was held in Rio de Janeiro, Brazil, and went into force in 1994. The 1997 Kyoto Protocol sought to toughen the FCCC commitments to reduce GHG emissions by the high-income signatory countries that generate the most emissions.84 The 2015 Paris Agree- ment is a legally binding set of additional com- mitments from signatories across the income spectrum to reduce global warming and pro- mote development that does not further exac- erbate environmental damage.85
Regardless of arguments about the precise causes of global warming, the alarming trends documented by the IPCC support the value of humans treading more lightly on the Earth. For example, alternative energy sources that har- ness solar, wind, or wave power may be able to produce energy that creates less pollution and less environmental damage than carbon-based fuels, hydroelectric power (which requires the building of massive dams and flooding of large swaths of land), and nuclear power (which remains dangerous because of the risk of a meltdown). The short- and long-term risks and benefits of projects that alter the environ- ment locally or more widely should be care- fully considered before projects are initiated, and the assessments should include health and environmental evaluations as well as economic ones.86 Strategic plans for public health initia- tives should examine the links between human and environmental health in the targeted pop- ulations and then account for the possible impact of climate change on health risks.87 In a globalized world, everyone has a stake in cre- ating and sustaining a healthy environment.88
▸ References 1. Prüss-Ustün A, Wolf J, Corvalán C, Bos R, Neira M.
Preventing disease through healthy environments: A global assessment of the burden of disease from environmental risks. Geneva: WHO; 2016.
2. Don’t pollute my future! The impact of the environment on children’s health. Geneva: WHO; 2017.
mortality.78 Extreme weather events decrease air quality by increasing particulates and pol- len in the air, and poor air quality exacerbates illness and mortality from respiratory and cardiovascular diseases.79 Floods, droughts, heat waves, and other weather extremes might reduce agricultural productivity, and ocean acidification might reduce aquacultural pro- ductivity, leading to greater levels of food insecurity.80 Extreme weather events can also increase the risks of diarrheal diseases, insect- borne infectious like malaria and dengue fever, and drowning and other types of inju- ries.81 The negative impacts of climate change are likely to be especially detrimental to the world’s lowest-income people, who often live in places with greater environmental vul- nerability and fewer resources to respond to threats.82
A series of international agreements have sought to combat climate change. The United Nations Framework Convention on Climate Change (FCCC) is an international environ- mental treaty that seeks to reduce greenhouse gas emissions.83 A greenhouse gas (GHG) is a gas in the atmosphere that traps heat and causes surface temperatures to increase. The GHGs of greatest concern include carbon dioxide (CO2), methane (CH4), nitrous oxide (N2O), and fluorinated gases such as sulfur hexafluoride (SF6), hydrofluorocarbons, and perfluorocarbons. The FCCC was negotiated
CDC/ Venecia Ramírez, Dominican Republic
94 Chapter 4 Environmental Determinants of Health
21. Progress toward sustainable energy 2017: Global tracking framework report. Washington DC: World Bank/IEA; 2017.
22. WHO guidelines for indoor air quality: Household fuel combustion. Geneva: WHO; 2014.
23. Fullerton DG, Bruce N, Gordon SB. Indoor air pollution from biomass fuel smoke is a major health concern in the developing world. Trans R Soc Trop Med Hyg. 2008;102:843–51.
24. Burning opportunity: Clean household energy for health, sustainable development, and wellbeing of women and children. Geneva: WHO; 2016.
25. The little green data book 2016. Washington DC: World Bank; 2016.
26. Kampa M, Castanas E. Human health effects of air pollution. Environ Pollut. 2008;151:362–7.
27. Brunekreef B, Holgate ST. Air pollution and health. Lancet. 2002;360:1233–42.
28. Smith KR, Pillarisetti A. Household air pollution from solid cookfuels and health (Chapter 7). Disease control priorities. 3rd ed. Injury prevention and environmental health (Volume 7). Washington DC: IBRD/World Bank; 2017.
29. Comparison of lifecycle greenhouse gas emissions of various electricity generation sources. London: World Nuclear Association (WNA); 2011.
30. Abrams HK. A short history of occupational health. J Public Health Policy. 2001;22:34–80.
31. Hughes RE. James Lind and the cure of scurvy: An experimental approach. Med Hist. 1975;19:342–51.
32. Waldron HA. A brief history of scrotal cancer. Br J Ind Med. 1983;40:390–401.
33. Abdalla S, Apramian S, Cantley L, Cullen M. Occupation and risk for injuries (Chapter 6). Disease control priorities. 3rd ed. Injury prevention and environmental health (Volume 7). Washington DC: IBRD/World Bank; 2017.
34. Encyclopedia of occupational health & safety. Geneva: ILO; 2017.
35. Leka S, Jain A. Health impact of the psychosocial hazards of work: An overview. Geneva: WHO; 2010.
36. A 5 step guide for employers, workers and their representatives on conducting workplace risk assessments. Geneva: ILO; 2014.
37. GBD 2015 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1545–602.
38. Safety and health at work: A vision for sustainable prevention. Geneva: ILO; 2014.
39. The prevention of occupational diseases. 4th ed. Geneva: ILO; 1998.
40. Safety and health in the use of chemicals at work. Geneva: ILO; 2013.
3. Landrigan PJ, Fuller R, Acosta NJR, et al. The Lancet Commission on pollution and health. Lancet. 2017. doi:10.1016/S0140-6736(17)32345-0
4. United Nations. Transforming our world: The 2030 Agenda for Sustainable Development. New York: UN; 2015.
5. UN Economic and Social Council. Report of the Inter-Agency and Expert Group on Sustainable Development Goal Indicators (E/CN.3/2016/2 /Rev.1). New York: UN; 2016.
6. Howard G, Bartram J. Domestic water quantity, service level and health. Geneva: WHO; 2003.
7. Guidelines for drinking water quality: 4th edition incorporating the first addendum. Geneva: WHO; 2017.
8. Water for life: Community water security. New York: Hesperian Foundation and UNDP; 2005.
9. Maupin MA, Kenney JF, Hutson SS, Lovelace JK, Barber NL, Linsey KS. Estimated use of water in the United States in 2010. Reston VA: U.S. Geological Survey; 2014.
10. Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF /WHO Joint Monitoring Programme for Water Supply and Sanitation; 2015.
11. Nordstrom DK. Worldwide occurrences of arsenic in ground water. Science. 2002;296:2143–4.
12. Smith AH, Lingas EO, Rahman M. Contamination of drinking-water by arsenic in Bangladesh: A public health emergency. Bull World Health Organ. 2000;78:1093–103.
13. Ahmed M, Jakariya M, Quaiyum M, Mahmud SN. An implementation guide for the Arsenic Mitigation Program. Dhaka: BRAC; 2002.
14. Kar K, Chambers R. Handbook on community-led total sanitation. London: Plan UK; 2008.
15. Preventing diarrhoea through better water, sanitation and hygiene: Exposures and impacts in low- and middle-income countries. Geneva: WHO; 2014.
16. World health statistics 2016. Geneva: WHO; 2016. 17. Mara D, Lane J, Scott B, Trouba D. Sanitation and
health. PLoS Med. 2010; 7:e1000363. 18. World development indicators 2016 (Table 2.9).
Washington: World Bank; 2016. 19. Hutton G, Chase C. Water supply, sanitation, and
hygiene (Chapter 9). Disease control priorities. 3rd ed. Injury prevention and environmental health (Volume 7). Washington DC: IBRD/World Bank; 2017.
20. Watkins D, Dabestani N, Nugent R, Levin C. Interventions to prevent injuries and reduce environ- mental and occupational hazards: A review of economic evaluations from low- and middle-income countries (Chapter 10). Disease control priorities. 3rd ed. Injury prevention and environmental health (Volume 7). Washington DC: IBRD/World Bank; 2017.
References 95
60. Nekola JC, Allen CD, Brown JH, et al. The Malthusian–Darwinian dynamic and the trajectory of civilization. Trends Ecol Evol. 2013;28:127–30.
61. Shiva A. Water wars: Privatization, pollution, and profit. Cambridge MA: South End Press; 2002.
62. National footprint accounts 2016. Oakland CA: Global Footprint Network; 2016.
63. Lélé SM. Sustainable development: A critical review. World Dev. 1991;19:607–21.
64. Barbier EB. The concept of sustainable economic development. Environ Conserv. 1987;14:101–10.
65. Shediac-Rizkallah MC, Bone LR. Planning for the sustainability of community-based health programs: Conceptual frameworks and future directions for research, practice and policy. Health Educ Res. 1998;13:87–108.
66. Zinsstag J, Schelling E, Waltner-Toews D, Tanner M. From “one medicine” to “one health” and systematic approaches to health and well-being. Prev Vet Med. 2011;101:148–56.
67. Whitmee S, Haines A, Beyrer C, et al. Safeguarding human health in the Anthropocene epoch: Report of The Rockefeller Foundation–Lancet Commission on planetary health. Lancet. 2015;386:1973–2028.
68. Living planet report 2016: Risk and resilience in a new era. Geneva: WWW International; 2016.
69. McMichael AJ, Campbell-Lendrum DH, Corvalán CF, et al. Climate change and human health: Risks and responses. Geneva: WHO; 2003.
70. Morse SS. Factors in the emergence of infectious diseases. Emerg Infect Dis. 1995;1:7–15.
71. Heacock M, Kelly CB, Asante KA, Birnbaum LS, Bergman Å, Bruné MN. E-waste and harm to vulnerable populations. Environ Health Perspect. 2016;124:550–5.
72. Diamond J. Collapse: How societies choose to fail or succeed. New York: Viking; 2005.
73. Pachauri RK, Meyer LA, editors. Climate change 2014: Synthesis report. Contribution of Working Groups I, II and III to the 5th Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge UK: Cambridge University Press; 2014.
74. Stocker TF, Qin D, Plattner GK, et al., editors. Climate change 2013: The physical science basis. Contribution of Working Group I to the 5th Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge UK: Cambridge University Press; 2013.
75. TBD. Health risks and costs of climate variability and change (Chapter 8). Disease control priorities. 3rd ed. Injury prevention and environmental health (Volume 7). Washington DC: IBRD/World Bank; 2017.
41. 2015 ATSDR Substance Priority List. Atlanta, GA: U.S. Agency for Toxic Substances and Disease Registry (ATSDR); 2015.
42. The world’s worst pollution problems 2016: The toxins beneath our feet. New York: Pure Earth; 2016.
43. Shibata Y, Yamashita S, Masyakin VB, Panasyuk GD, Nagataki S. 15 years after Chernobyl: New evidence of thyroid cancer. Lancet. 2001;358:1965–6.
44. Mehta PS, Mehta AS, Mehta SJ, Makhijani AB. Bhopal tragedy’s health effects: A review of methyl isocyanate toxicity. JAMA. 1990;265:2781–7.
45. International Programme on the Elimination of Child Labour (IPEC). Children in hazardous work: What we know, what we need to do. Geneva: ILO; 2011.
46. Making progress against child labour: Global estimates and trends 2000–2012. Geneva: ILO; 2013.
47. WHO Global Plan of Action on Workers’ Health (2008–2017): Baseline for implementation. Geneva: WHO; 2013.
48. Dahly DL, Adair LS. Quantifying the urban environment: A scale measure of urbanicity outperforms the urban-rural dichotomy. Soc Sci Med. 2007;64:1407–19.
49. UN Department of Economic and Social Affairs. World urbanization prospects: The 2014 revision. New York: UN; 2014.
50. Health as the pulse of the new urban agenda: United Nations conference on housing and sustainable urban development, Quito, October 2016. Geneva: WHO; 2016.
51. Vlahov D, Galea S. Urbanization, urbanicity, and health. J Urban Health. 2002;79(Suppl 4):S1–12.
52. Moore M, Gould P, Keary BS. Global urbanization and impact on health. Int J Hyg Environ Health. 2003;206:269–78.
53. Galea S, Vlahov D. Urban health: Evidence, challenges, and directions. Annu Rev Public Health. 2005;26:341–65.
54. McMichael AJ. The urban environment and health in a world of increasing globalization: Issues for developing countries. Bull World Health Organ. 2000;78:1117–26.
55. Our common future. Geneva: World Commission on Environment and Development (WCED); 1987.
56. Goodland R. The concept of environmental sustainability. Annu Rev Ecol Systematics. 1995;26:1–24.
57. Inheriting a sustainable world? Atlas on children’s health and the environment. Geneva: WHO; 2017.
58. UN Department of Economic and Social Affairs. World population to 2300. New York: UN; 2004.
59. Gerland P, Raftery AE, Ševčíková H, et al. World population stabilization unlikely this century. Science. 2014;346:234–7.
96 Chapter 4 Environmental Determinants of Health
82. Watts N, Adger WN, Agnolucci P, et al. Health and climate change: Policy responses to protect public health. Lancet. 2015;386:1861–914.
83. United Nations Framework Convention on Climate Change. New York: UN; 1992.
84. Kyoto Protocol to the United Nations Framework Convention on Climate Change. New York: UN; 1998.
85. Adoption of the Paris Agreement. (FCCC /CP/2015/L.9/Rev.1). New York: UN; 2015.
86. WHO guidance to protect health from climate change through health adaptation planning. Geneva: WHO; 2014.
87. Frumkin H, Hess J, Luber G, Malilay J, McGeehin M. Climate change: The public health response. Am J Public Health. 2008;98:435–45.
88. McMichael AJ, Beaglehole R. The changing global context of public health. Lancet. 2000;356:495–9.
76. Field CB, Barros VR, Mastrandrea MD, et al., editors. Climate change 2014: Impacts, adaptation, and vulnerability. Contribution of Working Group II to the 5th Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge UK: Cambridge University Press; 2014.
77. Costello A, Abbas M, Allen A, et al. Managing the health effects of climate change. Lancet. 2009;373:1693–733.
78. Luber G, McGeehin M. Climate change and extreme heat events. Am J Prev Med. 2008;35:429–35.
79. D’Amato G, Cecchi L, D’Amato M, Annesi-Maesano I. Climate change and respiratory diseases. Eur Respir Rev. 2014;23:161–9.
80. Watts N, Adger WN, Ayeb-Karlsson S, et al. The Lancet countdown: Tracking progress on health and climate change. Lancet. 2017;389:1151–64.
81. Quantitative risk assessment of the effects of climate change on selected causes of death, 2030s and 2050s. Geneva: WHO; 2014.
References 97
© Xinzheng. All Rights Reserved/Moment/Getty
CHAPTER 5
Health and Humans Rights Global health is founded on the principle that all people have the right to the highest attainable standard of health. By becoming signatories to the Universal Declaration of Human Rights, all of the world’s countries have agreed that there are many human rights that every person is entitled to, including the right to medical care. Governments have an obligation to ensure that everyone has access to water, health services, essential medicines, and other basic human needs. Members of low-income households, victims of natural disasters and complex humanitarian emergencies, people in prison, and people with disabilities often have difficulty accessing health services and other human rights. One of the roles of global health is to advocate for the human rights of those vulnerable populations.
▸ 5.1 Health and Human Rights
The preamble to the Constitution of the World Health Organization (WHO), which has been affirmed by the nearly 200 countries that have membership in the United Nations (UN), lists nine principles that serve as the foun- dational values for the field of global health (FIGURE 5–1). The boldest claim is that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being” (principle 2).1 This state- ment calls for quality health services to be accessible and affordable so that everyone has access to at least basic medical and psycholog- ical care (principle 7), especially children and people who are members of vulnerable popu- lation groups (principles 2 and 6). The pream- ble also notes that health is linked with peace
(principle 3) and security (principles 4 and 5), that everyone is at risk of outbreaks of infec- tious disease (principle 5), and that both the public (principle 8) and governments (princi- ple 9) must take active responsibility for public health. Two key terms in the preamble require careful definition: human rights and standard of health.
Human rights are entitlements that are due to every person simply because that person is human. Human rights are consid- ered to be universal, which means that they apply to every person of all ages in all cir- cumstances. The Universal Declaration of Human Rights (UDHR), which was unani- mously adopted by the member states of the United Nations in 1948, spells out more than two dozen civil, political, economic, social, and cultural human rights (FIGURE 5–2).2 Articles 3–21 define civil and political rights that protect the foundational freedoms of
98
humans, such as the right to privacy and the right to freedom from torture. These rights are about protections rather than provisions, and they can be granted and upheld with limited financial costs to governments. Articles 22–28 outline economic, social, and cultural rights that, if realized, would contribute to human flourishing. These rights, such as the right to social security, the right to education, and the right to a standard of living adequate for health and well-being, obligate governments to pro- vide certain services to their people.3 Because these rights carry real monetary costs, they are somewhat aspirational. However, countries
are called to make progress toward increasing the economic, social, and cultural rights of their populations.
The UDHR does not state that people have a right to be healthy. No government can guarantee health for anyone. For many diseases and disorders, there are currently no effective preventive methods or curative treat- ments, so there is no way for any entity to alle- viate the burden from those health issues. But the UDHR does state that all people have the right to medical care and the underlying tools for health, such as safe drinking water and adequate nutrition, no matter where they live.4
1 Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.
2 The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic, or social condition.
3 The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest cooperation of individuals and States.
4 The achievement of any State in the promotion and protection of health is of value to all.
5 Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a common danger.
6 Healthy development of the child is of basic importance; the ability to live harmoniously in a changing total environment is essential to such development.
7 The extension to all peoples of the benefits of medical, psychological, and related knowledge is essential to the fullest attainment of health.
8 Informed opinion and active cooperation on the part of the public are of the utmost importance in the improvement of the health of the people.
9 Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures.
FIGURE 5–1 Health principles articulated in the Preamble to the Constitution of the World Health Organization. Data from Constitution of the World Health Organization. New York: United Nations; 1946.
5.1 Health and Human Rights 99
Human Right UDHR Articles
Right to equal dignity and human rights for all humans 1, 2
Right to life, liberty, and security of person 3
Freedom from slavery and servitude 4
Freedom from torture and cruel, inhuman, or degrading treatment or punishment 5
Right to recognition as a person 6
Freedom from discrimination 7
Right to legal protection of human rights 8
Freedom from arbitrary arrest, detention, or exile 9
Right to a fair trial 10
Right to be presumed innocent until proven guilty 11
Right to privacy 12
Freedom of movement 13
Right to asylum 14
Right to a nationality 15
Right to marry and found a family 16
Right to own property 17
Freedom of thought, conscience, and religion 18
Freedom of opinion and expression 19
Freedom of peaceful assembly and association 20
Right to participate in government 21
Right to social security 22
Right to work 23
(continues)
100 Chapter 5 Health and Humans Rights
Before the concept of the “right to health” can be fully integrated into national health strat- egies and operationalized at the global level, four key questions will need to be answered9: (1) What are the services and goods guaranteed to every person under the human right to health? (2) What responsibilities do states have for the health of their own populations? (3) What duties do states owe to people beyond their borders in securing the right to health? (4) What kind of global governance for health is needed to ensure that all states live up to their mutual responsi- bilities? However, the shared commitment to ensuring that everyone has the basic tools for survival and health has already been recognized in numerous international agreements.
▸ 5.2 Access to Basic Human Needs
The most fundamental human right is the right to life. Human survival is dependent on having enough food, water, and air to support physiological processes and having sufficient shelter and clothing to protect the body from external exposures. These basic human needs are incorporated into the Sustainable Devel- opment Goals (SDGs) in targets that seek to
The term standard of health refers to targets that governments set for improving the health of the populations they govern. Achieving the “highest attainable standard of health” requires increasing access to healthcare services and to the tools for health. All governments can strive to increase access to preventive and thera- peutic services, starting with a basic package of healthcare services (such as antenatal care, childhood vaccinations, treatment of common infectious diseases, and access to clean water) and then expanding the range of services that are available to the entire population.5
Health and human rights are intertwined. People who are denied their human rights are unable to advocate for their own health, and populations that are unhealthy are unable to advocate for their rights.6 By adopting the UDHR, all UN member countries have affirmed their agreement that human rights are universal.7 When people in one country are being denied their human rights, people in other countries have the obligation to call attention to those violations. The goals of the field of health and human rights include pro- viding education about rights, exposing human rights violations, increasing accountability for governments and other organizations involved in health and human services, and improving access to health and related services.8
FIGURE 5–2 Key articles in the Universal Declaration of Human Rights. Data from The universal declaration of human rights. New York: United Nations; 1948.
Human Right UDHR Articles
Right to rest and leisure 24
Right to a standard of living adequate for the health and well-being of the individual and his/her family, including food, clothing, housing, medical care, and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, or old age
25
Right to education 26
Right to participate in the cultural life of a community 27
5.2 Access to Basic Human Needs 101
sources, such as personal wells and storage tanks, and they were even forbidden to collect rainwa- ter without a paid permit.15 After several months of escalating protests, the water system was re-nationalized. Water privatization schemes in countries in Latin America, Asia, Africa, and other parts of the world are generating similar concerns about how to guarantee that the poor- est residents can access safe drinking water.16
Problems with ensuring equitable and affordable water access are not limited to low- and middle-income countries (LMICs). In 2015 alone, tens of thousands of households in both Detroit and Philadelphia, two large cities in the United States, had their water supplies shut off,17 and the discovery of high levels of lead in the municipal water system in Flint, Michigan, triggered a state of emergency that forced tens of thousands of households to rely on bottled water for drinking, cooking, and hygiene.18 In many western U.S. states, where a growing human population and agri- cultural intensification have placed extreme demands on the watershed, the ownership of various supplies of water is determined based on so-called water rights that were sold many decades ago to cities, farmers, ranchers, and miners. It is illegal for people who do not own rights to the local watershed to use river water or collect rainwater.19 When large cities like Los Angeles and Las Vegas require additional water for their growing populations, they can buy water rights from distant sources. Then, large volumes of water from those source rivers are rerouted to the purchasing city. In some places, diversion of water or excessive use of water by upstream consumers has left downstream communities that have histor- ically had adequate water supplies with an insufficient amount of water.20 It can be dif- ficult for those downstream populations to make a legal case for their right to the miss- ing water, especially if the water crosses a state or national border (such as the U.S.–Mexican border). These sorts of ethical challenges will only become more acute as more people move to dry climates.
“ensure that all men and women, in particu- lar the poor and vulnerable, have equal rights to economic resources, as well as to basic services” (SDG 1.4) and to “ensure access for all to adequate, safe, and affordable housing and basic services” (SDG 11.1).10 Additional aspects of meeting these basic human needs are included in targets specific to health and nutrition, education, water and sanitation, energy, housing, and other goals.
Because drinking water is something that everyone requires on a daily basis just to survive, access to water is considered to be a human right.11 This does not mean that every- one has a right to an unlimited amount of free water, but it does mean that everyone has a right to an adequate quantity of clean water for consumption and hygiene at a reasonable cost.12 Increasing access to water requires investments in water system infrastructure, which usually means digging new groundwa- ter wells and protecting surface water sources, installing miles of pipelines and pumps to transport water from sources to consumers, and sometimes also constructing facilities to store and treat water. These improvements can be expensive, and the costs of building and maintaining the water system must usually be recouped through taxes or user fees. Addi- tionally, user fees help promote conservation, which is important in places where freshwater resources are limited. Thus, freshwater is con- sidered to be both an essential human need and a consumer good.13
Low-income households may struggle to access the water they need. For example, mas- sive protests occurred in 2000 in Cochabamba, Bolivia’s third largest city, after the government leased the city’s water rights to a U.S.-based cor- poration in order to improve services and sat- isfy a condition of a World Bank loan.14 To raise capital for modernizing the water system, the company significantly increased user fees. For many low-income households, the higher cost of water was a huge burden. There was no legal way to reduce the cost of the household’s water. Residents were banned from using other water
102 Chapter 5 Health and Humans Rights
mean adapting to cultural expectations, such as ensuring that a female healthcare provider examines female patients in nonemergency situations if that is the cultural expectation of the patient. The quality of healthcare services is based on having well-maintained facilities that are stocked with appropriate supplies and staffed by appropriately skilled workers. These criteria set a minimum standard for access to health care. They do not specify what consti- tutes an acceptable level of access to health personnel, medical specialists, tests and pro- cedures, medications, and health technology. Those details are expected to be defined by each country for its own people.
The right to health does not mean the right for everyone to have access to every health resource on demand. The economic reality is that most health systems cannot provide organ transplants to everyone who needs one to stay alive, expensive high-tech cancer treatments for everyone whose life could be extended by them, or years of intensive rehabilitation for everyone whose quality of life would improve with long-term care. Countries must make dif- ficult decisions about which routine preventive health services and screenings will be covered by the national health plan, what types of emer- gency care will be provided to everyone with life-threatening injuries, which medications will be part of the health system’s formulary, who will be eligible for particular surgical pro- cedures, and countless other considerations. These selections should be made after evaluat- ing the effectiveness and cost-effectiveness of various medications, devices, and procedures aimed at improving survival and quality of life.22 The right to health requires equitable access to covered services, so the services included in a national health plan must be in alignment with the resources available, such as the number of medical specialists and support staff available to implement covered procedures.23
The level of access to quality health ser- vices is a major social, economic, and political concern in countries across the income spec- trum. The United States has sought for decades
Growing concerns about water scarcity in many countries and regions require conserva- tion of precious freshwater resources (including the reduction of water loss during transport), clarification of the laws that govern water mar- kets and water use, and a commitment to ensure adequate water access to vulnerable populations.
▸ 5.3 Access to Health Services
The right to health care is one of many human rights recognized in the Universal Declara- tion of Human Rights. Article 25 states that “everyone has the right to a standard of living adequate for the health and well-being of him- self and of his family, including food, cloth- ing, housing, and medical care and necessary social services.”1 Several key criteria are used to evaluate access to health care, including availability, accessibility, affordability, accept- ability, and quality.21 Health services are avail- able when there are an adequate number of medical facilities that are functioning, staffed, and stocked with the necessary supplies. They are accessible when they are geographically and physically accessible to everyone, regard- less of residential location and physical ability. Health services are affordable when they are economically accessible and payment for ser- vices is commensurate with ability to pay. They are acceptable when clinical care providers are respectful of patients from all ethnicities, sexes, ages, and other population groups. This may
© Asianet-Pakistan/Shutterstock
5.3 Access to Health Services 103
access to safe and affordable surgical services (FIGURE 5–7).31
One of the factors contributing to these inequalities in access to human resources for health is brain drain, the migration of healthcare professionals trained in LMICs to higher paying jobs in high-income countries.32 In 2014, about 17% of physicians and 6% of nurses working in the 22 high-income coun- tries that are members of the Organisation for Economic Co-operation and Development (OECD) had been trained in other coun- tries.33 In the United States, 25% of physicians and 6% of nurses were trained in other coun- tries. In Germany, the percentages were 9% and 6%, respectively. Hundreds of thousands of physicians and nurses trained in India, China, Iran, Nigeria, and other LMICs work
to figure out how to increase the proportion of the population with health insurance, con- tain rising healthcare costs, and regulate pri- vate health insurance plans.24 Brazil, India, and China are all committed to providing universal access to healthcare services, but they are struggling to fund their health sys- tems, improve the quality of care, and ensure access in rural areas.25 Every country has to make decisions about what healthcare ser- vices should be provided and who should pay for those services, and these decisions have human rights implications.
The SDGs aim to “substantially increase health financing and the recruitment, devel- opment, training, and retention of the health workforce in developing countries and small island developing states” (SDG 3.c).10 At present, there is a very uneven distribution of healthcare workers across the globe. The WHO estimates that about 4.45 doctors, nurses, and nurse-midwives per 1000 people is the minimum ratio required for sustainable development. Higher ratios allow for higher- quality services to be provided. At present, there are about 14 skilled health professionals per 1000 people in high-income countries, 6 per 1000 in upper-middle-income countries, 4 per 1000 in lower-middle-income coun- tries, and only 1.5 per 1000 in low-income countries (FIGURE 5–3).26 This means that the number of people each clinician has to care for is higher in low-income countries than in high-income countries. For example, while there is about one physician, nurse, or nurse-midwife for every 75 residents of Germany, there is only one skilled health pro- fessional for every 3570 residents of Ethiopia (FIGURE 5–4).27 Lower-income countries also have insufficient numbers of mental health- care providers (FIGURE 5–5)28 and an inad- equate number of dentists (FIGURE 5–6).29 Lower-income countries also have too few surgeons,30 which means that the majority of residents in these areas do not have timely
FIGURE 5–3 There are many more physicians, nurses and midwives, and other health workers per 1000 residents in high-income countries than in low- income countries. Data from Health workforce requirements for universal health coverage and the Sustainable Development Goals. Geneva: WHO; 2016.
0
2
4
6
8
10
12
14
Other health workers Nurses & midwives Physicians
Upper middle income
Lower middle income
High income
C lin
ic ia
ns p
er 1
00 0
pe op
le
minimum acceptable rate
Low income
104 Chapter 5 Health and Humans Rights
in OECD countries.33 This means that LMICs bear the cost of training these clinicians, and high- income countries reap the benefits of that investment in education. While it would be unethical to deny health professionals the opportunity to emigrate, it is problematic when skilled clinicians in countries with insufficient numbers of medical professionals are actively recruited by high- income countries.34 The health SDGs will not be able to be met by 2030 if there is not a rapid expansion in the number of students enrolled in educational programs in medicine, nursing, and other health profes- sions both in the lower-income countries that have the lowest clinician-per-population ratios as well as in the high-income countries that rely on foreign-born clinicians because they are not training enough clinicians within their own educational systems.35
FIGURE 5–4 Skilled health professionals (physicians, nurses, and nurse-midwives) in low- and middle- income countries must serve many more people than clinicians in high-income countries. Data from World health statistics 2016. Geneva: WHO; 2016.
USA 82
74
105
435
318
415
498
3571
Germany
Iran
Brazil
China
India
Nigeria
Ethiopia
FIGURE 5–5 Mental health workers per 100,000 people. Data from Mental health atlas 2014. Geneva: WHO; 2015.
0
10
20
30
40
50
60
Low income
Lower middle income
Upper middle income
High income
M en
ta l h
ea lth
w or
ke rs
p er
1 00
,0 00
p eo
pl e
0
5
10
15
20
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
USA
D en
tis ts
p er
1 0,
00 0
pe op
le
FIGURE 5–6 Dentists per 10,000 people. Data from The challenge of oral disease: A call for global action. The oral health atlas. 2nd edition. Geneva: FDI World Dental Federation; 2015.
5.3 Access to Health Services 105
discovery through the regulatory review pro- cess in Europe.39 In exchange for their research and development (R&D) investments, phar- maceutical companies with a newly approved product are granted a patent, the exclusive rights to sell the new product for at least 20 years (or other periods of time negotiated with governmental and intergovernmental agen- cies).40 This provides the company with a win- dow of opportunity in which to recoup R&D costs and possibly make a profit.
The World Trade Organization (WTO) is a UN-related organization that negotiates and enforces trade agreements among UN mem- ber nations.41 Three WTO-sponsored interna- tional agreements spell out the rules for trade in goods, services, and intellectual property: the General Agreement on Tariffs and Trade (GATT) that focuses on goods; the General Agreement on Trade in Services (GATS); and the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement, which protects patents, copyrights, registered trade- marks, and industrial designs across national boundaries. Additional patent protections are provided to pharmaceutical and medical device companies through the World Intellec- tual Property Organization (WIPO) and some trade agreements between two or more coun- tries. For example, trade agreements might extend the duration of a patent on a medica- tion or device and enforce rules that prohibit generic versions of the products from being manufactured or imported.
Having a highly regulated international pharmaceutical industry protects public safety. Licensed brand-name and generic medications are subject to strict manufacturing and packag- ing regulations that ensure the quality and safety of the product. A counterfeit drug is an illegal product that is marketed deceptively. For exam- ple, counterfeiters may package sugar pills in boxes with the name of a brand-name medica- tion on them or they may repackage legally pro- duced medicines that are past their expiration dates in containers with new dates that make it look like the pills were just manufactured.
▸ 5.4 Access to Medicines Creating and testing new medications is a long and expensive process.36 New compounds must be created, tested in the laboratory, and then undergo several rounds of testing in humans. A clinical trial is a research study that eval- uates the safety and effectiveness of a health intervention. A series of phase 1, 2, and 3 trials evaluate the safety and efficacy of the product in several thousand human volunteers.37 Can- didate drugs that perform well in clinical trials are then submitted for governmental review. In the United States, it takes about 15 years and costs about $1.4 billion in expenditures to move a new product through the process of development, testing, and review by the Food and Drug Administration (FDA).38 It is similarly costly to move a new product from
FIGURE 5–7 Most people in low- and middle-income countries do not have timely access to safe and affordable surgery. Data from Alkire BC, Raykar NP, Shrime MG, Weiser TG, Bickler SW, Rose JA, et al. Global access to surgical care: A modelling study. Lancet Glob Health 2015;3:e316–23.
No access to surgery Access to surgery
High inome
Upper middle inome
Lower middle inome
Low inome
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
106 Chapter 5 Health and Humans Rights
2000s, pharmaceutical companies, govern- mental health agencies, and advocacy groups worked together to make patented medica- tions available at lower prices in LMICs. The 2001 Doha Declaration clarified the relation- ship between TRIPS and public health, not- ing that the TRIPS Agreement “does not and should not prevent members from taking measures to protect public health,” that “the Agreement can and should be interpreted and implemented in a manner supportive of WTO members’ right to protect public health and, in particular, to promote access to medicines for all,” and that countries facing a “national emergency or other circumstances of extreme urgency” could issue “compulsory licenses” for medications to be manufactured locally.44 This has helped increase legal access to criti- cal medications, but significant inequalities in access to medications remain.45
The WHO core list of essential medicines that healthcare systems should stock includes about 400 anti-infective, anti-allergic, analge- sic, antipsychotic, and hormonal drugs along with medications for noncommunicable dis- eases such as epilepsy, migraines, heart dis- ease, asthma, and gastrointestinal diseases.42 In most low-income countries, the national formulary includes fewer than those 400 med- ications. In most high-income countries, more than 1000 additional products are on the list of approved and available medications.46 People in high-income countries spend much more each year on medicines per person (public and private spending combined) than people in LMICs. The typical person in the United States (or his/her health insurance provider) spends about $1000 on pharmaceutical products each year. By contrast, annual spending on medi- cation is only $12 per person in India, $6 in Nigeria, and $5 in Ethiopia (FIGURE 5–8).47
The ethical principle of distributive justice posits that needed resources in a pop- ulation should be fairly allocated. The right to health in the Universal Declaration of Human Rights implies that signatories have an ethi- cal responsibility to expand the availability of
Some counterfeit products are both ineffective and unsafe because they do not contain any active pharmaceutical agent but might contain dangerous contaminants. A rigorous approval process for medications and devices ensures the quality and safety of licensed products. How- ever, trade agreements that regulate pharmaceu- tical products may restrict the ability of LMICs to legally produce or procure low-cost versions of medications. A generic drug is a medication with the same active ingredient as a brand-name medication that is produced after the patent for the brand-name medication expires. Generic medications usually cost less than brand-name ones, but generics cannot be sold legally until after the expiration of the exclusivity period granted to the patent recipient.
An essential medication is a drug that has been identified as a high priority for a country’s health system to have in stock at all times because it is a cost-effective treatment for a common health issue.42 Concerns about access to essential medications in LMICs became a prominent global health issue as the HIV/AIDS epidemic expanded in the 1990s. New antiretroviral medications (ARVs) that were saving lives in high-income countries were too expensive to be widely dispensed in LMICs. Countries like Brazil, India, and South Africa that tried to produce generic versions of patented ARVs or that imported generic medications produced elsewhere faced penalties for violating international intellectual property regulations.43 In the early
© Adul10/Shutterstock
5.4 Access to Medicines 107
medications for diseases that for-profit com- panies are unlikely to invest in because of the limited revenue expected from a product cre- ated primarily for use in LMICs.49 When these partnerships are funded by governments or philanthropic organizations, the medications they produce can be made available at an afford- able price as soon as they are proven to be safe and effective. Other types of partnerships work to accelerate the time line for making existing vaccines, diagnostic tools, and medicines legally available at affordable prices in LMICs.50
▸ 5.5 Health and Natural Disasters
Both natural and human-generated disasters can lead to urgent humanitarian situations (FIGURE 5–9). The critical needs immediately after any humanitarian incident include (1) water, sanitation, and hygiene; (2) food; (3) shelter and essential nonfood items, such as personal care items, clothing, bedding, cook- ing and eating utensils, fuel, and lighting; and (4) essential health services for injuries, infec- tions, sexual and reproductive health, mental health, and noncommunicable diseases.51
The players involved in a particular humanitarian response depend on the scale of the incident (FIGURE 5–10).52 A crisis is a small-scale event that can easily be addressed locally, like when a tornado damages several homes in a small town and neighbors provide aid to the affected households. An emergency is a larger event that stresses local resources but can still be managed locally. A disaster occurs when the need for assistance exceeds local capacity. The type of response is also dependent on whether an incident affects just a small community or is an international event (FIGURE 5–11).53 A catastrophe overwhelms the local response network and requires exten- sive outside assistance.54
A well-managed international response to a natural disaster or catastrophe begins when
vaccines, diagnostic tests, and medicines that are free or affordable for people who live in low- income countries.48 This value is expressed in the SDG target that aims to “support the research and development of vaccines and medicines for the communicable and non- communicable dis- eases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Dec- laration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use the full provisions in the Agree- ment on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all” (SDG 3.b).10 One model for achieving this goal is the creation of public– private partnerships that target development of
Ethiopia
Nigeria
India
China
Brazil
Iran
Germany
USA $970
$667
$24
$128
$72
$12
$6
$5
FIGURE 5–8 High-income countries spend much more on pharmaceutical products per person each year than lower-income countries (2014). Data from The pharmaceutical industry and global health: Facts and figures 2017. Geneva: International Federation of Pharmaceutical Manufacturers & Associations (IFPMA); 2017.
108 Chapter 5 Health and Humans Rights
Natural Disasters Human-Generated Disasters
Weather-related disasters ■ Floods ■ Landslides/mudslides ■ Hurricanes/cyclones/typhoons ■ Tornadoes ■ Winter storms
Geophysical disasters ■ Earthquakes ■ Tsunamis ■ Volcanic eruptions
Climate-related disasters ■ Droughts ■ Extreme heat ■ Extreme cold ■ Wildfires and forest fires
Biological disasters ■ Pandemic disease ■ Insect infestations
Intentional ■ War ■ Genocide/ethnic cleansing ■ Terrorism ■ Refugee crises ■ Internally displaced person crises
Unintentional ■ Transportation accidents ■ Industrial accidents ■ Hazardous materials spills ■ Explosions/fires ■ Radiation ■ Structural collapses (buildings, bridges, dams,
and tunnels)
FIGURE 5–9 Examples of types of disasters.
FIGURE 5–10 The scale of critical incidents depends on capacity and demand. Data from Quarantelli E.L. Just as a disaster is not simply a big accident, so a catastrophe is not just a big disaster. J Am Soc Prof Emerg Planners 1996;3:68–71.
1 Crisis Capacity > demand Local response is sufficient
2 Emergency Capacity = demand Local response is sufficient
3 Disaster Demand > capacity Outside assistance is necessary
4 Catastrophe Demand >> capacity Extensive outside assistance is necessary
an affected country invites the United Nations and other organizations to assist. A lead agency, usually the UN Office for the Coor- dination of Humanitarian Affairs (OCHA), is designated to coordinate the response by other UN agencies, government agencies (including militaries), the national Red Cross or Red Crescent society, and nongovernmen- tal organizations. These groups work together to meet essential needs that have been des- ignated as humanitarian response “clusters” (FIGURE 5–12).55 National and local responses
benefit from similar coordination strate- gies. In the United States, for example, the National Incident Management System (NIMS) specifies how different governmental agencies and nongovernmental organizations work together to respond to a disaster, and the Incident Command System (ICS) is an orga- nizational structure used in the field to pro- vide a clear chain of command for responders. The national response plan also identifies 15 Essential Support Functions (ESFs), critical service areas that require immediate attention
5.5 Health and Natural Disasters 109
PICE Stage
Potential for Additional Casualties
Effect on Local Resources
Extent of Geographic Involvement
Projected Need for Outside Assistance
Status of Outside Help
0 Static Controlled Local Little to none Inactive
1 Dynamic Disruptive Regional Small Alert
2 Dynamic Paralytic National Moderate Standby
3 Dynamic Paralytic International Great Dispatch
FIGURE 5–11 PICE (potential injury-creating event) nomenclature. Data from Koenig KL, Dinerman N, Kuehl AE. Disaster nomenclature—a functional impact approach: The PICE system. Acad Emerg Med 1996;3:723–7.
Cluster Lead UN Agency
Overall Coordination OCHA
Technical Clusters
Camp coordination and management IOM and UNHCR
Early recovery UNDP
Education UNICEF (and Save the Children)
Food security WFP and FAO
Health WHO
Nutrition UNICEF
Protection UNHCR
Shelter IFRC and UNHCR
Water, sanitation, and hygiene UNICEF
Support Clusters Emergency telecommunications WFP
Logistics WFP
FIGURE 5–12 Humanitarian response clusters. Data from Stumpenhorst M, Stumpenhorst R, Razum O. The UN OCHA cluster approach: Gaps between theory and practice. J Public Health 2011;19:587–92.
110 Chapter 5 Health and Humans Rights
responders do not coordinate their efforts, the result can be chaos. In the weeks after the mas- sive earthquake in Haiti in 2010, thousands of well-intentioned volunteers flew to Port- au- Prince to assist. Many of these spontaneous volunteers were unaffiliated with a Haiti-based host organization and arrived without ade- quate personal supplies, so they ended up being a burden rather than a help.58 Supplies remained stockpiled at the airport because the Haitian government, local institutions,
after a disaster, and names a lead agency that is responsible for each ESF during a disas- ter response (FIGURE 5–13).56 A coordinated response maximizes resources and saves lives.
Interagency coordination helps facilitate a timely and comprehensive response, espe- cially when this process ensures that volun- teers and their host organizations complete appropriate training before traveling to the disaster site and are prepared to fully provide for themselves in the field.57 If the various
ESF #1 Transportation
ESF #2 Communications
ESF #3 Public works and engineering
ESF #4 Firefighting
ESF #5 Emergency management
ESF #6 Mass care, emergency assistance, housing, and human services
ESF #7 Logistics management and resource support
ESF #8 Public health and medical services
ESF #9 Search and rescue
ESF #10 Oil and hazardous materials response
ESF #11 Agriculture and natural resources
ESF #12 Energy
ESF #13 Public safety and security
ESF #14 Long-term community recovery
ESF #15 External affairs
FIGURE 5–13 Essential support functions (ESFs) in the National Incident Management System (NIMS) of the United States. Data from National incidence management system. Washington U.S. Department of Homeland Security; 2008.
5.5 Health and Natural Disasters 111
Emergency management is about more than just responding to crises.62 Emergency management, also called disaster manage- ment, oversees all resources and responsi- bilities related to emergencies and disasters, including prevention, preparedness, response, and recovery. The emergency management cycle includes four steps, sometimes called the “4 Rs” (FIGURE 5–15): (1) Reduction of risks, or mitigation, is the process of implement- ing preemptive measures to protect people and property from hazards, such as by enforc- ing building codes. These activities enhance resilience, the ability of a community or nation to resist, survive, adapt to, and recover from natural disasters and other adverse events. (2) Readiness, or preparedness, for responding to an emergency includes the cre- ation and refinement of emergency operations plans, the establishment of emergency com- munication infrastructure, and the training of public employees and emergency response volunteers. (3) Response to an imminent, ongoing, or recent threat includes provision of emergency medical assistance, shelter, and other critical services. (4) Recovery is a phase in which continued efforts focus on rebuilding affected communities and attending to other aspects of reconstruction and rehabilitation.
▸ 5.6 Conflict and War A complex humanitarian emergency occurs when civil conflict or war causes mass migration of civilian populations, food insecu- rity, and long-term public health concerns.63 Natural disasters usually create an immediate period of acute need but quickly transition into recovery mode. By contrast, complex humanitarian emergencies may remain in an acute phase for years or even decades. Because natural disasters are generally seen as apoliti- cal events, it is usually fairly easy for aid agen- cies to assist survivors. Responses to complex humanitarian emergencies are much more complicated because military commanders
and various international governmental and nongovernmental organizations had difficulty communicating about on-the-ground needs, securing local transportation, and coordinat- ing distribution efforts. Similar logistical issues have occurred after other large-scale natural disasters, including the devastating tsunami that hit Southeast Asia in 2004.59
The SDGs address disaster preparedness and response in several targets, including a rec- ognition of the need to “strengthen the capac- ity of all countries, in particular developing countries, for early warning, risk reduction, and management of national and global health risks” (SDG 3.d) (FIGURE 5–14).10 Mitigating risks and preparing for potential critical inci- dents before they happen are the best ways to enable a smooth response and recovery when a natural or human-generated disaster does occur. The Sendai Framework for Disaster Risk Reduction is a global agreement that aims to significantly diminish the number of deaths and the magnitude of destruction caused by natural disasters.60 The priority areas with the Sendai Framework include increasing aware- ness of disaster risks, strengthening emer- gency management capacities in all countries, promoting investment in risk reduction, and enhancing the effectiveness of response and recovery efforts, including ensuring that the rebuilt structures are more resilient to future hazardous events.61 The need for improved disaster preparedness is especially acute in lower-income countries.
© Stefano Ember/Shuttertstock
112 Chapter 5 Health and Humans Rights
and faction leaders engaged in armed con- flicts are often disinclined to allow outsiders to assess and assist vulnerable populations.64
Numerous public health challenges arise during complex emergencies. The breakdown of water and sanitation systems and public health services may lead to frequent outbreaks of com- municable diseases. Diarrheal diseases may become very common. Vaccine-preventable diseases such as measles and meningitis may resurge when routine childhood vaccination programs are interrupted. Respiratory infec- tions like pneumonia and tuberculosis may become more prevalent due to inadequate shel- ter. Other infectious disease concerns include the intensification of malaria in endemic areas, outbreaks of viral hepatitis, and an increased incidence of sexually transmitted infections,
1.5 Build the resilience of the poor and those in vulnerable situations and reduce their exposure and vulnerability to climate-related extreme events and other economic, social, and environmental shocks and disasters.
2.4 Ensure sustainable food production systems and implement resilient agricultural practices that … strengthen capacity for adaptation to climate change, extreme weather, drought, flooding, and other disasters.
9.1 Develop quality, reliable, sustainable, and resilient infrastructure.
11.5 Significantly reduce the number of deaths and the number of people affected and substantially decrease the direct economic losses relative to global gross domestic product caused by disasters, including water-related disasters, with a focus on protecting the poor and people in vulnerable situations.
11.b Substantially increase the number of cities and human settlements adopting integrated policies and plans toward inclusion, resource, efficiency, mitigation and adaptation to climate change, resilience to disasters, and develop and implement, in line with the Sendai Framework for Disaster Risk Reduction 2015–2030, holistic disaster risk management at all levels.
13.1 Strengthen resilience and adaptive capacity to climate-related hazards and natural disasters in all countries.
16.1 Significantly reduce all forms of violence and related death rates everywhere.
FIGURE 5–14 SDG targets focused on disaster preparedness and response. Data from United Nations. Transforming our world: The 2030 agenda for sustainable development. New York: UN; 2015.
Reduction (Mitigation)
Readiness (Preparedness)Response
Recovery
FIGURE 5–15 Four stages of the emergency management cycle.
5.6 Conflict and War 113
conflict, and provide basic services to civilians, such as food, water, and medical assistance. The ICRC is funded through governmen- tal support, contributions from national Red Cross and Red Crescent societies, and private donations. National Red Cross and Red Cres- cent societies are autonomous from the ICRC, and they provide a variety of services that meet needs in their communities, such as maintain- ing blood banks, providing first aid training, and offering assistance to residents who have been affected by natural disasters. The ICRC and its affiliates generally attempt to maintain neutrality by carefully avoiding actions that could appear to take sides with any particular political party and by not releasing statements that could be construed as political.71
MSF plays a very different role in global health than the ICRC. Médecins Sans Frontières (MSF), more often called Doctors Without Borders in the United States, pro- vides medical care to people harmed by violence no matter what the victims’ races, religions, and political affiliations are.72 MSF often sets up clinics in places that are so unsta- ble that other organizations refuse to deploy resources to them.73 The core values of MSF include independence, impartiality, and bear- ing witness to violations of human rights.72 To MSF, impartiality does not mean silence.74 Impartiality means that all governmental agencies and other bodies are equally open to criticism from MSF when they engage in or allow injustices.75
which may be spread through gender-based violence and then remain untreated because of lack of access to health care.65
International humanitarian laws are sup- posed to protect civilians and combatants,66 but these rules are not always enforced.67 Rape and sexual violence have been used as mili- tary tactics in many conflicts.68 Reproductive health services, including family planning and obstetric care, and psychiatric services tend to be severely inadequate during conflicts. Mal- nutrition is also a major concern during war and civil conflicts.69 Food production tends to decrease as farms are abandoned, and it is more difficult to import affordable food during times of instability. Food supply chains that enable food products to be processed, trans- ported, stored, and sold are often interrupted by conflict and uncertainty. Large numbers of people may be migrating and in need of a daily supply of nutrients. The combination of too few calories, vitamins, and minerals plus lack of care for other diseases often leads to severe undernutrition.
Two of the most prominent organiza- tions involved in providing health services and other types of assistance during times of war are the Red Cross and Médecins Sans Fron- tières. The International Committee of the Red Cross (ICRC) is unique among private organizations because it is an independent organization guided by its own set of rules and principles—humanity, impartiality, neutrality, independence, voluntary service, unity, and universality—but it is officially sanctioned by the Geneva Convention and international law to provide specific humanitarian services.70 The ICRC works with more than 185 national Red Cross and Red Crescent societies and the International Federation of Red Cross and Red Crescent Societies to provide humanitarian aid to both civilian and military victims of conflicts. Red Cross representatives visit prisoners of war, search for missing persons, transmit messages between separated family members, reunify dispersed families, monitor compliance with the international laws that pertain to armed © Joseph Sohm/Shutterstock
114 Chapter 5 Health and Humans Rights
amputated limbs need to be refitted with new devices as they grow.79
Access to basic health care is considered to be a fundamental human right, but wars and civil conflicts often restrict access to health services and the foundational tools for health.80 International organizations can play a critical role in advocating for human rights, promoting health, and providing medical care during times of conflict and war. In postcon- flict areas, public health work can facilitate the transition back to peace by implementing initiatives that improve population health sta- tus and strengthen social connections across diverse populations.81
▸ 5.7 Bioterrorism Bioterrorism is the deliberate release of pathogens, chemicals, or other agents that can cause illness and possibly death of peo- ple, animals, or plants. Chemical and biolog- ical warfare are not new.82 During the Tartar siege of the city of Kaffa (now in the Ukraine) in the 14th century, the bodies of plague vic- tims were catapulted over city walls to spark an epidemic. During the French and Indian War in the 1760s, the British army sent smallpox-infected blankets to American Indians who supported the French. During World War I, several European nations used biological agents against the livestock of ene- mies. What is new is that there are now more tools available for creating and spreading bio- terror agents and the scale on which such acts can occur is much larger.
A bioweapon may be selected because it produces severe disease or death, the target population is susceptible to the agent, and the target population has limited or no access to immunization or treatment. Additionally, a particular agent may be selected for use because it can be produced relatively easily and rapidly, it is relatively inexpensive, it is environmentally stable, it has a low infectious dose, it has a simple delivery mechanism (such
In postconflict areas (and also in areas that have been devastated by natural disasters), a diversity of local, national, and international organizations typically help with reconstruc- tion by responding to urgent needs, assisting with long-term recovery, and helping to pre- vent future crises. Political and economic sys- tems need to be rebuilt, and educational and social services need to be restored after a civil conflict or war. Postconflict areas also need to repair health systems (because of lost infra- structure and personnel, among other issues), expand access to physical rehabilitation and mental healthcare services, and address envi- ronmental health concerns. Contaminated environments often take longer to renovate than hospitals and clinics.76 For example, a landmine is a buried explosive device, and landmines and other unexploded ordnance buried during wartime remain hazards to workers, children, and communities long after the conflict is over. This means, among many other problems, that large tracts of potential farmland are unable to be cultivated because of the risk of encountering a mine while clear- ing a field. Most people who sustain landmine injuries are civilians. Children may have ele- vated risk of injuries because they do not know how to recognize explosive devices and may pick them up and even play with them. Landmines and other explosive remnants of war remain a concern in many parts of the world, killing thousands of civilians each year and seriously injuring thousands of others.77 Although it only costs a few dollars to pur- chase and plant a mine, it can cost thousands of dollars to safely remove one.78 The direct costs to injured individuals and their families can be very high when they must pay for sur- gery, a lengthy hospitalization, and a lifetime of assistive devices for people who survive with lost limbs, burn contractures, blindness, and other permanent disabilities. A prosthetic is a replacement body part, such an artificial leg or arm that might be used after a limb is lost in a landmine explosion. Even a low-tech prosthetic can be expensive, and children with
5.7 Bioterrorism 115
concern because the bacterium was used in a postal bioterrorism attack in the United States in 2001.85 Naturally occurring cases of anthrax are diagnosed every year in people who work with sheep and livestock because anthrax spores (dormant bacteria) can survive in the environment for years. These cases are usually cutaneous (skin) infections. In the laboratory, anthrax can be made into a fine powder that can cause an inhalational anthrax that affects the lungs. Anthrax is not passed from per- son to person, but the weaponized form can be aerosolized and breathed in.86 Anthrax disease can be cured with antibiotics if is detected early, but advanced cases are often fatal. Category B agents are moderately easy to spread but usually cause relatively few deaths. Examples of Category B agents include bru- cellosis, ricin (a toxin from the plant Ricinus communis, also known as castorbean or caster
as through air, water, or food), it is highly infectious, it has a desirable incubation period (either short so immediate disease is produced or longer so that the asymptomatic contagious stage is lengthy), and it causes disease that is difficult to diagnose.83 While the goal of some bioterrorists is to kill or seriously injure large numbers of people, the most common goal is to cause widespread fear, panic, and social disruption.
In the United States, potential bioter- ror agents are classified into three groups (FIGURE 5–16).84 Category A represents high- priority agents that pose a significant risk because they can be easily transmitted from one person to another or have high mortality rates. Category A agents include anthrax, smallpox, plague, botulism, tularemia, and viral hemor- rhagic fevers like Ebola and Marburg virus. Anthrax (Bacillus anthracis) is of particular
Category Agents
Category A ■ Anthrax (Bacillus anthracis) ■ Botulism (Clostridium botulinum toxin) ■ Plague (Yersinia pestis) ■ Smallpox (variola major) ■ Tularemia (Francisella tularensis) ■ Viral hemorrhagic fevers (such as Ebola, Marburg, Lassa, and Machupo viruses)
Category B ■ Brucellosis (Brucella species) ■ Glanders (Burkholderia mallei) ■ Melioidosis (Burkholderia pseudomallei) ■ Psittacosis (Chlamydia psittaci) ■ Q fever (Coxiella burnetii) ■ Toxins (such as ricin, Staphylococcus enterotoxin, and the epsilon toxin of
Clostridium perfringens) ■ Typhus fever (Rickettsia prowazekii) ■ Food- and waterborne diseases (such as Cryptosporidium parvum,
Escherichia coli O157:H7, hepatitis A virus, Salmonella, Shigella, and Vibrio cholerae) ■ Mosquito-borne encephalitis viruses
Category C ■ Emerging infectious diseases, including drug-resistant pathogens
FIGURE 5–16 U.S. classifications of potential bioterrorism agents. Data from Rotz LD, Khan AS, Lillibridge SR, Ostroff SM, Hughes JM. Public health assessment of potential biological terrorism agents. Emerg Infect Dis 2002;8:225–30.
116 Chapter 5 Health and Humans Rights
a strong laboratory network, trained public health departments that are prepared to coor- dinate response activities, the cooperation of healthcare providers and emergency respond- ers, and an adequate stockpile of essential vaccines and medications.84 Strong commu- nication systems are also necessary for keep- ing the public informed of developments and encouraging appropriate personal responses. Global communication may also play a role in preventing some acts of terrorism and responding to attacks that do occur.
In any response, careful attention must be paid to protecting the civil, political, economic,
oil plants), Q fever, typhus fever, viral enceph- alitis infections, food safety threats, such as Salmonella, Shigella, and E. coli O157:H7, and water supply threats, such as cholera and cryp- tosporidiosis. Category C agents are emerging infectious diseases like hantaviruses that are potential threats in part because they are not well understood. Chemical agents may also pose a threat (FIGURE 5–17).87
The best defense against a bioterrorism attack is early detection so that an outbreak can be contained and exposed or at-risk people can receive immunization, post-exposure pro- phylaxis, and medical treatment. This requires
Category Examples
Nerve agents Tabun, sarin, soman, GF, VX
Blood agents Hydrogen cyanide, cyanogen chloride
Blister agents Lewisite, nitrogen and sulfur mustards, phosgene oxime
Heavy metals Arsenic, lead, mercury
Volatile toxins Benzene, chloroform, trihalomethanes
Pulmonary agents Phosgene, chlorine, vinyl chloride
Incapacitating agents BZ
Explosive nitro compounds and oxidizers Ammonium nitrate combined with fuel oil
Flammable industrial gases and liquids Gasoline, propane
Poisonous industrial gases, liquids, and solids Cyanides, nitriles
Corrosive industrial acids and bases Nitric acid, sulfuric acid
Other agents Esticides, dioxins, furans, polychlorinated biphenyls
FIGURE 5–17 Possible chemical bioweapons. Data from Biological and chemical terrorism: Strategic plan for preparedness and response. Recommendations of the CDC Strategic Planning Workgroup. MMWR Recomm Rep. 2000;49(RR-1):1–14.
5.7 Bioterrorism 117
(FIGURE 5–19).89 Prisons, jails, and deten- tion centers house convicted criminals and may also accommodate suspects waiting for trial, juvenile offenders, and undocumented immigrants.
Many people entering prison already have health problems related to mental ill- ness, drug abuse, and poverty. Incarceration may exacerbate existing health conditions and create new health problems as a result of exposure to severe overcrowding, poor ventilation, poor nutrition, unhygienic conditions, lack of access to medical care, abuse by guards, and prisoner-on- prisoner violence, including beatings and sexual assault. Prison populations worldwide have higher rates of HIV, tuberculosis, and other infectious diseases than the general popu- lation.90 Tuberculosis (TB) is of particular concern because it is an airborne infectious disease. TB spreads easily in crowded prison blocks, and late diagnosis and inad- equate treatment may allow prisoners with TB to remain contagious for lengthy peri- ods of time. Interruptions in treatment can facilitate the emergence and spread of drug-resistant strains that are not able to be cured by the standard antibiotics used
social, and cultural rights of affected persons. In some situations, individual and collective rights must be balanced. A nonderogable right is a human right that is irrevocable, such as the rights to freedom from slavery and freedom from torture. But some other rights may be temporarily suspended under special circumstances when restrictions on some individual rights protect the community as a whole. For example, freedom of movement for people with highly contagious infections may be temporarily limited during an outbreak so that the health rights of other people can be protected.88 If rights are derogated during or immediately after a critical incident, the new rules must not be discriminatory, and full rights should be restored as soon as possible.
▸ 5.8 Health in Prisons On any given day, nearly 10 million people across the globe are incarcerated, including more than 2.2 million people in the United States and 1.7 million in China (FIGURE 5–18).89 The incarceration rate varies considerably between countries, but the country with the highest rate, by far, is the United States
2,217,000 USA
4,999,133 Rest of the
world
63,628 Germany
225,624 Iran
607,731 Brazil1,657,812
China
418,536 India56,620
Nigeria
111,050 Ethiopia
FIGURE 5–18 More than 10 million people worldwide are in prison each day. Data from Walmsley R. World prison population list. 11th ed. London: International Centre for Prison Studies; 2016.
FIGURE 5–19 The United States has the world’s highest incarceration rate. Data from Walmsley R. World prison population list. 11th ed. London: International Centre for Prison Studies; 2016.
0
100
200
300
400
500
600
700
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
USA
P ris
on p
op ul
at io
n pe
r 10
0, 00
0 pe
op le
global average
118 Chapter 5 Health and Humans Rights
impairment and the social and environmen- tal context in which a person with impair- ment interacts with other people and the world (FIGURE 5–20). About 15% of the world’s people—more than 1 billion people total—have a moderate or severe disability.94 People with disabilities are entitled to all of their human rights, including the right to be treated with dignity, to have the autonomy to make deci- sions for themselves (if they are cognitively capable of doing so), and to be active members of society.95
An impairment may affect numerous domains, such as self-care, mobility, commu- nication, and learning (FIGURE 5–21).96 Some people with impairments need assistance with activities of daily living (ADLs), the routine daily self-care functions that are required for health and survival, such as dressing, eating, ambulating, using the toilet, and taking care of personal hygiene (FIGURE 5–22). Some peo- ple with impairments can manage the ADLs but require assistance with the instrumental activities of daily living (IADLs) required for independent living, such as shopping, housekeeping, managing personal finances, preparing foods, and navigating transporta- tion. Some people with impairments manage their own ADLs and IADLs, but experience limitations in full participation in social events because of stigma and other barriers.
Rehabilitation is the process of restor- ing, improving, or maintaining the highest
to treat TB. Over time, an increase in TB in prisons will increase the amount of TB in the general population. When individuals infected with TB are released from prison, they may spread TB to their family and friends. To prevent further increases in the prevalence of TB in prisons, it is important for every case of TB in incarcerated people to be detected early and treated consistently with no interruptions in antibiotic therapy.91
Prisoners are entitled to all fundamental human rights, and they have a right to be pro- tected from medical neglect, starvation, abuse, forced medical experimentation, and other civil rights violations.92 Contracting potentially life-threatening infections is not part of any prisoner’s sentence. It is considered unjust not to provide incarcerated people with medical and dental care, adequate nutrition, protection from infectious diseases, and safe conditions.93
▸ 5.9 People with Disabilities
An impairment is a difference or limitation in an anatomical structure, mental or sensory function, or physiological function that con- strains the capacity of an individual to do a task or action. A disability occurs when an impairment leads to restrictions in activity and participation. Disability is the result of both an
FIGURE 5–20 Disabilities are a function of biological, social, and environmental factors.
Activity limitations and participation restrictions
Impairment of body structures (anatomy) or functions (physiology)
Environmental factors
Personal and social factors
© txking/Shutterstock
5.9 People with Disabilities 119
high-income country where rehabilitation facilities are routinely accessible might cause permanent disability in a low-income country where rehabilitation services are not available. People with physical and mental impair- ments and disabilities also benefit from being included to the fullest extent possible in the activities of their families and communities.
level of function possible in order to maximize independence and quality of life. Adults and children of all ages who have impairments can benefit from timely access to appropriate physical therapy, occupational therapy, speech–language therapy, and other types of rehabilitation services.97 A condition that might be preventable or treatable in a
Domain Activities
Learning and applying knowledge
Watching, listening, learning to read, learning to write, learning to calculate, solving problems
General tasks and demands Undertaking a single task, undertaking multiple tasks
Communication Receiving spoken messages, receiving nonverbal messages, speaking, producing nonverbal messages, conversation
Mobility Lifting and carrying objects, fine hand use (such as picking up objects or grasping them), walking, moving around using equipment (such as a wheelchair), using transportation
Self-care Washing oneself (such as washing hands, bathing, and using a towel), caring for body parts (by brushing teeth, shaving, and grooming), toileting, dressing, eating, drinking, looking after one’s own health
Domestic life Acquisition of goods and services (such as by shopping), preparation of meals (such as by cooking), doing housework (such as cleaning house, washing dishes, doing laundry, and ironing), assisting others
Interpersonal interactions and relationships
Basic interpersonal interactions, complex interpersonal interactions, relating to strangers, formal relationships, informal social relationships, family relationships, intimate relationships
Major life areas Informal education, school education, higher education, remunerative employment, basic economic transactions, economic self-sufficiency
Community, social, and civic life
Community life, recreation and leisure, religion and spirituality, human rights, political life, and citizenship
FIGURE 5–21 Domains of activity and participation from the International Classification of Functioning, Disability, and Health. Data from International Classification of Functioning, Disability, and Health (ICF). Geneva: WHO; 2001.
120 Chapter 5 Health and Humans Rights
work (SDG 8.5), transportation (SDG 11.2), public spaces (SDG 11.7), and civic events (SDG 16.7).99 People with disabilities have an increased risk of living in poverty. The direct costs associated with paying for medical care and assistance can be overwhelming. Health issues restrict the ability of some people with disabilities to work, and family caregivers may need to limit their paid employment and home productivity. These economic factors are exac- erbated when people with disabilities have lim- ited access to the public services, education, and employment opportunities that would enable a higher standard of living. A safe and accessible physical environment and a strong social net- work are critical for maximizing the activities and social participation of all people who have impairments and disabilities (FIGURE 5–23).96
People with impairments may have their activities facilitated or restricted by their envi- ronment and the resources available to them. An assistive device, also called assistive technology, is a tool that helps with the per- formance of a task. Assistive devices such as wheelchairs and canes, prosthetics for people with missing arms or legs, orthotics and braces for people with various types of musculoskel- etal disorders, hearing aids, and glasses can enable independence and fuller participation in social activities. However, only about 10% of people worldwide who would benefit from medical assistive devices have them.98 A person who uses a wheelchair may easily access public transportation, sidewalks, and public buildings in Germany, but might find it impossible to navigate the unpaved pathways of rural Ethi- opia. An American with a visual impairment may have access to books through Braille edi- tions, electronic magnifiers, and audio record- ings, but a similarly impaired person in Nigeria might not have access to any of these tools.
The SDGs feature numerous targets geared toward increasing the ability of people with disabilities to access social protections (SDGs 1.3 and 10.2), education (SDGs 4.5 and 4.a),
Activities of Daily Living (ADLs): Self-care
Instrumental Activities of Daily Living (IADLs): Independence
Dressing Shopping
Eating Housekeeping
Ambulating (mobility)
Accounting (personal finances)
Toileting Food preparation
Hygiene Transportation
FIGURE 5–22 Activities of daily living.
CDC/Molly Kurnit, M.P.H./Paul Chenoweth
5.9 People with Disabilities 121
3. Leckie S. Another step towards indivisibility: Identifying the key features of violations of economic, social and cultural rights. Human Rights Q. 1998;20:81–124.
4. Hunt P. The human right to the highest attainable standard of health: New opportunities and challenges. Trans R Soc Trop Med Hyg. 2006;100:603–7.
5. International Covenant on Economic, Social and Cultural Rights (A/RES/21/2200). New York: UN; 1966.
6. Mann JM, Gostin LO, Gruskin S, Brennan T, Lazzarini Z, Fineberg HV. Health and human rights. Health Hum Rights. 1994;1:6–23.
7. Global health ethics: Key issues. Geneva: WHO; 2015. 8. Farmer P. Pathologies of power: Rethinking
health and human rights. Am J Public Health. 1999;89:1486–96.
9. Gostin LO, Friedman EA, Ooms G, et al. The joint action and learning initiative: Towards a global agreement on national and global responsibilities for health. PLoS Med. 2011;8:e1001031.
10. United Nations. Transforming Our World: The 2030 Agenda for Sustainable Development. New York: UN; 2015.
The WHO defines health as “a state of complete physical, mental, and social well-being.”1 By that definition, any action that improves social well-being will improve overall health status. Increasing the social inclusion of people with disabilities will yield health ben- efits for those individuals and their families, and also for their communities. Global health is founded on the principle that all people have the right to the highest attainable standard of health. Advocating for everyone’s human rights is a core part of achieving that shared goal.
▸ References 1. Constitution of the World Health Organization. New
York: United Nations; 1946. 2. The Universal Declaration of Human Rights. New
York: United Nations; 1948.
Environment Environmental Characteristics
Products and technology Products for personal consumption (food, medicines), for personal use in daily living, for personal indoor and outdoor mobility and transportation, for communication; design, construction, and building materials of buildings for public use and buildings for private use
Natural environment and human-made changes to the environment
Climate, light, sound
Support and relationships Support of and relationships with immediate family, friends, acquaintances, peers, colleagues, neighbors, community members, people in positions of authority, personal care providers and personal assistants, healthcare professionals
Attitudes Individual attitudes of immediate family members, friends, personal care providers and personal assistants, healthcare professionals; societal attitudes; social norms, practices, and ideologies
Services, systems, and policies
Services, systems, and policies related to housing, communication, transportation, legal, social, health, education and training, labor and employment
FIGURE 5–23 Environmental characteristics that relate to activities and participation. Data from International Classification of Functioning, Disability, and Health (ICF). Geneva: WHO; 2001.
122 Chapter 5 Health and Humans Rights
31. Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgical care: A modelling study. Lancet Glob Health. 2015;3:e316–23.
32. Taylor AL, Hwenda L, Larsen BI, Daulaire N. Stemming the brain drain: A WHO Global Code of Practice on International Recruitment of Health Personnel. N Engl J Med. 2011;365:2348–51.
33. Dumont J, Lafortune G. International migration of doctors and nurses to OECD countries: Recent trends and policy implications. Geneva: WHO High-Level Commission on Health Employment and Economic Growth; 2016.
34. User’s guide to the WHO Global Code of Practice on the International Recruitment of Health Personnel. Geneva: WHO; 2010.
35. Global strategy on human resources for health: Workforce 2030. Geneva: WHO; 2016.
36. The pharmaceutical industry and global health: Facts and figures 2017. Geneva: International Federation of Pharmaceutical Manufacturers & Associations (IFPMA); 2017.
37. Good review practice: Clinical review of investigational new drug applications. Silver Spring MD: U.S. Food and Drug Administration (FDA); 2013.
38. DiMasi JA, Grabowski HG, Hansen RW. Innovation in the pharmaceutical industry: New estimates of R&D costs. J Health Econ. 2016;47:20–33.
39. Van Norman GA. Drugs and devices: Comparison of European and U.S. approval processes. JACC Basic Transl Sci. 2016;1:399–412.
40. Managing access to medicines and health technologies (MDS-3). Arlington VA: Management Sciences for Health (MSH); 2012.
41. Fidler DP, Drager N, Lee K. Managing the pursuit of health and wealth: The key challenges. Lancet. 2009;373:325–31.
42. WHO model list of essential medicines (19th list). Geneva: WHO; 2015.
43. ‘t Hoen E, Berger J, Calmy A, Moon S. Driving a decade of change: HIV/AIDS, patents and access to medicines for all. J Int AIDS Soc. 2011;14:15.
44. World Trade Organization (Doha WTO Ministerial 2001). Declaration on the TRIPS agreement and public health (WT/MIN(01)/DEC/2); 2001.
45. Smith RD, Correa C, Oh C. Trade, TRIPS, and pharmaceuticals. Lancet. 2009;373:684–91.
46. van den Ham R, Bero L, Laing R. Selection of essential medicines. In: The world medicines situation 2011. 3rd ed. Geneva: WHO; 2011.
47. The pharmaceutical industry and global health: Facts and figures 2015. Geneva: International Federation of Pharmaceutical Manufacturers & Associations (IFPMA); 2015.
48. Lee JY, Hunt P. Human rights responsibilities of pharmaceutical companies in relation to access to medicines. J Law Med Ethics. 2012;40:220–33.
11. Gliek PH. The human right to water. Water Policy. 1998;1:487–503.
12. Howard G, Bartram J. Domestic water quantity, service level and health. Geneva: WHO; 2003.
13. Bleumel EB. The implications of formulating a human right to water. Ecol Law Q. 2004;31:957–1006.
14. Nickson A, Vargas C. The limitations of water regulation: The failure of the Cochabamba concession in Bolivia. Bull Latin Am Res. 2002;21:99–120.
15. Morgan. Water: Frontier markets and cosmopolitan activism. Soundings J Polit Nat. 2004;28:10–24.
16. Mirosa O, Harris LM. Human right to water: Contemporary challenges and contours of a global debate. Antipode. 2012;44:932–49.
17. Jones PA, Moulton A. The invisible crisis: Water unaffordability in the United States. Cambridge MA: Unitarian Universalist Service Committee (UUSC); 2016.
18. Markel H. Remember flint. Milbank Q. 2016;94:229–36.
19. Hundley N Jr. Water and the West: The Colorado River compact and the politics of water in the American West. Los Angeles CA: University of California Press; 2009.
20. Glennon R. Water scarcity, marketing, and privatization. Texas Law Rev. 2005;83:1873–902.
21. United Nations Committee on Economic, Social and Cultural Rights. General Comment 14: The right to the highest attainable standard of health (E/C 12/2000/4). Geneva: UN Office for the High Commissioner for Human Rights; 2000.
22. Spiegelhalter DJ, Gore SM, Fitzpatrick R, Fletcher AE, Jones DR, Cox DR. Quality of life measurements in health care. III: Resource allocation. BMJ. 1992;305:1205–9.
23. A universal truth: No health without a workforce. Geneva: WHO/Global Health Workforce Alliance (GHWA); 2014.
24. Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and cost. Health Aff. 2008; 27:759–69.
25. Marten R, McIntyre D, Travassos C, et al. An assessment of progress towards universal health coverage in Brazil, Russia, India, China, and South Africa (BRICS). Lancet. 2014;384:2164–71.
26. Health workforce requirements for universal health coverage and the Sustainable Development Goals. Geneva: WHO; 2016.
27. World health statistics 2016. Geneva: WHO; 2016. 28. Mental health atlas 2014. Geneva: WHO; 2015. 29. The challenge of oral disease: A call for global action.
The oral health atlas. 2nd ed. Geneva: FDI World Dental Federation; 2015.
30. Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569–624.
References 123
68. Kivlahan C, Ewigman N. Rape as a weapon of war in modern conflicts. BMJ. 2010;340:c3270.
69. Young H, Borrel A, Holland D, Salama P. Public nutrition in complex emergencies. Lancet. 2004;364:1899–909.
70. The fundamental principles of the Red Cross and Red Crescent. Geneva: ICRC; 2016.
71. Minear L. The theory and practice of neutrality: Some thoughts on the tensions. Int Rev Red Cross. 1999;833.
72. International activity report 2015. 2nd ed. Geneva: MSF; 2016.
73. Hope in hell: Inside the world of Doctors Without Borders. 3rd rev. ed. Richmond Hill ON: Firefly Books; 2010.
74. Barnett M. Humanitarianism transformed. Persp Politics. 2005;3:723–40.
75. Redfield P. A less modest witness: Collective advocacy and motivated truth in a medical humanitarian movement. Am Ethnologist. 2006; 33:3–26.
76. Brown VJ. BattleScars: Global conflicts and environmental health. Environ Health Perspect. 2004;112:A994–1003.
77. Landmine monitor 2016. Geneva: International Campaign to Ban Landmines; 2016.
78. Machel G. Impact of armed conflict on children (report A/51/306). New York: United Nations; 1996.
79. Assistance to victims of landmines and explosive remnants of war: Guidance on child-focused victim assistance. New York: UNICEF; 2014.
80. Protecting health care: Key recommendation. Geneva: ICRC; 2016.
81. MacQueen G, Santa-Barbara J. Peace building through health initiatives. BMJ. 2000;321:293–6.
82. Noah DL, Huebner KD, Darling RG, Waeckerle JF. The history and threat of biological warfare and terrorism. Emerg Med Clin N Am. 2002;20:255–71.
83. Beeching NJ, Dance DAB, Miller ARO, Spencer RC. Biological warfare and bioterrorism. BMJ. 2002;324:336–9.
84. Rotz LD, Khan AS, Lillibridge SR, Ostroff SM, Hughes JM. Public health assessment of potential biological terrorism agents. Emerg Infect Dis. 2002;8:225–30.
85. Inglesby TV, O’Toole T, Henderson DA, et al. Anthrax as a biological weapon, 2002: Updated recommendations for management. JAMA. 2002;287:2236–52.
86. Jernigan DB, Raghunathan PL, Bell BP, et al. Investigation of bioterrorism-related anthrax, United States, 2001: Epidemiologic findings. Emerg Infect Dis. 2002;8:1019–28.
87. Biological and chemical terrorism: Strategic plan for preparedness and response. Recommendations of the CDC Strategic Planning Workgroup. MMWR Recomm Rep. 2000;49(RR-1):1–14.
49. Howitt P, Darzi A, Yang GZ, et al. Technologies for global health. Lancet. 2012;380:507–35.
50. Access to medicine index 2016. Haarlem, Netherlands: Access to Medicine Foundation; 2016.
51. The Sphere Project. Humanitarian charter and minimum standards in humanitarian response. 3rd ed. Rugby UK: Practical Action Publishing; 2011.
52. Quarantelli EL. Just as a disaster is not simply a big accident, so a catastrophe is not just a big disaster. J Am Soc Prof Emerg Planners. 1996;3:68–71.
53. Koenig KL, Dinerman N, Kuehl AE. Disaster nomenclature—A functional impact approach: The PICE system. Acad Emerg Med. 1996;3:723–7.
54. Holguín-Veras J, Jaller M, Van Wassenhove LN, et al. On the unique features of post-disaster humanitarian logistics. J Oper Manag. 2012;30:494–506.
55. Stumpenhorst M, Stumpenhorst R, Razum O. The UN OCHA cluster approach: Gaps between theory and practice. J Public Health. 2011;19:587–92.
56. National Incident Management System. Washington DC: U.S. Department of Homeland Security; 2008.
57. Krin CS, Giannou C, Seppelt IM, et al. Appropriate response to humanitarian crises. BMJ. 2010;340: c562.
58. Jobe K. Disaster relief in post-earthquake Haiti: Unintended consequences of humanitarian volunteerism. Travel Med Infect Dis. 2011;9:1–5.
59. VanRooyen M, Leaning J. After the tsunami: Facing the public health challenges. N Engl J Med. 2005;352:435–8.
60. Aitsi-Selmi A, Egawa S, Sasaki H, Wannous C, Murray V. The Sendai framework for disaster risk reduction: Renewing the global commitment to people’s resilience, health, and well-being. Int J Disaster Risk Sci. 2015;6:164–76.
61. Sendai Framework for Disaster Risk Reduction 2015– 2030. Geneva: United Nations Office for Disaster Risk Reduction (UNISDR); 2015.
62. McLoughlin D. A framework for integrated emergency management. Public Admin Rev. 1985;45(Special Issue):165–72.
63. Salama P, Spiegel P, Talley L, Waldman R. Lessons learned from complex emergencies over past decade. Lancet. 2004;364:1801–13.
64. Spiegel PB. Differences in world responses to natural disasters and complex emergencies. JAMA. 2005;293:1915–18.
65. Toole MJ, Waldman RJ. The public health aspects of complex emergencies and refugee situations. Annu Rev Public Health. 1997;18:283–312.
66. Melzer N. International humanitarian law: A comprehensive introduction. Geneva: ICRC; 2016.
67. Kalshoven F, Zegveld L. Constraints on the waging of war. 4th ed. Cambridge UK: Cambridge University Press; 2011.
124 Chapter 5 Health and Humans Rights
93. Standard minimum rules for the treatment of prisoners. Geneva: Office of the United Nations High Commissioner for Human Rights; 1977.
94. World report on disability 2011. Geneva: WHO; 2011.
95. Convention on the Rights of Persons with Disabilities and optional protocol. New York: UN; 2006.
96. International Classification of Functioning, Disability, and Health (ICF). Geneva: WHO; 2001.
97. WHO Global Disability Action Plan 2014–2021: Better health for all people with disability. Geneva: WHO; 2014.
98. Priority assistive products list. Geneva: WHO; 2016. 99. United Nations Economic and Social Council. Report
of the Inter-Agency and Expert Group on Sustainable Development Goal Indicators (E/CN.3/2016/2/ Rev.1). New York: UN; 2016.
88. Thompson AK, Faith K, Gibson JL, Upshur REG. Pandemic influenza preparedness: An ethical framework to guide decision-making. BMC Med Ethics. 2006;7:12.
89. Walmsley R. World prison population list. 11th ed. London UK: International Centre for Prison Studies; 2016.
90. Watson R, Stimpson A, Hostick T. Prison health care: A review of the literature. Int J Nurs Stud. 2004;41:199–28.
91. Dara M, Grzemska M, Kimerling ME, Reyes H, Zagorskiy A. Guidelines for control of tuberculosis in prisons. Washington DC: USAID; 2009.
92. Møller L, Stöver H, Jürgens R, Gatherer A, Nikogosian H, editors. Health in prisons: A WHO guide to the essentials in prison health. Copenhagen: WHO Europe; 2007.
References 125
© Xinzheng. All Rights Reserved/Moment/Getty
CHAPTER 6
Global Health Financing Health is a big business, with trillions of dollars spent annually on health services worldwide. Most individual and public health expenses in high-income countries are paid for with tax revenue or mandatory insurance plans that enable universal access to critical health services. In lower-income countries, people who are unable to pay out-of-pocket for health services may be denied access to clinical care. Global health activities financed with government funds from host and donor countries as well as by charitable contributions from philanthropies, businesses, and private donors facilitate improvements in health promotion and disease prevention in vulnerable populations.
▸ 6.1 Personal and Public Health
Health expenditures are a significant compo- nent of the global economy, accounting for more than 8% of the world’s total gross domes- tic product (GDP) (FIGURE 6–1).1 The costs of health can be divided into two categories: (1) money spent on personal health and (2) money spent on public health. Personal health expenses relate to the health of one individual or family, such as the cost of purchasing anti- biotics to treat a bacterial infection, paying for a midwife to help deliver a baby, or buying test strips for self- monitoring of blood glucose levels by people with diabetes. Public health expenses relate to shared activities that protect a community, a nation, or the global popula- tion at large, such as the costs associated with
0
18 16 14 12 10 8 6 4 2
USA
Ger m
an y
Ira n
Bra zil
Chin a
In dia
Nige ria
Eth iop
ia
global average
FIGURE 6–1 High-income countries spend a high percentage of their gross domestic product on health. Data from Global Burden of Disease Health Financing Collaborator Network. Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. Lancet 2017; 389:1981–2004.
126
investigating and containing outbreaks of infectious diseases, marketing the mass polio vaccination days that are part of the global eradication campaign, using insecticides in outdoor areas to kill the mosquitoes that can transmit dangerous pathogens to humans, and developing evidence-based clinical guidelines for managing chronic diseases.
Worldwide, more than $9 trillion was spent on health care in 2015, and annual spending could increase to $16 trillion by 2030.2 High- income countries spend much more per resi- dent on healthcare services than low- income countries do (FIGURE 6–2). This difference remains significant even after adjusting for differences in the cost of living (FIGURE 6–3).1 There are a diversity of mechanisms for pay- ing for personal health expenses. Some coun- tries have a publicly funded healthcare system that is paid for with tax revenue, some have a healthcare system in which the medical care of individuals is usually funded by private health insurance or the personal funds of the
Missing/Excluded
Less than 50
50 to 200
200 to 500
500 to 1500
1500 and above
FIGURE 6–2 Health spending per capita (2014). Data from Health system financing profile by country. Geneva: WHO Global Health Expenditure Database; 2017.
0
1000
2000
3000
4000
5000
6000
High income
S pe
nd in
g on
h ea
lth p
er p
er so
n
Upper middle income
Lower middle income
Low
FIGURE 6–3 Total spending on health care per capita by country income level (2014). Data from Global Burden of Disease Health Financing Collaborator Network. Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. Lancet 2017; 389:1981–2004.
6.1 Personal and Public Health 127
© Djohan Shahrin/Shutterstock © fivepointsix/Shutterstock
FIGURE 6–4 Governments in high-income countries use tax revenue to pay for most health services; in low- income countries, a more diverse set of funders pay for health activities.
PERSONAL HEALTH
PUBLIC HEALTH
Governments (via taxes)
Governments (via taxes)
Households & others
Governments & donors
FUNDERS Who pays?
Typical HIGH-income
country
Typical LOW-income
country
individual and his or her family, and some countries pay for personal health services with a combination of public and private sources (FIGURE 6–4).3 Most public health activities in
higher-income countries are funded by taxes. Public health initiatives in lower- income coun- tries are often financed with a combination of governmental and external support.
© Pablo Rogat/Shutterstock © Iakov Filimonov/Shutterstock
128 Chapter 6 Global Health Financing
Financing is the provision of money for a particular activity and the management of that investment. Financing for global health is allocated to both personal and public functions. Some global health funding helps lower-income countries expand the personal healthcare services that they offer to resi- dents. For example, some donors have pro- vided financing that enables more women in low-income countries to give birth at hos- pitals at no cost to the family, more children to be treated for intestinal worm infections through school-based programs, and more people living with HIV to access free and low- cost antiretroviral medications. Some global health funding supports global health gover- nance,4 pandemic preparedness and response, the development and dissemination of new health technologies, and other public health functions.5 There are also expenses that blend the personal and public health categories, like the costs associated with educating healthcare workers, ensuring that clinicians are licensed and staying up to date on best practices, and building and maintaining hospitals to ensure that everyone has access to essential health services. These activities are public health functions that enable individuals to have access to quality personal health care. All of these activities are part of functioning health systems.
▸ 6.2 Health Systems A health system includes all of the people, facilities, products, resources, and organiza- tional structures that deliver health services to a population. The World Health Organiza- tion (WHO) has identified six core building blocks of health systems: (1) the provision of effective personal and population-based healthcare services; (2) a well-trained and productive health workforce that is able to provide quality care to all population groups; (3) a strong health information system that collects, analyzes, and disseminates the
information about population health and health systems performance that is critical for health system decision-making;6 (4) access to essential medicines, medical devices, vac- cines, and other health technologies; (5) a health financing system that enables every- one to access affordable services when they are needed while providing incentives to limit overuse of services; and (6) effective oversight of the system to ensure safety, efficiency, and accountability.7
The Sustainable Development Goals (SDGs) aim by 2030 to “achieve universal health coverage, including financial risk pro- tection, access to quality essential healthcare services, and access to safe, effective, quality, and affordable medicines and vaccines for all” (SDG 3.8).8 Universal health coverage (UHC) is present when everyone in a coun- try has access to high-quality health services (including preventive care, diagnosis, treat- ment, and rehabilitation) and everyone is protected from major health-associated finan- cial shocks via a tax-based financing system or a health insurance plan.9 In places where patients and their families pay out-of-pocket for most health services, the poorest house- holds are often excluded from accessing qual- ity care. By contrast, countries that spread the cost of health services across the entire pop- ulation through tax revenue or mandatory participation in highly regulated insurance plans enable everyone to access the services that are included in the national health plan (FIGURE 6–5).10 These services typically include family planning (contraception), obstetric and newborn care, child vaccines, medications for common infections and noncommunicable diseases (such as high blood pressure and dia- betes), care for acute injuries, and other ser- vices that have been identified as population priorities.11
Every government has finite financial reserves, so it is not possible for national health systems to provide every procedure for every condition for every person. Government offi- cials and other people with health leadership
6.2 Health Systems 129
responsibilities in countries aiming to achieve UHC must make difficult decisions about which goods and services will be provided to everyone. For example, health system leaders must decide which procedures will and will not be available in public hospitals and which medications will and will not be included in the national formulary. Resource limitations may mean that only part of a comprehen- sive strategy for improving population health status can be publicly funded. For example, budgeting authorities might determine that it is possible to improve access to in-hospital trauma care for injured people but there is not sufficient funding to simultaneously support injury prevention activities, train and equip more emergency responders, and provide more physical therapy and rehabilitation ser- vices for survivors. The decision to increase coverage for one type of service sometimes requires decreases in support for other types of health services.
Government officials must also make critical determinations about how much funding can be allocated to the health system and how much must be dedicated to main- taining other necessary services. Increases
in government spending on health often require decreases in funding for education and other social services. Funding decisions have a very tangible impact on the quality of services that are provided. The governments of high-income countries with aging popula- tions usually allocate more of their budget to health than to education.12 In these countries, surveys that ask residents about their percep- tions of social services and their overall qual- ity of life typically show that satisfaction with health services exceeds levels of satisfaction with the education system (FIGURE 6–6).13 The governments of low- and middle- income countries with a large proportion of children in their populations usually allocate more funding to education than to health. Surveys in these countries usually show a higher level of satisfaction with schools than with the healthcare system. Health system strengthening requires a process of identi- fying priorities and resources, strategizing about the policies that will achieve key goals, transforming those ideas into operational action plans, and then implementing changes and tracking progress toward meeting the targets.14
FIGURE 6–5 Universal health coverage spreads the cost burden for health services across the entire population. Data from World health report 1999. Geneva: WHO; 1999.
Source of Funds
Private Public Mostly private
Mostly public
Out-of- pocket
Private insurance
Social insurance/
sickness funds
General revenue (taxes)
Payment
Individuals Whole
population Cost Burden
Poorest excluded
UniversalCoverage
Increasingly pooled risk
Increasingly equitable
130 Chapter 6 Global Health Financing
▸ 6.3 Paying for Personal Health
Each country has a unique mix of strategies for paying for personal health expenses, but there are some general patterns by country income level (FIGURE 6–7).1 Most high-income countries have a government-sponsored healthcare system that is paid for through general tax revenue, mandatory payments into a government-run social security sys- tem, or other types of compulsory contribu- tions. Health services are typically provided at government health facilities or at private facilities that receive most of their funds from the government. (The health financing and delivery system in the United States is a nota- ble exception to the general global trend for high-income countries.)
USA Germany Iran Brazil China India Nigeria Ethiopia
0%
20%
40%
60%
80%
100%
Health care quality Education quality Quality of life
% s
at is
fie d
FIGURE 6–6 Satisfaction with healthcare quality is highest in high-income countries. Data from World health statistics 2016. Geneva: WHO; 2016.
In most middle-income countries, gov- ernments pay for a portion of health costs but the remaining money spent on health is expended in the form of out-of-pocket (OOP) payments, cash disbursements made by patients and their families in order to receive health services (FIGURE 6–8).1 The range of services covered by government health plans vary widely. Some health sys- tems pay for all the expenses of hospitaliza- tion for a range of causes, while others require the patient to pay part or most of the cost of a hospital stay. Some health systems require users to pay a fee at the time of service and pay OOP for prescription medications and therapy, while others do not. Only a few gov- ernment health plans include dental care and vision care in their health packages. In places where private healthcare coverage is available to supplement government services, there are
6.3 Paying for Personal Health 131
women can give birth for free at public hospi- tals (if they can afford transportation to a hos- pital, which is not always possible for women who live in rural areas). In other low-income countries, women must pay OOP to give birth at a hospital or must pay midwives OOP to help deliver their babies at home. When families cannot afford to hire help, women must deliver at home without a trained birth assistant. Similarly, in some low-income countries, everyone with HIV can access free or low-cost antiretroviral medications, with the price tied to income to ensure free access to low-income individuals. However, in other countries, people from higher-income households who can afford the medications
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
USA
Out-of-pocket
Development assistance for health (DAH)
Prepaid private
Domestic government
FIGURE 6–8 Sources of funding for health in featured countries. (Prepaid private spending includes private insurance and spending by nongovernmental organizations.) Data from Global Burden of Disease Health Financing Collaborator Network. Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. Lancet 2017; 389:1981–2004.
Out-of-pocket
Prepaid private
Development assistance for health (DAH) Domestic government
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
High income
Upper middle income
Lower middle income
Low
FIGURE 6–7 Total spending on health by payer and country income level. Data from Global Burden of Disease Health Financing Collaborator Network. Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. Lancet 2017; 389:1981–2004.
wide variations in the prices of private plans and differences in the quality of services cov- ered by the plans.
In most low-income countries, some basic clinical services that have been deemed necessary for achieving high-priority global health goals are financed by domestic gov- ernments and international donors to ensure that these services are available to everyone who needs them. For other health conditions, both public and private healthcare facilities may charge user fees and require additional OOP payments for medications and sup- plies.15 When subsidized healthcare services are unavailable or the quality of local health services is poor, families are often unable to access any type of skilled care. For example, in some low-income countries, all pregnant
132 Chapter 6 Global Health Financing
develop a very serious chronic condition or suffer a catastrophic injury. However, because everyone is at risk of unexpected health cri- ses, most people are willing to pay additional taxes or purchase insurance that protects them against the small possibility of needing to forego essential medical care because they cannot afford it or acquiring a lifetime of unmanageable, impoverishing debt as a result of one medical incident.16
The country that spends the most on health each year, by far, is the United States (FIGURE 6–9),1 which has a health system that is unique among high-income countries because it is not a universal health coverage system. Nearly all health services are pro- vided in private facilities, and a mix of private insurance and government funding is used to pay for healthcare services. Pooled risk was at the core of the U.S. Patient Protection and Affordable Care Act (ACA) of 2010, which made participation in an insurance plan mandatory for those who could afford it and provided financial support for lower-income households to purchase private coverage or
take them and those from lower-income households who cannot afford the medica- tions do not take them. Increasing access to affordable health services for the most vul- nerable populations is one of the major goals for health system strengthening in most low- income countries.
▸ 6.4 Health Insurance Insurance is a risk management strategy that protects purchasers against major finan- cial losses. Health insurance is intended to protect insured people from incurring over- whelming expenses if they happen to develop an expensive health condition. Health insur- ance systems, whether private or public, are funded based on the principle of pooled risk. Pooled risk assumes that if many low-risk people and a few high-risk people all pay pre- miums to the insurance system over many years, there will be a pot of money that can be used to pay for major illnesses and inju- ries when they occur. Only a few people will
0
2000
4000
6000
8000
10000
USA Germany Iran Brazil China India Nigeria Ethiopia
Iran Brazil China India Nigeria
0
200
400
600
800
1000
1400
1200
EthiopiaS pe
nd in
g on
h ea
lth p
er p
er so
n
FIGURE 6–9 Total spending on health care per capita in featured countries (2014). Data from Global Burden of Disease Health Financing Collaborator Network. Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. Lancet 2017; 389:1981–2004.
6.4 Health Insurance 133
The major governmental insurance plans provide healthcare coverage for older adults, low-income households, and military person- nel. Medicare is the federal health funding system for people who are 65 years old and older, and it also provides coverage for some younger people with serious permanent dis- abilities. Medicare coverage is based on age and disability status, and it is not tied to income. Medicaid is a federal program that provides funding to states to support state-sponsored health coverage for very low-income citizens. The government also provides healthcare ser- vices to injured military veterans through the Veterans Administration hospital system and to some indigenous Americans through the Indian Health Services.
Health insurance in the United States was originally designed to cover only the cat- astrophic expenses that arise from serious illnesses or injuries. Today, many insurance plans also pay for preventive care and minor health problems. This is because health econ- omists have determined that health systems save money when minor conditions are treated before they become major problems. For example, an insurance company may cal- culate that it is cheaper to pay for thousands of people to be screened for early-stage can- cer, which can usually be treated at a relatively low cost, than it is to pay for expensive treat- ment for one person with advanced-stage cancer. If screening many people and treating several patients with early-stage cancer will prevent a few insured people from requiring expensive treatments for cancers that were not detected until they were at an advanced stage, the insurance company may conclude that encouraging all of its clients to partici- pate in the cancer screening program will yield financial benefits for the company. Or the company may calculate that it is cheaper to pay for frequent routine checkups for peo- ple with chronic diseases like diabetes and asthma than it is to pay for emergencies that require hospitalization. The company may
gain access to government-sponsored health coverage plans. The proportion of Americans who were uninsured decreased after the ACA insurance mandate went into effect in 2014, but the percentage of uninsured people did not reach 0%.17 In 2015, about 91% of Amer- icans had health insurance coverage and 9% had no health insurance.17 Of the insured individuals, about two-thirds had private health insurance and about one-third were on a government plan.17
Most working-aged Americans and their children have employment-based private health insurance. The majority of adults who are employed full-time (and some who are employed part-time) receive healthcare cov- erage for themselves, their spouses, and their minor children through an employer’s plan. Most plans require the employee to pay for a portion of the coverage through monthly premiums. Most plans also have deductibles. A deductible is the amount that an insured person must spend OOP on health care each year, in addition to premiums, before the insur- ance company begins paying for health ser- vices. Insurance plans with lower premiums have higher deductibles, which means that patients are only reimbursed for expenses after they have paid thousands of dollars OOP. After meeting the deductible for a plan year, patients sometimes must continue to pay OOP copays or co-insurance payments until they reach the maximum OOP amount for the plan year. A copay is usually a fixed fee that is paid when receiving routine health services, such as a fee of $50 for each clinic visit or $25 for each prescrip- tion for a generic medication. Co-insurance requires patients to pay a percentage of the costs of care, such as 20% of the total cost. Copays and co-insurance are intended to discourage overuse of the health system. Insurance plans that cover the full spectrum of care, including medications, preventive care, clinic visits for minor conditions, hospitalizations for serious illnesses, and surgeries, are often expensive for businesses and employees.
134 Chapter 6 Global Health Financing
▸ 6.5 Paying for Global Health Interventions
The money spent on global public health initiatives comes from a different set of sources than the money that pays for individual health care. In addition to the local and national governmental spending that pays for most of the public health interventions around the world, global health activities are funded by a combination of grants from one country to another, grants and loans from intergovernmental agencies, and gifts from private-sector foundations, businesses, and individuals (FIGURE 6–10).22 The best financing mechanisms for new global health initiatives are sources that are stable and sustainable over time, that are new funding lines rather than money redirected from other health programs, and that are man- aged efficiently without demanding heavy administrative costs or burdening recipient populations.23
Donors have a variety of motivations for giving.24 For the governments of high-income countries, health funding for lower-income countries is part of foreign policy strategies for building trade alliances and protecting homeland security.25 Multilateral lending groups may consider global health projects to be good financial investments, especially when aid is provided in the form of loans that will be repaid with interest. Philanthropic organizations focused on reducing poverty and promoting human flourishing may view global health as a tool for achieving their mis- sions. Disease-specific charities may be able to multiply their impact by addressing concerns worldwide rather than limiting their work to a single country or region. Expanding their project portfolios may also attract new donors and volunteers. Large corporations may use global health work to cultivate customer
provide incentives for people with these chronic diseases to participate in disease management programs that catch emerging problems early and avert the need for expen- sive emergency care.
Some other high-income countries use health insurance as part of their strategies for UHC. For example, in Germany, every resident must belong to a highly regulated “sickness fund.”18 All sickness funds provide the same services to members at the same cost to users, and OOP payments for health services are minimal. Employers pay half of the sickness fund costs for employees, and the government covers the full cost for chil- dren and unemployed adults. Inpatient care is provided at both public and private hospi- tals, and most outpatient care is provided at private clinics. The payments that providers receive for their services are identical no mat- ter where they work.
Health insurance is also being used by a growing number of residents of middle-income countries so they can access advanced care from high-quality private healthcare providers.19 For example, lower- income households in Brazil usually receive healthcare services at public facilities that are funded by tax revenue, but a large propor- tion of higher- income households (or their employers) purchase private insurance plans and seek medical and surgical care at private facilities.20 Everyone in Brazil can access free primary and emergency health care at pub- lic facilities—this is an important right guar- anteed under Brazil’s constitution—but the public health system offers a limited range of services and technologies.21 Health insur- ance allows wealthier households to access a greater range of health services, procedures, medications, and equipment from their pre- ferred providers, and having those individ- uals use the private health system allows the public health system to allocate more of its resources to care for the lowest-income residents.
6.5 Paying for Global Health Interventions 135
country. For example, bilateral food aid agree- ments may require food to be purchased in the donor country and shipped by donor-country carriers to the recipient (as is the case for most U.S. food assistance26).
Most ODA is donated to low- and middle- income countries (LMICs) by high-income countries that are members of the Develop- ment Assistance Committee (DAC) of the Organisation for Economic Co- operation and Development (OECD), but a growing number of upper middle- income countries are includ- ing small amounts of ODA in their annual budgets. The SDGs call for “developed coun- tries to implement fully their official develop- ment assistance commitments, including the commitment by many developed countries to achieve the target of 0.7% of gross national income (GNI) for ODA to developing coun- tries and 0.15%–0.20% of GNI to least devel- oped countries” (SDG 17.2).8 In 2015, the five donor nations that provided the greatest
loyalty in new markets, take advantage of tax breaks, and foster a shared sense of purpose among employees. Most of these rationales for funding global health involve benefits for both the recipients and the donors, and the best global health projects achieve goals that are beneficial to all involved parties.
▸ 6.6 Official Development Assistance
Official development assistance (ODA) is money given by the government of a high- income country to the government of a low- income country to support socioeconomic development. Although some aid is given simply to fight poverty, aid is often tied to the political and economic interests of the donor
IMPLEMENTERSDONORS
High-income country
governments
Private foundations
CHANNELS
Bilateral agencies
Multilateral organizations
International NGOs
Local NGOs
Recipient country governments
Others
FIGURE 6–10 Typical pathway from global health funders to implementers.
136 Chapter 6 Global Health Financing
amount of ODA in total dollars were the United States, the United Kingdom, Germany, Japan, and France.27 As a percentage of their GNI, the largest donors were Sweden, Norway, Lux- embourg, Denmark, the Netherlands, and the United Kingdom, which all spent at least 0.7% of their GNI on ODA. Germany invested about 0.52% of GNI on ODA in 2015 and the United States spent 0.17% of its GNI on ODA, a rate far below the 0.7% target in the SDGs even though the United States had the world’s largest ODA budget.
The foreign aid spending by the United States in 2015 provides an illustration of an annual foreign aid budget. In 2015, the United States spent about $32 billion on humanitarian and other foreign aid, which was about 0.9% of the total national gov- ernment spending. When the $17 billion spent on foreign military and security assistance (which is only a small portion of the military budget used for international humanitarian operations and other joint responses with allies) is combined with non- military/security foreign aid, the total spending on foreign assistance was about 1.3% of the national governmental spending
6.8%
27.8%
5.7%
16.0%
32.6%
11.2%
17.1%
8.7%
24.4%
49.8%
Foreign aid Foreign aid including military/security aid
Bilateral development
Humanitarian aid
Military assistance
Multilateral development
Political and strategic development
Non-military security assistance
FIGURE 6–11 Foreign aid expenditures by the United States in 2015 by spending category, with and without military/security assistance. Data from Tarnoff C, Lawson ML. Foreign aid: an introduction to U.S. programs and policy. Washington: Congressional Research Service (CRS); 2016.
(FIGURE 6–11).26 Aid may be given in the form of cash transfers, equipment and com- modities (such as food and computers), training and expert advice, or infrastructure development (such as building schools and health clinics in post-conflict areas). Most non-military/security ODA flows through the U.S. Agency for International Devel- opment (USAID). Most military aid flows through the Department of Defense (DOD). The U.S. Government considers foreign aid to be a critical contributor to national secu- rity because aid supports economic growth, promotes stability, and combats illegal activ- ities.26 The top recipients of non-military/ security ODA from the United States in 2015 were Afghanistan, Jordan, Pakistan, Kenya, Ethiopia, South Sudan, Syria, and the Dem- ocratic Republic of the Congo.28 All of these countries were engaged in civil conflicts or were located adjacent to conflict areas and were housing large refugee populations.
The amount spent on foreign aid by donor countries and the various types of projects that are supported by ODA can vary considerably from year to year, but global health has become a prominent ODA priority.
6.6 Official Development Assistance 137
Development assistance for health (DAH), sometimes called donor aid for health, is ODA designated for health activities. DAH is an important component of the health budget in low-income countries (FIGURE 6–12),29 and it is a large portion of current foreign aid bud- gets. Globally, more than $20 billion of ODA was spent on global health in 2015.30 The United States allocated nearly $10 billion of its foreign aid budget to global health activ- ities in 2015,30 making the United States the largest contributor of DAH worldwide both in terms of the percentage of its foreign aid budget assigned to DAH and the total budget for DAH (FIGURE 6–13).31 About 70% of those funds were dedicated to HIV/AIDS, tuber- culosis, and malaria programs.32 Other sup- ported activities were in the areas of neglected tropical diseases, reproductive health, child health, nutrition, water and sanitation, and global health security.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1990 1995 2000 2005 2010 2015
Other
Debt repayments
Corporate donations
Foundations
Other governments
United States
Domestic funding DAH
Ethiopia Nigeria
India China Brazil
Iran Germany
USA
0% 20% 40% 60% 80% 100%
FIGURE 6–12 Development assistance for health (DAH) is an important component of total spending on health in low-income countries. Data from Global Burden of Disease Health Financing Collaborator Network. Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. Lancet 2017; 389:1981–2004.
The SDGs emphasize that ODA is only part of the plan for funding develop- ment activities, and they call for action to “strengthen domestic resource mobilization, including through international support to developing countries, to improve domestic capacity for tax and other revenue collection” (SDG 17.1) and to “mobilize additional finan- cial resources for developing countries from multiple sources,” including foreign direct investments and remittances (SDG 17.3).8 Foreign direct investment (FDI) is a busi- ness investment made by a corporation or an individual in another country. Remittances are funds transferred by international workers back to family members in their home com- munities. The total amount of ODA globally in 2015 neared $150 billion (about 0.3% of GNI in DAC countries).27 That was a lower amount than the money distributed to lower-income
FIGURE 6–13 The United States is a large donor of development assistance for health (DAH). Data from Financing global health 2015: development assistance steady on the path to new Global Goals. Seattle: Institute for Health Metrics and Evaluation (IHME); 2016.
138 Chapter 6 Global Health Financing
Two multilateral institutions have played a unique role in financing economic development projects because they offer both loans (borrowed money that must be repaid with interest) and grants (money that does not have to be repaid): the World Bank and the International Monetary Fund (IMF). Both institutions were founded in 1944 during a summit held at Bretton Woods, New Hampshire, in the United States. Both are headquartered in Washing- ton, DC. Both are owned by their nearly 180 member nations. Both the World Bank and the IMF may require recipient countries to implement economic policy reforms as a condition of receiving loans, such as rais- ing taxes, reducing government spending, devaluing the country’s currency, eliminat- ing price controls and subsidies, and increas- ing the production of exports. However, the two institutions have distinct functions and modes of operating.36
The World Bank is an investment bank that makes loans to developing countries. Its board of governors is composed of repre- sentatives from each member country, who are usually member countries’ ministers of finance (or the equivalent, such as the Sec- retary of the Treasury of the United States). Its president has always been a U.S. citizen. World Bank loans must be repaid with inter- est. Debt repayments are usually used to make new loans for development projects in other countries, including projects focused on health.
The World Bank’s primary lending insti- tute is the International Bank for Reconstruc- tion and Development (IBRD), which issues bonds in order to be able to make loans to middle-income member countries. These loans carry an interest rate that is slightly above the market rate, and they are usually supposed to be repaid within 15 years. Most IBRD loans are for specific infrastructure projects, although funds can also be used
countries through FDI and remittances.33 In 2015, about $765 billion in FDI was invested in LMICs34 and about $430 billion in remittances were sent to LMICs.35
▸ 6.7 Multilateral Aid There are two main types of ODA: bilat- eral aid and multilateral aid. Bilateral aid is money given directly from one country (usually a high-income country) to another country (usually a lower-income country). Multilateral aid is funding pooled from many donor countries. The largest multilateral organizations include the United Nations, the World Bank and other development banks, and the European Union.
Multilateral organizations, sometimes called intergovernmental organizations, receive two types of funds from member nations. Assessed contributions are mandatory dues calculated from each country’s economic and population statistics. Voluntary contributions are extra funds a country opts to donate. Man- datory funds go to the general budget of the multilateral organizations. Voluntary contribu- tions can be designated as core (unrestricted) or noncore (restricted) funding. Core funding can be used by the recipient multilateral organi- zation on any projects the organization deems to be priorities. Some of these projects address the specific needs of particular low- income countries, but many of them are global initia- tives that are of value to all countries (such as support for outbreak prevention and control). Noncore funding is given for a specific purpose by the donor and must be spent on that partic- ular activity. In 2013, about 59% of ODA was bilateral ODA distributed by bilateral agencies, about 28% was core multilateral ODA from assessed and voluntary contributions, and about 13% was noncore bilateral aid that was distributed through multilateral organizations to designated recipient countries.33
6.7 Multilateral Aid 139
problems associated with overwhelming debt in low-income countries, and they aim to “assist developing countries in attaining long- term debt sustainability through coordinated policies aimed at fostering debt financing, debt relief, and debt restructuring, as appro- priate, and address the external debt of highly indebted poor countries to reduce debt dis- tress” (SDG 17.4).8 The World Bank and the IMF have established plans for debt forgive- ness in the poorest, most indebted countries, so that those countries can devote more of their resources to their own health and edu- cational systems rather than requiring those countries to prioritize debt repayment. How- ever, concerns about debt burden are one of the reasons that development banks are now playing less of a role in global health funding than they did in the past. In 2000, more than 20% of DAH came from development banks. By 2015, less than 10% of DAH was disbursed through development banks.31
▸ 6.8 Foundations and Corporate Donations
A foundation is a charitable trust that gives grants to other nonprofit organizations. A pri- vate foundation is one that is established and funded by an individual, family, or corporation as a mechanism for making tax-deductible donations to entities that align with values of the funders. The word foundation is also often used to describe public charities that solicit financial support from other individuals, foun- dations, and government agencies in order to engage in nonprofit activities. The particular regulations that apply to various types of foun- dations are specific to each country, but tax laws typically require public charities to have a diverse board of directors and disburse a set percentage of their assets each year in order to maintain their tax-exempt status.
for other economic development purposes. The International Development Associa- tion (IDA) makes interest- free loans to low- income member nations using money that has been donated from high-income coun- tries. IDA loans are usually supposed to be paid back over a 40-year period. The World Bank Group is also home to the International Finance Corporation, which supports private sector development; the Multilateral Invest- ment Guarantee Agency, which supports FDI in low- and middle-income countries; and the International Centre for Settlement of Invest- ment Disputes.
The International Monetary Fund (IMF) provides a structure for international monetary policy and currency exchanges, and it also makes loans to countries of any income level that have a balance of payment need and would otherwise not be able to make payments on their other international loans. The IMF’s managing director has always been a European. The IMF is funded by membership fees (called quotas) paid by its member countries, and it operates like a credit union. The goal of IMF loans is to allow countries to rebuild their monetary reserves, stabilize their currencies, continue paying for imports, and create conditions for economic growth and high employment rates. The interest rates for IMF funds are usually slightly below market rates, and loans from the IMF are usually supposed to be paid back within a few years.
A major criticism of the international loan system is that interest payments divert money away from education, health, clean water, and other essential human services in lower-income countries. When interest rates are high, countries that are allocating large portions of their annual budgets to inter- est payments may still not be making good progress toward lowering the amount of principal that must be repaid in the future. The SDGs acknowledge the significant
140 Chapter 6 Global Health Financing
An endowment is a large donation made to a nonprofit organization so that the funds can be invested and the interest from the investments can be used to support the operation of the charity. The Bill & Melinda Gates Foundation is the largest private foundation in the world. It had $40.4 billion in assets at the end of 2015. Other founda- tions with large endowments include the Ford Foundation ($12.2 billion in assets in 2015), the Robert Wood Johnson Founda- tion (RWJF) ($10.3 billion), the W. K. Kellogg Foundation ($8.4 billion), and the Bloomberg Family Foundation ($7.2 billion).37 These endowments are so large that they enable the foundations to give away large sums of money each year. The Gates Foundation distributed nearly $4 billion in 2015, with about $2.9 bil- lion of that total allocated to health projects.31 The recipients of Gates Foundation funding included, among others, the Global Alliance for TB Drug Development, the International AIDS Vaccine Initiative, CARE, Family Health International, PATH, UNICEF, the World Health Organization, other organiza- tions that do applied global health work, and a diversity of universities and other research institutes working on agricultural and health technologies.38 The Ford Foundation gave away $512 million in 2015, RWJF gave $348 million, the Kellogg Foundation gave $322 million, and Bloomberg Philanthropies gave $280 million.37
Many large companies have established corporate foundations to do charitable work related to their areas of expertise, and many also support other forms of benevolent engagement.39 A corporate social respon- sibility (CSR) plan spells out the positive social and environmental actions a company voluntarily supports. For example, a company may choose to build its facilities with sustain- able materials and implement a recycling pro- gram, even when these actions are not legally required, or it may sponsor local charities
that are important to employees. The major multinational companies that manufacture food and beverage products and produce personal care items are among the many cor- porations with CSR strategies that support global health. For example, Unilever, Nestlé, Danone, Mondelēz (formerly Kraft Foods), Mars, PepsiCo, the Kellogg Company, Gen- eral Mills, and Coca-Cola have made com- mitments to improve access to nutritious food products,40 and all of them are taking action to improve their social and environ- mental practices.41
In-kind donations of goods or services related to the corporation’s core business are often part of CSR programs. Pharma- ceutical companies are some of the largest donors to global health initiatives. Each year, GlaxoSmithKline (GSK), Merck, Johnson & Johnson, Eisai, Novartis, Pfizer, and other drug companies donate millions of doses of medications to disease control programs.42 For example, many millions of people have been treated through Merck’s Mectizan® (ivermectin) donation program that targets onchocerciasis (river blindness) and lymphatic filariasis, Pfizer’s Zithromax® (azithromycin) program for trachoma, and GSK’s Zentel® (albendazole) program for lymphatic filariasis and soil- transmitted helminths.
In addition to being an expression of humanitarian values, and often a tax deduc- tion, corporate donations help develop international markets and increase brand rec- ognition among potential customers. Popula- tions with increased incomes and decreased health expenditures as a result of success- ful charitable health initiatives have more money to spend on other goods and services. By investing in helping potential and current consumers become healthy and maintain their health, companies are doing good work while expanding their markets and gaining brand loyalty.
6.8 Foundations and Corporate Donations 141
Another popular giving option for indi- vidual donors is child sponsorship, a chari- table donation model in which a donor selects a child to sponsor and then receives regular updates about that particular child (often including an annual photograph and a thank- you letter written by the child) in exchange for continued monthly contributions to the host organization. Some child sponsorship pro- grams make direct cash transfers to the families of sponsored children, but many use the funds to support community development projects (like clean water and sanitation projects and school improvement projects) that benefit both sponsored and non-sponsored children in a community. Well-run child sponsorship programs are effective at increasing the educa- tional attainment of participating children and improving their employment opportunities in adulthood.47
While many of the recipients of indi- vidual donations are charities that work on a small scale, some have large budgets and are prominent players in global health ini- tiatives. More than twenty nonprofit orga- nizations in the United States that work in the international arena generated revenue exceeding $250 million in the 2015 fiscal year (including funds from charitable donations and from governmental contracts for imple- menting international development projects) (FIGURE 6–14), as did a variety of nonprofit health and social service charities focused primarily on work within the United States (FIGURE 6–15).48 The best-rated charities spend a relatively small proportion of their budgets on administration and fund- raising, and they apply most of their income to direct program expenses. The annual reports of registered charities allow potential donors to evaluate the financial performance of orga- nizations before making a contribution, and the organizations’ websites and other online tools allow potential donors to assess the importance and effectiveness of the organi- zations’ work.49
▸ 6.9 Personal Donations Charitable donations are crucial sources of funding for a diversity of health-related proj- ects, and many people all over the world have been and continue to be generous in their support of nonprofit entities. For example, people in the United States donated nearly $375 billion to charity in 2015, with 71% of this total given by individuals, 16% by foundations, 9% from bequests (donations released to a charity from the estate of a deceased person who named the charity in her or her will), and 5% by corporations.43 In total, those donations represent about 2.1% of the country’s total GDP, and individual dona- tions account for 2% of all disposable income in the United States. The major recipients of funding were religious groups (32% of dona- tions), educational institutions (15%), human services organizations (12%), and health charities (8%).43 Because many of the non- profit organizations within all of these cat- egories provide services that support health and the tools for health, a large proportion of all donations went toward activities related to health promotion.
The generosity of individual donors is especially visible after major natural disasters, when charities may receive millions of dollars of donations in the days immediately after the event.22 The American Red Cross received $488 million in designated donations after the mas- sive earthquake in Haiti in 2010,44 $581 million in designated donations after the devastat- ing Indian Ocean tsunami in 2004,45 and $2.1 billion after Hurricane Katrina hit the Gulf Coast of the United States in 2005.46 These amounts represent only a fraction of all donated funds, since the Red Cross was just one of numerous organizations receiving human- itarian donations after these catastrophes. Americans gave billions of dollars to charities providing humanitarian services in the affected areas, and individuals from other countries were also generous with their donations.
142 Chapter 6 Global Health Financing
Na m
e Lo
ca tio
n To
ta l
Re ve
nu e
Co nt
rib ut
io ns
fr
om
Go ve
rn m
en t
Gr an
ts (%
) To
ta l
Ex pe
ns es
Ad m
in .
Ex pe
ns es
(%
)
Fu nd
- Ra
isi ng
Ex
pe ns
es (%
)
Am ou
nt
Sp en
t t o
Ra ise
$1
Fo od
fo r t
he P
oo r
Co co
nu t C
re ek
, F L
$1 15
8 m
ill io
n 0.
1 $1
15 8
m illi
on 0.
7 3.
4 $0
.0 3
W or
ld V
isi on
Fe de
ra l W
ay , W
A $1
00 5
m ill
io n
17 .2
$9 93
m ill
io n
5. 3
10 .6
$0 .1
0
D ire
ct R
el ie
f G
ol et
a, C
A $8
89 m
ill io
n 0
$7 17
m ill
io n
0. 4
0. 2
< $0
.0 1
Co m
pa ss
io n
In te
rn at
io na
l Co
lo ra
do
Sp rin
gs , C
O $7
68 m
ill io
n 0
$7 76
m ill
io n
6. 8
10 .0
$0 .1
0
Am er
ic ar
es St
am fo
rd , C
T $7
52 m
ill io
n 0.
2 $6
41 m
ill io
n 0.
6 1.
4 <
$0 .0
1
Ca th
ol ic
R el
ie f S
er vi
ce s
Ba lti
m or
e, M
D $7
31 m
ill io
n 46
.9 $7
33 m
ill io
n 3.
3 4.
2 $0
.0 4
In te
rn at
io na
l R es
cu e
Co m
m itt
ee N
ew Y
or k,
N Y
$6 89
m ill
io n
66 .5
$6 74
m ill
io n
4. 9
2. 6
$0 .0
2
Sa ve
th e
Ch ild
re n
Fa irf
ie ld
, C T
$6 41
m ill
io n
41 .5
$6 36
m ill
io n
4. 9
5. 3
$0 .0
5
Sa m
ar ita
n’ s P
ur se
Bo on
e, N
C $5
94 m
ill io
n 5.
8 $5
05 m
ill io
n 4.
6 7.
5 $0
.0 6
M AP
In te
rn at
io na
l Br
un sw
ic k,
G A
$5 47
m ill
io n
0 $4
87 m
ill io
n 0.
1 0.
5 <
$0 .0
1
CA RE
At la
nt a,
G A
$5 30
m ill
io n
26 .1
$5 28
m ill
io n
5. 7
4. 6
$0 .0
4
U .S
. F un
d fo
r U N
IC EF
N ew
Y or
k, N
Y $5
15 m
ill io
n 0
$5 41
m ill
io n
2. 6
7. 0
$0 .0
6
(c on
tin ue
s)
6.9 Personal Donations 143
Na m
e Lo
ca tio
n To
ta l
Re ve
nu e
Co nt
rib ut
io ns
fr
om
Go ve
rn m
en t
Gr an
ts (%
) To
ta l
Ex pe
ns es
Ad m
in .
Ex pe
ns es
(%
)
Fu nd
- Ra
isi ng
Ex
pe ns
es (%
)
Am ou
nt
Sp en
t t o
Ra ise
$1
Fe ed
th e
Ch ild
re n
O kl
ah om
a, O
K $4
51 m
ill io
n 0.
4 $4
49 m
ill io
n 3.
0 6.
6 $0
.0 6
D oc
to rs
W ith
ou t
Bo rd
er s,
U SA
N ew
Y or
k, N
Y $3
51 m
ill io
n 0
$2 96
m ill
io n
1. 1
10 .4
$0 .0
9
M er
cy C
or ps
Po rt
la nd
, O R
$3 29
m ill
io n
70 .8
$3 26
m ill
io n
11 .3
4. 8
$0 .0
4
Th e
Ro ta
ry F
ou nd
at io
n of
R ot
ar y
In te
rn at
io na
l Ev
an st
on , I
L $3
18 m
ill io
n 0
$2 74
m ill
io n
3. 3
6. 5
$0 .0
6
Ca th
ol ic
M ed
ic al
M
iss io
n Bo
ar d
N ew
Y or
k, N
Y $3
11 m
ill io
n 3.
1 $3
14 m
ill io
n 1.
4 1.
1 <
$0 .0
1
PA TH
Se at
tle , W
A $2
89 m
ill io
n 27
.8 $2
77 m
ill io
n 15
.4 0.
9 <
$0 .0
1
O pe
ra tio
n Bl
es sin
g In
te rn
at io
na l
Vi rg
in ia
B ea
ch , V
A $2
56 m
ill io
n 0.
8 $2
58 m
ill io
n 0.
3 0.
6 <
$0 .0
1
Pr oj
ec t H
O PE
M ill
w oo
d, V
A $2
54 m
ill io
n 4.
3 $2
72 m
ill io
n 1.
6 2.
9 $0
.0 2
FI GU
RE 6
–1 4
M aj
or n
on pr
of it
or ga
ni za
tio ns
b as
ed in
th e
U ni
te d
St at
es a
nd w
or ki
ng in
te rn
at io
na lly
. Da
ta ar
e f or
th e 2
01 5 f
isc al
ye ar.
Da
ta fr
om Ch
ar ity
N av
iga to
r. Gl
en Ro
ck N
J: Ch
ar ity
N av
iga to
r; 20
17 .
144 Chapter 6 Global Health Financing
Na m
e Lo
ca tio
n To
ta l
Co nt
rib ut
io ns
Co nt
rib ut
io ns
fr
om
Go ve
rn m
en t
Gr an
ts (%
) To
ta l
Ex pe
ns es
Ad m
in .
Ex pe
ns es
(%
)
Fu nd
- Ra
isi ng
Ex
pe ns
es
(% )
Am ou
nt
Sp en
t t o
Ra ise
$1
Am er
ic an
R ed
C ro
ss W
as hi
ng to
n, D
C $2
72 7
m ill
io n
7. 0
$2 88
6 m
illi on
3. 8
5. 9
$0 .2
1
Fe ed
in g
Am er
ic a
Ch ic
ag o,
IL $2
20 1
m ill
io n
0 $2
18 5
m illi
on 0.
3 1.
1 <
$0 .0
1
AL SA
C St
. J ud
e Ch
ild re
n’ s R
es ea
rc h
H os
pi ta
l
M em
ph is,
T N
$1 38
8 m
ill io
n 6.
6 $1
09 5
m illi
on 10
.8 16
.1 $0
.1 5
Am er
ic an
C an
ce r
So ci
et y
At la
nt a,
G A
$8 62
m ill
io n
0. 6
$8 40
m ill
io n
5. 8
34 .2
$0 .3
6
Am er
ic an
H ea
rt
As so
ci at
io n
D al
la s,
TX $7
80 m
ill io
n 0.
8 $7
44 m
ill io
n 8.
8 12
.3 $0
.1 4
Al zh
ei m
er ’s
As so
ci at
io n
Ch ic
ag o,
IL $3
14 m
ill io
n 4.
4 $2
79 m
ill io
n 7.
4 19
.5 $0
.1 9
Th e
Le uk
em ia
&
Ly m
ph om
a So
ci et
y Ry
e Br
oo k,
N Y
$2 82
m ill
io n
0 $2
77 m
ill io
n 8.
8 17
.9 $0
.1 8
Am er
ic an
K id
ne y
Fu nd
Ro ck
vi lle
, M D
$2 65
m ill
io n
0 $2
66 m
ill io
n 0.
7 1.
8 <
$0 .0
1
FI GU
RE 6
–1 5
M aj
or m
ul tip
ur po
se h
um an
se rv
ic es
a nd
d ise
as e-
sp ec
ifi c
ch ar
iti es
b as
ed in
th e
U ni
te d
St at
es .
Da ta
fo r t
he 20
15 fis
ca l y
ea r.
Da ta
fr om
Ch ar
ity N
av iga
to r.
Gl en
Ro ck
N J:
Ch ar
ity N
av iga
to r;
20 17
.
6.9 Personal Donations 145
18. Busse R, Blümel M. Germany: Health system review. Health Syst Transit. 2014;16:2.
19. Mills A. Health care systems in low- and middle- income countries. N Engl J Med. 2014;370:552–7.
20. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: History, advances, and challenges. Lancet. 2011;377:1778–97.
21. Macinko J, Harris MJ. Brazil’s family health strategy: Delivering community-based primary care in a universal health system. N Engl J Med. 2015;372:2177–81.
22. Global humanitarian assistance report 2016. Bristol UK: Development Initiatives Ltd; 2016.
23. Fast-track: Ending the AIDS epidemic by 2030. Geneva: UNAIDS; 2014.
24. Stuckler D, McKee M. Five metaphors about global- health policy. Lancet. 2008;372:95–7.
25. Yach D, Bettcher D. The globalization of public health, II: The convergence of self-interest and altruism. Am J Public Health. 1998;88:738–41.
26. Tarnoff C, Lawson ML. Foreign aid: An introduction to U.S. programs and policy. Washington DC: Congressional Research Service (CRS); 2016.
27. Development co-operation report 2016. Paris: OECD; 2016.
28. Aid at a glance. Paris: OECD; 2016. 29. Bendavid E, Ottersen T, Schaferhoff M, Padian
N, Nugent R, Rottingen JA. Donor assistance for health (Chapter 15). Disease control priorities. 3rd ed. Disease control priorities (Volume 9). Washington DC: IBRD/World Bank; 2017.
30. The U.S. Government engagement in global health: A primer. Menlo Park CA: The Henry J. Kaiser Family Foundation; 2017.
31. Financing global health 2015: Development assistance steady on the path to new Global Goals. Seattle WA: Institute for Health Metrics and Evaluation (IHME); 2016.
32. Salaam-Blyther T. U.S. global health assistance: FY2001-FY2016. Washington DC: Congressional Research Service (CRS); 2015.
33. Multilateral aid 2015: Better partnerships for a post- 2015 world. Paris: OECD Publishing; 2015.
34. World investment report 2016. Geneva: United Nations Conference on Trade and Development (UNCTAD); 2016.
35. Migration and remittances: Recent developments and outlook. Washington DC: World Bank; 2016.
36. Driscoll DD. The IMF and the World Bank: How do they differ? Washington DC: IMF; 1996.
37. Foundations: Top 50 by assets. New York: Foundation Center; 2017.
38. 2015 Annual tax return (Form 990-PF). Seattle WA: Gates Foundation; 2016.
▸ References 1. Global Burden of Disease Health Financing
Collaborator Network. Evolution and patterns of global health financing 1995–2014: Development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. Lancet. 2017;389:1981–2004.
2. Global Burden of Disease Health Financing Collaborator Network. Future and potential spending on health 2015–40: Development assistance for health, and government, prepaid private, and out- of-pocket health spending in 184 countries. Lancet. 2017;389:2005–30.
3. Kutzin J, Witter S, Jowett M, Bayarsaikhan D. Developing a national health financing strategy: A reference guide. Geneva: WHO; 2017.
4. Frenk J, Moon S. Governance challenges in global health. N Engl J Med 2013;368:936–42.
5. Schäferhoff M, Fewer S, Kraus J, et al. How much donor financing for health is channeled to global versus country-specific aid functions? Lancet. 2015;386:2436–41.
6. Monitoring the building blocks of health systems: A handbook of indicators and their measurement strategies. Geneva: WHO; 2010.
7. Everybody’s business: Strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva: WHO; 2007.
8. United Nations. Transforming Our World: The 2030 Agenda for Sustainable Development. New York: UN; 2015.
9. The world health report 2013: Research for universal health coverage. Geneva: WHO; 2013.
10. World health report 1999. Geneva: WHO; 1999. 11. Tracking universal health coverage: First global
monitoring report. Geneva: WHO/World Bank; 2015. 12. Human development report 2016. New York: UNDP;
2016. 13. World health statistics 2016. Geneva: WHO; 2016. 14. Schmets G, Rajan D, Kadandale S, editors.
Strategizing national health in the 21st century: A handbook. Geneva: WHO; 2016.
15. Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D. Comparative performance of private and public healthcare systems in low- and middle-income countries. PLoS Med. 2012;9:e1001244.
16. Gottret P, Schieber G. Health financing revisited: A practitioner’s guide. Washington DC: World Bank; 2006.
17. Barnett JC, Vornovitsky MS. Health insurance coverage in the United States: 2015. Washington DC: U.S. Census Bureau; 2016.
146 Chapter 6 Global Health Financing
39. Giving in numbers: 2016 edition. New York: The Committee Encouraging Corporate Philanthropy (CECP); 2016.
40. Access to Nutrition Index: Global index 2016. Utrecht: Access to Nutrition Foundation; 2016.
41. The journey to sustainable food: A three-year update on the Behind the Brands campaign. Oxford: Oxfam; 2016.
42. Access to medicine index 2016. Haarlem, Netherlands: Access to Medicine Foundation; 2016.
43. Giving USA 2015: Highlights. Chicago IL: The Giving Institute; 2016.
44. Haiti earthquake response: Five-year update (January 2015). Washington DC: American Red Cross; 2015.
45. Tsunami recovery program: Five-year report. Washington DC: American Red Cross; 2009.
46. The face of recovery: The American Red Cross response to Hurricanes Katrina, Rita, and Wilma. Washington DC: American Red Cross; 2007.
47. Wydick B, Glewwe P, Rutledge L. Does international child sponsorship work? A six-country study of impacts on adult life outcomes. J Political Econ. 2013;121:393–436.
48. Charity Navigator. Glen Rock NJ: Charity Navigator; 2017.
49. MacAskill W. Doing good better: How effective altruism can help you help others, do work that matters, and make smarter choices about giving back. New York: Gotham Books; 2015.
References 147
© Xinzheng. All Rights Reserved/Moment/Getty
CHAPTER 7
Global Health Implementation Global health interventions are implemented in countries and communities by national and local governments as well as by international cooperation agencies, United Nations organizations, public– private partnerships, nonprofit organizations, and corporate contractors. Monitoring and evaluation processes help ensure that initiatives aiming to expand access to clinical services, distribute relief aid, promote community development, disseminate new health products, and support other health- related activities are achieving their stated goals.
▸ 7.1 Global Health Interventions
The groups that set global health priorities and fund global health activities usually are distinct from the entities that implement health projects at the national and commu- nity levels.1 The typical funding pathway for a global health initiative is for a donor (usu- ally a high-income country government or a large foundation) to give money to a first-level recipient (such as an international cooperation agency, a United Nations agency, or a global partnership), which then passes funding along to numerous second-level recipients (such as government agencies, nongovernmental orga- nizations, and private-sector contractors) that implement the projects (FIGURE 7–1).
Funders often use terms like strategy and policy to describe the outputs they generate. A strategy is a big picture plan for how to achieve a major goal. A policy is a set of principles and procedures that guide decision-making and resource allocation. An action plan describes
all of the steps that will be taken to achieve strategic goals and implement approved poli- cies. A scheme is an operationalized plan that spells out the desired outcomes and comple- tion timelines for an action plan.
By contrast, implementers more often use terms like program and project to describe their work. A program is a portfolio of related proj- ects that together achieve part of an action plan. A project is a series of coordinated tasks that are completed within a limited time period in order to achieve a specific target. A deliverable is a product, service, or other result of a project. Project management is the process of initiat- ing, planning, executing, monitoring and con- trolling, and closing out projects.2 Most funded projects have stated outcomes that must be achieved by the project implementation team to meet the terms of the contract between the funder and the recipient. A project manager is responsible for ensuring that deliverables are completed on time and within budget. The same series of steps are implemented for nearly all global health projects, even when they have very different objectives.
148
Global health implementers provide services in a diversity of specialty areas. Many implementation groups provide clin- ical care at hospitals and clinics or through community-based healthcare providers. Clin- ical initiatives are often described as being hor- izontal or vertical.3 A horizontal program strengthens an existing health system so that it can deliver additional health services. Horizon- tal programs are often described as integrat- ing newly funded packages of health services into existing primary care delivery systems. A vertical program delivers disease-specific services that are not fully integrated into the health system. Vertical programs are often used to address global health priorities like disease eradication efforts that demand an intensive but time-limited series of coordinated efforts.
Some agencies and organizations have expertise in responding quickly to emergencies, and others have experience in working along- side communities to promote lasting economic growth. Relief is aid that meets the immedi- ate needs of people who might otherwise not have access to water, food, shelter, emergency
medical care, and other urgent necessities after major natural disasters and during wars and other types of humanitarian crises. Devel- opment is a long-term process of improving the socioeconomic and environmental condi- tions that are associated with poor population health status. Some development programs are designed centrally by professionals and dis- seminated to participating localities. Some use a slower community development process in which community members identify their own priorities and take action to achieve them with the support of partner organizations. Relief groups quickly deliver the material goods needed for survival, while community develop- ment groups make long-term investments in capacity building and sustainable change.
Some global health groups have strengths in advocacy, the process of increasing aware- ness of a specific cause in order to influence policy and resource allocation decisions related to that issue. A variety of commu- nication tactics are used for advocacy. For example, social media, electronic communi- cation tools that allow users to generate and
IMPLEMENTERSDONORS
High-income country
governments
Private foundations
CHANNELS
Bilateral agencies
Multilateral organizations
International NGOs
Local NGOs
Recipient country governments
Others
FIGURE 7–1 Typical pathway from global health funders to implementers.
7.1 Global Health Interventions 149
share content, are often used to disseminate news about emerging public health prob- lems to large audiences in live time. Some global health implementers have expertise in logistics, the process of coordinating com- plex operations, especially the movement of supplies and equipment. Logistics specialists are able to efficiently procure or produce, package, transport, store, and deliver food, medications, medical devices, and other goods to people and communities in need. Advocacy calls for an action to be taken, and logistics makes that action happen after fund- ing for the activity has been secured.
Many of the most prominent global health implementers are governmental and intergovern- mental agencies, large nonprofit organizations, and businesses that work in several functional areas in multiple world regions. Smaller imple- menting entities may focus on one area of exper- tise and work within a limited geographic zone.
▸ 7.2 Local and National Governments
In most countries, the majority of clinical health services are provided at government-owned
and operated health facilities or at private non- profit or for-profit health facilities that are reg- ulated by governments. Governments decide, at least in part, the list of services that are cov- ered by public funds, social security, or health insurance schemes and the choices (if any) that people have about which healthcare facilities and clinicians provide their care. Governments are also responsible for the public health system (FIGURE 7–2).4 Government public health agen- cies protect residents from unsafe foods, med- ications, medical products, and environmental hazards; provide recommendations and regu- lations about nutrition, vaccination, screening tests, worker safety, and other actions that pro- mote health and prevent disease; and respond to outbreaks and other threats to public health.5
The lead governmental health agency in a country is often called the Ministry of Health. In most countries, the majority of clinical health services and public health programs are implemented by national min- istries of health and their state or provincial and district health offices or with the approval of these agencies.6 The national health agency also typically takes the lead on communicat- ing about health-related issues with intergov- ernmental agencies (such as the World Health Organization), global partnerships, and other
IMPLEMENTERS who provides?
PERSONAL HEALTH
PUBLIC HEALTH
Governments Typical
HIGH-income country
Typical LOW-income
country
Public facilities or a mix of
public & private facilities
Public facilities, informal
providers, & others
Governments, NGOs, &
others
FIGURE 7–2 Governments are responsible for implementing most public health activities.
150 Chapter 7 Global Health Implementation
In the United States, the Department of Health and Human Services (HHS) performs the functions of a health ministry plus additional tasks. HHS’s lead health protection agency is the Centers for Disease Control and Preven- tion (CDC). One of the many roles of CDC is responding to outbreaks and other public health emergencies, including participating in inter- national responses when foreign governments invite CDC to collaborate.7 The CDC also works with partners in other countries to conduct field research, set up monitoring and surveillance systems, and train public health workers. The National Institutes of Health (NIH) is HHS’s division that conducts health research. Although most NIH research is conducted at study sites within the United States, NIH research may be conducted internationally when the research protocol meets the rigorous standards for ethical research established by NIH and by host country governments. Other operating divisions of HHS include the Agency for Healthcare Research and Quality (AHRQ), the Agency for Toxic Sub- stances and Disease Registry (ATSDR), the Cen- ters for Medicare & Medicaid Services, the Food and Drug Administration (FDA), the Health Resources and Services Administration (HRSA), the Indian Health Service, and the Substance Abuse and Mental Health Services Administra- tion ( SAMHSA), among others. Other countries have similarly complex organizational structures within their health ministries.
▸ 7.3 International Cooperation
Foreign policy describes the strategies and approaches a country uses to engage with other nations and protect its own interests as they per- tain to security, trade, and other critical func- tions.8 The “3 Ds” of foreign policy have been described as diplomacy, defense, and develop- ment.9 Diplomacy is the process of negotiating agreements between countries, resolving dis- putes peacefully, and navigating other aspects of international relations.10 Health diplomacy
external groups. For example, international laws require a country’s lead health agency to submit timely reports about outbreaks of dan- gerous infectious diseases and make formal requests for assistance before international teams can be deployed to support epidemic containment efforts. Ministries of health also oversee the training and licensure of all cli- nicians working within their borders, includ- ing ensuring that visiting clinicians providing patient care are qualified practitioners.
Even when formal approval prior to the implementation of a new health initiative is not mandated, projects often benefit from the advice and support of governmental officials. For example, suppose that a nonprofit organi- zation based in the United States wants to dis- tribute free insecticide-treated bednets (ITNs) in rural communities in Nigeria. A typical first step toward implementation would be for rep- resentatives from the nonprofit organization and their Nigerian partner organization(s) to meet with leaders from the local government and other community organizations, including religious groups, to ask for their support. If the project is deemed to be one that will benefit the targeted communities, these local leaders and other community representatives will be able to help the nonprofit group design an appropriate distribution system and spread the word about the free ITNs to the participating communities. The local leaders will also be able to tell Amer- ican visitors if their community members do not need or do not want ITNs, if the visitors are scheduled to come at a bad time (such as arriving during harvest time or on the day of a special event), or if hosting the visitors, who might need meals and places to sleep, will place an undue burden on some communities. With- out doing these sorts of pre- implementation checks, well-intentioned groups might unin- tentionally inconvenience recipient commu- nities, violate laws about taxation of imported products, duplicate existing malaria control programs, undermine the community health outreach programs of local hospitals and clin- ics, financially harm local vendors who sell ITNs, or encounter other preventable problems.
7.3 International Cooperation 151
an equivalent agency). International coopera- tion agencies typically send representatives to recipient countries to oversee projects and pro- vide technical and logistical support.
International cooperation is about more than high-income countries (and a growing number of upper-middle-income countries) sending money to a low- or middle-income partner country to alleviate poverty and improve health. Sponsored projects are integral parts of donor countries’ foreign policy strate- gies. The targeted recipient countries, goals, and methods are selected based on the political situations and historic connections of the donor
uses health projects as part of meeting for- eign policy goals.11 Defense is carried out by militaries. Development in the foreign policy context is often called international coop- eration or development cooperation, and it includes financial assistance, capacity building, and other actions that improve the economic situation in lower-income countries, promote stability, and foster future opportunities for expanded trade. Many donor countries have a specialized agency that leads bilateral coop- eration efforts (FIGURE 7–3). Other countries implement international cooperation initia- tives through a Ministry of Foreign Affairs (or
Country Abbreviation Agency
Austria ADA Austrian Development Agency
Belgium BTC Belgian Development Agency
Czech Republic CzDA Czech Development Agency
France AFD Agence Française de Développement
Germany GIZ Deutsche Gesellschaft für Internationale Zusammenarbeit
Iceland ICEIDA Icelandic International Development Agency
Ireland Irish Aid Irish Aid
Japan JICA Japan International Cooperation Agency
Republic of Korea KOICA Korean International Cooperation Agency
Luxembourg LuxDev Lux-Development
Norway Norad Norwegian Agency for Development Cooperation
Spain AECID Agencia Española de Cooperación Internacional para el Desarrollo (Spanish Agency for International Development Cooperation)
Sweden Sida Swedish International Development Cooperation Agency
Switzerland SDC Swiss Agency for Development and Cooperation
United Kingdom DFID Department for International Development
United States USAID United States Agency for International Development
FIGURE 7–3 Examples of international development and cooperation agencies.
152 Chapter 7 Global Health Implementation
was founded by 51 member states in 1945, at the end of World War II. The member- ship list has expanded to include more than 190 member nations. The goals of the UN are “to maintain international peace and secu- rity,” “to develop friendly relations among nations,” and “to achieve international co- operation in solving international problems of an economic, social, cultural, or human- itarian character.”16 The UN is governed by its main bodies: the UN General Assembly, which is the chief policy- setting group for the UN and is composed of one voting rep- resentative from each member state; the 15-member UN Security Council, which is responsible for peace-building, mediation, and security operations; the Economic and Social Council; the International Court of Justice, which provides legal judgments and advisory opinions; and the UN Secretariat, which is run by the Secretary-General of the UN and manages numerous departments and offices, including the Department of Eco- nomic and Social Affairs, the Office of the UN High Commissioner for Human Rights (OHCHR), and the UN Office on Drugs and Crime (UNODC). The UN also hosts pro- grams and funds, specialized agencies, and several UN- related organizations, including the International Atomic Energy Agency (IAEA), the International Organization for Migration (IOM), and the World Trade Orga- nization (WTO).
The programs and funds of the UN are overseen by the General Assembly and financed through voluntary contributions from member nations (FIGURE 7–4). The UN Development Programme (UNDP) focuses on poverty reduction. The UN Environment Programme (UNEP) pro- motes healthy ecosystems and sustainable use of natural resources.17 The UN Population Fund (UNFPA), formerly the UN Fund for Population Activities, supports reproduc- tive health programs. The United Nations Children’s Fund (UNICEF), formerly the UN International Children’s Emergency Fund, advocates for children’s rights and
nation. For example, the United Kingdom’s Department for International Development (DFID) tends to work especially closely with members of the Commonwealth of Nations (formerly the British Commonwealth), which are almost exclusively former British colonies or protectorates,12 and the Japan International Cooperation Agency (JICA) works worldwide but is especially active in the Asian countries with which it has strong economic ties.13
USAID, the United States Agency for International Development, is a major donor to global health activities and also operates global health programs, partners with other groups to implement global health activities, engages in global health diplomacy, supports research and development, and provides technical assis- tance related to global health.14 USAID has been active for several decades in supporting maternal and child health programs, infection control efforts, and health systems strengthen- ing, as well as other aspects of global health.15 The State Department and the Millennium Challenge Corporation also engage in health diplomacy on behalf of the United States.
▸ 7.4 The World Health Organization and the United Nations
The United Nations (UN) is the world’s larg- est intergovernmental organization. The UN
© No
rth fo
to /S
hu tte
rst oc
k
7.4 The World Health Organization and the United Nations 153
work with the UN and are funded through both assessed contributions and volun- tary donations (FIGURE 7–5). The Food and
provides humanitarian assistance for chil- dren. UNICEF aims to end preventable deaths of children, newborns, and their mothers and to promote the healthy development of all children from birth through adulthood.18 UN- Habitat, the United Nations Human Set- tlements Programme, advises on sustainable urban development. The Office of the UN High Commissioner for Refugees (UNHCR) is the UN Refugee Agency. UN Women is the UN Entity for Gender Equality and the Empowerment of Women. The World Food Programme (WFP) aims to eradicate hunger and malnutrition.
The specialized agencies of the UN are autonomous international organizations that
Program or Fund Primary Work Area
UNCTAD United Nations Conference on Trade and Development
International trade
UNDP United Nations Development Programme Poverty reduction and resilience
UNEP United Nations Environment Programme Environment
UNFPA United Nations Population Fund Reproductive health
UN-HABITAT United Nations Human Settlements Programme
Urban development
UNHCR Office of the United Nations High Commissioner for Refugees
Refugees
UNICEF United Nations Children’s Fund Children and mothers
UNODC United Nations Office on Drugs and Crime Drugs
UNRWA United Nations Relief and Works Agency for Palestinian Refugees
Palestinian refugees
UN Women UN Women Women
WFP World Food Program Hunger and malnutrition
FIGURE 7–4 United Nations programs and funds.
© M
C2 Ju
sti n Y
ar bo
ro ug
h/ U.
S. Na
vy
154 Chapter 7 Global Health Implementation
International Labour Organization (ILO), UNESCO, WHO, and the World Bank—to advance HIV/AIDS prevention and control. Other UN entities that are not specialized agencies but work with them include the UN Office for Disaster Reduction (UNISDR) and the UN Office for Project Services (UNOPS).
Agriculture Organization (FAO), the World Bank, and many of the other agencies work on sociopolitical, economic, and environ- mental issues that are related to health. The Joint United Nations Programme on HIV/ AIDS (UNAIDS) is an entity co- sponsored by 10 UN system agencies—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, the
Agency Primary Work Area
FAO Food and Agriculture Organization Hunger
ICAO International Civilian Aviation Organization Aviation
IFAD International Fund for Agricultural Development
Rural development
ILO International Labour Organization Labor rights
IMF International Monetary Fund Economic growth
IMO International Maritime Organization Shipping
ITU International Telecommunication Union Information and communication technologies
UNESCO United Nations Educational, Scientific and Cultural Organization
Culture
UNIDO United Nations Industrial Development Organization
Industrial development
UNWTO World Tourism Organization Tourism
UPU Universal Postal Union Postal services
WHO World Health Organization Health
WIPO World Intellectual Property Organization Intellectual property
WMO World Meteorological Organization Meteorology
World Bank Group World Bank Poverty reduction
FIGURE 7–5 United Nations agencies.
7.4 The World Health Organization and the United Nations 155
between all of the member countries of the UN. Under the IHR, all countries agree to notify the WHO immediately about situations that might become public health emergencies and to share critical information with all member nations when outbreaks are occurring.22 The member nations also agree to develop and maintain pub- lic health systems that are able to monitor popu- lation health status, identify emerging problems, and respond to health crises, and they pledge to engage in travel and transportation practices that protect global public health.
The IHR are derived from agreements negotiated in the mid-1800s by several Euro- pean countries that worked together to prevent the spread of cholera outbreaks without stifling international shipping and trade.23 The WHO was established in 1948. In 1951, the member nations adopted a set of International Sanitary Regulations that were based on the existing cholera control frameworks. These interna- tional laws governing global health security were renamed the International Health Regu- lations in 1969 and were updated to focus on controlling six infectious diseases: cholera, plague, relapsing fever, smallpox, typhus, and yellow fever. Modifications made in 1973 and 1981 reduced the number of reportable diseases to just three: cholera, plague, and yellow fever. A major overhaul of the IHR adopted in 2005 increased requirements for shared commu- nication about and coordinated responses to influenza, viral hemorrhagic fevers, and other emerging infectious diseases and events of potential international public health concern.24
The 2005 updates were a response to the emergence of SARS (severe acute respiratory syndrome), a coronavirus infec- tion that caused its victims to become critically ill with pneumonia.25 The first cases of SARS were identified in Guangdong, in southern China, in November 2002. In March 2003, SARS spread to Hong Kong, and a secondary outbreak occurred in Toronto, Canada. Cases were diagnosed in more than two dozen coun- tries across five continents.26 The SARS pan- demic was contained by isolating patients and
The World Organisation for Animal Health (known as OIE, the acronym for the Office International des Epizooties, the orga- nization’s original name in French) is an inter- governmental group that is not part of the UN system but works closely with FAO and World Health Organization to control the spread of zoonotic infectious diseases and to promote food safety.
The World Health Organization (WHO), launched in 1948, is a specialized agency of the UN that serves as its primary health agency.19 The WHO is governed by the World Health Assembly (WHA), composed of one representative from each UN mem- ber state. The WHA convenes every May to approve a budget, make policy decisions, and approve conventions, agreements, and regula- tions. The core functions of the WHO are to provide leadership for the health work being done across the UN; identify global health research priorities; develop standards of prac- tice, such as child growth charts and recom- mendations for laboratory and diagnostic procedures; formulate evidence-based policy recommendations; provide technical support to UN member nations; and monitor disease epidemics and compile health statistics.20 Current priority areas include health systems strengthening, health promotion across the life span, and emergency preparedness and response.20
▸ 7.5 International Health Regulations
Globalization means that humans are tied together more tightly than ever before, and a problem in one part of the world can quickly become a global issue.21 One of the roles of global health agencies is to prevent dangerous out- breaks from spreading across national borders and causing widespread morbidity and mortal- ity. The International Health Regulations (IHR) are a global health security agreement
156 Chapter 7 Global Health Implementation
carefully observing the people they had contact with, so that anyone who developed symptoms could be isolated immediately and treated under strict infection control protocols.27 How- ever, the outbreak raised alarms about gaps in global health communication, surveillance, and response capacity.28 The 2005 IHR address all types of risks, mandating more communica- tion about health events from member nations and obligating countries to strengthen their surveillance and response activities.29
Health surveillance is the process of con- tinually monitoring health events in a popula- tion so that emerging problems can be detected and appropriate control measures can be implemented quickly. Surveillance is the first step in a public health approach to responding to threats (FIGURE 7–6).30 Surveillance systems, which are usually run by governments, track infectious disease reports from hospitals and other information sources to look for possible outbreaks or clusters of disease, which occur when there is an unusually high incidence of disease in a particular place (spatial cluster- ing) or time (temporal clustering). The health statistics collected as part of surveillance allow communities, states and provinces, and nations to know what diseases are common in their populations and to recognize when an unusual health situation is emerging. Base- line data about incidence and prevalence from routine surveillance allow epidemiologists to identify when an atypically large number of cases are being diagnosed.
It is not necessary for surveillance sys- tems to track an entire population. Sentinel surveillance is the continuous collection and
analysis of high-quality data from a limited num- ber of clinics or hospitals so that public health officials will be able to detect changes in health status in the larger population from which the sentinel sites were sampled. If an outbreak is suspected based on data from sentinel sites, a more rigorous investigation involving addi- tional clinics, hospitals, and laboratories can be conducted. Passive surveillance collects man- datory reports of notifiable disease diagnoses from medical laboratories. Active surveillance involves public health officials contacting health- care providers to ask about how often they are diagnosing particular types of diseases. Syn- dromic surveillance tracks potential outbreaks or other disease events based on reports of symp- toms, school absentee reports, spikes in Internet searches for particular diseases, and other types of data rather than relying solely on counts of laboratory- confirmed diagnoses.
Several epidemiological terms are used to describe how often diseases occur in a popula- tion. An endemic disease is an adverse health condition that is always present in a particular population. For example, malaria and dengue are constant threats to health in many parts of the world and are considered to be endemic in those places. An outbreak is characterized by at least several people becoming ill from a disease that is not usually present in a population, as happens when dozens of people contract a food- borne illness by eating at the same restaurant. An epidemic occurs when a disease is occur- ring more often than usual and there are more than a few sporadic occurrences of disease. A pandemic is a worldwide epidemic. The term pandemic describes the distribution of disease
Surveillance
What is the problem?
Risk Factors
What is the cause of the
problem?
Evaluation of Interventions
What interventions
work?
Implementation
What resources are needed to
solve the problem?
FIGURE 7–6 Surveillance is the first step in a public health approach to responding to threats to health. Adapted from Holder Y, Peden M, Krug E, Lund J, Gururaj G, Kobusingye O, editors. Injury survellance guidelines. Geneva: WHO; 2001.
7.5 International Health Regulations 157
events across the globe, and it is not necessarily an indicator of the severity of the disease. Pan- demics of highly pathogenic infectious diseases are global health priorities because they have the potential to wreak havoc on global travel and trade in addition to causing widespread illness and death. Historic pandemics of influenza, cholera, and other severe infectious diseases have shaped international health agreements and global preparedness and response plans.31
Under the 2005 IHR, a public health emergency of international concern (PHEIC) can be declared when an infectious disease outbreak is causing serious illnesses, is likely to spread to other countries, and requires a coordinated global response. Several events have been declared to meet the PHEIC criteria, including the 2009 H1N1 influenza pandemic; a resurgence of polio that occurred in 2014; the 2014 West African outbreak of Ebola virus dis- ease, a hemorrhagic fever transmitted via con- tact with the body fluids of infected individuals; and the spread of Zika virus in the Americas in 2016.32 PHEIC status enables international resources to be released to support the response to the disease event, and it also obligates the affected countries to act on the disease control recommendations issued by the WHO.
▸ 7.6 Global Partnerships A public–private partnership (PPP) is a long-term collaboration in which the costs, risks, and benefits are shared by governmental
and nongovernmental entities. For global health PPPs, the public partners are the national governments of countries from across the income spectrum. Since 2000, PPPs have been increasing in popularity as channels for dispersing development assistance for health (DAH) (FIGURE 7–7).33 The private partners in global health PPPs include nonprofit foun- dations and for-profit corporations. Global health PPPs are developing new products (such as new medications, vaccines, and diagnostic tools), improving the quality and regulation of products, distributing donated and subsidized health products, educating the public about particular health issues, strengthening health services and health informatics systems, and coordinating complex global health efforts.34
Dozens of PPPs are currently working to set and accomplish goals for selected global health issues. The two largest global health
Um id
Sh ar
ap ov
, M .D
., M .Sc
. C en
te rs
fo r D
ise as
e C on
tro l a
nd
Pr ev
en tio
n/ CD
C C on
ne cts
0%
20%
40%
60%
80%
100%
1990 1995 2000 2005 2010 2015
Development banks
Public–private partnerships
United Nations agencies
Non-governmental organizations (NGOs) and foundations Bilateral agencies
FIGURE 7–7 The channels involved in disbursing development assistance for health (DAH) are shifting in prominence. Data from Financing global health 2015: Development assistance steady on the path to new global goals. Seattle: Institute for Health Metrics and Evaluation (IHME); 2016.
158 Chapter 7 Global Health Implementation
Co py
rig ht
© 20
16 Ro
ta ry
In te
rn at
ion al
partnerships are The Global Fund to Fight AIDS, Malaria and Tuberculosis and Gavi, the Vaccine Alliance.33 The Global Fund finances infection control and prevention initiatives in low- and middle-income countries. Applicant countries propose their own sets of projects, and they manage the implementation of funded programs. The Global Fund provides technical support and negotiates with phar- maceutical companies and other manufactur- ers to procure medications and other health products at low costs. The Global Fund is able to make these tools for health affordable by signing contracts to purchase massive quan- tities of commonly desired products—enough to meet the demand in many countries— and guaranteeing that the manufacturer will receive payment for its products.35 Gavi works with low- and middle-income countries to identify priority vaccines and negotiates with manufacturing companies to increase the production of desired vaccines. Gavi and the recipient countries share the costs of the vac- cines. Countries pay larger shares of the costs as their economies grow, until they are fully sustaining their own vaccination programs.36
One of the goals of many PPPs is to increase access to new technologies and other tools for health. A health product is only valu- able for global health when the intended users can afford the product and when they choose to use the product for its intended purposes. Increasing the number of users requires the product to gain local acceptance and be adopted by end users, and that process requires
product advocacy and buy-in from a variety of stakeholders, including donors, policymakers, and end users.37 Social marketing is the use of marketing strategies to change behaviors in targeted populations. Partners with expertise in social marketing can increase demand for products, and partners with expertise in man- ufacturing can ensure that there are enough supplies to meet demand.
Successful global health partnerships yield benefits for all of the partners who con- tribute to research, production, and distribu- tion activities. Corporate partners are able to make a profit on reduced-price products by selling a larger volume of products than they would sell if they were not part of the part- nership. They also benefit when subsidized health products open up new markets to the company and enhance their reputations. The governments of high-income countries attain an effective mechanism for achieving their foreign policy, scientific, and humanitarian goals. Most importantly, the health of the world’s people is advanced when partnerships increase the visibility of specific health issues, raise funds to address those issues, stimulate research and development, implement new treatment protocols and technical standards, and improve access to health care and the tools for health.38
▸ 7.7 The Nonprofit Sector
A nonprofit organization (NPO) is a mission-driven group that reinvests surplus revenue in the organization rather than distrib- uting extra income to owners or shareholders. Some NPOs are led by unpaid volunteers, but many have paid staff. A nongovernmental organization (NGO), sometime called a pri- vate voluntary organization, is a nonprofit organization that is privately managed and receives at least some of its funding from pri- vate sources. NGOs from countries across
7.7 The Nonprofit Sector 159
the income spectrum are involved in provid- ing clinical care and public health services, disseminating relief aid, leading community development work, engaging in advocacy, and managing logistics for health programs and projects. NGOs with global health portfolios may focus on one key health issue (such as spe- cializing in raising awareness about HIV pre- vention or providing surgical services) or they may address multiple issues in a particular location (such as delivering a comprehensive set of socioeconomic development, environ- mental sustainability, and health interventions in one country or a smaller geographic area). Some large international NGOs (INGOs) have diverse portfolios of projects that they imple- ment in numerous countries. Some NGOs are faith-based organizations (FBOs) spon- sored by a religious or religiously affiliated entity. FBOs rarely require that aid recipients adhere to a particular faith or listen to an evan- gelistic message, but they openly represent a particular religious tradition. Examples of FBOs include the American Jewish World Ser- vice, Catholic Relief Services, Church World Service, Islamic Relief, and World Vision.
Most large global health NGOs raise funds from individuals, private foundations, and governmental sources. One challenge for many NGOs is balancing the goals of donors and the desires and needs of recipients.39 Directed donations are ones in which the donor stip- ulates that the contributed funds or supplies must be used in a particular way. Sometimes this works well, but when donors are not aware of conditions in the recipient community, the donation may not generate the intended out- come. A community that wants to upgrade its local health clinic by adding a solar panel to provide electricity to the building may instead receive a microscope that cannot be used with- out electricity. A nursing school may receive a donation of textbooks written in a language not spoken by any of the students or containing obsolete content. Or a donor may send used medical equipment that cannot be maintained by the community, expired medications that
have to be discarded immediately, or a water pump that cannot be locally repaired. (Appro- priate technology is affordable and environ- mentally sustainable technology that can be locally operated and maintained.) Donors may also demand input into operational decisions. They may insist that expatriates, rather than host-country staff, manage projects and over- see budgets. This may inhibit capacity building in host communities.
NGOs working in global health aim to improve the well-being of individuals, commu- nities, and nations, but well-intentioned efforts can sometimes have harmful side effects. The actions of an NGO may have unintended social and political consequences.40 For example, the presence of a relief NGO may exacerbate con- flicts by providing supplies that allow violence and instability to continue or by encouraging displaced people to congregate in one area that could be targeted for attack. The long-term presence of a community development NGO may promote a “culture of dependency” and prevent the development of governmental or commercial service providers.
Skills in effective cross-cultural com- munication are a requirement for everyone working in global health, especially for INGO leaders who have to navigate complex political terrains. For example, some of the largest U.S.- based INGOs receive a substantial portion of their budgets from the U.S. government. Their workers may be seen by host communities as agents of a foreign government. Other chal- lenges arise from the political landscapes in host countries. INGOs must decide how closely they will work with officials from host coun- tries and how to address potential problems with corruption and mismanagement. Some humanitarian groups feel that it is import- ant to remain publicly neutral about political matters, while others feel compelled to speak openly about any injustices they witness.
NGOs that successfully maneuver through these complex situations play a very important role in global health. Since NGOs often work for decades in the same
160 Chapter 7 Global Health Implementation
USAID is one of the major channels for disbursing global health funding to companies. USAID does not have the staff to implement all of its own projects, so many of its projects are managed by outside groups. Several of the lead- ing USAID contractors are for-profit companies, including Chemonics, John Snow Inc., DAI, Abt Associates, and Tetra Tech (FIGURE 7–8).43 Most of the other leading USAID contractors are nonprofit organizations that receive nearly all of their funds from government contracts and are not dependent on fund-raising from private donors. These groups include FHI 360, Man- agement Sciences for Health (MSH), Jhpiego, and RTI. Only a few of the major recipients of USAID funding are charities that manage large government contracts but still rely heavily on private donations for a large portion of their portfolio of projects, such as Catholic Relief Services and Mercy Corps.
Among the global health implementing groups that have annual budgets of millions of dollars, the functional differences between for-profits and nonprofits are often minimal. For example, both for-profit and nonprofit con- tractors typically offer their professional staff from high-income countries professional-level salaries and compensation packages, no matter what setting they are working in. For both, pro- fessional staff from low- and middle-income countries who are working in their home countries—“host-country nationals,” in inter- national development lingo—typically earn salaries that are locally competitive but lower than their peers from high-income countries,44 even though these pay differentials can become a source of workplace tension.45 Charities that primarily remain dependent on private donors tend to offer smaller compensation packages to employees.
Food and beverage companies, phar- maceutical companies, manufacturers of medical devices, manufacturers of hygiene supplies and personal care products, and other corporations that produce health- related goods and provide health-related services play an important role in facilitating
communities, their employees and volunteers build relationships and trust with community members. NGOs can then serve as points of connection between communities and donors (and other funding channels), with NGOs using their networks to help new proj- ects and programs quickly reach their target audiences. NGOs are often the organizations that actually deliver global health interven- tions to the people who will most benefit from them. For example, Rotary International members worldwide have worked together on the global polio eradication campaign, with local Rotary clubs in endemic areas facili- tating vaccination campaigns in their own communities.41
▸ 7.8 The Corporate Sector
A variety of businesses play a role in global health. Some companies specialize in proj- ect implementation, and they receive con- tracts from funding agencies and other global health financing channels to manage the delivery of global health services. Some companies are the private partners in PPPs, and they are paid to manufacture the medi- cations, vaccines, and other products that are distributed as part of global health initiatives. (These companies might also donate some of their products as part of their corporate social responsibility plans, but that is a sepa- rate function from participation in contracted manufacturing of health products.) Some companies involved in global health excel at supply chain management, the process of coordinating all the steps from selecting and procuring products through the logistics of transporting, storing, and delivering them.42 Many companies that are not primarily focused on global health play a role in influ- encing health behaviors and health status, whether they are multinational corporations or smaller businesses.
7.8 The Corporate Sector 161
communities where they work, producing and selling healthy products, and participat- ing in public health alliances.47
▸ 7.9 Research and the Academic Sector
Universities in countries across the income spectrum play several roles in global health. The most important role is education. Uni- versities provide training in medicine,
health for populations around the world. These businesses are typically not part of the funder–channel–implementer pathway for large-scale global health initiatives, but they are key contributors to achieving global health goals via market-based strategies. Any company may play a role in influencing health via marketing (especially if its prod- ucts are ones that promote or inhibit health), lobbying, and corporate social responsibil- ity activities.46 Corporations can also play a role in health promotion by protecting the health and safety of their employees and the
Name Headquarters Type
Chemonics International, Inc. Washington, DC For-profit
Partnership for Supply Chain Management (a collaboration founded by JSI and MSH)
Arlington, VA Nonprofit
FHI 360 (formerly Family Health International)
Durham, NC Nonprofit
John Snow Incorporated (JSI) Boston, MA For-profit
DAI Bethesda, MD For-profit
Management Sciences for Health (MSH) Medford, MA Nonprofit
Jhpiego Baltimore, MD Nonprofit
Abt Associates Cambridge, MA For-profit
RTI International Research Triangle Park, NC Nonprofit
Catholic Relief Services Baltimore, MD Charity
Mercy Corps Portland, OR Charity
Tetra Tech, Inc. Pasadena, CA For-profit
FIGURE 7–8 Many of the groups with the largest USAID contracts in 2015 were for-profit corporations. This list excludes multilateral organizations, such as the World Bank, the World Food Program, UNICEF, Gavi, and WHO. Data from Top 40 vendors. Washington DC: USAID; 2015.
162 Chapter 7 Global Health Implementation
▸ 7.10 Measuring Impact
Many public health intervention packages would increase the quality of life of millions of people at a relatively low cost per per- son. However, all of these interventions together add up to a lot of money, espe- cially for low-income countries where the total amount spent on health per person per year is significantly less than $100. Trillions of dollars each year would be required to implement global health strategies for all of the various causes of disease, disability, and death. Difficult decisions have to be made about how to allocate limited resources. Because resources for global health are scarce, funding recipients are expected to demonstrate to global health financers that their resources are being well used.
A typical project passes through plan- ning, implementation, and evaluation stages, with assessment strategies applied through- out the project cycle. Monitoring is a pro- cess of ongoing assessment of a project or program to track progress toward achieving predefined targets. If the monitoring process reveals that a project or program is not ful- filling its mandate, adjustments can be made to increase the impact of the intervention. Evaluation is an assessment of how well a project, program, or policy has met its goals. Together, monitoring and evaluation (M&E) is the systematic collection of infor- mation about an ongoing intervention (pro- cess evaluation) and the determination of whether the intervention achieved its objec- tives (impact evaluation). Most contracts for global health implementation work mandate that the recipient group have a robust M&E plan that examines the inputs into a program, the processes used during the intervention period, the outputs generated during the implementation process, and the short-term outcomes and longer-term impacts that can be attributed to the program.
nursing, dentistry, physiotherapy, counsel- ing, other clinical disciplines, public health, pharmacology, engineering, statistics, infor- matics, business, marketing, public policy, public administration, law, international relations, education, the biomedical sci- ences, and all the other fields that contribute to global health.
Universities also conduct research. Research is the process of systematically investigating a topic in order to discover new insights about the world. Researchers conduct epidemiological studies that quan- tify the burden of various health conditions; identify the socioeconomic, behavioral, envi- ronmental, and other risk factors for diseases and the protective factors that can keep peo- ple healthy; and carry out experimental tri- als to determine which interventions are the safest and most effective. Research at univer- sities contributes to the development of new medications, vaccines, diagnostic tools, and medical devices.48 The journal articles and other publications written by researchers in the academic sector and by people who work at research institutes, think tanks, and other organizations provide a critical foundation of scientific evidence that is used to develop global health strategies and design interven- tion plans. Researchers also contribute to needs assessments, prioritization exercises, and evaluations of the outcomes of global health initiatives.
While most of the global health funding that flows through universities is for educa- tional and research activities, some universi- ties also accept contracts to implement global health programs and subcontracts from other implementers to participate in some aspects of program implementation. Many students, trainees, professors, staff, and other members of university communities are also active in voluntary service that contributes to global health. The traditional functions of universi- ties are teaching, research, and service, and all three of these areas are being used to advance global health.
7.10 Measuring Impact 163
endemic areas, and bednets for malaria pre- vention.50 Expensive, high-tech solutions, such as coronary artery bypass surgery for treatment of ischemic heart disease, tend to be among the least cost-effective interventions.
CEA is not by itself sufficient for mak- ing decisions about health financing priori- ties and evaluating the value of global health programs. One limitation is that cost-benefit analyses tend to promote interventions that have already proven to be successful, and they tend to undervalue pioneering interven- tions that have not yet been proven to reliably achieve results. New innovations are necessary for moving global health forward, but creative ideas are sometimes considered to be risky uses of resources. For example, successful vac- cine programs are very cost-effective, but the upfront cost of research and development for a new vaccine is high and there is no guaran- tee that a safe, effective, licensed vaccine will be produced. It is important for some funding agencies and research organizations to be will- ing to risk failure so that new technologies and innovative approaches to solving global health problems can be developed.
Some cost-effectiveness analyses compare the cost of action to the cost of inaction. The costs of inaction include lost lives, lost pro- ductivity due to disease and disability, and the direct and indirect costs of medical care that are incurred when an intervention is not implemented to reduce the incidence and prevalence of preventable and treatable health conditions. When it is expensive not to address public health problems, cost-effectiveness analyses can demonstrate that disease preven- tion and control initiatives will yield long-term savings. However, this reveals another short- coming of cost–benefit analysis: CEA often requires analysts to make judgments about what a healthy life is worth. The calculations may require an estimate of how much it costs a disabled person to be unable to work, or they may demand an approximation of how much an additional year of life is worth for a
M&E uses quantitative indicators (numeric metrics) and qualitative indicators (descriptive observations) as measures of the success of a program. In addition to measuring population health outcomes like mortality and disability, M&E can be used to track the performance of health systems by quantifying the coverage rates for various interventions, tallying the financial, human, and material resources invested in health systems, evaluating the satisfaction of clients with health service providers and public health programs, determining which interventions are cost-effective, and tracking the inequalities that may remain within a health system.49 M&E can also examine whether progress is being made toward a program becoming locally sustainable.
Effectiveness is a measure of the success of an intervention under real-world condi- tions (as opposed to efficacy, which measures success in ideal, laboratory-controlled condi- tions). Efficiency is an evaluation of the cost- effectiveness of an intervention that is based on both its effectiveness and resource consid- erations. Cost-effectiveness analysis (CEA) is a type of economic analysis that compares the health gains from an intervention to the financial costs of that intervention. The goal of CEA is to confirm that the funds spent on a health initiative are achieving the planned out- comes and are making efficient use of financial and other resources. CEA works best when the goals of a project are specific and measurable.
The most cost-effective global health interventions tend to be relatively inexpensive, can be easily distributed to many people, focus on prevention rather than treatment, and are targeted toward children and young adults so that they can avert many potential years of life lost to long-term disability or premature death. Some of the most cost-effective interventions include hygiene promotion for the prevention of diarrheal diseases, deworming medications to reduce the prevalence of soil-transmitted helminths in endemic areas, first-aid training for emergency care, intermittent preventive treatment of malaria in pregnant women in
164 Chapter 7 Global Health Implementation
4. Szlezák NA, Bloom BR, Jamison JT, et al. The global health system: Actors, norms, and expectations in transition. PLoS Med. 2010;7:e1000183.
5. Frieden TR. Government’s role in protecting health and safety. N Engl J Med. 2013;368:1857–9.
6. Macfarlane S, Racelis M, Muli-Musiime F. Public health in developing countries. Lancet. 2000;356:841–6.
7. Centers for Disease Control and Prevention’s Strategic Framework FY 2016–FY 2020. Atlanta GA: CDC; 2016.
8. Feldbaum H, Lee K, Michaud J. Global health and foreign policy. Epidemiol Rev. 2010;32:82–92.
9. 3D planning guide: Diplomacy, development, defense. Washington DC: USAID; 2012.
10. Katz R, Kornblet S, Arnold G, Lief E, Fischer JE. Defining health diplomacy: Changing demands in the era of globalization. Milbank Q. 2011;89:503–23.
11. Feldbaum H, Michaud J. Health diplomacy and the enduring relevance of foreign policy interests. PLoS Med. 2010;7:e1000226.
12. Annual Report and Accounts 2015–16. London: DFID; 2016.
13. Japan International Cooperation Agency Annual Report 2016. Tokyo: JICA; 2016.
14. Shared progress, shared future: Agency financial report fiscal year 2016. Washington DC: USAID; 2016.
15. Himelfarb T. 50 years of global health: Saving lives and building futures. Washington DC: USAID; 2013.
16. Charter of the United Nations. San Francisco CA: UN; 1945.
17. Global environmental outlook 5 (GEO5): Environment for the future we want. Nairobi: UNEP; 2012.
18. UNICEF’s strategy for health (2016–2030). New York: UNICEF; 2015.
19. Brown TM, Cueto M, Fee E. The World Health Organization and the transition from “international” to “global” public health. Am J Public Health. 2006;96:62–72.
20. WHO 12th General Programme of Work 2014–2019: Not merely the absence of disease. Geneva: WHO; 2014.
21. Bettcher D, Lee K. Globalisation and public health. J Epidemiol Commun Health. 2002;56:8–17.
22. International Health Regulations (2005): Areas of work for implementation. Geneva: WHO; 2007.
23. Lee K, Dodgson R. Globalization and cholera: Implications for global governance. Glob Gov. 2000; 6:213–36.
24. International Health Regulations (2005). 3rd ed. Geneva: WHO; 2016.
25. Peiris JSM, Yuen KY, Osterhaus ADME, Stöhr K. The severe acute respiratory syndrome. N Engl J Med. 2003;349:2431–41.
26. Cherry JD. The chronology of the 2002–2003 SARS mini pandemic. Pediatr Respir Rev. 2004;5:262–69.
70-year-old compared to a 7-year-old. While these sorts of estimates may be helpful at the population planning level, they break down at the individual level. Estimates of lost wages do not capture the burden of lost self-sufficiency that may accompany a disability, and few fam- ilies would put a price tag on grandpa and deem his year of life to be worth less than that of his grandchild.
Global health statistics, budget spread- sheets, and numbers-heavy progress reports sometimes seem to reduce real people to nameless, faceless masses: a few million children dying from preventable diseases like diarrhea and malaria, a few million people with treatable mental health disor- ders lacking access to therapy, a few million young adults with HIV infection gaining access to lifesaving antiretroviral medica- tions, and a few million households gaining access to a reliable source of clean drinking water. But statistics cannot capture the pro- found grief experienced by families who lose a child, just as they cannot fully express how life-changing a new water well can be. Many groups include photographs of people in their annual reports and other publica- tions as a reminder that their work is about real people whose lives are being affected in very real ways by health problems and health interventions. Even when monitoring and evaluation activities appear to be coldly quantitative, empathy and shared humanity are central to the process.
▸ References 1. McCoy D, Chand S, Sridhar D. Global health
funding: How much, where it comes from and where it goes. Health Policy Plann. 2009;24:407–17.
2. A guide to the project management body of knowledge (PMBOK® guide). 5th ed. Newtown Square PA: Project Management Institute (PMI); 2013.
3. Oliveira-Cruz V, Kurowski C, Mills A. Delivery of priority health services: Serving for synergies within the vertical versus horizontal debate. J Int Dev. 2003;15:67–86.
References 165
38. Buse K, Harmer AM. Seven habits of highly effective global public-private health partnerships: Practice and potential. Soc Sci Med. 2007;64:259–71.
39. Antrobus P. Funding for NGOs: Issues and options. World Dev. 1987;15(Suppl 1):95–102.
40. Stein JG. In the eye of the storm: Humanitarian NGOs, complex emergencies, and conflict resolution. Peace Conflict Stud. 2001;8:2.
41. Majiyagbe J. The volunteers’ contribution to polio eradication. Bull World Health Organ. 2004;82:2.
42. The logistics handbook: A practical guide for the supply chain management of health commodities. 2nd ed. Arlington VA: USAID; 2011.
43. Top 40 vendors. Washington DC: USAID; 2015. 44. Carr SC, McWha I, MacLachlan M, Furnham A.
International–local remuneration differences across six countries: Do they undermine poverty reduction work? Int J Psychol. 45:321–40.
45. Bonache J, Sanchez JI, Zárraga-Oberty C. The interaction of expatriate pay differential and expatriate inputs on host country nationals’ pay unfairness. Int J Hum Resour Manage. 2009;20:2135–49.
46. Kickbusch I, Allen L, Franz C. The commercial determinants of health. Lancet Global Health. 2016;4:e895–6.
47. The Bangkok Charter for Health Promotion in a Globalized World. Geneva: WHO; 2005.
48. Moran M. The grand convergence: Closing the divide between public health funding and global health needs. PLoS Biol. 2016;14:e1002363.
49. Murray CJ, Frenk J. Health metrics and evaluation: Strengthening the science. Lancet. 2008;371:1191–9.
50. Laxminarayan R, Mills AJ, Breman JG, et al. Advancement of global health: Key messages from the disease control priorities project. Lancet. 2006;367:1193–208.
27. Lipsitch M, Cohen T, Cooper B, et al. Transmission dynamics and control of severe acute respiratory syndrome. Science. 2003;300:1966–70.
28. Heymann DL. The international response to the outbreak of SARS in 2003. Philos Trans R Soc Lond B Biol Sci. 2004;359:1227–9.
29. Fidler DP, Gostin LO. The new International Health Regulations: An historic development for international law and public health. J Law Med Ethics. 2006;34:85–94.
30. Mercy JA, Rosenberg ML, Powell KE, Broome CV, Roper WL. Public health policy for preventing violence. Health Aff. 1993;12:7–29.
31. Madhav N, Opopenheim B, Gallivan M, Mulembakani P, Rubin E, Wolfe N. Pandemics: Risks, impacts, and mitigation (Chapter 17). Disease control priorities, 3rd ed. Disease control priorities (Volume 9). Washington DC: IBRD/World Bank; 2017.
32. Bennett B, Carney T. Public health emergencies of international concern: Global, regional, and local responses to risk. Med Law Rev. 2017;25:223–39.
33. Financing global health 2015: Development assistance steady on the path to new Global Goals. Seattle: Institute for Health Metrics and Evaluation; 2016.
34. Widdus R. Public–private partnerships for health: Their main targets, their diversity and their future directions. Bull World Health Organ. 2001;79:713–20.
35. Results Report 2016. Geneva: The Global Fund; 2016. 36. Keeping children healthy: The vaccine alliance
progress report 2015. Washington DC: Gavi; 2015. 37. Frost LJ, Reich MR. Access: How do good health
technologies get to poor people in poor countries? Cambridge MA: Harvard Center for Population and Development Studies; 2008.
166 Chapter 7 Global Health Implementation
© Xinzheng. All Rights Reserved/Moment/Getty
CHAPTER 8
HIV/AIDS and Tuberculosis
▸ 8.1 HIV/AIDS, TB, and Global Health
HIV/AIDS, tuberculosis (TB), and malaria are among the infections that cause the most deaths worldwide each year. These “big three” infec- tious diseases have been the target of numer- ous initiatives that aim to prevent, diagnose, and treat as many cases as possible. The rapid expansion of the global HIV epidemic during the 1980s and 1990s, in particular, was the pri- mary driver of the shift from traditional interna- tional health practices to modern global health approaches.1 Together, the three diseases are the focus of the Global Fund to Fight AIDS, TB and Malaria (usually just called the Global Fund), which was founded in 2002 and has used more than $30 billion donated by the governments of high-income countries and other partner orga- nizations to provide antiretroviral medications to millions of people with HIV, distribute bil- lions of condoms, dispense antibiotics to mil- lions of people with TB, distribute hundreds of
millions of bednets to people living in malaria- endemic areas, treat millions of cases of malaria, and strengthen health systems in low- and mid- dle-income countries, among other achieve- ments.2 These diseases are also the focus of specialized multilateral organizations and agen- cies, like the Joint United Nations Programme on HIV/AIDS (UNAIDS); global partner- ships and alliances, like the Stop TB Partner- ship; diplomatic efforts, such as the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI) in the United States; scientific collaborations like the International AIDS Vaccine Initiative (IAVI) and the TB Drug Accelerator program; and countless charitable organizations. These investments are made for a diversity of overlap- ping reasons: the humanitarian impulse to save lives, the recognition that contagious diseases can easily spread across national borders, and the observation that healthier countries and communities promote global security because they tend to have stronger economies and more stable political systems.3
The coordinated global efforts to respond to the HIV pandemic in the 1990s and 2000s transformed global health, significantly expanding the financial resources available for combatting infectious diseases and bringing together public- and private-sector partners from countries across the income spectrum. Collaborative approaches for financing and implementing global health activities are also being used to address shared concerns about tuberculosis, drug-resistant infections, and other dangerous infectious diseases.
167
Most large-scale HIV, TB, and malaria programs have targeted just one of the dis- eases, and a comparison of the three condi- tions shows why integrated programs have not been the norm (FIGURE 8–1). Each of the three infections is caused by a different type of agent, and they require different types of clinical care. Each has a distinct primary mode of transmission, which means that dif- ferent prevention strategies are required. Each causes hundreds of thousands of deaths each year, so each demands a large-scale response. Each affects people of all ages, but children bear a greater burden from malaria than from HIV and TB. However, there are similarities across the disease control strategies, too, with all requiring the financial, technical, and oper- ational support of dozens of different players,
including international and national govern- mental agencies, a variety of nongovernmental organizations, businesses, charitable founda- tions, scientists and other researchers, health professionals, and local volunteers.
▸ 8.2 Viruses, Bacteria, and Fungi
There are many different types of pathogens that can cause infection, including viruses, bacteria, fungi, and parasites ( FIGURE 8–2). Dif- ferent infectious agents require different meth- ods of prevention and treatment. Approaches for the prevention and control of HIV, TB, and other infections must be tailored to the type of
Disease HIV/AIDS TB Malaria
Type of infectious agent Virus Bacterium Protozoan
Infectious agent Human immunodeficiency virus (HIV)
Mycobacterium tuberculosis
Several types of Plasmodium
Primary mode(s) of transmission
Sexual contact and injecting drug use
Airborne by droplet spread
Mosquito bites
Can it be cured with medication?
No Yes Yes
Estimated number of deaths in 2015
1,100,000 1,769,000 (including 389,000 people with HIV)
438,000
Estimated number of deaths of children in 2015
Aged 0–14 years 110,000
Aged 0–14 years 210,000 (including 41,000 children with HIV)
Aged 0–5 years 306,000
% of deaths from the disease that occur in children
Aged 0–14 years 10%
Aged 0–14 years 12%
Aged 0–5 years 70%
FIGURE 8–1 Comparison of HIV/AIDS, TB, and malaria. Data from AIDS by the numbers 2016. Geneva: UNAIDS; 2016. Global tuberculosis report 2016. Geneva: WHO; 2016. World malaria report 2015. Geneva: WHO; 2015.
168 Chapter 8 HIV/AIDS and Tuberculosis
infection, the usual mode of transmission, and the technologies and other resources that are available to prevent and treat the infection.
A virus is a piece of nucleic acid (DNA or RNA) encased in a shell made of proteins and sometimes also fatty acids. Viruses are extremely tiny, and because they are acellular (not cells), they are generally not considered to be alive. They can only replicate by invading the cells of a living host and taking control of the cells’ nuclei. When a virus enters the body, spikes on the outer part of the virus, called a capsid, attach to the surface of a human cell. The outside of the virus is shed and the genetic material from inside the virus penetrates the cell and travels to the nucleus, where the virus takes command and directs the infected cell to make many new copies of the virus. The newly formed copies of the virus travel to the edge of the cell and enter new capsids. When released from the cell, the new virus particles travel to other parts of the body, infecting other cells, or they are shed from the body to infect other people.
The human body will clear most acute viral infections on its own, but some viruses become chronic infections, such as HIV and hepatitis
C virus. For some types of viral infections, it is possible to take medications that reduce the number of virus particles present in the body and help mitigate the symptoms of infection. For example, antiviral medications can slow the progression of HIV infection, suppress the lesions caused by the herpes virus, and make influenza infections less severe. However, the better option is to take steps to prevent con- tracting a virus. Some viral infections can be prevented by vaccines, including chickenpox, hepatitis B, human papillomavirus (HPV), measles, polio, and rotavirus. Personal hygiene and health practices, such as handwashing and covering one’s mouth when sneezing or coughing, can limit the transmission of many other viruses. Viral infections cannot be cured by antibiotics designed to kill bacteria and parasites. Treating viral infections inappropri- ately by prescribing antibiotics poses a serious threat to global health by contributing to the development of antimicrobial resistance.
A bacterium is a microscopic single-celled prokaryotic organism. Bacteria can be differenti- ated based on their shapes, such as rods (bacilli), spheres (cocci), and spirals (spirochetes, vibrios,
Type of Agent Viruses Bacteria Fungi
Relative size Small Medium Large
Number of cells Acellular (non-cellular)
Single-celled prokaryote
Single-celled or multi- cellular eukaryote
Nucleic acids DNA or RNA (1 nucleocapsid)
DNA and RNA (1 chromosome)
DNA and RNA (2+ chromosomes)
Cell nucleus None Nucleoid region True nucleus
Nuclear membrane No No Yes
Cell organelles No No Yes
Cellular membrane No Yes Yes
Cell wall No Yes (peptidoglycan) Yes (chitin)
FIGURE 8–2 Comparison of viruses, bacteria, and fungi.
8.2 Viruses, Bacteria, and Fungi 169
and spirilla); by relative size (although all are very small); and by the amount of a substance called peptidoglycan in their cell walls. The peptidogly- can on the surface of Gram-positive bacteria will bond to a special dye. Gram-negative bacteria have an outer membrane over the peptidoglycan layer, so the dye will not stain them. Bacteria are found nearly everywhere on the planet, from the arctic tundra to hot springs deep in the ocean. They play an important role in decomposition and chemical cycling, in the fixation of nitro- gen into plants, and in the production of alco- hol and foods like cheese and yogurt. Millions of helpful bacteria line the digestive tracts and other surfaces of humans, crowding out harmful bacteria. However, some types of bacteria can cause disease. For example, some strains of Esch- erichia coli can cause diarrhea, and some strains of Staphylococcus can cause skin disease.
Bacteria cause illness in a variety of ways. Many symptoms of gastrointestinal bacterial infections are the result of endotoxins being released from Gram-negative bacteria when the bacteria die and disintegrate. Some bacte- ria produce exotoxins, like the ones that cause botulism and tetanus. Tetanus and several other bacterial diseases are vaccine- preventable, including whooping cough, pneumococcal pneumonia, and bacterial meningitis. Most bacterial infections can be cured with antibiot- ics, although a growing number of pathogenic (disease-causing) bacteria are becoming resis- tant to common antibiotics.
A fungus is a eukaryotic organism. Fungi come in many forms, including molds (mul- ticellular threads or filaments called hyphae) and yeasts (single-celled fungi that reproduce by budding). Fungi are important decom- posers used to make bread, wine, and cheese, but some are pathogenic. Fungal diseases fre- quently occur after the bacteria that normally live in or on the body are disturbed by anti- biotic use or immunosuppression. For exam- ple, the fungus Candida albicans is normally found on human skin, especially around moist areas like the mouth, groin, and underarms. Sometimes an overgrowth of Candida, called
candidiasis, occurs and presents as thrush (a white coating on the tongue), a vaginal yeast infection, or diaper rash. Other examples of fungal infections include histoplasmosis, which is spread through animal droppings, and dermatomycoses (fungal diseases of the skin) like ringworm and athlete’s foot. Fungi thrive in moist, dark places, and are especially common in the tropics. Antifungal medica- tions can treat some fungal diseases.
▸ 8.3 HIV and AIDS Human immunodeficiency virus (HIV) is a viral infection spread when body fluids like blood, semen, vaginal fluid, or breastmilk are exchanged during sexual contact, the sharing of needles used to inject drugs, or by mother-to-child transmission during child- birth or breastfeeding. HIV is not transmitted through casual contact like shaking hands, sharing eating utensils, or using the same toi- let. Transmission of HIV through blood trans- fusions is rare now that donated blood and blood products can be tested for HIV. The virus destroys specialized white blood cells that are needed by the immune system to fight infec- tion, especially CD4 cells, also called T cells or CD4+ T-helper cells, which are lymphocytes that have a CD4 glycoprotein on their surfaces. Most HIV infections are caused by HIV virus type 1, or HIV-1. There is also an HIV-2 virus that accounts for a small fraction of the HIV cases, primarily in West Africa. HIV-2 pro- gresses more slowly and causes milder symp- toms than HIV-1.4
Acquired immunodeficiency syndrome (AIDS) is characterized by the onset of illnesses occurring as a result of the destruction of immune system cells by the HIV virus. A sign is an objective indicator of disease that can be clinically observed, such as a rash, cough, fever, or elevated blood pressure. A symptom is a subjective indication of illness that is experi- enced by an individual but cannot be observed by others, such as a headache, stomachache,
170 Chapter 8 HIV/AIDS and Tuberculosis
most common OIs include TB, bacterial pneu- monia, chronic diarrhea, and fungal infections, such as Cryptococcus.5
A person newly infected with HIV may experience flu-like symptoms for a few days or weeks, but is often asymptomatic ( FIGURE 8–3). During this stage, the newly infected individual still has a normal num- ber of CD4 cells, but there is a high viral load in the blood (with many virus particles per cubic millimeter) and it is possible to trans- mit the virus. The World Health Organiza- tion (WHO) identifies four clinical stages of HIV infection and AIDS disease that follow primary infection (FIGURE 8–4).5 In stages 1 and 2, which can last from a few weeks to more than 20 years, the infected person is asymptomatic or has only minor symptoms like skin infections and recurrent respiratory infections. Stage 3 is marked by more severe symptoms like recurrent respiratory infec- tions, persistent fevers, TB, mouth ulcers, and the loss of more than 10% of body weight
pain, or fatigue. A syndrome is a collection of signs and symptoms that occur together. HIV is contagious, because it is a transmissible virus; AIDS is not contagious, because it is a syndrome related to HIV infection and it is not an infec- tious agent. The secondary infections associated with AIDS are called opportunistic infections (OIs) because they only occur when the body’s immune system is weakened enough to give the infectious agents an opportunity to invade. The
FIGURE 8–3 CD4+ cell count and viral load following HIV infection.
© Pu
wa do
l J at
ur aw
ut th
ich ai/
Sh ut
te rst
oc k
X-ray showing signs of pulmonary tuberculosis.
1000
200
0
C D
4� C
el l C
ou nt
Early Infection
Asymptomatic Symptoms Begin
More Severe Symptoms
AIDS
CD4� cell count Viral load (# virus particles per mm3)
8.3 HIV and AIDS 171
St ag
e Pr
im ar
y H IV
In fe
ct io
n Cl
in ica
l S ta
ge 1
Cl in
ica l S
ta ge
2 Cl
in ica
l S ta
ge 3
Cl in
ica l S
ta ge
4 (A
ID S)
H IV
-a ss
oc ia
te d
sy m
pt om
s M
ild As
ym pt
om at
ic M
ild Ad
va nc
ed Se
ve re
W ei
gh t
N or
m al
N or
m al
Lo ss
o f l
es s t
ha n
10 %
of
b od
y w
ei gh
t Lo
ss o
f m or
e th
an
10 %
o f b
od y
w ei
gh t
H IV
w as
tin g
sy nd
ro m
e
Ac tiv
ity le
ve l
As ym
pt om
at ic
As ym
pt om
at ic
, n or
m al
ac
tiv ity
Sy m
pt om
at ic
, n or
m al
ac
tiv ity
Be dr
id de
n le
ss th
an
50 %
o f t
he d
ay in
th
e la
st m
on th
Be dr
id de
n m
or e
th an
5 0%
o f t
he
da y
du rin
g th
e la
st
m on
th
Ex am
pl es
o f
co m
m on
c lin
ic al
co
nd iti
on s
Ac ut
e re
tr ov
ira l
sy nd
ro m
e: fl
u- lik
e sy
m pt
om s a
bo ut
2–
4 w
ee ks
a fte
r i ni
tia l
in fe
ct io
n th
at re
so lv
e w
ith in
a fe
w w
ee ks
Pe rs
ist en
t e nl
ar ge
m en
t of
ly m
ph n
od es
in
se ve
ra l p
ar ts
o f b
od y
M in
or sk
in p
ro bl
em s
(li ke
fu ng
al in
fe ct
io ns
an
d m
ou th
u lc
er s)
an
d up
pe r r
es pi
ra to
ry
in fe
ct io
ns
Ch ro
ni c
di ar
rh ea
, ch
ro ni
c fe
ve rs
, th
ru sh
, p ul
m on
ar y
TB , a
nd se
ve re
ba
ct er
ia l i
nf ec
tio ns
lik
e pn
eu m
on ia
a nd
m
en in
gi tis
Ch ro
ni c
di ar
rh ea
, ch
ro ni
c fe
ve rs
, co
m pl
ex
in fe
ct io
ns , a
nd
H IV
-a ss
oc ia
te d
ca nc
er s
FI GU
RE 8
–4 C
lin ic
al st
ag in
g sy
st em
fo r H
IV /A
ID S.
Da ta
fr om
W HO
ca se
de fin
iti on
s o f H
IV fo
r s ur
ve illa
nc e a
nd re
vis ed
cl ini
ca l s
ta gin
g a nd
im mu
no log
ica l c
las sif
ica tio
n o f H
IV -re
lat ed
di se
as e i
n a du
lts an
d c hil
dr en
. G en
ev a:
W HO
; 2 00
7.
172 Chapter 8 HIV/AIDS and Tuberculosis
both the duration of time between infection and the onset of clinical AIDS and the time between onset of AIDS and death, extending the lives of people with HIV infection by years or even decades.11 The current WHO recom- mendation is for treatment with ARVs to begin immediately after diagnosis, since earlier use of ARVs is associated with better outcomes than delayed treatment.12 Use of prophylac- tic doses of co-trimoxazole (a combination of two antibiotics, sulfamethoxazole and tri- methoprim) is recommended for people with advanced HIV to reduce the risk of bacterial, fungal, and protozoal OIs, and isoniazid can be used as preventive treatment in people with HIV who are at risk of TB disease.12
▸ 8.4 HIV/AIDS Epidemiology
Phylogenetic analysis of stored serological specimens suggest that the first cases of HIV infection in humans probably occurred in the 1920s in Central Africa in what is now the Democratic Republic of the Congo.13 The first cases of AIDS were not diagnosed until 1981, when clusters of homosexual men in the United States were diagnosed with fun- gal Pneumocystis carinii pneumonia (PCP)14 and with Kaposi’s sarcoma, which until then had been a very infrequently observed type of cancer.15 The HIV-1 virus was not identi- fied by virologists until several years later.16 Over the subsequent years, the epidemic spread across the globe and the prevalence of HIV infection increased dramatically.17 By 1990, there were nearly 10 million peo- ple living with HIV. That number increased to 20 million by the mid-1990s, more than 30 million by 2005, and about 37 million by 2015 (FIGURE 8–5).18 Sub-Saharan Africa was hit the hardest. In the 1990s and early 2000s, AIDS caused life expectancies to plummet in many countries, and it dramatically altered the social structure in many communities.19
due to chronic diarrhea. The CD4 count begins to fall and the viral load in the blood begins to increase. In stage 4, serious OIs mark the onset of AIDS, and the CD4 count becomes very low (below 200 particles per mm3) and may fall to undetectable levels.
There is currently no HIV vaccine and no medication that can cure HIV infection.6 How- ever, people who have contracted the virus can take antiretroviral (ARV) medications to keep the viral count low and slow the progression of symptoms. Antiretroviral therapy (ART), also called highly active antiretroviral therapy (HAART), uses combinations ( sometimes called “cocktails”) of three or more different medicines to combat HIV, including nucleo- side reverse transcriptase inhibitors (NRTIs), such as tenofovir, lamivudine, abacavir, emtric- itabine, and zidovudine (AZT); non- nucleoside reverse transcriptase inhibitors (NNRTIs), such as efavirenz and nevirapine; protease inhibitors, such as lopinavir, ritonavir, and darunavir; and integrase inhibitors. ART does not work for all people with HIV: some cannot tolerate the side effects, some do not adhere to the treatment regimen and skip too many doses for the med- icines to be effective, and some have a drug- resistant strain of HIV.7 Even if the medications reduce the viral load, they do not cure the HIV infection or alleviate all of the symptoms. How- ever, for most people with HIV, ART is effective at managing HIV as a chronic condition and enabling many years of healthy life that would be impossible without the medicines. Even if one of the many HIV candidate vaccines under development proves to be highly effective and is added to the tools available for HIV preven- tion,8 there will still be a continued need for HIV treatment services for individuals who already have HIV infections.9
The natural history of disease describes the typical timeline from initial infection with a particular agent to either recovery or death. The median survival time after infection with HIV if a person does not take ART is about 10 years, including an average of 2 years from onset of clinical AIDS to death.10 ART prolongs
8.4 HIV/AIDS Epidemiology 173
young grandchildren. Orphans and vulnera- ble children (OVCs) without family caregivers often ended up homeless and living in extreme poverty.20
UNAIDS estimates that about 2 million people contract HIV each year. This is an improvement from the more than 3 million cases per year that were occurring at the turn of the century.21 However, it is concerning that the incidence plateaued after the year 2010 rather than continuing to decrease. UNAIDS and its many collaborators aim to dramatically reduce both the number of new HIV infections and the number of AIDS-related deaths between 2010 and 2030.22 The ultimate target is to shrink the incidence to zero. As of 2015, little progress had been made toward reducing the annual number of incident cases to below 500,000 by 2020 and being on track to reduce the number of new cases to below 200,000 by 2030 (FIGURE 8–6).21
By contrast, the increasing number of peo- ple living with HIV is seen as a public health success, because it is the result of people with
Because nearly all infections and deaths were occurring in young- and middle-aged adults, many older adults had to become caregivers for both their sick adult children and their
0
5
10
15
20
25
30
35
40
1990 1995 2000 2005 2010 2015
N um
be r
of p
eo pl
e liv
in g
w ith
H IV
(in m
ill io
ns )
FIGURE 8–5 HIV prevalence: The number of people living with HIV worldwide has increased. Data from GBD 2015 HIV Collaborators. Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015: The Global Burden of Disease Study 2015. Lancet. HIV 2016;3:e361–87.
3,500,000
3,000,000
2,500,000
2,000,000
1,500,000
1,000,000
500,000
0 2000 2005 2010 2015 2020 2025 2030
<500,000 by 2020 <200,000
by 2030
Incident cases Incident target
N um
be r
of n
ew H
IV in
fe ct
io ns
FIGURE 8–6 HIV incidence: The number of new HIV infections each year has stabilized rather than continuing to decrease. Data from AIDS by the numbers 2016. Geneva: UNAIDS; 2016.
174 Chapter 8 HIV/AIDS and Tuberculosis
(FIGURE 8–8). Some countries (such as Iran) have a rate close to 0%, while some countries in sub-Saharan Africa (such as Nigeria) have a prevalence considerably higher than the global average (FIGURE 8–9). The proportionate mortality rate is the percentage of all deceased people who succumbed to a particular cause. About 1 in 50 people worldwide who died in 2015 died from HIV/AIDS, but the proportion- ate mortality rates for HIV/AIDS by country are heterogeneous (FIGURE 8–10). There are also sig- nificant differences by country in the HIV mor- tality rate per 100,000 residents (FIGURE 8–11).
More than half of the people living with HIV worldwide in 2015 were females ( FIGURE 8–12), and half of new cases of HIV worldwide occurred in females (FIGURE 8–13), with significant variations between countries in the distribution of cases by age and sex.18 Hormones and vaginal anatomy, physiology, and microbiology make females more sus- ceptible than males to HIV and other sexually transmitted infections.23 Women are at least twice as likely as men to acquire HIV from an
HIV living longer. There were about 1.1 million HIV/AIDS deaths in 2015, which was much lower than the 2 million deaths that occurred during the peak of the epidemic in 2005.21 This represents good progress toward reducing HIV mortality to below 500,000 deaths in 2020 and 200,000 deaths in 2030 (FIGURE 8–7). In the absence of a cure for HIV, the long-term goal is to stabilize the prevalence of HIV by reducing the incidence to zero and lowering the mor- tality rate from AIDS to zero, and then for the prevalence of HIV to slowly decrease to zero as people with HIV die in older adulthood of diseases not related to HIV infection.
One of the challenges in tracking prog- ress toward achieving these epidemiological goals is that many countries do not compile and disseminate reliable statistics about HIV incidence, prevalence, and mortality. However, model-based estimates, such as those from the Global Burden of Disease collaboration, allow for a comparison of the epidemiological situ- ations in each nation.18 About 1 in 200 people worldwide (across all ages) has HIV infection
2,500,000
2,000,000
1,500,000
1,000,000
500,000
0 2000 2005 2010 2015 2020 2025 2030
<500,000 by 2020
<200,000 by 2030
Deaths Target
N um
be r
of d
ea th
s fr
om H
IV
FIGURE 8–7 HIV mortality: The number of deaths from HIV each year has decreased as more people gain access to ART. Data from AIDS by the numbers 2016. Geneva: UNAIDS; 2016.
8.4 HIV/AIDS Epidemiology 175
Missing/Excluded
Less than 0.1
0.1 to 0.5
0.5 to 1
1 to 5
5 and above
FIGURE 8–8 Prevalence of HIV among people 15–49 years old (2015). Data from GBD 2015 HIV Collaborators. Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015: The Global Burden of Disease Study 2015. Lancet. HIV 2016;3:e361–87.
0
0.5
1
1.5
2
2.5
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
USA
global average
% o
f p eo
pl e
w ith
H IV
( al
l a ge
s)
FIGURE 8–9 HIV prevalence: Percentage of people (all ages) living with HIV in featured countries in 2015. Data from GBD 2015 HIV Collaborators. Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015: The Global Burden of Disease Study 2015. Lancet. HIV 2016;3:e361–87.
0
2
4
6
8
10
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
USA
global average
% o
f d ea
th s
fr om
H IV
/A ID
S
FIGURE 8–10 HIV mortality: Percentage of total deaths (all ages) due to HIV/AIDS in featured countries in 2015. Data from GBD 2015 HIV Collaborators. Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015: The Global Burden of Disease Study 2015. Lancet. HIV 2016;3:e361–87.
176 Chapter 8 HIV/AIDS and Tuberculosis
0
10
20
30
40
50
60
70
80
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
USA
global average
M or
ta lit
y ra
te p
er 1
00 ,0
00
FIGURE 8–11 HIV mortality: HIV death rates per 100,000 people (all ages) in featured countries in 2015. Data from GBD 2015 HIV Collaborators. Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015: The Global Burden of Disease Study 2015. Lancet. HIV 2016;3:e361–87.
0% 25% 50% 75% 100%
Ethiopia
Nigeria
India
China
Brazil
Iran
Germany
USA
Global average
Female Male
HIV prevalence (all ages)
FIGURE 8–12 HIV prevalence: Percentage of people living with HIV in featured countries in 2015 who were female. Data from GBD 2015 HIV Collaborators. Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015: The Global Burden of Disease Study 2015. Lancet. HIV 2016;3:e361–87.
Males 45+
Males 35-44
Males 25-34
Males 15-24
Males 0-14
Females 45+
Females 35-44
Females 25-34
Females 15-24
Females 0-14
0%
20%
40%
60%
80%
100%
USA Germany Iran Brazil China India Nigeria Ethiopia
In ci
de nt
c as
es b
y se
x an
d ag
e
FIGURE 8–13 HIV incidence: Percentage of new cases by age and sex in featured countries in 2015. Data from GBD 2015 HIV Collaborators. Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015: The Global Burden of Disease Study 2015. Lancet. HIV 2016;3:e361–87.
8.4 HIV/AIDS Epidemiology 177
Some populations have an elevated rate of HIV infection because they engage in behav- iors that increase the likelihood of contact with blood and other body fluids or because discrim- ination may limit their access to health care. Key populations known to have special vulnerability to HIV infection include men who have sex with men (MSM), people who inject drugs (PWID), people in prison or other criminal justice deten- tion centers, sex workers, and transgender peo- ple.26 In most high-income countries, MSM, PWID, and their partners account for the
act of heterosexual intercourse.24 Women also face sociocultural risks for contracting HIV. Women generally marry at younger ages than men, they may not have the power to demand condom use, and they are more likely than men to be the victims of sexual violence.25 Women tend to become infected with HIV at younger ages than men (FIGURE 8–14).18 The incidence rate among people who are 15–29 years old is considerably higher for females than males. For all older age groups, men have a higher incidence rate than women.
FIGURE 8–14 HIV incidence: The peak incidence rate occurs at younger ages for females than for males. Data from GBD 2015 HIV Collaborators. Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015: The Global Burden of Disease Study 2015. Lancet. HIV 2016;3:e361–87.
80+75 to 79
70 to 74
65 to 69
60 to 64
55 to 59
50 to 54
45 to 49
40 to 44
35 to 39
30 to 34
25 to 29
20 to 24
15 to 19
10 to 14
5 to 9
0 to 4
Female Male
178 Chapter 8 HIV/AIDS and Tuberculosis
can access treatment. Voluntary counseling and testing (VCT), also called HIV testing and counseling (HTC), is a process of pre-test counseling about risk assessment, the testing process, and planned prevention and coping strategies; performance of an HIV test, typi- cally using a rapid diagnostic test of blood or oral fluids; receipt of test results; and posttest counseling about risk reduction and disclosure of HIV status.28 Testing is recommended for a diversity of individuals, including everyone with known exposure to HIV, everyone who is a member of a high-risk population, everyone with symptoms consistent with HIV infection, everyone diagnosed with a sexually transmit- ted infection, everyone diagnosed with TB, all pregnant women, and all blood donors.29 All HIV testing services should ensure that the “5Cs” are present: consent, confidentiality, counseling before and after the test, correct (valid) test results, and connection through referral to prevention and treatment services.29
There has been a rapid increase in the per- centage of people with HIV who are receiving ARVs (FIGURE 8–15).21 The “15 by 15” goal of
majority of new infections, and most incident cases occur in men; in the sub-Saharan African countries with the highest incidence rates, the majority of incident cases occur in women and members of these key populations account for only a minority of cases.21
▸ 8.5 HIV Interventions The ultimate goal for control of the global HIV epidemic is to reduce the incidence of new viral infections to zero cases while simulta- neously allowing all people who already have HIV infection to live long, healthy lives.27 The reduction in the HIV mortality rate in recent years is a direct function of increased access to ART. Treating people with HIV is also a crit- ical component of HIV prevention strategies because people who are taking ARVs often reduce their viral counts to such low levels that there is almost no risk of them passing the virus on to a sexual partner, even though the use of condoms is still recommended.
Testing for HIV enables people who have HIV infection to be diagnosed so that they
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2000 2005 2010 2015 2020
People with HIV on ART
Target
90% by 2020
P eo
pl e
w ith
H IV
o n
A R
T
FIGURE 8–15 HIV treatment: The percentage of people with HIV who are taking ART has increased rapidly. Data from AIDS by the numbers 2016. Geneva: UNAIDS; 2016.
8.5 HIV Interventions 179
of any ARV interventions, a baby born to an HIV-infected mother has about a 15%–30% risk of contracting HIV during delivery.33 If the infant is breastfed for several months, the
15 million people taking ART daily by 2015 was achieved (FIGURE 8–16).30 However, an acceler- ation in the scale-up of ART programs will be necessary to meet the Fast-Track “90–90–90” goal of having at least 90% of people with HIV infection know their status, at least 90% of people with diagnosed HIV taking ART, and at least 90% of people on ART achieving viral suppression by 2020 (and then raising all three values to 95% by 2030).31 Projections suggest that the target of having 30 million people with HIV on ART by 2020 is achievable, but many low- and middle-income countries are not on track to reach 90% ART use by 2020 ( FIGURE 8–17). There are still millions of peo- ple with HIV infection who would benefit from access to HAART but do not have access to it because they cannot afford the treatment.
Mother-to-child transmission (MTCT), also called vertical transmission, is a mode of HIV transmission in which a pregnant woman passes a pathogen on to her offspring during pregnancy, delivery, or breastfeeding.32 ARV use by pregnant women is a form of pre- vention of MTCT (PMTCT). In the absence
0%
20%
40%
60%
80%
100%
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
USA
target for 2020
global average in 2015
P eo
pl e
w ith
H IV
o n
A R
T
FIGURE 8–17 HIV treatment: ART use in featured countries in 2015. Data from GBD 2015 HIV Collaborators. Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015: The Global Burden of Disease Study 2015. Lancet. HIV 2016;3:e361–87.
FIGURE 8–16 HIV treatment: The number of people with HIV who are taking ART has increased rapidly. Data from AIDS by the numbers 2016. Geneva: UNAIDS; 2016.
People with HIV on ART
Target
30,000,000
25,000,000
20,000,000
15,000,000
10,000,000
5,000,000
0
2000 2005 2010 2015 2020
“15 by 15” target
30 million by 2020
N um
be r
of p
eo pl
e w
ith H
IV o
n A
R T
180 Chapter 8 HIV/AIDS and Tuberculosis
year are evidence that too many pregnant and breastfeeding women with HIV are not tak- ing ARV, because most incident cases of HIV in children are due to MTCT. Some of these women are not able to access the formal health system or prefer not to take medications. Some cannot afford ARVs or would be at risk of violence if they were found to be taking HIV medications. Some do not know their infec- tion status, so they do not take steps to prevent vertical transmission.
ARVs are also used for post-exposure prophylaxis (PEP), the process of taking medications after exposure to a pathogen in order to reduce the likelihood of contracting an infection. People with occupational expo- sures to HIV, such as a healthcare workers who have sustained a needle stick injury while treating a patient with HIV, and those with other unexpected potential exposures to HIV, such as the victims of sexual assaults, can take ARVs for a month as PEP to reduce the likeli- hood of infection.36
cumulative risk can be as high as 25%–45%.33 If the mother takes ARVs during pregnancy and delivery—and in the weeks after delivery, if she is breastfeeding—the likelihood of trans- mission is much lower, only about 1% or 2%.34 New mothers taking ARVs who have unde- tectable HIV viral counts are encouraged to breastfeed.35 Some mothers with HIV infection who are not taking ARVs are encouraged to use formula instead of breastmilk when replace- ment feeding is acceptable, feasible, affordable, sustainable, and safe (AFASS).35 When women cannot reliably afford formula or do not have consistent access to clean water, the risk of infant death due to diarrhea from unsafe water used to mix the formula may be greater than the risk of contracting HIV through breastmilk.
An increase in access to ARVs for preg- nant women has helped to significantly decrease the number of new cases of HIV in children occurring each year (FIGURE 8–18).21 Unfortunately, the tens of thousands of infants who are still acquiring HIV infection each
500,000
400,000
300,000
200,000
100,000
0 2000 2005 2010 2015 2020 2025 2030
<50,000 by 2020
Incident cases in children Target
N um
be r
of n
ew H
IV in
fe ct
io ns
FIGURE 8–18 HIV incidence: The number of new HIV infections each year among children has decreased. Data from AIDS by the numbers 2016. Geneva: UNAIDS; 2016.
8.5 HIV Interventions 181
helped reduce incidence.43 Using a combina- tion of approaches is often the best option to ensure protection of individuals and commu- nities.44 However, limited budgets for disease prevention and control mean that in most places only a few types of HIV services can be offered.45
Low- and middle-income countries (LMICs) are paying an increasing share of the costs of HIV prevention and treatment pro- grams within their own borders— reaching nearly $11 billion by 2015—but international assistance for ARV programs and other services remains critical to the success of global control efforts.22 In 2015, the governments of high- income countries invested about $7.5 billion in HIV/AIDS programs in LMICs.46 About three-quarters of this spending was bilateral, with funding from the donor country being directly transferred to the recipient coun- try. The remaining governmental funds were multilateral spending distributed through the Global Fund, Unitaid, and other partnerships. Private-sector donations to HIV/AIDS pro- grams in LMICs from foundations, corpora- tions, and individuals were estimated to exceed $600 million in 2015, with the Bill & Melinda Gates Foundation being the largest donor.46
The United States is the largest funder of HIV programs in LMICs in terms of dollars spent each year. The U.S. President’s Emer- gency Plan for AIDS Relief (PEPFAR) was launched in 2003 when few people living with HIV in sub-Saharan Africa had access to ART. PEPFAR funding has enabled millions of peo- ple in LMICs to gain access to life-extending medications, and it has allowed millions of babies to be born HIV-free to mothers with HIV infection. In 2015 alone, nearly 6 million people in partner LMICs were receiving ARVs as a result of direct support from PEPFAR and nearly 4 million more were benefiting from technical support for ART programs.47 PEP- FAR also supports VCT programs that test tens of millions of people annually, sponsors VMMC programs in targeted regions, and funds programs that care for OVCs.47
Pre-exposure prophylaxis (PrEP) is the process of taking medications prior to a likely exposure to a pathogen in order to reduce the risk of contracting an infection. When both partners in a relationship undergo HIV testing and they are found to be discordant, with one member HIV-positive and the other HIV-neg- ative, the HIV-negative partner can opt to take PrEP to reduce the risk of infection.37
There are also behavioral prevention methods that are recommended for all people to reduce the risk of contracting HIV. One is universal precautions, the use of barriers like gloves to prevent contact with blood or body fluids when caring for a sick person or cleaning up a spill or soiled laundry. Another is following the ABCs of HIV prevention: absti- nence, being faithful to a partner if sexually active, and consistently and correctly using a condom during all sexual acts.38 Although the risk of HIV per sexual act is usually low—less than 1 in 250 heterosexual contacts with a person who has HIV infection—the cumula- tive risk can be high, so consistent condom use is necessary.39 Routine use of health services is also beneficial, since detection and treatment of other sexually transmitted infections reduce biological vulnerability to HIV.40 Health work- ers in all regions of the world must continue HIV/AIDS education efforts because the inci- dence of new cases tends to increase when people stop worrying about their risk.
Several other harm reduction strategies are also being used for HIV prevention. Male circumcision is the surgical removal of the foreskin of the penis. Voluntary male medi- cal circumcision (VMMC) in countries with high levels of HIV transmission where cir- cumcision of male infants has not been the traditional practice has been shown to reduce incidence of HIV infection in men who undergo the procedure.41 VMMC reduces the risk of HIV infection, but it does not negate the need to use condoms as protection against HIV and other sexually transmitted infections.42 In some places, needle exchanges for injecting drug users have successfully
182 Chapter 8 HIV/AIDS and Tuberculosis
untreated, both infections can cause chronic health problems, such as pelvic inflamma- tory disease (PID), an infection in the upper reproductive system (the uterus, ovaries, and other structures) that can cause pain and lead to scarring and infertility. Cases of drug- resistant gonorrhea that do not respond to standard therapies are a growing global health concern.52 Syphilis is an infection with Treponema pall- idum. About 5.6 million people contract syphi- lis each year, and the global prevalence is about 18 million because many people with syphilis have not been treated for it.53 Untreated syphi- lis progresses through three clinical stages. Pri- mary syphilis presents as a painless skin lesion called a chancre. The second stage is character- ized by a rash on the palms of the hands and the soles of the feet as well as other symptoms, such as swollen lymph nodes and fatigue. Late stage syphilis may persist for years and cause weakened arterial walls and nervous system impairment.54 When pregnant women have syphilis, there is a high rate of stillbirth, neona- tal mortality, and birth defects associated with congenital syphilis.55
▸ 8.6 Other Sexually Transmitted Infections
Besides HIV, several other pathogens can be transmitted through sexual contact ( FIGURE 8–19). A sexually transmitted infection (STI) is an infection spread through sexual intercourse or other types of sexual contact.48 STIs are often asymptomatic. When symptoms of an STI are present, the affected individual is considered to have a sexually transmitted disease (STD), also called a vene- real disease.
Some of the most frequently occurring bacterial STIs worldwide are chlamydia, gon- orrhea, and syphilis. About 130 million people each year contract chlamydia, an infection with Chlamydia trachomatis.49 About 80 million people each year contract gonorrhea, an infec- tion with Neisseria gonorrhoeae.50 Gonorrhea and chlamydia are both often asymptomatic, especially in women,51 but they may cause reproductive tract discharge and a burning sen- sation when urinating. If left undiagnosed and
Disease Agent Name Type of Agent
Chlamydia Chlamydia trachomatis Bacterium
Gonorrhea Neisseria gonorrhoeae Bacterium
Syphilis Treponema pallidum Bacterium
HIV Human immunodeficiency virus (HIV, retrovirus family) Virus
Herpes Herpes simplex virus (HSV-2, herpesvirus family) Virus
HPV Human papillomavirus (HPV, papillomavirus family) Virus
Trichomoniasis Trichomonas vaginalis Protozoan
Crabs Pthirus pubis (crab louse) Insect
FIGURE 8–19 Examples of sexually transmitted infections (STIs).
8.6 Other Sexually Transmitted Infections 183
▸ 8.7 Tuberculosis Tuberculosis (TB) is caused by the bacte- rium Mycobacterium tuberculosis, which is spread through airborne droplets.66 TB can affect any part of the body, but it usually occurs in the lungs. TB affecting the lungs is called pulmonary TB. TB outside of the lungs is called extrapulmonary TB. Pulmonary TB used to be called consumption because people with the disease were “consumed” by it and developed a bloody cough, persistent fever, wasting, and pale skin. Anyone can become infected with TB, but the rate of infection is higher among low-income individuals and those who are undernourished, have under- lying medical conditions, smoke tobacco, and live or work in crowded facilities that have poor ventilation and high levels of indoor air pollution.67
A distinction is made between having TB infection (latent TB) and having TB disease (active TB). An infection occurs when an infectious agent begins to reproduce inside a person. This usually causes an immuno- logic response specific to the agent, and that response can often be detected through labo- ratory testing. Many infections have a latent phase (also called an incubation period) when the infectious agent multiplies in the host but the infected individual does not feel sick. For TB, this stage is called latent TB infection (LTBI). LTBI may persist for decades. Disease occurs when an infected person develops symptoms and becomes ill. When LTBI converts into a symptomatic, contagious form, it is called TB disease (or active TB). The symptoms of TB disease include fevers, weight loss, night sweats, and a cough that may produce bloody spu- tum (phlegm from the lungs). People with active TB are contagious, and if untreated they may infect several other people each year, especially if they have frequent and prolonged interactions with susceptible indi- viduals.68 About one in three people world- wide has been infected with the TB bacillus,
Several STIs are caused by viruses, includ- ing herpes and HPV. Genital herpes is an infection with herpes simplex virus type 2 (HSV-2) that can cause painful genital ulcers.56 More than 400 million people worldwide have HSV-2 infections, with an annual incidence of about 20 million cases.57 (A related virus, HSV- 1, causes lesions on the mouth that are often called “cold sores.”58) Human papillomavirus (HPV) causes genital warts and significantly increases the risk of cervical cancer and can- cers of the oropharynx, especially the throat.59 A vaccine for HPV is now available in some countries,60 but no successful vaccine has been developed for HIV or herpes. Although some medications, such as interferon, can help sup- press some viral infections, no cures for these viral infections have been discovered.
A few parasites are also transmitted through sexual contact. Trichomoniasis is a protozoal infection with Trichomonas vagina- lis that affects about 140 million people each year.61 Pubic lice (Pthirus pubis), also called crabs or pediculosis pubis, are ectoparasites that cling to human hair, feed on human blood, and cause intense itching.62
STIs can be prevented by abstinence from sexual activity, the use of barriers such as con- doms that limit direct contact with body fluids (although some infections may occur even with condom use), and treatment of infected individ- uals so that they do not transmit the infection to sexual partners.63 Public health interventions to reduce the population-level burden from STIs include sex education, risk reduction counsel- ing, condom distribution, HPV vaccination, screening for asymptomatic infections, treat- ment or management of diagnosed cases, and offering testing and treatment to sexual partners of known cases.64 Partner notification is the process of a patient diagnosed with an STI com- municating with his or her sexual partners (or a public health official communicating with the partners of the diagnosed individual) about their need to be tested so that they can receive appro- priate treatment, if necessary, and they can take steps to protect the health of future partners.65
184 Chapter 8 HIV/AIDS and Tuberculosis
▸ 8.8 TB Interventions The standard treatment regimen for TB involves taking a combination of up to five different medications (isoniazid, rifampicin, pyrazinamide, ethambutol, and streptomy- cin) every day for 6 months or longer.73 The first 2 months are the most crucial, but fol- lowing through with the full course of treat- ment is essential so that all of the bacteria are killed, including the hardiest organisms. The WHO-recommended treatment protocol is called DOTS, which is an acronym for directly observed therapy, short-course. DOTS is sometimes shortened to just DOT to empha- size that the key part of DOTS is the directly observed component. TB patients receiving DOTS are required to have a trained observer watch them take their pills every day. If the patient is hospitalized or reports to a clinic for his or her daily treatment, the observer might be a physician or nurse. If the treatment is community-based, the observer might be a shopkeeper or other community leader, or a family member who is supervised by another community member. If the patient misses a dose, a public health worker will track the patient down and try to ensure compliance. (Some countries have public health laws stip- ulating that people who are not compliant with TB treatment can be hospitalized under guard or imprisoned for the duration of their treatment, but most do not enforce these reg- ulations.) However, the case detection rate
but only about 5%–15% of people with LTBI who do not have HIV infection will develop TB disease during their lifetimes.69 Bacillus Calmette-Guérin (BCG) is a TB vaccine used in many countries to confer some child- hood protection against TB disease (and related complications, such as disseminated TB disease, which is the spread of TB bac- teria from the lungs into other parts of the body), but BCG is not effective at preventing TB infection.70
The standard test for TB is the purified protein derivative (PPD) test, also called the Mantoux tuberculin skin test (TST), in which a small amount of TB bacterial protein is injected under the skin and the reaction is monitored. A person with TB infection will have an immune response and develop a rash at the injection site. (One of the dis- advantages of BCG is that people who have received BCG usually test positive on PPD tests. Some workplaces and schools require employees and students to prove that they do not have TB, and people who have received BCG may require extra testing to show that they do not actually have TB.) An interferon-gamma release assay (IGRA) blood test is also available. If a person has a positive skin or blood test, a chest X-ray will be taken to look for lesions that might be pockets of TB infection. If pulmonary TB is suspected, a sputum smear test is conducted on the phlegm produced by deep coughs. A microscope is used to check the stained specimen for the presence of acid-fast bacilli (AFB). The diagnosis can be confirmed with a positive culture grown in a laboratory for several days. Laboratory tests for TB are used for clinically diagnosing people with symp- toms of TB disease; as part of routine screen- ing for people who have elevated risk for TB, such as people with HIV infection and those who have occupational exposure to silica;71 and as part of outbreak responses that test contacts of TB cases so that treatment can be initiated before infected contacts develop TB disease.72
CD C/
Ga br
iel le
Be ne
ns on
/G re
g K no
blo ch
Tuberculin skin test (TST).
8.8 TB Interventions 185
as those with HIV, are a priority for LTBI treatment programs.76 Strategies to reduce TB prevalence also reduce TB mortality.
Good progress toward reducing the global burden from TB was made under the Stop TB Strategy, with the incidence of TB disease decreasing gradually but steadily after 2000.77 Between 2000 and 2015, there was a 42% reduction in overall prevalence of TB disease and a 47% reduction in mortality among peo- ple without HIV infection.77 The Stop TB strat- egy has been replaced by a new End TB plan. The End TB Strategy (2016–2035) supports the achievement of the Sustainable Develop- ment Goals that aim to reduce TB incidence by 80% and TB deaths by 90% between 2015 and 2030. By 2035, the End TB Strategy aims to reduce TB incidence by 90% and TB deaths by 95% compared to 2015 levels.78
In 2015, there were an estimated 10.4 million new cases of TB disease world- wide, which is equivalent to an incidence rate of 142 per 100,000 people (FIGURE 8–20).69 However, there is considerable uncertainty
(CDR), the proportion of people with TB dis- ease who are diagnosed, is low in many places. This means that many people who should take DOTS for TB are not undergoing treatment. A higher CDR would increase the treatment rate and decrease the TB mortality rate.
The Stop TB Strategy (2006–2015) led by the WHO spelled out a plan for achieving the Millennium Development Goals (MDGs) plans to reduce the prevalence of TB disease, reduce the number of deaths each year from TB, and increase the proportion of TB disease cases that are diagnosed and treated using a DOTS protocol.74 The TB prevalence, which is the total number of people with active TB at any point in time, is reduced by lowering the incidence of TB and by curing active TB cases more quickly. The incidence of TB disease can be reduced by decreasing the incidence of LTBI and treating LTBI before it advances to TB disease. (Several new TB vaccines are being developed and tested, but they are not yet ready for widespread use.75) People with a high likelihood of developing active TB, such
Missing/Excluded Less then 10 10 to 25 25 to 75 75 to 200 200 and above
FIGURE 8–20 Incidence of new cases of TB disease per 100,000 people (2015). Data from Global tuberculosis report 2016. Geneva: WHO; 2016.
186 Chapter 8 HIV/AIDS and Tuberculosis
died as a result of TB infection.69 HIV- negative people who develop TB disease and are not treated for it have about a 43% case fatality rate; HIV-positive people who develop TB dis- ease and are not taking ARVs or receiving TB treatment have about a 78% case fatality rate.77 However, people with HIV infection can be successfully treated for TB if they are strong enough to survive several months of antibiotic treatment.81 Treatment of LTBI, early diagnosis and initiation of treatment of TB disease, and early initiation of ART after HIV diagnosis all contribute to improved survival rates for people with HIV/TB coinfection.82
HIV/TB coinfections occur in every coun- try, but the countries with the highest HIV prevalence rates have the highest burden from HIV-associated TB. In 2015, 1.2 million (11%) of the 10.4 million incident cases of TB dis- ease worldwide occurred in people with HIV infection (FIGURE 8–23).69 TB fatalities among people with HIV are classified as HIV deaths rather than as TB deaths, and in 2015, there
about this number because of underdiagnosis and underreporting.79 The actual incidence might be higher. The End TB Strategy aims to reduce the global incidence rate to 10 new cases per 100,000 people per year by 2035 ( FIGURE 8–21). There is a special emphasis on the countries that have the highest TB rates and those with the highest number of cases. In 2015, six countries were home to 60% of the world’s TB cases: India, Indonesia, China, Nigeria, Pakistan, and South Africa. That year, 1.4 million people died from TB, for a global mortality rate of 24 per 100,000 people.69 The End TB Strategy aims to reduce the global TB mortality rate by 95% between 2015 and 2035 (FIGURE 8–22).
HIV treatment programs are an import- ant contributor to TB control. People with HIV infection are about 30 times more likely to develop active TB disease than people with- out HIV infection, and TB is the leading cause of death for people with HIV.80 In 2015, about one in three people who died from HIV/AIDS
180
160
140
120
100
80
60
40
20
1990 1995 2000 2005 2010 2015 2020 2025 2030 2035
20% by 2020
50% by 2025
80% by 2030
90% by 2035
TB incidence Target
0
N ew
c as
es o
f T B
d is
ea se
p er
1 00
,0 00
FIGURE 8–21 TB incidence: Approximate targets for reduction of the TB incidence rate. Data from Global tuberculosis report 2016. Geneva: WHO; 2016.
8.8 TB Interventions 187
FIGURE 8–22 TB mortality: Approximate targets for reduction in the number of TB deaths (not including death from TB/HIV coinfection). Data from Global tuberculosis report 2016. Geneva: WHO; 2016.
2.0
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0 2000 2005 2010 2015 2020 2025 2030 2035
N um
be r
of d
ea th
s fr
om T
B (
in m
ill io
ns )
35%by 2020
75%by 2025
90%by 2030 95%by
2035
TB deaths Target
were about 390,000 people with HIV who died from TB in addition to the 1.4 million TB deaths in people without HIV (FIGURE 8–24). With access to treatment for HIV and TB, the TB survival rate for people with HIV infection is only slightly lower than the survival rate for people without HIV.69
Control of the spread of TB requires structures to be in place to support diagnosis and treatment, including a supply chain that provides consistent access to all essential TB medications in every country and a reporting system that allows governments to track their progress toward improved prevention, diag- nosis, and treatment. Clinicians, public health workers, and members of communities with
a high prevalence of TB play critical roles in local and national TB control by diagnosing, treating, and supporting individuals with TB disease. At the global level, TB control efforts are being led by the Stop TB Partnership, founded in 2000, which brings together rep- resentatives from hundreds of organizations— including WHO and other UN agencies, national and subnational governmental orga- nizations, foundations, charities (including patient support networks), private-sector enti- ties (including pharmaceutical and diagnos- tic companies), and universities and research institutions—to develop and operationalize action plans for reducing the global burden from TB.
188 Chapter 8 HIV/AIDS and Tuberculosis
▸ 8.9 Antimicrobial Resistance
Antibiotic medications that cure bacterial infections are a core part of many infectious disease control programs. There are also antimicrobial medications for other types of disease-causing agents, including antivirals, antiparasitics, and antifungal medications. A pathogen is sensitive to a medication if it is vulnerable to it. Bacteria are usually suscep- tible to certain types of antibiotics, and they will be killed when they are exposed to correct doses of the right classes of these medications. However, a growing number of these agents have developed resistance to at least some of the types of antibiotics that were once effec- tive against them.84 A pathogen is resistant to a medication if can withstand treatment with
The Stop TB partners aim to eliminate TB as a public health problem by reducing the incidence of TB to less than 1 case per 1 million people by 2050.83 This will be impos- sible to achieve without increased funding from domestic and international sources. In 2016, about $6.6 billion was spent on TB pre- vention and treatment in LMICs, but this was at least $2 billion less than the amount needed to fully implement the global TB strategy.69 About 84% of this TB financing was from domestic sources, including out-of-pocket payments by people with TB and their fami- lies. Middle-income countries like Brazil and China fully fund their own TB programs, but the TB control programs in lower-income countries like India, Nigeria, and Ethiopia need additional support from international donors in order to make progress toward achieving global TB goals.69
USA Germany Brazil ChinaIran NigeriaIndia Ethiopia
H IV
prevalence (% )
TB among HIV -
TB among HIV +
HIV prevalence
T B
in ci
de nc
e pe
r 10
0, 00
0
140 3
2
1
0
120
100
80
60
40
20
0
•
•
• • •
• •
•
• FIGURE 8–23 TB incidence: New cases of TB disease per 100,000 residents in 2015. Data from Global tuberculosis report 2016. Geneva: WHO; 2016.
8.9 Antimicrobial Resistance 189
TB among HIV -
TB among HIV +
HIV prevalence•
USA Germany Brazil ChinaIran NigeriaIndia Ethiopia
H IV
prevalence (% )
T B
d ea
th s
pe r
10 0,
00 0
140 3
2
1
0
120
100
80
60
40
20
0
•
•
• • •
• •
•
means that it will be harder for that person to fight off the infection with common antibiot- ics. Worse yet, that person could spread this hardier strain to other people, for whom the common first-line antibiotics will not work at all. Antibiotics are also frequently overused in cattle, pigs, poultry, and other animal popu- lations raised for food production.86 Another misuse of antimicrobials is taking antibiotics for viral infections like the common cold. The individual taking the medications is not being helped by the antibiotic, and instead is killing off the body’s helpful bacteria and allowing potentially harmful bacteria that are already in the body to proliferate. These stronger bacteria may develop drug resistance, necessitating that the infected person take yet another antibiotic.
Drug-resistant TB (DR-TB) is a grow- ing global health problem. Among those who
it. Drug susceptibility testing (DST) can deter- mine whether an infectious agent is sensitive or resistant to particular antimicrobials.
Antimicrobial resistance (AMR), or drug resistance, occurs when a pathogen that used to be susceptible to a particular type of therapeutic agent mutates in a way that makes the medication ineffective. The misuse and overuse of antibiotics are driving the develop- ment of AMR.85 If someone has a mild bacte- rial infection, such as bronchitis or a mild ear infection, and takes antibiotics for only a few days rather than finishing the entire prescrip- tion, or if that person skips a few doses, that per- son will have killed off the susceptible, weaker bacteria, but the hardier bacteria will survive. This is a process that biologists call selection. The remaining bacteria may have developed resistance to the misused medication, which
FIGURE 8–24 TB mortality: Deaths per 100,000 residents in 2015 (including cases among people with HIV infection). Data from Global tuberculosis report 2016. Geneva: WHO; 2016.
190 Chapter 8 HIV/AIDS and Tuberculosis
is contracted while receiving care in a hospi- tal, nursing or rehabilitation center, or another medical facility. HAIs include central line associ- ated bloodstream infections, catheter associated urinary tract infections, surgical site infections, ventilator-associated pneumonia, Clostridium difficile infections, and others.90 Some HAIs are drug resistant, such as MRSA. Methicillin- resistant Staphylococcus aureus (MRSA) is very difficult to treat, and it can cause severe “flesh- eating” infections (necrotizing fasciitis) and bloodstream infections. The first cases of MRSA were reported within months of methicillin being released for use as an antibiotic in 1960.91 MRSA is now common in hospitals (where it is called hospital-acquired or HA-MRSA), but the infec- tion can also be transmitted by unsterilized sports equipment and other everyday items that cause community-acquired MRSA (CA-MRSA).92 Handwashing (by healthcare workers, patients, and visitors), the use of personal protective equipment, clean laundry, sterilized equipment, environmental sanitation, and waste manage- ment help prevent the spread of HAIs.93 Patient risk is also reduced by avoiding unnecessary medical procedures and minimizing the use of invasive medical devices. Antimicrobial steward- ship programs that ensure that patients are pre- scribed the right medications at the right doses for the right durations and through the right routes serve to limit the risk of adverse outcomes of HAIs, including drug- resistant infections.94
Inappropriate access to and use of med- ications in one nation can rapidly cause a global antimicrobial resistance problem.95 Pub- lic health threats from drug resistance come from DR-TB, MRSA, drug- resistant types of Enterobacteriaceae (such as cephalosporin- and fluoroquinolone-resistant E. coli and cephalosporin- and carbapenem-resistant Kleb- siella pneumoniae), penicillin-resistant Strepto- coccus pneumoniae, fluoroquinolone-resistant Salmonella and Shigella, and cephalosporin- resistant N. gonorrhoeae.96 They also come from numerous other agents, including multidrug- resistant Acinetobacter, drug- resistant Campylobacter, vancomycin-resistant Entero- coccus (VRE), multidrug-resistant Pseudomonas
test positive for TB and begin treatment, the default rate, the proportion of people who are diagnosed but do not complete the full course of treatment, is high in some places. People who develop DR-TB as a result of defaulting on their treatment put their own lives at risk, and they also cause anyone they infect to have potentially life-threatening DR-TB. Multidrug-resistant TB (MDR-TB) is a TB strain that does not respond to two of the standard antibiotic therapies, rifampicin and isoniazid.87 New concerns are arising about extensively drug-resistant TB (XDR-TB) that is resistant to rifampicin, isoniazid, fluoroquino- lones, and at least one second-line injectable TB drug.88 In 2015, about 3.9% of new cases of TB and 21% of previously treated cases were rifampicin-resistant TB (RR-TB) or MDR-TB, but in some countries and regions, the propor- tion is higher (FIGURE 8–25).69 The MDR-TB rates are especially high in Eastern Europe and Central Asia. MDR-TB can be treated using a directly observed therapy approach (through a protocol sometimes called DOTS-Plus), but the medications are more expensive and the course of treatment is much longer, up to 2 years rather than 6 months.89
A healthcare-associated infection (HAI), also called hospital-acquired infection or a nosocomial infection, is an infection that
0%
1%
2%
3%
4%
5%
6%
7%
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
USA
global average
C ou
nt ry
% o
f n ew
c as
es th
at ar
e M
D R
/R R
-T B
FIGURE 8–25 Percentage of new TB cases in 2015 that were multidrug-resistant (MDR-TB) and rifampicin-resistant (RR-TB). Data from Global tuberculosis report 2016. Geneva: WHO; 2016.
8.9 Antimicrobial Resistance 191
12. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: Recommendations for a public health approach. 2nd ed. Geneva: WHO; 2016.
13. Faria NR, Rambaut A, Suchard MA, et al. The early spread and epidemic ignition of HIV-1 in human populations. Science. 2014;346:56–61.
14. Pneumocystis pneumonia—Los Angeles, 1981. MMWR Morb Mortal Wkly Rep. 1981;30:250–2.
15. Jaffe HW, Bregman DJ, Selik RM. Acquired immune deficiency syndrome in the United States: The first 1000 cases. J Infect Dis. 1983;148:339–45.
16. Gallo RC, Montagnier L. The discovery of HIV as the cause of AIDS. N Engl J Med. 2003;349:2283–5.
17. Danforth K, Baxi S, Wideman D, Padian N. Global mortality and morbidity from HIV/AIDS (Chapter 2). Disease control priorities. 3rd ed. Major infectious diseases (Volume 6). Washington DC: IBRD/World Bank; 2017.
18. GBD 2015 HIV Collaborators. Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015: The Global Burden of Disease Study 2015. Lancet. HIV 2016;3:e361–87.
19. Global health sector response to HIV, 2000–2015: Focus on innovations in Africa. Geneva: WHO; 2015.
20. Andrews G, Skinner D, Zuma K. Epidemiology of health and vulnerability among children orphaned and made vulnerable by HIV/AIDS in sub-Saharan Africa. AIDS Care. 2006;18:269–76.
21. AIDS by the numbers 2016. Geneva: UNAIDS; 2016. 22. Fast-Track: Ending the AIDS epidemic by 2030.
Geneva: UNAIDS; 2014. 23. Quinn TC, Overbaugh J. HIV/AIDS in women: An
expanding epidemic. Science. 2005;308:1582–3. 24. Higgins JA, Hoffman S, Dworkin SL. Rethinking
gender, heterosexual men, and women’s vulnerability to HIV/AIDS. Am J Public Health. 2010;100:435–45.
25. Integrating gender into HIV/AIDS programmers in the health sector: Tools to improve responsiveness to women’s needs. Geneva: WHO; 2009.
26. Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. Geneva: WHO; 2016.
27. Global health sector strategy on HIV, 2016–2021: Towards ending AIDS. Geneva: WHO; 2016.
28. Denison JA, O’Reilly KR, Schmid GP, Kennedy CE, Sweat MD. HIV voluntary counseling and testing and behavioral risk reduction in developing countries: A meta-analysis, 1990–2005. AIDS Behav. 2008;12:363–73.
29. Consolidated guidelines on HIV testing services—5 Cs: Consent, confidentiality, counselling, correct results and connection. Geneva: WHO; 2015.
30. “15 by 15”: A global target achieved. Geneva: UNAIDS; 2015.
aeruginosa, and others.97 AMR prevention strat- egies include preventing infections so that anti- biotics are not needed, expanding the use of diagnostic tests to ensure that appropriate antibi- otics are prescribed, reducing the overuse of anti- biotics to treat diseases in humans and livestock, and developing new types of antibiotics.98 A new “superbug” that evolves anywhere in the world poses a threat to the whole world, so all countries must be committed to taking steps to prevent pathogens from developing resistance to new antibiotic medications and acting to address the challenges of containing the AMR strains already in circulation.99
▸ References 1. Brandt AM. How AIDS invented global health. N
Engl J Med. 2013;368:2149–52. 2. Results report 2016. Geneva: The Global Fund; 2016. 3. Horton R, Lo S. Investing in health: Why, what, and
three reflections. Lancet. 2013;382:1859–61. 4. Maartens G, Celum C, Lewin SR. HIV infection:
Epidemiology, pathogenesis, treatment, and prevention. Lancet. 2014;384:258–71.
5. WHO case definitions of HIV for surveillance and revised clinical staging and immunological classification of HIV-related disease in adults and children. Geneva: WHO; 2007.
6. The International AIDS Society Scientific Working Group on HIV Cure. Towards an HIV cure: A global scientific strategy. Nat Rev Immunol. 2012;12:607–14.
7. Chaiyachati KH, Ogbuoji O, Price M, Suthar AB, Negussie EK, Bärnighausen T. Interventions to improve adherence to antiretroviral therapy: A rapid systematic review. AIDS. 2014;28(Suppl 2): S187–204.
8. Safrit JT, Fast PE, Gieber L, Kuipers H, Dean HJ, Koff WC. Status of vaccine research and development of vaccines for HIV-1. Vaccine. 2016;34:2921–5.
9. Gray GE, Laher F, Doherty T, et al. Which new health technologies do we need to achieve an end to HIV/AIDS? PLoS Biol. 2016;14:e1002372.
10. Jaffar S, Grant AD, Whitworth J, Smith PG, Whittle H. The natural history of HIV-1 and HIV-2 infections in adults in Africa: A literature review. Bull World Health Organ. 2004;82:462–9.
11. Holmes C, Hallett T, Walensky R, Bärnighausen T, Pillay Y, Cohen M. Effectiveness and cost- effectiveness of treatment as prevention for HIV (Chapter 5). Disease control priorities. 3rd ed. Major infectious diseases (Volume 6). Washington DC: IBRD/World Bank; 2017.
192 Chapter 8 HIV/AIDS and Tuberculosis
Disease control priorities. 3rd ed. Major infectious diseases (Volume 6). Washington DC: IBRD/World Bank; 2017.
46. Kates J, Wexler A, Lief E. Financing the response to HIV in low- and middle-income countries: International assistance from donor governments in 2015. Menlo Park CA: The Henry J. Kaiser Family Foundation/UNAIDS; 2016.
47. PEPFAR 2016 Annual Report to Congress. Washington DC: U.S. Department of State; 2016.
48. Chesson HW, Mayaud P, Aral SO. Sexually transmitted infections: Impact and cost-effectiveness of prevention (Chapter 10). Disease control priorities. 3rd ed. Major infectious diseases (Volume 6). Washington DC: IBRD /World Bank; 2017.
49. WHO guidelines for the treatment of Chlamydia trachomatis. Geneva: WHO; 2016.
50. WHO guidelines for the treatment of Neisseria gonorrhoeae. Geneva: WHO; 2016.
51. Global health sector strategy on sexually transmitted infections 2016–2021: Towards ending STIs. Geneva: WHO; 2016.
52. Unemo M, Nicholas RA. Emergence of multidrug- resistant, extensively drug-resistant and untreatable gonorrhea. Future Microbiol. 2012;7:1401–22.
53. WHO guidelines for the treatment of Treponema pallidum (syphilis). Geneva: WHO; 2016.
54. Hook EW 3rd. Syphilis. Lancet. 2017;389:1550–7. 55. Newman L, Kamb M, Hawkes S, et al. Global estimates
of syphilis in pregnancy and associated adverse outcomes: Analysis of multinational antenatal surveillance data. PLoS Med. 2013;10:e1001396.
56. WHO guidelines for the treatment of genital herpes simplex virus. Geneva: WHO; 2016.
57. Looker KJ, Magaret AS, Turner KME, Vickerman P, Gottlieb SL, Newman LM. Global estimates of prevalent and incident herpes simplex virus type 2 infections in 2012. PLoS One. 2015;10:e114989.
58. Looker KJ, Magaret AS, May MT, et al. Global and regional estimates of prevalent and incident herpes simplex virus type 1 infections in 2012. PLoS One. 2015;10:e0140765.
59. Plummer M, de Martel C, Vignat J, Ferlay J, Bray F, Franceschi S. Global burden of cancers attributable to infections in 2012: A synthetic analysis. Lancet Glob Health. 2016;4:e609–16.
60. Bruni L, Diaz M, Barrionuevo-Rosas L, et al. Global estimates of human papillomavirus vaccination coverage by region and income level: A pooled analysis. Lancet Glob Health. 2016;4:e453–63.
61. Poole DN, McClelland RS. Global epidemiology of Trichomonas vaginalis. Sex Transm Infect. 2013;89: 418–22.
62. Orion E, Matz H, Wolf R. Ectoparasitic sexually transmitted diseases: Scabies and pediculosis. Clin Dermatol. 2004;22:513–19.
31. 90–90–90: An ambitious treatment target to help end the AIDS epidemic. Geneva: UNAIDS; 2014.
32. John-Stewart G, Peeling R, Levin C, Garcia P, Mabey D, Kinuthia J. Prevention of mother-to-child transmission of HIV and syphilis (Chapter 6). Disease control priorities. 3rd ed. Major infectious diseases (Volume 6). Washington DC: IBRD/World Bank; 2017.
33. De Cock KM, Fowler MG, Mercier E, et al. Prevention of mother-to-child HIV transmission in resource-poor countries: Translating research into policy and practice. JAMA. 2000;283:1175–82.
34. Siegfried NL, van der Merwe L, Brocklehurst P, Sint TT. Antiretrovirals for reducing the risk of mother- to-child transmission of HIV infection. Cochrane Database Syst Rev. 2007;(1):CD003510.
35. Guideline: Updates on HIV and infant feeding: The duration of breastfeeding, and support from health services to improve feeding practices among mothers living with HIV. Geneva: WHO/UNICEF; 2016.
36. Guidelines on post-exposure prophylaxis for HIV and the use of co-trimoxazole prophylaxis for HIV-related infections among adults, adolescents and children: Recommendations for a public health approach. Geneva: WHO; 2014.
37. WHO technical update on pre-exposure prophylaxis (PrEP). Geneva: WHO; 2015.
38. Murphy EM, Greene ME, Mihailovic A, Olupot- Olupot P. Was the “ABC” approach (abstinence, being faithful, using condoms) responsible for Uganda’s decline in HIV? PLoS Med. 2006;3:e379.
39. Boily MC, Baggaley RF, Wang L, et al. Heterosexual risk of HIV-1 infection per sexual act: A systematic review and meta-analysis of observational studies. Lancet Infect Dis. 2009;9:118–29.
40. Global strategy for the prevention and control of sexually transmitted infections 2006–2015: Breaking the chain of transmission. Geneva: WHO; 2007.
41. Joint strategic action framework to accelerate the scale-up of voluntary medical male circumcision for HIV prevention in eastern and southern Africa 2012– 2016. Geneva: WHO/UNAIDS; 2011.
42. Sawires SR, Dworkin SL, Fiamma A, Peacock D, Szekeres G, Coates TJ. Male circumcision and HIV /AIDS: Challenges and opportunities. Lancet. 2007; 369:708–13.
43. Wodak A, Cooney A. Do needle syringe programs reduce HIV infection among injecting drug users: A comprehensive review of the international evidence. Subst Use Misuse. 2006;41:777–813.
44. Kurth AE, Celum C, Baeten JM, Vermund SH, Wasserheit JN. Combination HIV prevention: Significance, challenges, and opportunities. Curr HIV/AIDS Rep. 2011;8:62–72.
45. Khan JG, Bollinger L, Stover J, Marseille E. Improving the efficiency of the HIV/AIDS policy response: A guide to resource allocation modeling (Chapter 9).
References 193
83. The Global Plan to Stop TB 2011–2015: Transforming the fight: Toward elimination of tuberculosis. Geneva: WHO; 2011.
84. Goldbert DE, Siliciano RF, Jacobs WR. Outwitting evolution: Fighting drug-resistant TB, malaria, and HIV. Cell. 2012;148:1271–83.
85. Global action plan on antimicrobial resistance. Geneva: WHO; 2015.
86. The OIE strategy on antimicrobial resistance and the prudent use of antimicrobials. Paris: World Organisation for Animal Health (OIE); 2014.
87. Guidelines for the programmatic management of drug-resistant tuberculosis. Geneva: WHO; 2016.
88. Matteelli A, Roggi A, Carvalho ACC. Extensively drug-resistant tuberculosis: Epidemiology and management. Clin Epidemiol. 2014;6:111–8.
89. Companion handbook to the WHO guidelines for the programmatic management of drug-resistant tuberculosis. Geneva: WHO; 2014.
90. National and state healthcare associated infections: Progress report (2014). Atlanta GA: CDC; 2016.
91. Grundmann H, Aires-de-Sousa M, Boyce J, Tiemersma E. Emergence and resurgence of meticillin-resistant Staphylococcus aureus as a public- health threat. Lancet. 2006; 368:874–85.
92. Stefani S, Chung DR, Lindsay JA, et al. Meticillin- resistant Staphylococcus aureus (MRSA): Global epidemiology and harmonization of typing methods. Int J Antimicrob Agents. 2012;39:273–82.
93. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: WHO; 2016.
94. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44:159–77.
95. Miller-Petrie M, Pant S, Laxminarayan R. Drug resistant infections (Chapter 18). Disease control priorities. 3rd ed. Major infectious diseases (Volume 6). Washington DC: IBRD/World Bank; 2017.
96. Antimicrobial resistance: Global report on surveillance. Geneva: WHO; 2014.
97. Antibiotic resistance threats in the United States, 2013. Atlanta, GA: CDC; 2013.
98. Laxminarayan R, Duse A, Wattal C, et al. Antibiotic resistance: The need for global solutions. Lancet Infect Dis. 2013;13:1057–98.
99. Laxminarayan R, Sridhar D, Blaser M, Wang M, Woolhouse M. Achieving global targets for antimicrobial resistance. Science. 2016;353:874–5.
63. Garnett G, Krishnaratne S, Harris K, et al. Cost- effectiveness of interventions to prevent HIV acquisition (Chapter 7). Disease control priorities. 3rd ed. Major infectious diseases (Volume 6). Washington DC: IBRD/World Bank; 2017.
64. Gottlieb SL, Low N, Newman LM, Bolan G, Kamb M, Broutet N. Toward global prevention of sexually transmitted infections (STIs): The need for STI vaccines. Vaccine. 2014; 32:1527–35.
65. Ferreira A, Young T, Mathews C, Zunza M, Low N. Strategies for partner notification for sexually transmitted infections, including HIV. Cochrane Database Syst Rev. 2013; (10):CD002843.
66. Dheda K, Barry CE 3rd, Maartens G. Tuberculosis. Lancet. 2015;387:1211–26.
67. Lönnroth K, Jaramillo E, Williams BG, Dye C, Raviglione M. Drivers of tuberculosis epidemics: The role of risk factors and social determinants. Soc Sci Med. 2009;68:2240–6.
68. Sepkowitz KA. How contagious is tuberculosis. Clin Infect Dis. 1996;23:954–62.
69. Global tuberculosis report 2016. Geneva: WHO; 2016. 70. BCG vaccine: WHO position paper. Wkly Epidemiol
Rec. 2004;79:27–38. 71. Systematic screening for active tuberculosis: An
operational guide. Geneva: WHO; 2015. 72. Implementing the End TB Strategy: The essentials.
Geneva: WHO; 2015. 73. Treatment of tuberculosis: Guidelines (4th edition).
Geneva: WHO; 2010. 74. The Stop TB Strategy: Building on and enhancing
DOTS to meet the TB-related Millennium Development Goals. Geneva: WHO; 2006.
75. Evans TG, Schrager L, Thole J. Status of vaccine research and development of vaccines for tuberculosis. Vaccine. 2016;34:2911–4.
76. Guidelines on the management of latent tuberculosis infection. Geneva: WHO; 2015.
77. Global tuberculosis report 2015. Geneva: WHO; 2015. 78. The End TB Strategy: Global strategy and targets for
tuberculosis prevention, care and control after 2015. Geneva: WHO; 2014.
79. Bloom BR, Atun R, Cohen T, et al. Tuberculosis (Chapter 11). Disease control priorities 3rd ed. Major infectious diseases (Volume 6). Washington DC: IBRD/World Bank; 2017.
80. A guide to monitoring and evaluation for collaborative TB/HIV activities (2015 revision). Geneva: WHO; 2015.
81. Harries AD, Zachariah R, Corbett EL, et al. The HIV-associated tuberculosis epidemic: When will we act? Lancet. 2010;375:1906–19.
82. WHO policy on collaborative TB/HIV activities: Guidelines for national programmes and other stakeholders. Geneva: WHO; 2012.
194 Chapter 8 HIV/AIDS and Tuberculosis
© Xinzheng. All Rights Reserved/Moment/Getty
CHAPTER 9
Diarrheal, Respiratory, and Other Common Infections
Infectious diseases remain common causes of death in low-income countries, and more than one- third of the victims are children. Most deaths from diarrheal diseases, pneumonia, and other common childhood infections can be prevented with vaccinations, antibiotics, and other low-cost preventive and therapeutic interventions. Global health initiatives are enabling significant reductions in the child mortality rate from infectious diseases. Global cooperation is also critical for containing new strains of influenza and other pathogens with the potential to spark dangerous pandemics.
▸ 9.1 Infectious Diseases and Global Health
Infectious diseases caused by bacteria, viruses, fungi, and parasites cause millions of deaths every year. In the early and middle decades of the 20th century, new laboratory techniques led to the identification of many disease- causing microbes and the development of vaccines and antibiotics like penicillin. These discoveries generated a great deal of optimism and confidence about the ability of humans to control and eradicate communicable diseases. But scientists now recognize that even though modern science has provided a good under- standing of the infectious disease process and has allowed for the development of therapies and cures for many types of infectious diseases,
microbes continue to adapt and emerge. Even with improved preventive and therapeutic techniques, infectious diseases continue to be a health risk in all populations in every part of the world. Developing new methods for the prevention, diagnosis, and treatment of infec- tious diseases remains an important part of global health.
Most people who live in high-income countries would correctly consider heart dis- ease, cancer, or diabetes to be their number one health concern. Few would mention infectious diseases as a top priority for their own health, except when a major infectious disease outbreak is getting a lot of media attention. This happens occasionally when there are new fears about the emergence of a particularly bad influenza strain or there is an outbreak linked to a food prod- uct or restaurant chain. These worries usually fade quickly. But in most low-income countries, infectious diseases remain responsible for a
195
large proportion of deaths (FIGURE 9–1).1 These deaths disproportionately affect children, the poor, and other vulnerable population groups.
The burden from easily preventable infec- tious diseases falls especially hard on children,2 who have a higher proportion of deaths from infectious diseases than adults (FIGURE 9–2).3 An estimated 8.8 million people world- wide died from infections in 2015, including 3.1 million children under 14 years of age: 0.6 million neonates in their first month of life, 1.1 million post-neonatal infants, 1.0 million children between their first and fifth birth- days, and 0.4 million children between their fifth and fifteenth birthdays (FIGURE 9–3).1 More than 99% of all infectious disease deaths in children occur in low- and middle-income countries, with low-income countries bear- ing a particularly disproportionate burden ( FIGURE 9–4). The vast majority of these infec- tions could have been prevented with inexpen- sive interventions like childhood vaccinations,
Other Infections
0%
20%
40%
60%
80%
100%
USA
Ger m
an y
Ira n
Bra zil
Chin a
In dia
Nige ria
Eth iop
ia
% o
f d ea
th s
at tr
ib ut
ab le
to in
fe ct
io ns
FIGURE 9–1 Infectious diseases cause a large proportion of deaths in lower-income countries. Data from GBD Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause- specific mortality for 249 causes of death, 1980–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016; 388:1459–544.
90
100
80
70
60
50
40
30
20
10
0 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
Age (years)
% o
f d ea
th s
fr om
in fe
ct io
n
USA Germany Brazil
China
Iran
NigeriaIndia Ethiopia
FIGURE 9–2 The percentage of deaths that are attributable to infectious diseases peaks in childhood. Data from GBD Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1459–544.
196 Chapter 9 Diarrheal, Respiratory, and Other Common Infections
reliable access to clean drinking water, and bednets to block mosquito bites. When pre- vention methods failed to stop the occurrence of an infection, the majority of deaths from these infectious diseases could still have been averted with antibiotic and other types of basic medical care.
The unnecessary burden of infectious diseases on children in low-income countries is more than sufficient reason for infectious disease prevention and control to remain a global health priority. One of the eight Millen- nium Development Goals was to reduce the mortality rate among children between birth and their fifth birthdays (“under-5” children) by two-thirds between 2000 and 2015 (MDG 4). The mortality rate dropped by more than half during that 15-year period, and infectious disease programs were critical contributors to the good progress made toward achieving this goal.4 This trajectory will need to continue in order to achieve the Sustainable Development Goals target of ending preventable deaths of young children by 2030 (SDG 3.2).5
But infectious diseases are not just about children. They are equal-opportunity killers, and they can kill or disable people of all ages, all socio- economic levels, and all geographies. Infectious diseases are spread through social networks, and the web of human contacts is becoming more complex as modern transportation allows people and products to travel almost anywhere in the world within a day. Infectious diseases can mutate, adapt, and disseminate themselves quickly, and that places everyone at risk.
Individuals, communities, health organi- zations, and governmental agencies all have a role to play in the control and prevention of infectious diseases. Individuals contribute to reducing the burden of infectious disease by engaging in healthy behaviors, such as wash- ing their hands frequently and staying home from work or school when sick, so they do not continue the chain of transmission. Commu- nities play key roles in environmental health, reducing infection transmission by increasing
< 1 month (0.6 million)
1 to 11 months (1.1 million)
1 to 4 years (1 million)
5 to 14 years (0.4 million)
15 to 49 years (2.1 million)
50 to 69 years (1.5 million)
70+ years (2.1 million)
FIGURE 9–3 More than 3 million children died from infectious diseases in 2015. Data from GBD Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1459–544.
FIGURE 9–4 Nearly all infectious disease deaths among children (aged 0–14 years) occur in lower- income countries. Data from GBD Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause- specific mortality for 249 causes of death, 1980–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1459–544.
100%
80%
60%
40%
20%
0%
<1 month 1 to 11 months 1 to 4 years
5 to 14 year
Population distribution (ages 0-14)
High income
Lower-middle income Upper-middle income
Low income
9.1 Infectious Diseases and Global Health 197
6 million children younger than 5 years old who died in 2015 succumbed to diarrhea, including nearly 16% of the deaths in chil- dren 1–59 months old.3 Most of these deaths occurred in low-income countries. Diarrhea mortality rates are especially high among chil- dren who are undernourished, including those who are not breastfed and those who are defi- cient in vitamin A or zinc.7
The most frequent diarrhea-causing pathogens include rotaviruses, noroviruses, astroviruses, and adenoviruses; bacteria such as Vibrio cholerae, Escherichia coli, Salmonella spe- cies (including the ones that cause typhoid and paratyphoid), Shigella, Campylobacter jejuni, and Aeromonas; and protozoa, such as Entam- oeba histolytica, Giardia, and Cryptosporidium.8 These are all called enteric infections because they are infections of the intestinal tract.
Rotavirus is the most frequent cause of severe diarrhea in infants and young children.9 Children with rotavirus infection typically have vomiting and watery diarrhea for 3–7 days.10 The number of deaths from rotavirus decreased from more than 500,000 worldwide in 2000 to about 200,000 by 2015 as access to the vaccine increased, but rotavirus remains the most common cause of child death from infectious diarrhea.11
Norovirus, part of the calicivirus family (and formerly called Norwalk-like virus), is the most frequent cause of severe diarrhea in adults.12 Norovirus is highly contagious, which is why it has been the cause of several notable outbreaks on cruise ships. Within just a few days at sea, the majority of passengers on a
drinking water quality and the amount of water available to each person, ensuring access to sanitation facilities, promoting proper waste management, implementing policies that reduce air pollution, reducing mosquito populations through water drainage and insecticides, and controlling rodent and snail populations. Local and national governments implement food safety regulations, enforce zoning laws that restrict the number of indi- viduals who can share a dwelling unit, require pet vaccination, and take other steps to mini- mize the infectious disease risks in the natural and built environments. At the national and international levels, scientists, policymakers, and others work together to create and dis- seminate technologies, such as new vaccines, and to track and address emerging infectious disease problems. One country alone cannot stop a pandemic. Infectious disease control requires international cooperation.
▸ 9.2 Diarrheal Diseases Diarrhea is characterized by loose or liquid feces and an increased frequency of defecation, and it can quickly cause dehydration and death in young children. Severe dehydration, the excessive loss of water from the body, can cause low blood pressure (because fluid loss decreases blood volume), a fast and weak pulse, rapid breathing (but insufficient oxygen intake), sunken dry eyes, loss of skin elasticity, mus- cle contractions, convulsions, and delirium. Imbalances of sodium, potassium, bicarbonate, and other electrolytes can lead to kidney and heart failure, and eventually to death. In addi- tion to diarrhea, people with gastroenteritis often have nausea, vomiting, cramps, and fever.
Infectious diarrhea affects all age groups, but it is especially dangerous in children.6 About 1.7 billion cases of diarrhea occur in under-5 children each year, and diarrheal diseases remain a major cause of mortality in young children.7 About 9% of the nearly Cholera cots in a cholera treatment center.
CD C
198 Chapter 9 Diarrheal, Respiratory, and Other Common Infections
occur globally in a typical year.18 Outbreaks periodically occur in other places, including in some countries in the Americas. An epidemic in Haiti after the devastating earthquake in 2010 was particularly notable because the ori- gin of the outbreak was traced back to United Nations peacekeepers from Nepal who were participating in the international response to the disaster. This unfortunate event has led to changes in the protocols for UN deployments, including mandatory cholera vaccinations and higher standards for sanitation.19
Escherichia coli bacteria are very com- mon, with E. coli present in most human intestines. Most types of E. coli are nonpatho- genic, which means that they are not harm- ful and do not cause disease. However, some strains are pathogenic. These types of E. coli are described by the damage they cause, such as enterotoxigenic E. coli (ETEC), which is a common cause of diarrhea in children and travelers, and enteropathogenic E. coli (EPEC), which can be fatal in infants.20 E. coli O157:H7, a Shiga toxin-producing E. coli (STEC), can cause hemolytic uremic syndrome, which is characterized by bloody diarrhea and kidney failure.21 E. coli O157:H7 bacteria are spread via fecal contamination of food (such as pro- duce or undercooked beef) and water (includ- ing swimming pools that are not properly maintained) and by person-to-person contact (typically in a daycare or other institutional setting).22 Food intoxication, illness caused when ingested bacteria produce toxins in the body, is also caused by some other types of bacteria, including Bacillus cereus, Clostrid- ium perfringens, and Staphylococcus aureus.23
Campylobacter, Salmonella, and Shigella are Gram-negative bacteria that are frequent causes of diarrhea. Campylobacteriosis, a dis- ease of the small intestines caused by infection with Campylobacter jejuni and other species, is usually acquired through undercooked poul- try and meat products.24 Salmonella infections are divided into two main categories, typhoid fever and non- typhoidal Salmonella.25 Typhoid
ship can be ill.13 Outbreaks have also occurred in daycare centers, restaurants, and other ven- ues. Most people recover quickly from noro- virus infection, but some may require hospital care for dehydration.
Cholera is an infection with Vibrio chol- erae bacteria that causes large volumes of severe watery diarrhea to be produced from liquid secreted by the body into the small intestine.14 A cholera cot is a simple bed with a hole cut in the center so that a bucket can be placed below the bed to capture the liquid being expelled from the intestines. Being able to quantify the amount of fluid lost allows an appropriate amount of water to be replaced through drinking or intravenous drips. Death can occur if the body’s electrolyte balance can- not be maintained through fluid replacement. Vibrio can live in harsh environments, includ- ing ocean water and sewage, and the bacteria can survive for long periods of time.15 A series of cholera pandemics in the 1800s was sparked by intensification of global trade.16 The threat to human health and economic well-being posed by cholera was the impetus behind the creation of the International Sanitary Regu- lations that were the direct precursor to the International Health Regulations.17 Today, many countries in sub-Saharan Africa (includ- ing Nigeria and Ethiopia) and a few countries in Asia (including India and a few provinces of China) are considered to be endemic for cholera, and nearly 3 million cholera cases
© pa
tta ng
/S hu
tte rst
oc k
9.2 Diarrheal Diseases 199
G. lamblia and G. duodenalis) that usually lasts for 3–6 weeks but can cause persistent diarrhea for several months or longer.34 Other chronic foodborne infections include brucellosis and Helicobacter pylori. Brucellosis is caused by bac- teria ( Brucella abortus and B. melitensis) that are transmitted to humans through unpasteur- ized dairy products and contact with livestock. If untreated, the infection may cause chronic cyclic fevers.35 Untreated H. pylori infection is associated with stomach ulcers.36 H. pylori is also an example of a foodborne disease that does not cause diarrhea, as are listeriosis and botulism. Listeria monocytogenes, which can be acquired from processed meats and other foods, is of public health concern because pregnant women who contract the bacterium have an increased risk of miscarriages, stillbirths, and preterm delivery.37 Botulism is a rare disease caused by ingesting toxins from Clostridium botulinum bacteria, usually in meals containing honey or improperly canned goods, and it causes cranial nerve palsies, descending paralysis, and the risk of respiratory failure and death.38
▸ 9.3 Diarrhea Interventions
Nearly all diarrheal infections are spread through fecal-oral transmission, which occurs when a person ingests products contaminated with fecal matter from animals or humans. Fecal- oral transmission is often described as being
(Salmonella Typhi = Salmonella enterica sero- type Typhi) causes severe diarrhea and a high fever. The symptoms of typhoid can persist for a month, and even with treatment, the disease can be fatal if it causes intestinal bleeding or perfora- tion.26 A typhoid vaccine is available, but it is not highly effective. An estimated 25 million cases of symptomatic typhoid fever occur globally every year,27 and a small percentage of people infected with typhoid bacteria become chronic carriers of the pathogen. A carrier is a person with a persistent contagious infection who does not have symptoms of the disease but can pass the infectious agent on to others through stool. Carriers play an important role in sustaining typhoid transmission in communities, because typhoid does not have an animal or environ- mental reservoir.28 There are more than 2600 serotypes of Salmonella, and they affect both the large and small intestines. The nearly 40 serotypes of Shigella typically affect only the colon.29 Dysentery is bloody diarrhea, with the blood often mixed with mucus, and it can be caused by several different types of bacteria and parasites.30 Bacillary dysentery is caused by Shi- gella bacteria. Amoebic dysentery is caused by E. histolytica, a protozoan.
Reliable access to and use of toilet facilities is important for reducing the community disease burden from Entamoeba species, cryptosporid- iosis, giardiasis, and other protozoal causes of diarrhea.31 Cryptosporidiosis is a waterborne protozoal disease (typically caused by Cryptospo- ridium hominis or C. parvum) that can be fatal in infants and immunocompromised adults.32 The parasites are often found in livestock, and outbreaks in humans can occur when drinking water supplies become contaminated. A 1993 outbreak of cryptosporidiosis in Wisconsin, in the United States, was caused by a failure of the water treatment system. The outbreak caused more than 100 deaths in the city of Milwaukee and made more than 400,000 people sick.33
While most diarrheal infections resolve after a few days, some bacterial and parasitic infec- tions can become chronic diseases. Giardiasis is an infection with Giardia intestinalis (also called
© El
Na riz
/S hu
tte rst
oc k
200 Chapter 9 Diarrheal, Respiratory, and Other Common Infections
ORT every time they pass watery stool for a total of at least one liter each day. If they also have vomiting, they need to drink more ORT to replace those lost fluids. Continued feeding is the process of encouraging children with diar- rhea to eat the same foods that they normally consume (as long as they are not vomiting too much to keep food down) and continuing to breastfeed infants and young children as usual during their illness. ORT combined with con- tinued feeding leads to the best health out- comes for children with diarrhea.44
A diverse package of cost-effective inter- ventions is the best option for reducing the burden from diarrheal diseases in childhood. Interventions to reduce the incidence of diar- rhea in children include improvements in access to a reliable source of safe drinking water, community-wide sanitation facilities for safely disposing of feces, and hygiene prac- tices, including frequent handwashing with soap; breastfeeding and nutrition promotion; vitamin A and zinc supplementation; and vaccinations against rotavirus, measles, and (where available) cholera.45 Interventions to reduce deaths in children who have diarrheal diseases include educating parents and com- munities about ORT and continued feeding as well as providing zinc treatment, probiotics, and antibiotics for diarrhea caused by dysen- teric diseases for which antimicrobial therapy has been shown to be effective at reducing
a function of the “5 Fs”: fluids, fields, fingers, flies, and food.39 When feces are not properly disposed of, they can contaminate drinking water (fluids) and soil (fields). The fecal mat- ter can then get onto hands (fingers), especially the hands of young children who frequently touch the ground. Hands can transport the fecal matter to food when people do not wash their hands before preparing food or before eating. Insects (flies) can also spread feces to food and water, and flies thrive where fecal matter is in the open. The five Fs are sometimes expanded to a set of 6 Fs that includes fomites. A fomite is an inanimate object or surface that has been contaminated with infectious agents, such as a doorknob, stethoscope, clothing, or other item that has become coated in pathogenic microbes. Diarrhea prevention methods there- fore include safe drinking water (fluids), access to toilets (fields), hand hygiene (fingers), insect control (flies), food safety (food), and surface disinfection (fomites).40 (Diarrhea can also be caused by other conditions, such as inflamma- tory bowel disorders like Crohn’s disease and ulcerative colitis, lactose intolerances and other food sensitivities that cause poor absorption of water, some antibiotics and other medications, and other conditions, but those are uncommon contributors to diarrhea mortality.41)
Once a child has diarrhea, the most important method for preventing death is oral rehydration therapy (ORT), drinking enough water to prevent or treat the dehydration caused by diarrhea. Oral rehydration salts (ORS), also called oral rehydration solution, are a mixture of sugar, salt, and clean drink- ing water that replaces lost fluids and restores the balance of electrolytes in the blood. ORS packets are sometimes distributed at clinics, usually in a low osmolarity formula that con- tains sodium, chloride, glucose, potassium, and citrate.42 Parents can also make their own ORS solution by mixing 8 teaspoons of sugar and one-half teaspoon of salt into one liter of boiled water.43 Potassium can be added to the solution through fruit juice, coconut water, or mashed bananas. Children with diarrhea need to drink Sim
on Be
rry , C
ola Lif
e, ht
tp s:/
/fl ic.
kr /p
/e 2w
5a B,
lic en
se d u
nd er
CC BY
-S A 2
.0
9.3 Diarrhea Interventions 201
than 1 per 1000 live births by 2025.44 Many of the low-income countries that have made significant progress in reducing deaths from diarrhea have current rates that are still con- siderably higher than this target level, but the trajectories show progress toward improvement (FIGURE 9–6).48 Only about 41% of the world’s under-5 children with diarrhea received ORT and continued feeding in 2015 (FIGURE 9–7),49 roughly the same proportion as in 2000,47 and increasing this rate is one of the key compo- nents of the GAPPD strategy.
Food safety is also critical for prevent- ing dangerous cases of diarrhea in people of all ages. A diversity of bacterial and viral pathogens are frequent causes of foodborne outbreaks in countries across the globe, including brucellosis, campylobacteriosis, cholera, E. coli, listeriosis, Mycobacterium bovis, salmonellosis, shigellosis, typhoid, paratyphoid, hepatitis A virus, and norovi- rus.50 Foodborne parasitic infections are less common in high-income countries than they are in low-income countries, but they do occur.51 For example, the United States has
adverse outcomes.45 After children recover from diarrhea, they should be encouraged to eat more food than normal to regain lost weight and lost nutrients. Undernutrition is a major underlying cause of child deaths from diarrhea and pneumonia, so this recovery period is critical for protecting children from the adverse outcomes of their next bout with an infectious disease.46
Although the numbers of cases and deaths from childhood diarrhea remain far above inter- national targets, they are significantly better than the numbers from just 15 years ago.47 The mortality rate from diarrhea among children younger than 5 years old decreased by more than 60% between 2000 and 2015, from 9.5 per 1000 live births to 3.8 per 1000 live births, and the number of deaths of children younger than 5 years old from diarrhea decreased from about 1.2 million in 2000 to 525,000 in 2015 (FIGURE 9–5).3 The Global Action Plan for Pneu- monia and Diarrhea (GAPPD), initiated by the World Health Organization (WHO), UNICEF, and dozens of partner groups, aims to reduce the under-5 diarrhea mortality rate to less
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
0 0
1
2 3
4
5
6
7
8
9
10
2000 2005 2010 2015 2020 2025
Number of deaths Mortality rate per 1000 live births
M or
ta lit
y ra
te p
er 1
00 0
liv e
bi rt
hs
GAPPD target
N um
be r
of d
ea th
s
FIGURE 9–5 The diarrhea mortality rate in children aged 0–59 months has decreased significantly since 2000. Data from Liu L, Oza S, Hogan D, Chu Y, Perin J, Zhu J, Lawn JE, Cousens S, Mathers C, Black RE. Global, regional, and national causes of under-5 mortality in 2000–15: An updated systematic analysis with implications for the Sustainable Development Goals. Lancet 2016; 388:3027–35.
202 Chapter 9 Diarrheal, Respiratory, and Other Common Infections
roles in ensuring the safety of foods and beverages.54
▸ 9.4 Pneumonia The main function of the body’s respira- tory system is the exchange of gases, which mostly means taking in oxygen and getting rid of carbon dioxide (FIGURE 9–8). When a person takes a breath, the air enters the lungs and fills tiny air sacs called alveoli. Each alve- olus is wrapped in tiny blood vessels called capillaries and has a very thin surface so that gas exchange can take place. When a person inhales, oxygen is absorbed into the blood in those capillaries. This oxygenated blood is pumped into the heart and then to the rest of the body so that all of the cells can receive the oxygen they need to function properly. When the cells take in oxygen from nearby capillaries, they can also get rid of carbon dioxide and other waste products by dump- ing them into the blood. These products can then be released from the blood into the alve- oli. When a person exhales, these wastes are expelled from the body. Pneumonia occurs when part of a lung fills with fluid. If the alve- oli are filled with fluid, they cannot efficiently exchange oxygen and carbon dioxide. The symptoms of pneumonia usually include a
had foodborne outbreaks of giardiasis, cryp- tosporidiosis, cyclosporiasis ( Cyclospora cay- etanensis), and toxoplasmosis ( Toxoplasma gondii).52 For consumers, the key food safety practices include maintaining a clean kitchen area and practicing good hand hygiene, sep- arating raw and cooked food, cooking food thoroughly, keeping food at safe hot or cold temperatures, and using safe water and food products.53 Food producers, processors, distributors, and retailers also play critical
USA Germany Brazil
China
Iran
NigeriaIndia Ethiopia
2000 2005 2010 2015 2020 2025 0
5
10
15
20
25
30
GAPPD target
M or
ta lit
y pe
r 10
00 c
hi ld
re n
FIGURE 9–6 The diarrhea mortality rate per 1000 live births in children aged 0–59 months has decreased significantly in lower-income countries. Data from Department of Evidence, Information and Research (WHO) and Maternal Child Epidemiology Estimation (MCEE) group. WHO-MCEE estimates for child causes of death 2000–2015. Geneva: WHO; 2016.
FIGURE 9–7 Percentage of children younger than 5 years old with diarrhea who receive oral rehydration salts (ORS). Data from State of the world’s children 2016. New York: UNICEF; 2016.
Iran 61%
India 26%
Nigeria 34%
Ethiopia 26%
Target number for 2015 is 90%
Path of Blood
Path of Blood
HEART
Right side of heart: Sends blood to lungs
Left side of heart: Sends blood to body
Cells of the BODY: Release CO2 into
blood and take oxygen from blood
LUNGS: Put oxygen into
blood and take CO2 from blood
FIGURE 9–8 Path of blood through the heart, lungs, and body.
9.4 Pneumonia 203
children die each year from pneumonia than from diarrhea, and more die from pneumo- nia than from other infectious causes like malaria, meningitis, HIV, measles, and per- tussis ( FIGURE 9–10).3 The Global Action Plan for Pneumonia and Diarrhea (GAPPD) aims to reduce the under-5 pneumonia mortal- ity rate to less than 3 per 1000 live births by 2025 (FIGURE 9–11).44
The agents that cause the highest num- ber of cases of childhood pneumonia include Streptococcus pneumoniae, Haemophilus influenzae type b (Hib), respiratory syn- cytial virus (RSV), and influenza virus.55 Pneumococcus is the disease caused by infection with S. pneumoniae,56 and pneu- mococcus can cause severe pneumonia as well as ear infections and sinus infections.57 Rarely, pneumococcus becomes an inva- sive disease when the bacteria cause blood infections (bacteremia) or infections of the brain and spinal cord (meningitis). “Hib” is a bacterial infection with H. influenzae type b.58 The inclusion of influenzae in the name indicates that the bacterium causes an
cough accompanied by difficult rapid breath- ing. People with pneumonia can feel like they are drowning as fluid fills their lungs and they develop hypoxia, an inadequate supply of oxygen in body tissues. A child with severe pneumonia may even turn bluish in color due to hypoxia.
The mortality rate from pneumonia among children younger than 5 years old decreased by more than 50% between 2000 and 2015, from 13.6 per 1000 live births to 6.6 per 1000 live births, and the num- ber of deaths from pneumonia of children younger than 5 years old decreased from about 1.74 million in 2000 to 920,000 in 2015 ( FIGURE 9–9).3 However, pneumonia remains the most frequent cause of infec- tious disease death in under-5 children, with most deaths occurring in low-income countries.47 In 2015, about 15.5% of the nearly 6 million children younger than 5 years old who died succumbed to pneumo- nia, and pneumonia was responsible for 6% of the deaths in newborns and 23% of the deaths in children 1–59 months old.3 More
2000 2005 2010 2015 2020 2025 0
2
4
6
8
10
12
14
162,000,000
1,800,000
1,600,000
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
0
Number of deaths Mortality rate per 1000 live births GAPPD target
M or
ta lit
y ra
te p
er 1
00 0
liv e
bi rt
hs
N um
be r
of d
ea th
s
FIGURE 9–9 The pneumonia mortality rate in children aged 0–59 months has decreased significantly since 2000. Data from Liu L, Oza S, Hogan D, Chu Y, Perin J, Zhu J, Lawn JE, Cousens S, Mathers C, Black RE. Global, regional, and national causes of under-5 mortality in 2000–15: An updated systematic analysis with implications for the Sustainable Development Goals. Lancet. 2016; 388:3027–35.
204 Chapter 9 Diarrheal, Respiratory, and Other Common Infections
include Mycobacterium tuberculosis, Myco- plasma pneumoniae, Chlamydia pneumoniae, Legionella pneumophila, Enterobacteriaceae, Chlamydia psittaci, Coxiella burnetii (which causes Q fever), Pseudomonas aeruginosa, and a diversity of respiratory viruses (such as adenoviruses and coronaviruses), among others.62
Bacterial pneumonia can often be cured by inexpensive oral antibiotics if treatment is sought soon after the onset of symptoms. However, only about 63% of the world’s under-5 children with suspected pneu- monia are taken to a healthcare provider ( FIGURE 9–13),49 and an even lower percent- age are treated with antibiotics. More than
influenza-like illness, but Hib is not influ- enza. Effective vaccines are available for both pneumococcus and Hib, which means that the deaths from these infections are completely preventable. Respiratory syn- cytial virus (RSV) is a common cause of severe pneumonia in preterm infants and other vulnerable babies,59 and it accounts for a high proportion of cases of severe pneu- monia in many higher-income countries (FIGURE 9–12).55 Influenza is a viral respi- ratory infection that may lead to second- ary bacterial pneumonia.60 Other common causes of pneumonia include Staphylococcus aureus and Klebsiella pneumoniae.61 Less- frequent pneumonia-causing pathogens
0%
20%
40%
60%
80%
100%
Other
Pertussis
Measles
HIV/AIDS
Meningitis
Malaria
Diarrhea
Pneumonia
EthiopiaNigeriaIndiaChinaBrazilIranGermanyUSA
D ea
th s
FIGURE 9–10 Percentage of deaths in children aged 1–59 months (post-neonatal under-5 mortality) caused by seven common infectious diseases in 2015. Data from Liu L, Oza S, Hogan D, Chu Y, Perin J, Zhu J, Lawn JE, Cousens S, Mathers C, Black RE. Global, regional, and national causes of under-5 mortality in 2000–15: An updated systematic analysis with implications for the Sustainable Development Goals. Lancet. 2016; 388:3027–35.
9.4 Pneumonia 205
▸ 9.5 Other Respiratory Infections
Pneumonia is not the only respiratory infectious disease of public health concern.
10 million children are hospitalized each year because of severe pneumonia, but more than one-third of children with severe pneu- monia are not treated in hospitals.63 More than 80% of child pneumonia deaths occur outside of hospitals, and many of those children could have survived if they had received medical care.63 Thus, an important component of improving child survival is educating caregivers about the importance of seeking medical care as soon as the symp- toms of pneumonia appear, so that a course of antibiotics can be started. Antibiotics will not speed recovery from colds and other upper respiratory infections (like bronchi- tis) that are usually caused by viruses, but they are usually effective against early-stage bacterial pneumonia. Oxygen therapy may also help prevent cases of severe pneumonia from becoming fatal.45
Other Influenza RSV
Hib Pneumococcus
0%
20%
40%
60%
80%
100%
USA
Ger m
an y
Ira n
Bra zil
Chin a
In dia
Nige ria
Eth iop
ia
FIGURE 9–12 Common causes of severe pneumonia in children aged 0–59 months in 2010. Data from Rudan I, O’Brien KL, Nair H, Liu L, Theodoratou E, Qazi S, Lukšić I, Fischer Walker CL, Black RE, Campbell H; Child Health Epidemiology Reference Group. Epidemiology and etiology of childhood pneumonia in 2010: Estimates of incidence, severe morbidity, mortality, underlying risk factors and causative pathogens for 192 countries. J Glob Health 2013; 3:010401.
CD C/
Br ian
Ju dd
/Ja m
es G
at ha
ny
USA Germany Brazil
China
Iran
NigeriaIndia Ethiopia
35
30
25
20
15
10
5
0
2000 2005 2010 2015 2020 2025
GAPPD targetM
or ta
lit y
pe r
10 00
c hi
ld re
n
FIGURE 9–11 The pneumonia mortality rate per 1000 live births in children aged 0–59 months has decreased significantly in lower-income countries. Data from Department of Evidence, Information and Research (WHO) and Maternal Child Epidemiology Estimation (MCEE) group. WHO-MCEE estimates for child causes of death 2000–2015. Geneva: WHO; 2016.
206 Chapter 9 Diarrheal, Respiratory, and Other Common Infections
contact with hands or surfaces that have been contaminated by droplets expelled from the airways of infected persons when they sneeze or cough. For example, adeno- viruses and the rhinoviruses that cause colds can live on some types of nonporous sur- faces for days.65 Some airborne pathogens are acquired from environmental sources rather than directly from infected humans.66 For example, infection with Legionellae bacteria, called Legionnaires’ disease when the symptoms are severe or Pontiac fever for milder disease, is acquired through the inhalation of moistened water from air con- ditioners, hot tubs, and humidifiers.67 Some hantaviruses are acquired by inhaling aero- solized rat urine or feces when cleaning, and they can cause fatal hantavirus pulmonary syndrome.68 Psittacosis, also called parrot fever, is acquired when bird owners inhale the dried droppings of pets infected with the bacterium Chlamydophila psittaci.69 Coc- cidioidomycosis, also called valley fever, is caused by Coccidiodes immitis, a fungus that lives in desert soil in places like the South- west of the United States.70 Histoplasmosis is caused by the fungus Histoplasma capsu- latum, which is found in the Americas and elsewhere as a mold in soil containing bird or bat droppings.71
Prevention methods for respiratory infections include isolating infected per- sons and providing them with appropriate medical treatment; vaccinating members of vulnerable population groups against Hib, pneumococcus, and pertussis; reducing exposure to indoor air pollution and smoke, since polluted air damages the respiratory tract and increases susceptibility to respi- ratory diseases; reducing household over- crowding; using protective equipment at workplaces where occupational exposure to respiratory pathogens is likely; and encour- aging frequent handwashing and the cover- ing of the nose and mouth when coughing or sneezing.45
An acute respiratory infection (ARI) is a short-term infection of the respiratory tract that typically has a rapid onset and resolves without becoming a chronic infec- tion. ARIs are divided into two categories. Upper respiratory tract infections (URIs or URTIs) include acute infections of the nose, sinuses, pharynx, larynx (voice box), and trachea. Most URIs are considered mild, like the common cold and tonsillitis, but some can cause long-term damage. Strep throat, an illness caused by a type of Group A Strep- tococcus, is a common childhood infection that if left untreated can lead to complica- tions such as scarlet fever or rheumatic fever, a condition that may cause permanent dam- age to the valves of the heart. Lower respira- tory infections (LRIs) are acute respiratory infections of the bronchi and lungs, includ- ing infectious bronchitis and pneumonia. URIs are usually viral in origin, while LRIs are most often caused by bacteria.64 Fungal pneumonias (such as aspergillosis, blasto- mycosis, and cryptococcosis) and parasitic pneumonias are uncommon compared to bacterial and viral respiratory infections, but they also occur.
Most respiratory infections are acquired through the air. Airborne transmission occurs when pathogens are aerosolized or suspended as droplets in the air and people inhale that contaminated air. Respiratory pathogens can also be transmitted through
Iran 76%
Brazil 50%
India 77%
Nigeria 35%
Ethiopia 27%
Target number for 2015 is 90%
FIGURE 9–13 Percentage of children younger than 5 years old with symptoms of pneumonia who receive care from a health facility or provider. Data from State of the world’s children 2016. New York: UNICEF; 2016.
9.5 Other Respiratory Infections 207
hemagglutinin (H) and neuraminidase (N). Influenza A strains are classified using abbre- viations like H3N2 and H1N1 that are derived from the viruses’ hemagglutinin and neur- aminidase types. The dominant strain changes over time. H1N1 was the most common human influenza from 1918 until it was dis- placed by H2N2 in the late 1950s; H2N2 was displaced by H3N2 in the late 1960s.77 A total of 17 types of influenza hemagglutinin types and 10 influenza neuraminidase types have been found in animals, but only a few have been found in humans.
Influenza viruses evade the immune sys- tems of their hosts by changing their surface antigens so that the hosts’ immune systems cannot recognize them. There are two pro- cesses by which surface antigens change, anti- genic drift and antigenic shift.78 Antigenic drift occurs when small genetic mutations bring about small changes in the antigens. Antigenic drift is the reason why infection with one version of H3N2 influenza might not confer immunity to another form of H3N2. Antigenic drift makes it necessary to develop a new influenza vaccine every year. Antigenic shift occurs when two very different types of influenza A viruses attack the same cell and the genetic material from both recombines to form a new type of influenza.79 Antigenic shift led to the emergence in 1997 of an H5N1 strain of avian influenza (“bird flu”) that spread rapidly through the bird populations in parts of Southeast Asia, affecting both domes- tic birds (such as ducks and chickens) and wild migrating fowl. The H5N1 strain of influenza was deemed to be a highly pathogenic avian influenza (HPAI) because it caused serious disease and high case fatality rates in affected birds.80
All infectious agents, whether newly emerging or long established in a population, are continually adapting and changing in ways that can make them more or less trans- missible, infective, pathogenic, and virulent.81 Transmissibility is the ease with which an
▸ 9.6 Influenza Influenza is a highly contagious respiratory viral infection. Influenza viruses cause fevers and respiratory disease, and they can exacer- bate existing medical conditions, especially lung and heart diseases, and lead to poten- tially fatal secondary infection with bacterial pneumonia.60 (“Stomach flu” is not caused by influenza viruses.) Although the highest fatality rates from influenza are usually among the elderly and immunocompromised individ- uals, anyone who contracts influenza can die from it.
Seasonal influenza outbreaks occur every year, and the viruses that cause these epidem- ics are constantly mutating. When a novel strain of influenza emerges, it can cause pan- demic influenza, sometimes shortened to just “pan flu.”72 The first influenza pandemic likely occurred in 1510, soon after the global ship- ping industry was launched, and other pan- demics occurred in the 1730s, 1760s, 1780s, 1830s, 1840s, 1890s, and several times there- after.73 The term pandemic is a description of the geographic dispersion of a pathogen, and it is not necessarily an indicator of the severity of the infection,74 but pandemic influenza strains can be dangerous. The most serious influ- enza pandemic in the 20th century occurred in 1918 and 1919 during World War I,75 and that strain killed a disproportionate number of young adults as it spread through populations across the globe.76 The emergence of a new strain of influenza can rapidly spark a global health crisis.
Two main types of influenza viruses cause epidemics in human populations, influenza A and influenza B. Influenza A viruses are fur- ther classified based on their surface antigens. An antigen is a foreign substance in the body that triggers an immune response, especially if the body’s immune system has previously been exposed to the antigen and is therefore able to quickly recognize and neutralize it. The two key surface antigens for influenza A are
208 Chapter 9 Diarrheal, Respiratory, and Other Common Infections
that affect humans originate in bird or mam- mal populations. When a virus mutates in a way that allows it to pass easily between humans and make humans severely ill, and it subsequently becomes established in human populations, that new strain is no longer a zoonosis.83 For example, when a type of H1N1 “swine flu” began circulating widely in human populations in 2009, it ceased being an influ- enza of pigs and became a disease of humans.84 Within months, human cases had been reported in 200 countries.85 In 2013, an H7N9 influenza that primarily affects poultry caused several humans to become severely ill.86 When H7N9, another strain of “bird flu,” or another type of influenza not currently circulating in human populations further mutates in a way that allows it to be easily transmitted between humans, a pandemic may result.
Rapid laboratory tests are available to confirm the presence of influenza A or B viral antigens in the body fluids of people suspected to have influenza infections. People with sus- pected influenza who have not tested positive for the virus are said to have an influenza-like illness (ILI). People who test positive for influ- enza can be prescribed antiviral medications that reduce the severity of symptoms from some strains of influenza. However, these medications do not cure the infection and they do not work against strains that have devel- oped resistance to antivirals.87
Several public health strategies have been used to contain outbreaks of influenza and other dangerous infectious diseases, including isolation of sick people and quarantine of their contacts.88 Isolation is the separation of peo- ple who have tested positive for a contagious infection from healthy people who are sus- ceptible to the infection. Caregivers of people in isolation take precautions to protect them- selves from infection with careful hygiene and personal protective equipment (PPE), such as gowns, gloves, facemasks, eye protection, and other barriers that prevent infection. The air supplies in isolation rooms may be filtered
infectious agent is passed from an infected host to another individual. Infectivity is the capacity of an infectious agent to cause infection in a susceptible host (one without immunity to the infection acquired from prior infection or vaccination) who is exposed to the agent. Infectivity is sometimes mea- sured by calculating the secondary attack rate, the proportion of susceptible people exposed to a contagious person who contract the infection. Pathogenicity is the capac- ity of an infectious agent to cause disease in an infected host. Virulence is the ability of an infectious agent to cause severe disease or death in a host, and it is measured by the proportion of severe or fatal cases among all people who become ill. A virulent infection will have a high case fatality rate, because a high percentage of people who become ill from the infection will die from that infection. A mutation that causes greater transmissibil- ity, infectivity, pathogenicity, or virulence in an influenza strain can pose a major threat to human populations globally.
Influenza viruses affect humans and also many types of animals, including chickens, ducks, pigs, horses, and even dogs, whales, and bats.82 An infectious disease that usually occurs only in humans is called an anthroponosis. An infectious disease that usually occurs in animals and only occasionally infects humans is called a zoonosis. Some strains of influenza circulate in human populations, and some strains are zoonoses. Most strains of influenza
© te
sti ng
/S hu
tte rst
oc k
9.6 Influenza 209
▸ 9.7 Immunization Vaccination is the intentional delivery of a substance into the body in order to stimulate development of immunity against a particular disease. Immunization is the process of a per- son’s immune system developing immunity against a particular infection. Vaccination is the action of delivering a vaccine to an individ- ual; immunization is what happens in the body after a vaccine is injected or otherwise dis- pensed. A vaccine prompts the body’s immune system to create antibodies specific to the anti- gens contained in the vaccine. An antibody is a protein produced by the human body (by B lymphocytes) in response to the presence of antigens. Antibodies can bind to antigens and destroy them. If a vaccinated person is later exposed to that same antigen when it is part of an infectious agent, the body’s immune system will be able to quickly recognize the agent and destroy it before it has a chance to multiply.
Active immunity is present when the body’s immune system produces antibod- ies against a specific infectious agent. This long-lasting protection against an infectious disease can be conferred by both infection and vaccination. By contrast, passive immunity is temporary protection from antibodies pro- duced by another human or an animal, and it lasts only a few months.92 Newborns and infants have some protection from mater- nal antibodies acquired transplacentally. For older children and adults, some protection can be conferred for a few weeks or months through blood products or immunoglobu- lin shots containing high concentrations of antibodies.
There are several different types of vac- cines.93 A live attenuated vaccine contains a pathogen that has been weakened using various laboratory techniques. A single dose of a live attenuated vaccine may be sufficient to confer lifelong immunity. However, live attenuated vaccines are not safe for some
and vented away from places where people might gather. Quarantine is the restriction of freedom of movement for contacts of infected people because they may become contagious, even though they have no signs of infection at the time they are quarantined. Isolation is for sick people; quarantine is for healthy con- tacts of sick people. Contact tracing is the process of identifying the primary contacts of infected individuals (and, sometimes, the contacts of those primary contacts, who are called secondary contacts), so that they can be tested and monitored. Vaccination is also an important tool for reducing the burden from influenza, when there is an available vaccine that is effective at protecting people from the circulating strain.89
Influenza is a prime example of how global travel contributes to the rapid spread of newly mutated infectious agents. An infected per- son can fly to any part of the world in a day or two and spark an outbreak in a new location.90 Globalization can also be beneficial for public health responses. Global communication sys- tems may facilitate the containment of a pan- demic by enabling public health officials to be alerted immediately to possible outbreaks of novel influenza strains. During the 2009 H1N1 pandemic, revised International Health Regu- lations guided the coordinated global response to the outbreak. Countries reported cases of H1N1 to the WHO, and WHO used its Pan- demic Alert System to keep member nations and the public informed about the spread of the epidemic.91 Coordinated capacity-building efforts initiated before the pandemic enabled pharmaceutical companies around the globe to expedite the development, testing, and man- ufacturing of H1N1 vaccines.85 Local, national, and global preparedness plans implemented years before the emergence of H1N1 guided the response to the pandemic, and the lessons learned from H1N1 have been integrated into refined plans that are ready for implementa- tion when the next major influenza pandemic emerges.
210 Chapter 9 Diarrheal, Respiratory, and Other Common Infections
before they are approved for widespread use. Pre- licensure studies demonstrate that the vaccine is safe and that it is efficacious in conferring immunity against the targeted dis- ease.95 There are three stages of clinical trials in humans.96 Phase 1 trials enroll 20–100 healthy volunteers to test safety and dosage. Phase 2 trials enroll several hundred volunteers to fur- ther examine safety, dosage, and the timing of initial and follow-up shots. Phase 3 trials expand the number of participants to several thousand people. After a vaccine is approved, post-licensure studies continue to monitor safety and effectiveness.97
Licensed vaccines have undergone exten- sive testing to prove that they safe for most people.93 An adverse reaction is a side effect of vaccination. The most typical adverse reactions are redness at the injection site, some local pain or swelling, and occasion- ally fevers or general achiness. Severe adverse reactions are extremely rare.98 (The term adverse event is used to encompass both adverse reactions and other medical events that occur after vaccination but appear to be coincidental rather than being a result of the vaccine.99) However, there are some people who cannot receive particular vaccines. A contraindication is a condition that makes it unsafe for an individual to receive a particular
people with compromised immune systems, and they must be maintained at precise tem- peratures to maintain their effectiveness. If the cold chain is interrupted, as often occurs in places with unreliable electrical systems, the vaccine will be useless to the recipient. An inactivated vaccine contains a killed bacterium or an inactive virus that has been rendered harmless by heat, chemicals, or radi- ation. Inactivated vaccines are safer and more stable than live attenuated vaccines, but they are not as effective at stimulating an immune response. Multiple doses of inactivated vac- cines may be required to confer and main- tain immunity. An adjuvant is an ingredient added to some types of vaccines to boost the body’s immune response to the vaccine. Some inactivated vaccines are whole-virus vaccines, and some are fractional vaccines that contain parts of a pathogen rather than the entire microbe. A toxoid vaccine is a frac- tional vaccine that protects from the toxins released by some bacteria, like the bacteria that cause diphtheria and tetanus. Subunit vaccines against bacteria and viruses have strong safety profiles, but they are a challenge to create. A conjugate vaccine is a fractional vaccine against a bacterial infection that is based on polysaccharides rather than pro- teins and has additional ingredients added to it to help infants’ immune systems develop immunity. Other types of vaccines created through more complex laboratory methods are also available or in development.94
Vaccination programs are a key compo- nent of many infectious disease prevention and control strategies. New vaccines are often developed by partnerships of scientists, clini- cians, pharmaceutical companies, nonprofit health organizations, and governments. These teams work together to select target diseases, create and test new vaccines, identify and educate the populations that would most ben- efit from the vaccine, and manufacture and deliver the vaccines to those populations. New vaccines undergo multiple rounds of testing
CD C/
Je ssi
ca Cu
rti s/S
ue Ch
u
Ink marks the fingers of children vaccinated during an immunization campaign event.
9.7 Immunization 211
for six vaccine-preventable diseases: mea- sles, polio, tuberculosis (BCG), diphtheria, tetanus, and pertussis.101 (The tuberculosis vaccine Bacillus Calmette-Guérin protects against serious tuberculosis disease but is of limited value in preventing colonization with the bacteria that cause tuberculosis.102 BCG is usually not used in high-income countries where the risk of tuberculosis infection is very low.) EPI continues to sup- port child vaccination programs today. The number of recommended pediatric vacci- nations has expanded significantly over the past 25 years.103 About a dozen vaccines are now routinely recommended for children, including mumps, rubella, hepatitis B, influ- enza, Hib, pneumococcus, and rotavirus ( FIGURE 9–14).
Measles is a very contagious viral infec- tion.104 The initial symptoms are a fever, cough, runny nose, and watery eyes. A few days later, small white spots (Koplik spots) appear on the inside of the mouth, then red spots show up on the face and progress down the trunk and extremities. Some chil- dren experience serious complications, such as pneumonia, encephalitis, deafness, brain damage, and death, especially if they are vitamin A deficient.105 Before a measles vac- cine was available, measles killed millions of children each year.106 The number of measles deaths worldwide per year decreased from an estimated 650,000 in 2000 to 135,000 in 2015—a remarkable 80% reduction—as the percentage of infants receiving at least one dose of a measles-containing vaccine increased from 72% to 85% (FIGURE 9–15).107 However, the vaccination rate remains lower than the target in many of the low-income countries where undernutrition is common and the risk of measles mortality is greatest (FIGURE 9–16).49
The measles vaccine is often distributed as part of a combination MMR (measles, mumps, rubella) vaccine. The most visible sign of mumps is swollen parotid salivary glands that cause the cheeks to swell, but
vaccine. For example, a serious allergy to a component of a vaccine is a contraindication against that particular vaccine. Some vaccines may also be inappropriate for women who are pregnant or for people weakened by age, mal- nutrition, cancer treatments, immunosup- pressive medications, or existing infections with other pathogens. A precaution is a con- dition that might make a vaccine ineffective at producing immunity or might increase the likelihood of an adverse reaction in a partic- ular individual. For example, the best option for people with acute illnesses may be to wait until they have recovered before they receive a new vaccine.
When individuals receive a vaccination, they are not just protecting themselves from dis- ease. They are also protecting the people around them who are unable to be vaccinated because of contraindications and those who are among the small percentage of vaccine recipients who do not develop immunity after vaccination. The theory of herd immunity says that reducing the proportion of a population that is susceptible to an infection protects the entire population, including those who are unable to receive vac- cines.100 Suppose that during an outbreak, each infected person exposes about ten other peo- ple to the infection. In a completely susceptible population, all ten of the exposed people might become infected, and each of those ten people could spread the infection to many others. But if 80% of the members of the population have been vaccinated, only two of the initial ten contacts are likely to result in infection, and those two newly infected people will not be able to spread the infection to many others. Herd immunity helps prevent epidemics.
▸ 9.8 Vaccine- Preventable Infections
The Expanded Program on Immunization (EPI) was established by the WHO in 1974 to ensure universal child access to vaccines
212 Chapter 9 Diarrheal, Respiratory, and Other Common Infections
Pertussis, also known as whooping cough, causes violent fits of coughing (paroxysms) punctuated by a “whoop” sound when inhal- ing.112 Periodic coughing fits may persist for 10 weeks or longer, and they may be so vig- orous that they cause rib fractures. Infants
mumps can also cause serious complications, including encephalitis, meningitis, deafness, and, in adolescent and adult males, testicu- lar inflammation (orchitis) that may cause infertility.108 Rubella, also called German measles, often causes just a mild rash, but when pregnant women contract it, the virus can cause miscarriages and serious birth defects associated with congenital rubella syndrome.109
A combination vaccine is usually used to confer protection against diphtheria, tetanus, and pertussis (FIGURE 9–17).49 Diphtheria causes inflammation of the airway and the production of thick mucus that can become a fatal airway obstruction. The infection can also damage the body’s nerves and the heart muscle.110 Tetanus, also called lockjaw, causes painful muscle spasms throughout the body, starting in the muscles of the lower face.111
Vaccine Type of Agent Agent
Diphtheria Bacterium Corynebacterium diphtheriae
Hepatitis B Virus Hepatitis B virus (HBV, hepadnavirus family)
Hib Bacterium Haemophilus influenzae type B
Influenza Virus Influenza virus (orthomyxovirus family)
Measles Virus Measles virus (paramyxovirus family)
Mumps Virus Mumps virus (paramyxovirus family)
Pertussis (whooping cough) Bacterium Bordetella pertussis
Pneumococcal disease (pneumococcus)
Bacterium Streptococcus pneumoniae
Polio Virus Poliovirus (picornavirus)
Rotavirus Virus Rotavirus (reovirus family)
Rubella (German measles) Virus Rubella virus (togavirus family)
Tetanus Bacterium Clostridium tetani
FIGURE 9–14 Routinely recommended childhood vaccinations.
Measles.
CD C/
M oll
y K ur
nit , M
.P. H.
9.8 Vaccine-Preventable Infections 213
who contract pertussis often do not cough, but instead suffer from bouts of apnea (long pauses in breathing) that may result in brain damage or death.113
Influenza,114 Hib,115 and pneumococcus116 vaccines protect against respiratory infections, and rotavirus vaccines protect infants and young children from a type of severe gastro- enteritis.117 Some countries have opted not to include these vaccines in their childhood vaccination schedules, usually because of the cost of these recently developed products. In 2015, only about one in two infants received three doses of Hib vaccine, one in three infants received three doses of pneumococcal conju- gate vaccine, and one in five infants received
4
3
2
1
0
100
90
80
70
60
50 2000 2005 2010 2015
Measles mortality rate Vaccine coverage
M ea
sl es
m or
ta lit
y pe
r 10
00 li
ve b
ir th
s
M easles vaccine coverage (%
)
FIGURE 9–15 The measles mortality rate per 1000 live births in children aged 0–59 months decreased as the infant vaccine coverage increased. Data from Department of Evidence, Information and Research (WHO) and Maternal Child Epidemiology Estimation (MCEE) group. WHO-MCEE estimates for child causes of death 2000–2015. Geneva: WHO; 2016.
USA
Ger m
an y
Ira n
Bra zil
Chin a
In dia
Nige ria
Eth iop
ia
global average
0%
20%
40%
60%
80%
100%
FIGURE 9–16 Percentage of infants receiving at least one dose of a measles-containing vaccine in 2015. Data from State of the world’s children 2016. New York: UNICEF; 2016.
214 Chapter 9 Diarrheal, Respiratory, and Other Common Infections
the rotavirus vaccine (FIGURE 9–18).49 Polio is a viral infection that causes paralysis in a small percentage of the people who contract it, and because it is the focus of a massive global erad- ication campaign, it is strongly recommended for all children.118
Other available vaccines that are recom- mended in some regions of the world, for some populations with high risk, and for some older age groups include anthrax, cholera,119 hepatitis A,120 human papillomavirus (HPV),121 Japanese encephalitis,122 meningococcus,123 rabies,124
tick-borne encephalitis,125 typhoid fever,126 varicella-zoster (chickenpox and shingles),127 and yellow fever128 (FIGURE 9–19).129 Additionally, several vaccines have been licensed in at least one country, such as ones for dengue130 and hepatitis E,131 and others are in advanced clin- ical trials, such as malaria,132 and soon may be approved for public use. These vaccines may become more widely available after additional data demonstrate the safety and efficacy of the formulations.
Significant progress is being made in increasing access to vaccinations in low- and middle-income countries through partner- ships like Gavi, the Vaccine Alliance (formerly GAVI, an acronym for Global Alliance for Vac- cines and Immunization), which works with national governments across the income spec- trum, WHO, UNICEF, The World Bank, char- ities like the Bill & Melinda Gates Foundation, and other entities to identify vaccine priorities and then procure and distribute the vaccines.133 Further increases in vaccination coverage will require concurrent strengthening of health sys- tems, disease surveillance coverage, laboratory testing capacity, health communications net- works, and safety monitoring systems.134
▸ 9.9 Viral Hepatitis Hepatitis is inflammation of the liver. Several types of viral hepatitis are of global public health concern, and each is caused by a very different type of virus that triggers liver inflammation (FIGURE 9–20).135 About 1 million people each year die from acute or chronic viral hepatitis or the complications of chronic infection, including HBV- and HCV- associated liver cancers.136
Hepatitis A virus (HAV) is primarily spread through direct person-to-person con- tact and by ingestion of contaminated food and water.137 HAV is an enteric pathogen that infects and replicates in the intestines. Young children who contract HAV typically have no
0%
20%
40%
60%
80%
100%
Eth iop
ia
Nige ria
In dia
Chin a
Bra zilIra
n
Ger m
an y
USA
global average
1 or 2 doses 3 doses
FIGURE 9–17 Percentage of infants receiving a diphtheria, tetanus, and pertussis (DTP) vaccine in 2015. Data from State of the world’s children 2016. New York: UNICEF; 2016.
CD C/
D r. T
ho m
as F.
Se lle
rs; Em
or y U
niv er
sit y
Jaundice caused by hepatitis A.
9.9 Viral Hepatitis 215
0%
20%
40%
60%
80%
100%
USA Germany Brazil ChinaIran India Nigeria Ethiopia
Global average Hib
Global average PCV
Global average rotavirus
Hib Pneumococcus Rotavirus
FIGURE 9–18 Percentage of infants receiving three doses of Hib (Haemophilus influenzae type B) vaccine, rotavirus vaccine, and three doses of pneumococcal conjugate vaccine in 2015. Data from State of the world’s children 2016. New York: UNICEF; 2016.
Vaccine Type of Agent Agent
Cholera Bacterium Vibrio cholerae
Hepatitis A Virus Hepatitis A virus (HAV, picornavirus family)
Hepatitis E Virus Hepatitis E virus (HEV, hepevirus family)
HPV Virus Human papillomavirus (HPV, papillomavirus family)
Japanese encephalitis Virus Japanese encephalitis virus (JEV, flavivirus family)
Meningococcal disease (meningococcus)
Bacterium Neisseria meningitidis
Rabies Virus Rabies virus (rhabdovirus family)
Tick-borne encephalitis (TBE) Virus Tick-borne encephalitis virus (flavivirus family)
Typhoid fever Bacterium Salmonella enterica Typhi
Varicella zoster(chickenpox / shingles)
Virus Varicella zoster virus (VZV, herpesvirus family)
Yellow fever Virus Yellow fever virus (flavivirus family)
FIGURE 9–19 Examples of other available vaccinations.
216 Chapter 9 Diarrheal, Respiratory, and Other Common Infections
of liver cancer.141 Vaccination against HBV is contributing to a decrease in the prevalence of chronic hepatitis B disease (FIGURE 9–21), but the rates remain high in some parts of Africa, Asia, and South America.142 Antiviral therapy can suppress the HBV virus but does not cure the infection, and HBV medications are not widely available in lower-income countries.139
Hepatitis C virus (HCV) is now trans- mitted primarily through injecting drug use.143 HCV can also be transmitted sexually and from mother to child. Most people who contract HCV develop a chronic infection that substantially increases their risk of liver complications like cirrhosis and hepatocel- lular carcinoma. Several antiviral medica- tions are available to suppress chronic HCV
symptoms, but older children and adults usu- ally develop jaundice, a yellowing of the skin and sclera (the whites of the eyes) due to the build-up of bilirubin levels in the blood, and they typically suffer from fevers, gastrointesti- nal symptoms, and fatigue for about 8 weeks. A small proportion of people with hepatitis A develop life-threatening fulminant hepatitis, also called acute liver failure. Chronic HAV infection does not occur, and lifelong protec- tion from the virus is conferred by infection and by vaccination. Most children in low- income countries contract HAV in very early childhood and develop immunity to the virus, but a large proportion of adults in high-income countries remain vulnerable to the infection.138
Hepatitis B virus (HBV) is transmit- ted through parenteral contact with blood or other body fluids as a result of a needle stick, an open wound (such as a cut or abrasion), or another tear in the skin or mucous membranes. The term parenteral describes the intake of a substance into the body through a route other than the digestive tract. HBV is also trans- mitted through sexual activity and through perinatal transmission in which the virus is passed from the mother to the neonate during delivery.139 Hepatitis B can cause chronic liver disease.140 Fewer than 5% of adults who con- tract HBV develop chronic infection, but about 95% of neonates do, and chronic HBV infec- tion increases the risk of cirrhosis (scarring of the liver) and hepatocellular carcinoma, a type
Disease Viral Family Primary Mode of Transmission
Risk of Chronic Disease?
Vaccine Preventable?
Hepatitis A Picornavirus Fecal-oral No Yes
Hepatitis B Hepadnavirus Parenteral Yes Yes
Hepatitis C Flavivirus Parenteral Yes No
Hepatitis E Hepevirus Fecal-oral No No
FIGURE 9–20 Major types of viral hepatitis.
0%
20%
40%
60%
80%
100%
USA
Ger m
an y
Ira n
Bra zil
Chin a
In dia
Nige ria
Eth iop
ia
global average
FIGURE 9–21 Percentage of infants receiving three doses of hepatitis B vaccine in 2015. Data from State of the world’s children 2016. New York: UNICEF; 2016.
9.9 Viral Hepatitis 217
Neisseria meningitidis (meningococcus), Haemophilus influenzae, and Listeria mono- cytogenes, among others.150 Three of those frequent causes are vaccine-preventable: pneu- mococcus, meningococcus, and Hib.
Meningococcus is the disease caused by infection with the bacterium Neisseria men- ingitidis, and it is one of the major causes of meningitis.151 Meningococcus occurs world- wide, but rates of the disease have been par- ticularly high in the “meningitis belt,” an area that extends across the northern countries of sub-Saharan Africa from Senegal in the west to Ethiopia in the east.152 Large outbreaks of meningococcus have historically occurred in these areas every few years during the dry season.153 That pattern might be changing now that there is an effective vaccine against the primary cause of bacterial meningitis. The incidence of meningitis in the “meningitis belt” decreased rapidly after the introduction of meningococcus vaccine to the region in 2010.154 However, cases are still occurring in countries across the region, and there is a need for continued surveillance to detect outbreaks early so that vaccination campaigns and other medical and public health measures can be implemented.155
▸ References 1. GBD 2015 Mortality and Causes of Death
Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1459–544.
2. Babigumira J, Gelband H, Garrison LP Jr. Cost- effectiveness of strategies for the diagnosis and treatment of febrile illness in children (Chapter 15). Disease control priorities. 3rd ed. Major infectious diseases (Volume 6). Washington DC: IBRD / World Bank; 2017.
3. Liu L, Oza S, Hogan D, et al. Global, regional, and national causes of under-5 mortality in 2000–15: An updated systematic analysis with implications for the Sustainable Development Goals. Lancet. 2016;388:3027–35.
4. The Millennium Development Goals report 2015. New York: UN; 2015.
infection, and some new medications com- pletely eliminate the virus from most people who complete a course of treatment. How- ever, these medications are too expensive to be widely available in lower-income countries or universally available in higher-income countries.144 There is no vaccine against HCV, and the prevalence of chronic hepatitis C is increasing.145
Hepatitis E virus (HEV) is usually spread through contaminated water, and it is a com- mon infection globally.146 Most people who contract HEV have only mild disease, but pregnant women, especially those in the third trimester, have a significantly elevated risk of acute liver failure and a case fatality rate that might be as high as 20%.147 Immunocompro- mised individuals may develop a chronic form of hepatitis E that causes rapid worsening of cirrhosis.148 A vaccination against HEV has been licensed in China but is not yet available for wider use.131
▸ 9.10 Meningitis Meningitis is an inflammation of the menin- ges, the membranes that cover the brain and spinal cord. Meningitis causes a severe head- ache and stiff neck along with other symp- toms, such as confusion, nausea, sensitivity to light, and possibly sepsis (commonly called blood poisoning). Encephalitis is an acute inflammation of the brain. The symptoms of encephalitis are similar to those of meningi- tis, and include headaches, confusion, drows- iness, hallucinations, and seizures. When both meningitis and encephalitis occur in the same person, it is called meningoencephalitis.
Meningitis can be caused by a diversity of infectious agents, including fungi and par- asites. Viral infections are the most common cause of meningitis, but bacterial meningitis is of greater concern because it has a higher case fatality rate.149 The agents that cause bacterial meningitis include Streptococcus pneumo- niae (pneumococcus), group B Streptococcus,
218 Chapter 9 Diarrheal, Respiratory, and Other Common Infections
22. Rangel JM, Sparling PH, Crowe C, Griffin PM, Swerdlow DL. Epidemiology of Escherichia coli O157:H7 outbreaks, United States, 1982–2002. Emerg Infect Dis. 2005;11:603–9.
23. Bennett SD, Walsh KA, Gould LH. Foodborne disease outbreaks caused by Bacillus cereus, Clostridium perfringens, and Staphylococcus aureus: United States, 1998–2008. Clin Infect Dis. 2013;57:425–33.
24. Kaakoush NO, Castaño-Rodríguez N, Mitchell HM, Man SM. Global epidemiology of Campylobacter infection. Clin Microbiol Rev. 2015;28:687–720.
25. Gal-Mor O, Boyle EC, Grassl GA. Same species, different diseases: How and why typhoidal and non- typhoidal Salmonella enterica serovars differ. Front Microbiol. 2014;5:391.
26. Wain J, Hendriksen RS, Mikoleit ML, Keddy KH, Ochiai RL. Typhoid fever. Lancet. 2015;385:1136–45.
27. Buckle GC, Fischer-Walker CL, Black RE. Typhoid fever and paratyphoid fever: Systematic review to estimate global morbidity and mortality for 2010. J Glob Health. 2012;2:010401.
28. Parry CM, Hien TT, Dougan G, White NJ, Farrar JJ. Typhoid fever. N Engl J Med. 2002;347:1770–82.
29. WHO Scientific Working Group. Enteric infections due to Campylobacter, Yersinia, Salmonella, and Shigella. Bull World Health Organ. 1980;58:519–37.
30. Pfeiffer ML, DuPont HL, Ochoa TJ. The patient presenting with acute dysentery: A systematic review. J Infect. 2012;64:374–86.
31. Speich B, Croll D, Fürst T, Utzinger J, Keiser J. Effect of sanitation and water treatment on intestinal protozoa infection: A systematic review and meta- analysis. Lancet Infect Dis. 2016;16:87–99.
32. Shirley DAT, Moonah SN, Kotloff KL. Burden of disease from cryptosporidiosis. Curr Opin Infect Dis. 2012;25:555–63.
33. Mac Kenzie WR, Hoxie NJ, Proctor ME, et al. A massive outbreak in Milwaukee of Cryptosporidium infection transmitted through the public water supply. N Engl J Med. 1994;331:161–7.
34. Escobedo AA, Hanevik K, Almirall P, Cimerman S, Alfonso M. Management of chronic Giardia infection. Expert Rev Anti Infect Ther. 2014;12:1143–57.
35. Dean AS, Crump L, Greter H, Hattendorf J, Schelling E, Zinsstag J. Clinical manifestations of human brucellosis: A systematic review and meta-analysis. PLoS Negl Trop Dis. 2012;6:e1929.
36. Kuipers EJ, Thijs JC, Festen HP. The prevalence of Helicobacter pylori in peptic ulcer disease. Aliment Pharmacol Ther. 1995;9(Suppl 2):59–69.
37. Ramaswamy V, Cresence VM, Rejitha JS, et al. Listeria: review of epidemiology and pathogenesis. J Microbiol Immunol Infect. 2007;40:4–13.
5. United Nations. Transforming our world: The 2030 Agenda for Sustainable Development. New York: UN; 2015.
6. Keusch GT, Fischer-Walker C, Das JK, Horton S, Habte D. Diarrheal diseases (Chapter 9). Disease control priorities. 3rd ed. Reproductive, maternal, newborn, and child health (Volume 2). Washington DC: IBRD / World Bank; 2016.
7. Fischer-Walker CL, Rudan I, Liu L, et al. Global burden of childhood pneumonia and diarrhoea. Lancet. 2013;381:1405–16.
8. Platts-Mills JA, Babji S, Bodhidatta L, et al. Pathogen- specific burdens of community diarrhoea in developing countries: A multistate birth cohort study (MAL-ED). Lancet Glob Health. 2015;3:e564–75.
9. Lanata CF, Fischer-Walker CL, Olascoaga AC, Torres CX, Aryee MJ, Black RE. Global causes of diarrheal disease mortality in children <5 years of age: A systematic review. PLoS One. 2013;8:e72788.
10. Glass RI, Parashar UD, Bresee JS, et al. Rotavirus vaccines: Current prospects and future challenges. Lancet. 2006;368:323–32.
11. Tate JE, Burton AH, Boschi-Pinto C, Parashar UD. Global, regional, and national estimates of rotavirus mortality in children <5 years of age, 2000–2013. Clin Infect Dis. 2016;62(Suppl 2):S96–105.
12. Glass RI, Parashar UD, Estes MK. Norovirus gastroenteritis. N Engl J Med. 2009;361:1776–85.
13. Bert F, Scaioli G, Gualano MR, et al. Norovirus outbreaks on commercial cruise ships: A systematic review and new targets for the public health agenda. Food Environ Virol. 2014;6:67–74.
14. Sack DA, Sack RB, Nair GB, Siddique AK. Cholera. Lancet. 2004;363:223–33.
15. Almagro-Moreno S, Taylor RK. Cholera: Environmental reservoirs and impact on disease transmission. Microbiol Spectr. 2013;1:OH-0003-2012.
16. Lee K. The global dimensions of cholera. Global Change Human Health. 2001;2:6–17.
17. Lee K, Dodgson R. Globalization and cholera: Implications for global governance. Glob Gov. 2000;6:213–36.
18. Ali M, Nelson AR, Lopez AL, Sack DA. Updated global burden of cholera in endemic countries. PLoS Negl Trop Dis. 2015;9:e0003832.
19. Piarroux R, Frerichs RR. Cholera and blame in Haiti. Lancet Infect Dis. 2015;15:1380–1.
20. Bad bug book: Foodborne pathogenic microorganisms and natural toxins handbook. 2nd ed. Silver Spring MD: FDA Center for Food Safety and Applied Nutrition (CFSAN); 2014.
21. Tarr PI, Gordon CA, Chandler WL. Shiga-toxin- producing Escherichia coli and haemolytic uraemic syndrome. Lancet. 2005;365:1073–86.
References 219
56. O’Brien KL, Wolfson LJ, Watt JP, et al. Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years: Global estimates. Lancet. 2009;374:893–902.
57. van der Poll T, Opal SM. Pathogenesis, treatment, and prevention of pneumococcal pneumonia. Lancet. 2009;374:1543–56.
58. Watt JP, Wolfson LJ, O’Brien KL, et al. Burden of disease caused by Haemophilus influenzae type b in children younger than 5 years: Global estimates. Lancet. 2009;374:903–11.
59. Nair H, Nokes DJ, Gessner BD, et al. Global burden of acute lower respiratory infections due to respiratory syncytial virus in young children: A systematic review and meta-analysis. Lancet. 2010;375:1545–55.
60. Gupta RK, George R, Nguyen-Van-Tam JS. Bacterial pneumonia and pandemic influenza planning. Emerg Infect Dis. 2008;14:1187–92.
61. Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H. Epidemiology and etiology of childhood pneumonia. Bull World Health Organ. 2008;86:408–16.
62. Prina E, Ranzani OT, Torres A. Community- acquired pneumonia. Lancet. 2015;386:1097–108.
63. Nair H, Simões EAF, Rudan I, et al. Global and regional burden of hospital admissions for severe acute lower respiratory infections in young children in 2010: A systematic analysis. Lancet. 2013;381:1380–90.
64. Ruuskanen O, Lahti E, Jennings LC, Murdoch Dr. Viral pneumonia. Lancet. 2011;377:1264–75.
65. Hall CB. The spread of influenza and other respiratory viruses: Complexities and conjectures. Clin Infect Dis. 2007;45:353–9.
66. Tang JW. The effect of environmental parameters on the survival of airborne infectious agents. J R Soc Interface. 2009;6(Suppl 6);S737–46.
67. Cunha BA, Burillo A, Bouza E. Legionnaires’ disease. Lancet. 2015;387:376–85.
68. Jonsson BC, Moraes Figueiredo LT, Vapalahti O. A global perspective on hantavirus ecology, epidemiology, and disease. Clin Microbiol Rev. 2010;23:412–41.
69. Vanrompay D, Harkinezhad T, van de Walle M, et al. Chlamydophila psittaci transmission from pet birds to humans. Emerg Infect Dis. 2007;13:1108–10.
70. Kirkland TN, Fierer J. Coccidioidomycosis: A reemerging infectious disease. Emerg Infect Dis. 1996;2:192–9.
71. Kauffman CA. Histoplasmosis: A clinical and laboratory update. Clin Microbiol Rev. 2007;20:115–32.
38. Sobel J. Botulism. Clin Infect Dis. 2005;41:1167–73. 39. Conant J, Fadem P. Community guide to
environmental health. Berkeley CA: Hesperian Foundation; 2008.
40. Julian TR. Environmental transmission of diarrheal pathogens in low and middle income countries. Environ Sci Process Impacts. 2016;18:944–55.
41. Juckett G, Trivedi R. Evaluation of chronic diarrhea. Am Fam Physician. 2011;84:1119–26.
42. Oral rehydration salts: Production of the new ORS. Geneva: WHO/UNICEF; 2006.
43. Where there is no doctor. Berkeley CA: Hesperian Health Guides; 2017.
44. Ending preventable child deaths from pneumonia and diarrhoea by 2025: The integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD). New York: UNICEF/WHO; 2013.
45. Bhutta ZA, Das JK, Walker N, et al. The Lancet Diarrhoea and Pneumonia Interventions Study Group. Interventions to address deaths from childhood pneumonia and diarrhea equitably: What works and at what cost? Lancet. 2013;381:1417–29.
46. Chopra M, Mason E, Borrazzo J, et al. Ending of preventable deaths from pneumonia and diarrhoea: An achievable goal. Lancet. 2013;381:1499–506.
47. One is too many: Ending child deaths from pneumonia and diarrhoea. New York: UNICEF; 2016.
48. Department of Evidence, Information and Research (WHO) and Maternal Child Epidemiology Estimation (MCEE) group. WHO-MCEE estimates for child causes of death 2000–2015. Geneva: WHO; 2016.
49. State of the world’s children 2016. New York: UNICEF; 2016.
50. Kirk MD, Pires SM, Black RE, et al. Global and regional disease burden of 22 foodborne bacterial, protozoal, and viral diseases, 2010: A data synthesis. PLoS Negl Trop Dis. 2015;12:e1001921.
51. Torgerson PR, Devleesschauwer B, Praet N, et al. World Health Organization estimates of the global and regional disease burden of 11 foodborne parasitic diseases, 2010: A data synthesis. PLoS Negl Trop Dis. 2015;12:e1001920.
52. Scallan E, Hoekstra RM, Angulo FJ, et al. Foodborne illness acquired in the United States: Major pathogens. Emerg Infect Dis. 2011;17:7–15.
53. Five keys to safer food manual. Geneva: WHO; 2006. 54. Codex Alimentarius Commission. Food hygiene:
Basic texts. 4th ed. Rome: WHO/FAO; 2009. 55. Rudan I, O’Brien KL, Nair H, et al. Epidemiology
and etiology of childhood pneumonia in 2010: Estimates of incidence, severe morbidity, mortality, underlying risk factors and causative pathogens for 192 countries. J Glob Health. 2013;3:010401.
220 Chapter 9 Diarrheal, Respiratory, and Other Common Infections
systematic review and meta-analysis. Lancet Infect Dis. 2012;12:36–44.
90. Viboud C, Bjørnstad ON, Smith DL, Simonsen L, Miller MA, Grenfell BT. Synchrony, waves, and spatial hierarchies in the spread of influenza. Science. 2006;312:447–51.
91. Gostin LO. Influenza A (H1N1) and pandemic preparedness under the rule of international law. JAMA. 2009;301:2376–8.
92. Keller MA, Stiehm ER. Passive immunity in prevention and treatment of infectious diseases. Clin Microbiol Rev. 2000;13:602–14.
93. Epidemiology and prevention of vaccine-preventable diseases. 13th ed. Atlanta GA: CDC; 2015.
94. Plotkin SA. Vaccines: Past, present and future. Nat Med. 2005;11(Suppl 4):S5–11.
95. Chen RT, Orenstein WA. Epidemiologic methods in immunization programs. Epidemiol Rev. 1996;18:99–117.
96. Pickering LK, Orenstein WA. Development of pediatric vaccine recommendations and policies. Semin Pediatr Infect Dis. 2002;13:148–54.
97. Hanquet G, Valenciano M, Simondon F, Moren A. Vaccine effects and impact of vaccination programmes in post-licensure studies. Vaccine. 2013;31:5634–42.
98. Miller ER, Moro PL, Cano M, Schimabukuro T. Deaths following vaccination: What does the evidence show? Vaccine. 2015;33:3288–92.
99. Ellenberg SS, Chen RT. The complicated task of monitoring vaccine safety. Public Health Rep. 1997;112:10–21.
100. Fine PE. Herd immunity: History, theory, practice. Epidemiol Rev. 1993;15:265–302.
101. Casey RM, Dumolard L, Danovaro C, et al. Global routine vaccination coverage, 2015. Wkly Epidemiol Rec. 2016;91:537–43.
102. BCG vaccine: WHO position paper. Wkly Epidemiol Rec. 2004;79:27–38.
103. Feikin DR, Flannery B, Hamel MJ, Stack M, Hansen PM. Vaccines for children in low- and middle- income countries (Chapter 10). Disease control priorities. 3rd ed. Reproductive, maternal, newborn, and child health (Volume 2). Washington DC: IBRD / World Bank; 2016.
104. Measles vaccines: WHO position paper. Wkly Epidemiol Rec. 2009;84:349–60.
105. Bester JC. Measles and measles vaccination: A review. JAMA Pediatr. 2016;170:1209–15.
106. Moss WJ. Measles. Lancet. 2012;379:153–64. 107. Patel MK, Gacic-Dobo M, Strebel PM, et al. Progress
toward regional measles elimination—worldwide, 2000–2015. Wkly Epidemiol Rec. 2016;91:525–35.
72. Doshi P. The elusive definition of pandemic influenza. Bull World Health Organ. 2011;89:532–8.
73. Morens DM, Fauci AS. The 1918 influenza pandemic: Insights for the 21st century. J Infect Dis. 2007;195:1018–28.
74. Card AJ. Pandemicity and severity are separate constructs. Am J Public Health. 2012;102:e12.
75. Brundage JF, Shanks G. Deaths from bacterial pneumonia during the 1918–19 influenza pandemic. Emerg Infect Dis. 2008;14:1193–9.
76. Murray CJL, Lopez AD, Chin B, Feehan D, Hill KH. Estimation of potential global pandemic influenza mortality on the basis of vital registry data from the 1918–20 pandemic: A quantitative analysis. Lancet. 2006;368:2211–18.
77. Glezen WP. Emerging infections: Pandemic influenza. Epidemiol Rev. 1996;18:64–76.
78. Bouvier NM, Palese P. The biology of influenza viruses. Vaccine. 2008;26(Suppl 4):D49–53.
79. Webster RG, Govorkova EA. Continuing challenges in influenza. Ann N Y Acad Sci. 2014;1323:115–39.
80. Kalthoff D, Globig A, Beer M. (Highly pathogenic) avian influenza as a zoonotic agent. Vet Microbiol. 2010;140:237–45.
81. Barreto ML, Teixeira MG, Carmo EH. Infectious disease epidemiology. J Epidemiol Community Health. 2006;60:192–5.
82. Yoon SW, Webby RJ, Webster RG. Evolution and ecology of influenza A viruses. Curr Top Microbiol Immunol. 2014;385:359–75.
83. Reperant LA, Kuiken T, Osterhaus AD. Adaptive pathways of zoonotic influenza viruses: From exposure to establishment in humans. Vaccine. 2012;30:4419–34.
84. Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team, Dawood FS, Jain S, Finelli L, et al. Emergence of a novel swine-origin influenza A (H1N1) virus in humans. N Engl J Med. 2009;360:2605–15.
85. Girard MP, Tam JS, Assossou OM, Kieny MP. The 2009 A (H1N1) influenza virus pandemic: A review. Vaccine. 2010;28:4895–902.
86. Gao R, Cao B, Hu Y, et al. Human infection with a novel avian-origin influenza A (H7N9) virus. N Engl J Med. 2013;368:1888–97.
87. Hayden FG, de Jong MD. Emerging influenza antiviral resistance threats. J Infect Dis. 2011;203:6–10.
88. Ferguson NM, Cummings DAT, Fraser C, Cajka JC, Cooley PC, Burke DS. Strategies for mitigating an influenza pandemic. Nature. 2006;442:448–52.
89. Osterholm MT, Kelley NS, Sommer A, Belongia EA. Efficacy and effectiveness of influenza vaccines: A
References 221
132. Malaria vaccine: WHO position paper—January 2016. Wkly Epidemiol Rec. 2016;91:33–52.
133. Keeping children healthy: The Vaccine Alliance progress report 2015. Washington DC: Gavi; 2015.
134. Global immunization vision and strategy 2006–2015. Geneva: WHO/UNICEF; 2005.
135. Global health sector strategy on viral hepatitis 2016–2021. Geneva: WHO; 2016.
136. Prevention & control of viral hepatitis infection: A strategy for global action. Geneva: WHO; 2011.
137. Jacobsen KH, Koopman JS. Declining hepatitis A seroprevalence: A global review and analysis. Epidemiol Infect. 2004;133:1005–22.
138. Jacobsen KH, Wiersma ST. Hepatitis A virus seroprevalence by age and world region, 1990 and 2005. Vaccine. 2010;28:6653–7.
139. Guidelines for the prevention, care and treatment of persons with chronic hepatitis B infection. Geneva: WHO; 2015.
140. Hepatitis B vaccines: WHO position paper. Wkly Epidemiol Rec. 2009;84:405–19.
141. Trépo C, Chan HLY, Lok A. Hepatitis B virus infection. Lancet. 2014;384:2053–63.
142. Ott J, Stevens GA, Groeger J, Wiersma ST. Global epidemiology of hepatitis B virus infection: New estimates of age-specific HBsAg seroprevalence and endemicity. Vaccine. 2012;30:2212–9.
143. Webster DP, Klenerman P, Dusheiko GM. Hepatitis C. Lancet. 2015;385:1124–35.
144. Guidelines for the screening, care and treatment of persons with hepatitis C infection. Geneva: WHO; 2014.
145. Mohd Hanafiah K, Groeger J, Flaxman AD, Wiersma ST. Global epidemiology of hepatitis C virus infection: New estimates of age-specific antibody to HCV seroprevalence. Hepatology. 2013;57: 1333–42.
146. Kamar N, Bendall R, Legrand-Abravanel F, et al. Hepatitis E. Lancet. 2012;379:2477–88.
147. Krain LJ, Nelson KE, Labrique AB. Host immune status and response to hepatitis E virus infection. Clin Microbiol Rev. 2014;27:139–65.
148. Hoofnagle JH, Nelson KE, Purcell RH. Hepatitis E. N Engl J Med. 2012;367:1237–44.
149. McGill F, Heyderman RS, Panagiotou S, Tunkel AR, Solomon T. Acute bacterial meningitis in adults. Lancet. 2016;388:3036–47.
150. Thigpen MC, Whitney CG, Messonier NE, et al. Bacterial meningitis in the United States, 1998–2007. N Engl J Med. 2011;364:2016–25.
151. Stephens DS, Greenwood B, Brandtzaeg P. Epidemic meningitis, meningococcaemia, and Neisseria meningitidis. Lancet. 2007;369:2196–210.
108. Mumps virus vaccines: WHO position paper. Wkly Epidemiol Rec. 2007;82:51–60.
109. Rubella vaccines: WHO position paper. Wkly Epidemiol Rec. 2011;86:301–16.
110. Diphtheria vaccine: WHO position paper. Wkly Epidemiol Rec. 2006;81:24–32.
111. Tetanus vaccine: WHO position paper. Wkly Epidemiol Rec. 2006;81:198–208.
112. Pertussis vaccines: WHO position paper—August 2015. Wkly Epidemiol Rec. 2015;90:433–60.
113. Forsyth K, Plotkin S, Tan T, Wirsing von König CH. Strategies to decrease pertussis transmission to infants. Pediatrics. 2015;135:e1475–82.
114. Vaccines against influenza: WHO position paper—November 2012. Wkly Epidemiol Rec. 2012;87:461–76.
115. Haemophilus influenzae type b (Hib) vaccination position paper—July 2013. Wkly Epidemiol Rec. 2013;88:413–26.
116. Pneumococcal vaccines: WHO position paper. Wkly Epidemiol Rec. 2012;87:129–44.
117. Rotavirus vaccines: WHO position paper—January 2013. Wkly Epidemiol Rec. 2013;88:49–64.
118. Polio vaccines: WHO position paper—March 2016. Wkly Epidemiol Rec. 2016;91:145–68.
119. Cholera vaccines: WHO position paper. Wkly Epidemiol Rec. 2010;85:117–128.
120. WHO position paper on hepatitis A vaccines—June 2012. Wkly Epidemiol Rec. 2012;87:261–76.
121. Human papilloma vaccines: WHO position paper, October 2014. Wkly Epidemiol Rec. 2014;89: 465–92.
122. Japanese encephalitis vaccines: WHO position paper—February 2015. Wkly Epidemiol Rec. 2015;90:69–88.
123. Meningococcal A conjugate vaccine: Updated guidance, February 2015. Wkly Epidemiol Rec. 2015;90:57–62.
124. Rabies vaccines: WHO position paper. Wkly Epidemiol Rec. 2010;85:309–20.
125. Vaccines against tick-borne encephalitis: WHO position paper. Wkly Epidemiol Rec. 2011;86:241–56.
126. Typhoid vaccines: WHO position paper. Wkly Epidemiol Rec. 2008;83:49–59.
127. Varicella and herpes zoster vaccines: WHO position paper, June 2014. Wkly Epidemiol Rec. 2014;89:265–88.
128. Vaccines and vaccination against yellow fever: WHO position paper—June 2013. Wkly Epidemiol Rec. 2013;88:269–84.
129. Global vaccine action plan 2011–2020. Geneva: WHO; 2013.
130. Dengue vaccine: WHO position paper—July 2016. Wkly Epidemiol Rec. 2016;91:349–64.
131. Hepatitis E vaccine: WHO position paper, May 2015. Wkly Epidemiol Rec. 2015;90:185–200.
222 Chapter 9 Diarrheal, Respiratory, and Other Common Infections
152. Molesworth AM, Thomson MC, Connor SJ, et al. Where is the meningitis belt? Defining an area at risk of epidemic meningitis in Africa. Trans R Soc Trop Med Hyg. 2002;96:242–9.
153. Agier L, Martiny N, Thiongane O, et al. Towards understanding the epidemiology of Neisseria meningitidis in the African meningitis belt: A multi-disciplinary overview. Int J Infect Dis. 2017;54:103–12.
154. Lingani C, Bergeron-Caron C, Stuart JM, et al. Meningococcal meningitis surveillance in the African meningitis belt, 2004–2013. Clin Infect Dis. 2015;61(Suppl 5):S410–5.
155. Meningococcal disease control in countries of the African meningitis belt, 2014. Wkly Epidemiol Rec. 2015;90:123–31.
References 223
© Xinzheng. All Rights Reserved/Moment/Getty
CHAPTER 10
Malaria and Neglected Tropical Diseases
People who live in lower-income countries are frequently ill with malaria, intestinal worms, and a diversity of other infectious and parasitic diseases that are rare in high-income countries. These neglected tropical diseases (NTDs) maim, disable, and kill many of their victims, and they impede economic growth in affected communities and countries. Investments in controlling vectorborne diseases, treating common NTDs, supporting eradication campaigns, and containing emerging infectious diseases yield financial and security benefits for all partners.
▸ 10.1 Malaria, NTDs, and Global Health
Malaria has been the target of international public health efforts since the late 1800s, when scientists first discovered that the malaria par- asite was transmitted to humans through the bites of infected mosquitoes. Initial research and development (R&D) investments by high-income countries focused on protecting military personnel and business interests in the tropics and on eliminating domestic threats posed by malaria.1 The U.S. Centers for Disease Control and Prevention (CDC) is headquar- tered in Atlanta because the agency evolved from the national malaria control program.2 Today, a diversity of governmental, charitable, and corporate partners are involved in develop- ing and implementing control and elimination
strategies for malaria and other debilitating infections.
Most countries where malaria still occurs are places where other dreadful tropical and parasitic diseases are also common. Many of these diseases are unimaginable to the typical person living in a high-income country, includ- ing parasites that cause body parts to swell to many times their normal size or leave their victims scarred and blind; disfiguring bacte- rial and protozoal infections that eat through skin, muscle, and even bones, causing perma- nent disability; and intestinal worms that can proliferate to completely block the digestive tract. A single photograph of any of these con- ditions would likely be enough to convince most people that these diseases deserve to be added to the list of priorities for global health funding. The need for prioritization becomes even clearer after seeing the epidemiological
224
statistics showing that these conditions are far from rare. Nearly all of the 1 billion people from the world’s lowest-income households— the so-called “bottom billion”3—have at least
one of the bacterial, viral, or parasitic condi- tions that are classified by the World Health Organization (WHO) as neglected tropical diseases (FIGURE 10–1).4
Disease Pathogen Section
Dengue Virus 10.5
Chagas disease Protozoan 10.6
Human African trypanosomiasis (sleeping sickness) Protozoan 10.6
Leishmaniases Protozoan 10.7
Schistosomiasis Helminth 10.8
Lymphatic filariasis Helminth 10.9
Onchocerciasis (river blindness) Helminth 10.10
Leprosy Bacterium 10.11
Buruli ulcer Bacterium 10.11
Trachoma Bacterium 10.11
Rabies Virus 10.12
Soil-transmitted helminthiases Helminth 10.13
Taeniasis and neurocysticercosis Helminth 10.14
Echinococcosis Helminth 10.14
Yaws (and other endemic treponematoses) Bacterium 10.14
Mycetoma Bacterium/fungus 10.14
Foodborne trematodiases (clonorchiasis, opisthorchiasis, fascioliasis, and paragonimiasis)
Helminth 10.14
Dracunculiasis (guinea worm disease) Helminth 10.15
FIGURE 10–1 Neglected tropical diseases recognized by the WHO. Data from Investing to overcome the global impact of neglected tropical diseases: 3rd WHO report on neglected tropical diseases. Geneva: WHO; 2015.
10.1 Malaria, NTDs, and Global Health 225
Neglected tropical diseases (NTDs) are infectious diseases that primarily affect the poorest regions of the world and have not historically been a priority for funding agen- cies, pharmaceutical companies, or global policymakers.5 The “big three” infectious diseases—HIV, tuberculosis, and malaria— have received the bulk of global health atten- tion and financing in recent decades. The NTD designation is intended to call attention to infectious diseases that have been relatively invisible to the major players in global health even though they affect millions of people in the lowest-income countries and contribute to the cycle of poverty by causing long-term illnesses and disability.6 “Neglected” does not mean infrequent, since NTDs affect more than one in six of the world’s people. Neglected describes conditions that were overlooked, disregarded, and ignored as the field of global health emerged in the early 21st century.7
The Millennium Development Goal that called for the world to “combat HIV/ AIDS, malaria, and other diseases” (MDG 6) has been expanded in the Sustainable
Development Goals to call for commitments to “end the epidemics of AIDS, TB, malaria, and neglected tropical diseases” by 2030 and “combat hepatitis, water-borne diseases, and other communicable diseases” (SDG 3.3) ( FIGURE 10–2).8 Donors have answered this call by increasing their support for malaria and NTD control. In 2012, the London Dec- laration on Neglected Tropical Diseases, an ambitious plan to control 10 NTDs by 2020, was launched by WHO, the Bill & Melinda Gates Foundation, several multinational pharmaceutical companies, and other part- ners.9 These groups have made commitments to help reduce infection transmission in endemic areas. In 2015 alone, pharmaceutical companies donated 1.5 billion doses of NTD treatments.10 Many major drug companies are working with ministries of health and other organizations to create new NTD medica- tions through product development partner- ships like the Drugs for Neglected Diseases initiative.11 These actions to recognize and address NTDs are a sign that NTDs are no longer being neglected. However, it will take
3.3.1 Number of new HIV infections per 1000 uninfected population
3.3.2 Tuberculosis incidence per 1000 persons per year
3.3.3 Malaria incident cases per 1000 persons per year
3.3.4 Number of new hepatitis B infections per 100,000 population per year
3.3.5 Number of people requiring interventions against neglected tropical diseases
3.8.1 Coverage of tracer interventions (universal health coverage of child immunization, antiretroviral therapy, tuberculosis treatment, and other health services)
3.b.1 Proportion of the population with access to affordable medicines and vaccines on a sustainable basis
FIGURE 10–2 Examples of Sustainable Development Goals targets focused on infectious diseases. Data from United Nations Economic and Social Council. Report of the Inter-Agency and Expert Group on Sustainable Development Goal Indicators (E/CN.3/2016/2 /Rev.1). New York: UN; 2016.
226 Chapter 10 Malaria and Neglected Tropical Diseases
There are two main types of eukaryotic parasites that affect human health: protozoa and helminths. A protozoan is a single-celled organism that has animal-like characteristics and often lives in water. Malaria is one of sev- eral diseases caused by protozoa. Protozoa are classified based on how they move and on the characteristics of their life cycles. For example, amoeba use pseudopods (“false feet”) to move, flagellates have a “tail” that assists with motion, and ciliates have rows of hair-like projections that help the organisms move. A fourth cate- gory is for sporozoa, spore-forming protozoa. Some sporozoa (including the parasites that cause malaria) are apicomplexa that have com- plex life cycles involving both sexual and asex- ual reproduction.
A helminth is a multicellular endopara- sitic worm that lives inside the body of its host. (Protozoa are also endoparasitic, living inside the body. In contrast, lice and the mites that cause scabies are ectoparasitic animals that live on the exterior surface of the body.12) Some worms are microscopic, but others grow to be several inches—or even several feet—long as they mature in the human body. Helminths are classified by shape as well as by their life cycles. There are three main types of helminths: nema- todes, cestodes, and trematodes. A nematode is a cylindrically shaped roundworm. There are many types of nematodes that have humans as hosts, including filarial worms, guinea worms, hookworms, pinworms, roundworms, thread- worms, and whipworms. Both cestodes and trematodes are flatworms in the platyhelminth phylum. A cestode is a tapeworm consist- ing of a mouthpiece (scolex) and numerous segments. Most tapeworms in humans (such as Echinococcus and Taenia) prefer to live in the human digestive tract, and some types of tapeworms can grow to be many feet long. A trematode is a fluke, and most trematodes have complex life cycles that involve two differ- ent animal hosts. In humans, trematodes infect a variety of body systems. For example, there are blood flukes (such as Schistosoma), liver
continued commitments from global part- nerships to alleviate the preventable burden that malaria and NTDs impose on the world’s poorest children and families.
▸ 10.2 Parasites: Protozoa and Helminths
Many of the most burdensome tropical dis- eases, including malaria, are parasitic dis- eases. A parasite is a eukaryotic organism that survives by living in or on a host organ- ism. A eukaryote consists of a complex cell or cells that have a membrane-bound nucleus. Bacteria and viruses are not eukaryotes, but fungi, plants, and animals are. Parasites can be acquired by walking barefoot in contaminated soil, wading in contaminated water, ingesting contaminated food or water, and being bit by parasite-infested insects. Some parasites only minimally affect their hosts, but others can cause serious illnesses and disability. Antipar- asitic medications will kill many parasites, but the medicines may not be effective against all life stages of the parasites. For some parasitic infections, drug resistance means that medica- tions that previously were effective treatments no longer work.
Paramecium are protozoa that are commonly found in environmental water sources.
© Ch
ok sa
wa td
iko rn
/S hu
tte rst
oc k
10.2 Parasites: Protozoa and Helminths 227
the species of Plasmodium), the red blood cells rupture, releasing parasites and tox- ins into the bloodstream and causing fever, chills, and anemia. The cycle can continue for 10–14 days, or longer if untreated.
Malaria usually causes cyclic fevers, head- aches, joint pain, and other symptoms con- sistent with influenza-like illnesses, but it can cause organ failure and death. Although anyone can contract malaria, children and pregnant women have a higher risk of severe and fatal complications.16 One common complication is severe malarial anemia due to the destruc- tion of so many red blood cells that the body cannot adequately transport oxygen through the bloodstream.17 Another complication in children is cerebral malaria, in which the infection causes seizures and coma (impaired consciousness).18 If children survive cerebral malaria, they may have permanent brain dam- age and learning disabilities.19 Adults who have grown up in endemic areas usually have some degree of resistance to severe malaria because of past infections.20 However, susceptibility to malaria increases during pregnancy, and complications are common because pregnant women are often already anemic even before additional red blood cells are destroyed by Plas- modium.21 As a result, babies born to mothers with malaria are at increased risk of low birth- weight and other birth complications.22
People with malaria can usually be treated successfully with inexpensive antimalarial
flukes (such as Clonorchis), and lung flukes (such as Paragonimus). Some of these hel- minths have complex life cycles and undergo life stages in several different animal hosts and in the environment. An intermediate host is an animal host in which an immature parasite (a larva) develops but does not reach sexual maturity. A definitive host is the animal host in which a parasite reaches sexual maturity and reproduces.
▸ 10.3 Malaria Malaria is a parasitic infection with proto- zoa from the Plasmodium species. There are five types of Plasmodium known to cause human infection: Plasmodium falciparum, P. vivax, P. malariae, P. ovale, and P. knowlesi. Falciparum malaria is the form most likely to cause life-threatening disease.13 Nearly 90% of all malaria cases and deaths occur in sub- Saharan Africa, and nearly 99% of these cases are caused by P. falciparum. Outside of sub- Saharan Africa, about half of malaria cases are caused by P. falciparum and half by P. vivax.14
The parasites that cause malaria have a very complex life cycle that involves developmental stages in both humans and mosquitoes (FIGURE 10–3).15 Anopheles mos- quitoes need a bloodmeal in order to pro- duce and lay eggs, and a female Anopheles mosquito acquires Plasmodium infection by biting an infected human. After the malaria parasites undergo several stages of develop- ment in the gut of the mosquito, they travel to the salivary gland of the mosquito and are injected into a human during a subse- quent bloodmeal. After the parasites enter the bloodstream of the human, they move to the liver and reproduce rapidly. After sev- eral days of maturation, the parasites enter the bloodstream and invade the red blood cells that carry oxygen throughout the body. The parasites grow and divide inside the red blood cells. Every 2–3 days (depending on
FIGURE 10–3 Life cycle of the Plasmodium parasites that cause malaria.
MOSQUITO HUMAN
salivary glands
liver midgut
red blood cells
sporozoites
gametocytes stomach
blood
228 Chapter 10 Malaria and Neglected Tropical Diseases
lower than the number of cases in 2000, and the number of deaths decreased by nearly half during those 15 years (FIGURE 10–4).14 The number of deaths in children younger than 5 years old decreased from about 725,000 to 300,000, and the percentage of malaria fatali- ties who were young children decreased from 85% to about 70%.14 These improvements are attributed to expanded access to malaria pre- vention and treatment interventions.
▸ 10.4 Malaria Interventions
The only way that humans contract malaria is by being bit by an infected mosquito, and the only way that mosquitoes become infected is by biting an infected human. There are there- fore two key sets of malaria control interven- tions. One set aims to reduce the likelihood of humans being bit by infected mosquitoes. The other set uses antiparasitic medications
tablets, but malaria can cause weeks or even months of illness due to relapses and fatigue. Reinfection with malaria is common. In many tropical areas, the average child has several bouts of malaria each year. Each bout of malaria causes several days or weeks of absence from work or school and the inability to be produc- tive at home. Infection is most common during the seasons when subsistence farmers grow and harvest their crops, and when malaria (or caring for people with malaria) keeps family members from being in the fields at this cru- cial time, it can result in long-term food inse- curity for all members of the household.23 The cost of lost productivity due to malaria extends to entire countries as well. Malaria-endemic countries have lower rates of economic growth than countries without malaria.24
More than 200 million cases of malaria occurred worldwide in 2015, and about 450,000 people died from the disease.25 These numbers are large, but they represent a signif- icant improvement from the year 2000.26 The number of cases in 2015 was about one-third
FIGURE 10–4 Global malaria cases and deaths decreased significantly between 2000 and 2015. Data from World malaria report 2015. Geneva: WHO; 2015.
160
140
120
100
80
60
40
20
0
50
45
40
35
30
25
20
15
10
5
0
2000 2005 2010 2015
D ea
th r
at e
pe r
10 0,
00 0
pe op
le a
t ris
k of
m al
ar ia
In ci
de nc
e pe
r 10
00 p
eo pl
e at
ris k
of m
al ar
ia
Axis Title
Cases Deaths
10.4 Malaria Interventions 229
small drop of blood within 15–30 minutes.30 If an RDT is positive for malaria, ACT can be prescribed. Prompt treatment of confirmed malaria reduces the likelihood of severe dis- ease and death. If an RDT is negative for malaria, the febrile individual can be referred for additional clinical laboratory testing to determine the actual cause of the illness so that appropriate treatment can be prescribed.
Intermittent preventive treatment (IPT) is the use of “preventive chemotherapy” with antimalarial medications in vulnera- ble people so that they maintain therapeutic drug levels in their blood during times of high risk for malaria. IPT in pregnancy (IPTp) is the routine distribution of antimalarial medications to all pregnant women who live in malaria-endemic countries, even if the women do not have symptoms of malaria at the time of treatment.31 IPTp medications are typically dispensed at two to four antenatal care visits during the second and third trimes- ters of pregnancy.32 Presumptive treatment for malaria with IPTp is effective at increasing the average birthweight and survival rates of babies born to women in endemic areas who receive the recommended doses.33 In very high-transmission areas, IPT of infants (IPTi) may also be a cost-effective intervention for reducing the burden from malaria.34
Although travelers from nonendemic areas to places where malaria is endemic generally take prophylactic (preventive) anti- malarial drugs, these are not fully effective in preventing the disease. More importantly, it is not realistic or healthy to encourage prophy- lactic use among people who live in highly endemic areas. The financial cost would be high, long-term drug use could be detri- mental to users’ health, and the widespread use of antiparasitic agents would contribute to the development of more drug-resistant Plasmodium at a time when many species are no longer susceptible to existing antimalarial medications.
Because the mosquitoes that spread malaria bite primarily at dawn and dusk, one of
to treat people who have malaria in order to reduce the risk of mosquitoes contracting malaria from humans. Both types of inter- ventions interrupt the mosquito–human– mosquito transmission cycle.
For decades, the drug of choice for treating malaria was chloroquine, but in most parts of the world, the common strains of malaria have become chloroquine-resistant and the medica- tion is no longer effective. Strains of malaria are also becoming resistant to other pharma- ceutical treatments, such as sulfadoxone/pyri- methamine (SP).27 Widespread drug resistance means that there are few antimalarial medica- tions that work today, and the complexity of the organisms that cause malaria makes it scientif- ically challenging to develop new therapeutic agents.28 Malaria control experts strongly urge the use of artemisinin-based combination therapy (ACT) that combines at least two dif- ferent antimalarial drugs (such as artemether plus lumefantrine or artesunate plus meflo- quine), one of which is an artemisinin-based agent, because combination medications slow the emergence of drug resistance.29
Another component of successful malaria control programs is prescribing antimalarial medications only to people with laboratory - confirmed malaria (with just a few exceptions that have proven to be safe and cost-effective). A rapid diagnostic test (RDT) can detect the presence of a pathogen (or markers for a pathogen, such as the presence of specific antigens produced by malaria parasites) in a
Rapid diagnostic test.
Co ur
te sy
of U
SA ID
230 Chapter 10 Malaria and Neglected Tropical Diseases
the members of the genus of mosquitoes that spread malaria, deposit their eggs in rela- tively still but well-oxygenated water, so any places where water collects (like ponds, lakes, and puddles) can serve as mosquito habitats, especially during rainy seasons. Environmen- tal changes related to road building, mining, logging, agriculture, and irrigation may also create breeding sites, further increasing the mosquito population.40 These factors can make the environmental control of insect pop- ulations through land and water management or the widespread application of outdoor pes- ticides prohibitively expensive.
Until the middle of the 20th century, malaria was endemic across much of the globe, with cases reported as far north as Canada and Siberia. The Global Malaria Eradication Pro- gramme that was implemented between 1955
the most effective ways to prevent new malaria infections is the use of an insecticide-treated net (ITN), a mesh sheet dipped in insecticides and then hung over a bed so that it provides a barrier between sleeping humans and mosqui- toes while also killing any mosquitoes that land on it. Most ITNs need to be re-dipped in a pyre- throid insecticide every 6 months or so in order to maintain their effectiveness. A long-lasting insecticidal net (LLIN) is an ITN that has been impregnated with a pesticide that remains effective for 2 years or longer before requiring retreatment.35 ITNs significantly reduce child mortality in malaria- endemic areas when they are used consistently.36 It is also important for malaria patients to stay under a bednet so mos- quitoes cannot bite them and become carriers of malaria. Since many adults who have grown up in malaria-endemic areas continue to have parasitemia (parasites in the blood) even when they are asymptomatic,37 it is advisable for all children and adults who live in at-risk areas to consistently use ITNs. While many res- idents of households in regions where malaria is common still do not have ITNs or do not use them every night, the proportion of young chil- dren in sub-Saharan Africa who sleep under an ITN increased significantly after the year 2000 ( FIGURE 10–5).14 About two-thirds of the reduc- tion in malaria cases between 2000 and 2015 is attributed to the scaled-up use of ITNs.38
Other barrier methods for insect bite protection include wearing clothes that cover the arms and legs during the times of the day when mosquitoes are most likely to bite and having screens or curtains cover the windows and doors of houses when it is possible to do this. Insect repellents like bug sprays, espe- cially those that contain DEET (N,N-diethyl- m- toluamide), can also be helpful when they are affordable and are used appropriately.39
Malaria control efforts also aim to reduce the risk of mosquito bites by limiting the number of mosquitoes that live in proximity to human populations. Most cases of malaria occur in the tropics, where mosquitoes sur- vive year-round. Anopheles mosquitoes,
FIGURE 10–5 The percentage of under-5 children in sub-Saharan Africa who sleep under an ITN has increased rapidly. Data from World malaria report 2015. Geneva: WHO; 2015.
% of households with at least one ITN % of the population sleeping under an ITN
% of children ages 6 to 59 months with malaria parasites
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2000 2005 2010 2015
10.4 Malaria Interventions 231
correctly, to preventing millions of malaria deaths.47 Although still controversial, the policy changes that have enabled the reintroduction of DDT for home protection may end up being an example of how people with different views on the risks and benefits of an environmental inter- vention can find a middle ground that is accept- able to most parties involved.
While individuals and households bear much of the responsibility for implementing malaria control strategies, they are supported by national and global initiatives to develop, promote, and finance strategies for malaria prevention, diagnosis, treatment, and con- trol.48 For example, the Roll Back Malaria Partnership brings together the WHO, UNICEF, other multilateral organizations, national governments from malaria-endemic countries and donor countries, research- ers, and representatives from foundations, nongovernmental organizations, academia, and the private sector in order to increase and sustain access to effective prevention and treatment technologies.49 Other partnerships, such as the Medicines for Malaria Venture and the Malaria Vaccine Initiative, are focused on creating new preventive, diagnostic, and treat- ment tools.50 Several vaccine candidates are in development.51 Nonprofit organizations and advocacy groups like Malaria No More allow individual donors to contribute to malaria control efforts.52 Continued financial, scien- tific, and social support for malaria elimina- tion efforts will be necessary to reach the SDG goal of ending malaria by 2030.53
and 1969 was a massive WHO-led insecticide spraying program that eliminated malaria from dozens of countries.41 One contributor to this success was the spraying of DDT (dichloro- diphenyl- trichloroethane) in large quanti- ties over cities and crops to kill mosquitoes.42 DDT does not easily degrade. It is a persistent organic pollutant (POP) that builds up in the food chain, eventually killing some types of birds and fish. The United States banned DDT in 1972 (in large part because of the uproar caused by Rachel Carson’s book Silent Spring, which had been published in 1962), and many other countries across the income spectrum also enacted DDT bans.43 DDT bans led to a drastic increase in the incidence of malaria in many countries.44 In 2001, a global treaty spon- sored by the UN Environment Programme (UNEP) and many private environmental organizations banned 11 other POPs, but the treaty made a special exemption for the indoor use of DDT for public health purposes.45 Use of the chemical is now limited but not banned.
Since the reversal of the DDT ban, many communities in malaria-endemic areas have begun using DDT in homes. Indoor residual spraying (IRS) is the application of long-lasting insecticides to walls and other surfaces where mosquitoes might rest. When mosquitoes land on IRS-treated surfaces any time during the 6 months (or longer) after IRS has been applied, they absorb a lethal dose of the insecticidal chem- ical.46 The environmental persistence that makes DDT a hazard when it is sprayed outdoors makes it appealing for in-home use as an insecticide. DDT sticks to the walls so that the pesticide only needs to be applied once or twice a year, and small amounts of DDT seem to be harmless to humans and household animals. DDT is also cheaper and more effective than most other pesticides.
DDT and other insecticides used for IRS only protect people from bites while they are indoors, and some mosquitoes are resistant to the effects of these chemicals. Still, the WHO now endorses the use of IRS for mosquito control in areas that have endemic or epidemic malaria transmission, and DDT could contribute, if used ©
M r.P
or ns
at id/
Sh ut
te rst
oc k
232 Chapter 10 Malaria and Neglected Tropical Diseases
FIGURE 10–6 Examples of bacterial and parasitic vectorborne diseases.
Disease Name of Pathogen Type of Pathogen Primary Vector (Genus)
African trypanosomiasis (sleeping sickness)
Trypanosoma brucei Protozoan (flagellate) Tsetse flies (Glossina)
Chagas disease Trypanosoma cruzi Protozoan (flagellate) Reduviid bugs (Triatominae)
Leishmaniasis Leishmania Protozoan (flagellate) Sandflies (Lutzomyia and Phlebotomus)
Loiasis (African eyeworm)
Loa loa Helminth (filarial nematode)
Deer flies (Chrysops)
Lyme disease (borreliosis) Borrelia burgdorferi Bacterium Ticks (Ixodes)
Lymphatic filariasis Wuchereria bancrofti, Brugia malayi, Brugia timori
Helminth (filarial nematode)
Mosquitoes (Culex)
Malaria Plasmodium Protozoan (sporozoan) Mosquitoes (Anopheles)
Onchocerciasis (river blindness)
Onchocerca volvulus Helminth (filarial nematode)
Blackflies (Simulium)
Plague Yersinia pestis Bacterium Fleas (Xenopsylla)
Rocky Mountain spotted fever
Rickettsia rickettsii Bacterium (rickettsia) Ticks (Dermacentor)
Tularemia Francisella tularensis Bacterium Ticks
Typhus fever Rickettsia prowazekii Bacterium (rickettsia) Body lice (Pediculus)
compound eyes, and two body sections: a cephalothorax and an abdomen.) The cycle of infection describes how an infectious agent passes between different species. Some infec- tions have a human–human–human cycle (like measles and sexually transmitted infec- tions). Some have a vertebrate– vertebrate– vertebrate cycle and only occasionally affect humans (like rabies). A vectorborne infec- tion has a human–arthropod–human cycle (or an animal– arthropod–animal cycle that occasionally affects a human). A wide variety of vectors can transmit infectious agents to humans (FIGURE 10–6).
▸ 10.5 Dengue and Other Arboviruses
Malaria is just one of many infections that are transmitted to humans by the bites of infected mosquitoes. A vectorborne infection is one that is transmitted to humans via an arthropod, such as an insect (like a mosquito, fly, or flea) or an arachnid (like a tick, louse, or mite). (An insect has six legs, an external cover- ing made of chitin, a pair of antennae, and three body sections: a head, thorax, and abdomen. An arachnid has eight legs, an exoskeleton,
10.5 Dengue and Other Arboviruses 233
A virus transmitted to humans by an arthropod is called an arbovirus, short for arthropod-borne virus. The pathogens that have recently caused large outbreaks of den- gue fever, yellow fever, and Zika virus infec- tions are arboviruses spread by mosquitoes. Some less common arborviruses, like the ones that cause Crimean-Congo hemorrhagic fever and tick-borne encephalitis, are spread by ticks ( FIGURE 10–7). All arboviruses are viral infections. Bacterial and parasitic infections, like malaria, are not arboviruses because they are not viral.
Dengue fever is an arbovirus spread by the bites of infected Aedes mosquitoes, a genus of mosquito that thrives in urban areas. There are four distinct serotypes of dengue virus.54 Infection with any one strain confers protection against future infections with that strain, but it does not protect against the other three dengue virus strains. Infection with a first strain is often asymptomatic, but it may cause a high fever, a severe headache, and pain in the eyes, joints, muscles, and bones. Infec- tion with a second strain can lead to dengue
FIGURE 10–7 Examples of arboviral diseases.
Disease Viral Family Primary Vector (Genus)
Chikungunya Togavirus Mosquitoes (Aedes)
Crimean-Congo hemorrhagic fever (CCHF) Bunyavirus Ticks (Hyalomma)
Dengue fever Flavivirus Mosquitoes (Aedes)
Japanese encephalitis (JE) Flavivirus Mosquitoes (Culex)
Rift Valley fever (RVF) Bunyavirus Mosquitoes (Aedes)
Tick-borne encephalitis (TBE) Flavivirus Ticks (Ixodes)
West Nile (WN) Flavivirus Mosquitoes (Culex)
Yellow fever Flavivirus Mosquitoes (Aedes)
Zika Flavivirus Mosquitoes (Aedes)
hemorrhagic fever and dengue shock syn- drome.55 About 100 million people become ill from dengue virus infections each year, and many more have asymptomatic infections. The heaviest burdens are in South Asia, South- east Asia, tropical South America, and some parts of tropical sub-Saharan Africa.56 The geographic range of places where dengue is endemic has expanded significantly over the past several decades.57 The countries already experiencing or at risk of dengue infection include Brazil, Nigeria, Ethiopia, and India as well as parts of the southern United States and southeastern China. Developing a tetrava- lent vaccine that is effective against all four serotypes has proven to be a major scientific challenge.58 However, a dengue vaccine was licensed for the first time at the end of 2015, and there is hope that an effective tetravalent vaccine may soon be widely available for use as a preventive intervention.59
Yellow fever is a disease named for the jaundice that turns the skin and eyes of vic- tims a bright yellow hue. About 1 in 20 people
234 Chapter 10 Malaria and Neglected Tropical Diseases
Zika virus spread to the Americas for the first time and an outbreak in Brazil was linked to a possible increase in the incidence of microcephaly in babies born to women who had been infected with Zika virus.64 Microcephaly is an abnormally small head that is a sign of aberrant brain development. Concerns about Zika were exacerbated by the discovery that Zika virus could be trans- mitted not only through the bites of infected mosquitoes but also through sexual contact.65
West Nile virus is spread by Culex mosquitoes, and it typically cycles between mosquitoes and birds but occasionally affects humans.66 Most people who become infected with West Nile virus have no symptoms or only mild symptoms, but a small percentage (<1%) develop severe neurologic complications.67 West Nile virus was first identified in Africa, but outbreaks have occurred in many world regions. After the virus started circulating in the New York City metropolitan area in 1999,68 the infection quickly spread across the conti- nental United States.69 Japanese encephalitis virus is closely related to West Nile virus. Like West Nile virus, most people who contract Jap- anese encephalitis virus are asymptomatic but a small proportion become seriously ill or die. Outbreaks of Japanese encephalitis occur regularly in Asia and Oceania even though the infection is vaccine-preventable.70
The dengue, yellow fever, Zika, West Nile, and Japanese encephalitis viruses are all in the flavivirus genus of the flavivirus family, but disease-causing viruses from other viral
who contract the yellow fever virus die from it, usually as a result of hemorrhagic fever.60 Epidemics of yellow fever occur primarily in tropical areas in South America and Africa, where the Aedes mosquitoes that transmit the yellow fever virus are common, but outbreaks have occurred in other regions.61 Yellow fever is vaccine-preventable, and the global infec- tious disease control protocols spelled out in the International Health Regulations often mandate vaccination for travelers to and from places where outbreaks are occurring.62
Until recently, infection with Zika virus was considered to be such an inconsequen- tial threat to human health that it was rarely tested for and only a few research papers had been published about it.63 That percep- tion changed dramatically in 2015, when
Aedes mosquito larva in water.
Aedes aegypti mosquito, the most common vector for dengue fever.
© m
rfi za
/S hu
tte rst
oc k
© Am
ir R idh
wa n/
Sh ut
te rst
oc k
CD C/
Pr of
. F ra
nk H
ad ley
Co lli
ns , D
ir. , C
nt r. f
or G
lo ba
l H ea
lth an
d In
fe cti
ou s D
ise as
es , U
ni v.
of N
ot re
D am
e/ Ja
m es
G at
ha ny
10.5 Dengue and Other Arboviruses 235
families are also spread by insects. For exam- ple, Rift Valley fever virus is in the phlebovirus genus of the bunyavirus family, and chikun- gunya virus is in the alphavirus genus of the togavirus family. Rift Valley fever is a zoono- sis that can cause outbreaks of pregnancy loss in livestock herds. Most humans who contract Rift Valley fever virus have a mild infection, but a small percentage develop vision loss, meningoencephalitis, or hemorrhagic fever.71 Chikungunya fever is notable because it can cause long-term disability. Most people with chikungunya virus infections suffer from weeks of severe pain in the joints of their arms and legs, but for some people the arthralgia and arthritis persist for months or even years.72
Vectorborne diseases can be at least par- tially contained through vector control inter- ventions that reduce the size and density of arthropod populations. Vector control is typ- ically achieved using insecticides and environ- mental modifications that limit the availability of insect breeding grounds. For example, com- munity prevention efforts for dengue fever often focus on eliminating the standing water where the Aedes mosquitoes that transmit the virus breed.73 Any small body of standing water, such as the water that collects in old cans and discarded tires, can become a breeding ground. One household that does not clean up its yard can put a whole neighborhood at risk, so all residents in a community must be involved in dengue prevention projects. Control of ani- mal populations and waste management that keeps rodents and other mammals away from humans can help to control the spread of other types of vectorborne infections that are trans- mitted by arthropods that live on mammals.
▸ 10.6 Chagas Disease and Trypanosomiasis
Two of the NTDs recognized by the WHO and partner groups are caused by protozoa from the trypanosoma genus: Chagas disease and
trypanosomiasis. Chagas disease, sometimes called American sleeping sickness, is an infec- tion with Trypanosoma cruzi parasites that are spread by triatomines (also called reduviids, cone-nosed bugs, or “kissing bugs”) that live in the cracks of walls and roofs of low- quality houses in Central and South America. The insects emerge at night to take bloodmeals from sleeping people. The feces of infected insects contain T. cruzi protozoa that can enter the human bloodstream through the wound left after the bloodmeal. Within a few days, a sore may develop at the site of the bite. This wound is often near the eye, where it may cause Romaña’s sign, a swollen eyelid characteristic of acute Chagas disease.74 About 20% to 30% of people who are infected with T. cruzi develop a chronic infection that over several decades causes severe damage to the heart (Chagas cardiomyopathy), digestive tract (gastrointestinal Chagas), or both.75 Chagas- associated heart disease causes chronic heart failure and can induce fatal arrhythmias.76 Vector control programs, screen- ing of blood donors, and treatment with antipar- asitic medications have reduced the incidence of new infections, but millions of people are already living with the damage caused by long- term infection.74 Because many of those adults are people who have migrated to other countries and now live in North America, Europe, Japan, Australia, and other locations,77 the need for improved Chagas disease care is a global one.
Human African trypanosomiasis (HAT), commonly called African sleeping sickness, is an infection with Trypanosoma brucei, which is transmitted to animals and humans by the bites of infected tsetse flies (biting flies from the Glossina genus).78 Two subspecies of the protozoan can cause human disease. T. b. rhodesiense is found in eastern and southern Africa, and it is primarily a zoonotic infection that affects cattle and other mammals. ( Animal African trypanosomiasis is sometimes called nagana.) Few human infections with T. b. rhod- esiense have been diagnosed in recent years.78 T. b. gambiense is found in western and central Africa, and it is primarily a human disease that
236 Chapter 10 Malaria and Neglected Tropical Diseases
The parasites are transmitted to humans by female phlebotomine sandflies that need blood from a mammal in order to develop their eggs. Leishmaniasis occurs across parts of Asia (including India and China), North Africa and the Middle East (including Iran), Africa (includ- ing Ethiopia), and South America (including Brazil).81 There are two common presentations of leishmaniasis disease. Cutaneous leishman- iasis causes lesions that can lead to permanent disfigurement, but they are not a life-threatening infection because they can be treated with wound care methods and antibiotics. Each year, about 700,000 to 1.2 million people develop cutane- ous leishmaniasis.82 Visceral leishmaniasis, also known as kala-azar, causes chronic fevers, weight loss, anemia, and swelling of the spleen and liver. People who are diagnosed as having visceral leishmaniasis are typically treated with combination antibiotic therapy.83 Without treat- ment, visceral leishmaniasis is fatal within a few years. Each year, about 200,000–400,000 peo- ple develop visceral leishmaniasis, and about 20,000–40,000 people die from the disease.82 Prevention and control strategies must be tar- geted to the particular types of Leishmania that are causing the disease in each affected country.83
▸ 10.8 Schistosomiasis Schistosoma are trematodes that cycle between snails and humans.84 Snails are the intermediate host for Schistosoma, which means that snails
affects rural populations. Infected people expe- rience chronic fevers and headaches in an ini- tial hemolymphatic stage, and then the disease progresses to a meningoencephalitic stage that leads to coma and death if not treated. Without treatment, HAT is fatal within a few weeks or months for T. b. rhodesiense and about 3 years for T. b. gambiense.79 The available treatments have limited efficacy, and they are often toxic, causing pain and dangerous side effects.80 Although fewer than 20,000 cases of HAT are thought to occur each year, HAT is an import- ant public health concern in affected regions because of the high case fatality rate.78
▸ 10.7 Leishmaniasis Leishmaniasis is an infection with protozoa from various species of the Leishmania genus.
A phlebotomine sand fly, the vector for lieshmaniasis.
CD C/
Dr . M
ae M
elv in
Er wi
n H ue
bn er,
U niv
er sit
y O f M
an ito
ba , W
inn ipe
g, Ca
na da
A triatomine (kissing bug), the vector for Chagas disease.
Trypanosoma brucei in blood.
CD C/
Fra nk
Co llin
s/J am
es G
at ha
ny
10.8 Schistosomiasis 237
More than 230 million people worldwide are thought to have schistosomiasis.85 An effective medication called praziquantel kills the parasites, but people who are treated for schistosomiasis are immediately susceptible to new infection when they come into contact with contaminated water. Each host in the cycle of infection must be considered for inclusion in an infection control plan. Molluscicides are sometimes used to kill the snails that live in infested waters, but snails will eventually move back into the waters, and new snail habitats are created when dams and irrigation systems are built. The prevalence of schistosomiasis increased significantly when the Aswan Dam was built on the Nile River in Egypt, when dams were built on the Senegal and Volta Rivers and in other locations in West Africa, and when small dams and irrigation projects have been introduced into villages in many parts of the world.87 A comprehensive control plan includes snail control, treatment of existing cases with praziquantel, a community-wide sanitation program, and health education to encourage consistent use of toilets.88
▸ 10.9 Lymphatic Filariasis
Lymphatic filariasis (LF) is an infection with one of three types of filarial nematodes: Wuchereria bancrofti, Brugia malayi, and B. timori.89 All three types of roundworms are
are hosts to immature parasites. Humans are the definitive host in which the parasites reach sexual maturity. Humans become infected by wading in water infested with parasite-infected snails while fishing, washing clothes, bathing, or doing other activities. Immature schistosomes are called cer- cariae, the name for the free- swimming larvae of trematodes. Schistosome cercariae penetrate through human skin, enter the blood supply, and then eventually travel to the veins of the intes- tines or bladder, where male–female pairs lay thousands of eggs. Some of those eggs become trapped in nearby tissues, where they trigger an inflammatory response that causes scarring. Some of the eggs pass through the abdominal tis- sues and enter the bladder or intestines. Infected humans who urinate or defecate in fresh water release those eggs into the environment, where the eggs hatch and release larvae called miracid- iae. The larvae penetrate snails that live in the water, and within the snails, the miracidiae mature and produce cercariae. When cercariae leave the snails, they seek out a new human host and restart the cycle of infection.
Schistosomiasis, sometimes called bil- harzia, is the disease caused by Schistosoma blood flukes. There are several different kinds of schistosomiasis.85 S. haematobium occurs primarily in parts of Africa and the Middle East, and it causes urogenital schis- tosomiasis. Urogenital schistosomiasis insti- gates bloody urine (hematuria) and anemia in its early stages. If untreated, the resulting fibrous scarring of the bladder can lead to bladder cancer.86 Chronic infection can also cause kidney damage. S. mansoni, which occurs in parts of South America and the Caribbean as well as in Africa and the Middle East, and S. japonicum, which occurs primar- ily in Asia, both cause intestinal schistoso- miasis. Intestinal schistosomiasis induces abdominal pain, diarrhea, and bloody stool, and it can also cause enlargement of the liver and spleen (hepatosplenomegaly). In each species, the worms infect both snails and humans, and the parasites cycles between these two species.
CD C/
Dr . D
.S. M
ar tin
Coupled male and female Schistosoma mansoni parasites.
238 Chapter 10 Malaria and Neglected Tropical Diseases
Mass drug administration (MDA), also called preventive chemotherapy, is the distribution of safe medications to large population groups at regular time intervals as part of strategies for preventing and controlling infectious diseases. The main scientific limitation of MDA is that for most infections, the recipients are almost immediately susceptible to reinfection. To be effective, MDA must be repeated in endemic areas and must be accompanied by health edu- cation and environmental health programs.
GPELF and its partners were successful in limiting the number of people with circulating microfilariae in 2015 to about one-third the number in 2000.92 That reduction represents significant progress toward elimination. How- ever, there are still nearly 1 billion people living in endemic areas in South America (includ- ing Brazil), the Caribbean, Africa (including both Ethiopia and Nigeria), South and South- east Asia (including India), and Oceania who remain at risk of contracting the worms that cause lymphatic filariasis.90
▸ 10.10 Onchocerciasis Onchocerciasis, also known as river blindness, is caused by a filarial helminth called Oncho- cerca volvulus that is transmitted to humans by the bites of infected black flies (from the Simulium genus).89 Adult worms form nodules in the subcutaneous tissue under the skin and release microfilariae into surrounding tissues. This causes a skin rash and intense itching, and it may also change the skin appearance, such as causing depigmentation of skin on the shins (a condition colloquially called leopard skin). If the microfilariae enter the eyes, they can scar the corneas and cause the host to become blind.
Preventive chemotherapy with an anti- parasitic medication called ivermectin is used to kill microfilariae in people who live in onchocerciasis-endemic areas. Ivermectin is typ- ically distributed to entire communities once or twice a year. MDA for onchocerciasis has been used since the 1970s by a variety of national,
transmitted by mosquitoes, and a diversity of mosquitoes can serve as vectors. Mosquitoes become infected by taking blood meals from humans who have immature nematode larvae, called microfilariae, circulating in their blood. After the larvae mature within the mosquito, they can be deposited in the skin of humans who are bitten during subsequent blood meals. The larvae mature into adults within the human lymph system. If the worms block the flow of lymph (tissue fluid), it can cause lymphedema, the swelling of body parts, usually the legs, due to retained lymph fluid in the tissues. Chronic lymphedema and poor hygiene can cause the skin of affected limbs to thicken and develop a coarse texture similar to that of an elephant’s leg, a condition called elephantiasis. Males with lymphatic filariasis may also develop lymphedema of the scrotum, a condition called hydrocele. In 2015, more than 1 million peo- ple were living with LF- associated lymphedema and more than 500,000 men had hydrocele.90
Elephantiasis and hydrocele may cause permanent disfigurement and disability, and antihelminthic medications are ineffective in killing adult worms.91 However, medications can kill microfilariae in the blood. Treatment of infected people is important for interrupting the cycle of infection by preventing new infections in mosquitoes. The WHO Global Programme to Eliminate Lymphatic Filariasis (GPELF) was launched in 2000, and it uses widespread distribution of antihelminthic medications in endemic places to reduce transmission rates.92
Elephantiasis caused by lymphatic filariasis.
CD C/
Am an
da M
oo re,
M T;
To dd
Pa rke
r, P hD
; A ud
ra M
ar sh
10.10 Onchocerciasis 239
not been public health priorities are receiving new attention because of their designation as NTDs. Leprosy, also called Hansen’s disease, was first described as a disease in ancient times, and it still exists.96 Leprosy is the dis- ease caused by Mycobacterium leprae infec- tion. Chronic infection causes skin lesions, and about one in three people with leprosy suffer nerve damage.97 When people have numb hands and feet, it is easy for them to accidentally burn or otherwise injure them- selves. Those injuries may become infected, and those secondary bacterial infections may cause amputation of the digits. More than 200,000 cases of leprosy are diagnosed every year, including more than 125,000 cases in India, 30,000 cases in Brazil, 4,000 cases in Ethiopia, and 3,000 cases in Nigeria.4 His- torically, leprosy was a disfiguring disease that caused its victims to be ostracized from their communities. Today, the infection can
regional, and global elimination initiatives.93 In the Americas, onchocerciasis control efforts were so successful that by 2015 the disease was occurring in only a small rural area at the border between Brazil and Venezuela.94 In sub-Saharan Africa, many countries were close to completely eliminating river blindness by 2015 and others were on track to achieve this goal within several years.95 However, about 185 million people still required MDA for onchocerciasis in 2015 (includ- ing people living in Ethiopia and Nigeria).94
▸ 10.11 Leprosy, Buruli Ulcer, and Trachoma
Several bacterial diseases that have been rec- ognized as problems for a long time but have
© W
HO /T
DR /A
nd y C
ra gg
s
A community health center staff member shows vil- lage health workers how to use a stick to determine the right dosage for ivermectin, the drug used for onchocerciasis. The colors are related to size based on height. Each color signifies a different dosage.
Statue of an adult blinded by onchocerciasis (river blindness) and guided by a child.
© W
HO /C
hr ist
op he
r B lac
k
240 Chapter 10 Malaria and Neglected Tropical Diseases
2 million in Brazil), more than 3 million peo- ple had an urgent need for surgery to prevent blindness, and nearly 2 million people were blind or seriously visually impaired as a result of trachoma.103 A global alliance estimated that it would cost about $1 billion to eliminate tra- choma as a public health problem by 2020.103
▸ 10.12 Rabies Rabies is an extremely virulent infection of the central nervous system caused by a virus in the lyssavirus genus of the rhabdovirus family. Humans contract the rabies virus when they are bitten by infected animals that are shedding the virus in their saliva. Rabies disease presents as either furious rabies, which is characterized by psychosis and cardiac arrest, or as paralytic rabies, which progresses through stages of ascending paralysis, coma, and death. No one who is bitten by a rabid animal survives without post-bite vaccination, a type of post-exposure prophylaxis (PEP). Each year, more than 10 million people receive rabies PEP within a few days after an animal attack, and this pre- vents hundreds of thousands of deaths.104 Most of the 60,000 rabies deaths worldwide each year occur in low-income countries in Africa and Asia where access to PEP is limited.105 These deaths are considered to be 100% preventable.
Rabies can occur in any mammal, includ- ing bats, and the rabies virus circulates in wild animal populations on every continent except
be treated with long-term courses of multiple types of antibiotics.98
Buruli ulcer, also called Mycobacterium ulcerans infection, causes necrotizing cutane- ous lesions. The wound is often painless even if it is a large ulcer. Advanced cases may prog- ress to osteomyelitis, contractures, and even amputation. The mode of transmission for the bacterium has not yet been confirmed, which makes the development of a prevention strategy impossible.99 Early infection can be treated with wound care and antibiotics, but later stages of the disease require surgery to remove dead tissue, cover open wounds, and correct deformities.100
Trachoma is an eye infection with the bac- terium Chlamydia trachomatis that can lead to blindness.101 The bacteria are spread between people by person-to-person contact, shared clothes, and flies. Chronic infections scar the inside of the eyelid, and the inward turning of the eyelids (a condition called trichiasis) causes the eyelashes to scratch the eyeball and scar the cornea. Trachoma is a direct result of poor facial hygiene, and face washing is a core part of the WHO-recommended trachoma control plan called the SAFE strategy: Surgery to treat trichiasis, Antibiotics to kill the bacteria, Facial cleanliness encouraged by hygiene edu- cation, and Environmental improvements to ensure reliable access to water and sanitation.102 In 2015, about 200 million people lived in places where trachoma is still endemic (includ- ing 75 million people in Ethiopia, 20 million people in Nigeria, tens of millions in India, and
Amputations due to leprosy. Dogs can spread rabies.
© N
iko m
M ae
lao Pr
od uc
tio n/
Sh ut
te rst
oc k
© Vi
cto ria
An to
no va
/S hu
tte rst
oc k
10.12 Rabies 241
The parasites are also associated with stunted growth, low energy levels, reduced cogni- tive performance, school absences, and other adverse health and development outcomes.111 The three most common STHs in humans are ascariasis, trichuriasis, and hookworm. Threadworm (Strongyloides stercoralis), pin- worm (Enterobius vermicularis), and toxoca- riasis (Toxocara species) are also prevalent in humans.112
Ascariasis is the most common helminth infection in the world, and it occurs after a person swallows eggs from Ascaris lumbri- coides. Ingested larvae hatch in the small intes- tine, penetrate the intestinal wall, and travel through the blood to the lungs, where they may be coughed up and swallowed and then develop into mature, egg-producing worms in the small intestine. Adult worms in the intestine grow, on average, to about a foot (30 centimeters) in length, and eggs passed in the stool may lead to infection in others if open defecation is practiced. Children with asca- riasis can host hundreds of intestinal worms. That can cause distension of the abdomen, and it sometimes leads to obstruction of the intestines and subsequent peritonitis. More than 800 million people worldwide have ascariasis.113
Trichuriasis, also known as whipworm, occurs when Trichuris trichiura are residing in the large intestine. When the eggs that cause trichuriasis are swallowed, the eggs hatch in the small intestine. The released larvae mature in the colon into adults that are about 1.5 inches (4 centimeters) long. Trichuriasis can cause chronic digestive system symptoms associated with colitis, including bloody diarrhea (dysen- tery) and rectal prolapse. About 460 million people worldwide have whipworm.113
Hookworm, an infection caused by Neca- tor americanus and Ancylostoma duodenale, is most often acquired by walking barefoot through contaminated soil. After the larvae penetrate human skin and pass through the bloodstream, heart, and lungs, they migrate to the gut, latch onto the wall of the small
Antarctica. Dogs are responsible for about 95% of human rabies cases, because dogs usually live in proximity to people.106 Vac- cinating pets is a key component of disease control strategies.107 Pre-exposure prophylaxis of humans is recommended for veterinarians, animal handlers, and others who know they will have occupational exposure to animals that might have rabies.108 Rabies cannot be eradicated because it circulates in wild animal populations. However, it is possible to prevent all human rabies deaths through expanded use of dog vaccinations, education promoting responsible pet ownership and bite preven- tion, and universal access to post-bite rabies treatment for humans.109
▸ 10.13 Soil-Transmitted Helminths
A soil-transmitted helminth (STH), also called a geohelminth, is a nematode infec- tion contracted through contact with soil mixed with feces that contain worm eggs.110 A reservoir is the environmental home for an infectious agent. Some agents have an environmental reservoir and live in soil or water. STHs have a soil reservoir. Once the worms are inside a human host, most STHs are intestinal parasites. They increase the risk of malnutrition because nutrients from food go to the worms instead of the human host.
Ascariasis lumbricoides passed from the intestines of a young child.
CD C/
He nr
y B ish
op /Ja
m es
G at
ha ny
242 Chapter 10 Malaria and Neglected Tropical Diseases
less than $1 per person per year in endemic areas when the drugs are distributed as part of an integrated control program.116 However, even though the treatment is inexpensive on a per capita level, the total cost to include mil- lions of people in MDA programs is greater than the health systems in many lower- income countries can afford. As of 2015, about 1.7 billion people lived in places where MDA programs for schistosomiasis, lymphatic fil- ariasis, onchocerciasis (river blindness), and soil-transmitted helminths would be benefi- cial (FIGURE 10–8).117 About 850 million peo- ple received preventive chemotherapy for one or more of those four NTDs in 2015, so about half of the global need for MDA was met ( FIGURE 10–9).117 In addition to MDA, community sanitation is helpful for reducing the disease burden from STHs because fewer helminth eggs will be in the soil if everyone consistently uses a toilet. However, sanita- tion facilities do not remove the eggs that are passed into the environment by infected live- stock and other animals.
intestine, and mature into adults that are about 0.4 inches (1 centimeter) long. Because they are attached to the intestinal wall, hook- worms cause the host to constantly lose small amounts of blood. This blood loss significantly increases the risk of anemia, especially in chil- dren and pregnant women. Globally, about 440 million children and adults have hookworm infection,113 and about 90 million people have hookworm-associated anemia.114
Deworming medications are effective for treating all three of these STH infections, but re-infection can occur quickly when eggs from the worms remain in the local environ- ment. Preventive chemotherapy, typically dis- tributed to schoolchildren in endemic areas once or twice per year, is the primary cur- rent approach to STH prevention and con- trol.115 The concurrent distribution of four medications— praziquantel for schistosomi- asis, ivermectin or diethylcarbamazine for lymphatic filariasis and onchocerciasis, azi- thromycin for trachoma, and albendazole or mebendazole for intestinal worms—can cost
FIGURE 10–8 Use of mass drug administration for helminth diseases in featured countries. Data from Investing to overcome the global impact of neglected tropical diseases: 3rd WHO report on neglected tropical diseases. Geneva: WHO; 2015.
Country Schistosomiasis Lymphatic filariasis
Onchocerciasis Soil-
transmitted helminths
USA
Germany
Iran
Brazil
China
India
Nigeria
Ethiopia
10.13 Soil-Transmitted Helminths 243
sub- Saharan Africa, and southern and east- ern Asia have taeniasis, and about 15% have serological evidence of past infection, with considerable variation in levels by country.120 About one in three people with epilepsy in endemic areas has seizures that are caused by neurocysticercosis.121 The interventions for preventing and controlling cysticercosis include treatment of already infected pigs and humans with antihelminthic medications along with improved sanitation, vaccination of pigs, and meat inspection and other food safety practices.122
Echinocococcus granulosus is a tapeworm with a life cycle that requires an early devel- opmental stage in sheep (or other livestock that serve as an intermediate host, such as cattle, goats, or pigs) followed by maturation in dogs (the definitive host). Humans are an accidental host who occasionally become infected from contact with dogs and develop echinococcosis. Most cases are asymptom- atic. However, in some people the larvae cause cysts in the liver and lungs, a life-threatening condition called hydatid cyst disease.123 Human cases of cystic echinococcosis can be treated with medication and surgery, and they can be prevented with responsible care of pets and stray dogs.124 The cycling of the cestode between animals can be slowed with sheep vaccination, but echinococcosis remains an expensive zoonotic disease that occurs in nearly every world region.125
A treponematosis is an infection with bacteria from the Treponema genus. Three endemic treponematoses are on the NTD pri- ority list: bejel (Treponema pallidum subspecies endemicum), which occurs in parts of Africa and the Middle East; pinta (T. carateum), which occurs in the Americas; and yaws (T. pallidum subspecies pertenue), which occurs in sub-Saharan Africa, southeast Asia (pri- marily Indonesia), and some Pacific Island nations.126 Yaws is the most prevalent endemic treponematosis. Yaws causes skin lesions that may be disfiguring. If untreated, the infection can cause permanent disability by spreading to
▸ 10.14 Other Neglected Tropical Diseases
Many of the recognized NTDs are helminthic diseases that thrive in tropical areas but can occur across a diversity of climates. Taenia solium is a tapeworm that undergoes early development in the muscle tissue of pigs and then matures in the intestines of humans who consume undercooked pork containing T. solium larvae. Pigs are the intermediate host, and humans are the definitive host for the worm. Pigs become infected by ingest- ing human feces containing tapeworm eggs. Taeniasis is the name for the disease caused by these tapeworms being present in human intestines. Cysticercosis is the name for the disease caused by the helminths forming cysts in muscle tissue or in other parts of the body. Taeniasis usually causes no symptoms in humans, but the tapeworms can cause serious problems if they invade the human nervous system.118 Neurocysticercosis occurs when T. solium larvae, called cysticerci, trigger epi- leptic seizures and other problems associated with brain lesions.119 About 1 in 25 people living in tropical countries of the Americas,
FIGURE 10–9 Many of the people in featured coun- tries who would have benefited from participa- tion in MDA programs did not receive preventive chemotherapy for an NTD in 2015. Data from Preventive chemotherapy for helminth diseases: Progress report, 2014. Wkly Epidemiol Rec. 2016;91:93–103.
Met need Unmet need
India Nigeria Ethiopia
700 600 500 400 300 200 100
0# of
p eo
pl e
(in m
ill io
ns )
244 Chapter 10 Malaria and Neglected Tropical Diseases
bone and cartilage. A single dose of an antibi- otic can cure yaws. The Global Yaws Control Programme that was implemented between 1952 and 1964 reduced the number of cases worldwide by 95% through mass treatment with penicillin injections.127 There has been a resurgence of yaws in recent years, with thousands of cases reported.128 In 2013, WHO approved a plan to attempt to eradicate yaws by 2020 by treating infected individuals with oral azithromycin.129
Mycetoma (also called Madura foot) is a chronic granulomatous inflammatory disease of the subcutaneous tissue of the foot (or other body part), and it is the newest addition to WHO’s list of NTDs.130 People with mycetoma have swollen, disfigured feet that ooze pus. Mycetoma is caused by a diversity of fungi (which cause eumyce- toma) and by bacteria in the Actinomycetes order (which cause actinomycetoma).131 Soil is thought to be the reservoir for the pathogens, and skin trauma is thought to provide a portal of entry.130 The number of cases worldwide has not yet been determined, but most victims are young men.131 Mycetoma.
Yaws lesions before treatment (left) and 3 weeks after treatment (right) with a single dose of azithromycin.
Re pr
od uc
ed fr
om As
ied u K
, F itz
pa tri
ck C,
Ja nn
in J. E
ra dic
at ion
of ya
ws : H
ist or
ica l e
ffo rts
an d a
ch iev
ing W
HO ’s 2
02 0 t
arg et
. PL
oS Ne
gl Tro
p D is.
20 14
;8( 9)
:e3 01
6. Fig
ur e 6
. P ho
to by
M r. L
am D
uc H
ien an
d M SF
-E pic
en tre
, P ar
is, Fr
an ce
. L ice
ns ed
un de
r C C B
Y 4 .0.
CD C/
Dr . V
ict or
ia (M
ex ico
); Dr
. L uc
ille K.
G eo
rg
10.14 Other Neglected Tropical Diseases 245
health problems in humans—can be acquired by consuming contaminated food products, such as angiostryongyliasis (a roundworm of mol- lusks), diphyllobothriasis (a tapeworm of fish), fascioliasis and fasciolopsiasis (liver flukes from aquatic plants), and trichinosis or trichinellosis (a tapeworm of pork and other meats), or by ingesting food contaminated with feces, such as enterobiasis (pinworm), hymenolepiasis (a tape- worm), and toxocariasis (a roundworm). Some protozoa can also be transmitted through food. For example, toxoplasmosis (Toxoplasma gondii) is a sporozoan infection that can harm fetuses if the mother becomes infected while preg- nant.134 Most of these infections can be treated with antiparasitic drugs, but these medications are not always available to the populations that need them. When NTDs cannot be controlled with preventive chemotherapy, innovative and intensified disease management can be used to scale up access to diagnosis and treatment. Other contributors to NTD control include vec- tor management (killing mosquitoes and other disease-transmitting insects), treating veterinary diseases that also affect humans, and increasing access to water and sanitation facilities.135
Treatment options include antibiotics and sur- gery. More research is required to understand the epidemiology of mycetoma and the options for prevention and control.
Four foodborne trematodiases are also included in the WHO list of NTDs: clonor- chiasis, opisthorchiasis, fascioliasis, and par- agonimiasis (FIGURE 10–10).132 Most of these trematodes are parasites that have vertebrates or mollusks as hosts.133 Clonorchiasis (Clonorchis sinensis), which occurs in many Asian coun- tries, and opisthorchiasis (Ophithorchis viverini and O. felineus), which is found in countries in Asia and Europe, are caused by ingesting the larvae of liver flukes found in raw or under- cooked fish. Fascioliasis (Fasciola hepatica and F. gigantica) is a liver fluke disease that is pres- ent in nearly every world region and is spread through vegetables. Paragonimiasis (various species of Paragonimus) is caused by a lung fluke acquired by eating raw or undercooked freshwater crabs and crayfish, and it occurs in parts of Africa, Asia, and the Americas.
A diversity of other helminth diseases— ones that have not been designated as NTDs, even though many are very common and cause
FIGURE 10–10 Presence of foodborne trematodiases. Data from Investing to overcome the global impact of neglected tropical diseases: 3rd WHO report on neglected tropical diseases. Geneva: WHO; 2015.
USA
Germany
Iran
Brazil
China
India
Nigeria
Ethiopia
Country Clonorchiasis Opisthorchiasis Fascioliasis Paragonimiasis
246 Chapter 10 Malaria and Neglected Tropical Diseases
candidates for eradication. Eradication cam- paigns require large numbers of employees and structural support for intense months or years of interventions and for many years of follow-up surveillance. Because it takes consid- erable time, money, and organizational sophis- tication to achieve eradication, only diseases that are severe and for which there is a high likelihood of a successful campaign are targeted for eradication. A global eradication campaign cannot begin unless there is widespread polit- ical commitment to achieving success and a support system to ensure completion.
The only infectious disease of humans eradicated thus far is smallpox. (A livestock dis- ease called rinderpest was declared eradicated in 2011.138) Smallpox was a viral disease that caused blisters to form over the body, starting on the face, then appearing on the extremities, and later showing up on the trunk.139 There were
▸ 10.15 Eradication To control an infectious disease is to use public health interventions to reduce the incidence and prevalence of a condition to a substantially lower level within a community or a larger geopolitical area. Infection control measures like behavior change, environmen- tal and vector control, vaccination, and mass drug administration can be used to limit the morbidity, disability, and mortality caused by an infectious disease in a local area. Control is achieved when the incidence or prevalence rates have dropped below a target threshold defined by the community, but a resurgence of the disease would likely occur if disease control measures ceased.136 When control measures remove all risk of new infection in a defined geopolitical area, reducing the inci- dence to zero cases in that location, the elimi- nation of the infection from that location has been achieved. For some infections, it is possi- ble, at least in theory, to completely eradicate the infectious agent. Eradication is achieved when there is no risk of infection or disease anywhere in the world, even in the absence of immunization or other control measures. The term eradication should not be used to describe the elimination of a disease within a country or region when cases are still occur- ring in other places. Eradication is a term reserved for global elimination.
To be a candidate for eradication, the infec- tious agent must usually meet several criteria.137 There must be an intervention that effectively interrupts the chain of transmission. If a vac- cine is used as part of the eradication strategy, the vaccine should confer lifelong or long-term immunity to the infection. The disease should be highly pathogenic so that people who con- tract the disease have obvious symptoms and can easily be tracked. Additionally, eradication is more likely when the infection only occurs in humans. If both humans and animals serve as hosts for the infection, it may be impossible to monitor and contain all human and ani- mal cases. Not all infections are appropriate
CD C/
Je an
Ro y
Smallpox.
10.15 Eradication 247
infections like cellulitis and abscesses can result. Instead, the worm is often tied to a stick, and the guinea worm is coiled around the stick as the worm slowly makes its way out of the human’s body, at a rate of an inch or so per day. Many people with an emerging worm only feel relief from the pain by putting their feet in cool water, but this causes the worm to release thousands of eggs. Those eggs can contaminate drinking water supplies and restart the cycle of infection.
There is no medication for dracunculia- sis and no vaccine, and humans who have had guinea worm in the past do not develop immu- nity against the disease. Even so, the disease is nearing eradication thanks to a campaign led by The Carter Center that emphasizes health edu- cation over technology. Guinea worm education programs promote the filtering of drinking water to remove the copepods that host the worm lar- vae, and they also teach infected people to stay
two strains of the smallpox virus, which was in the poxvirus family of the orthopoxvirus genus. Variola major was the most common strain, and one in three people who contracted it died. Variola minor was the less common strain, but it had only a 1% case fatality rate. Nearly all smallpox survivors had severe scarring, and some were blind from corneal ulceration or had disabilities from skeletal complications.140 An aggressive worldwide immunization cam- paign that included re-vaccination in areas where any new case of smallpox occurred led to the successful eradication of the disease in the late 1970s.141 Because several laboratories stored samples of smallpox virus, the disease is not considered to be extinct. Eradication is achieved when an infectious agent is no longer circulating in humans. Extinction is complete when an agent no longer exists in nature or in the laboratory. There is some concern that via- ble smallpox virus could be obtained from a lab- oratory or corpse and used as a bioweapon.142
Two diseases are far along in the process toward eradication: dracunculiasis and polio. Dracunculiasis, also known as guinea worm disease, is a painful helminth infection.143 Peo- ple contract the guinea worm (Dracunculus medinensis) by drinking water that contains water fleas called copepods that are infected with worm larvae. Stomach acids kill ingested copepods and release guinea worm larvae, which migrate into the abdominal cavity of the human. A mature female guinea worm may grow inside the subcutaneous tissues of the human body to nearly 3 feet (1 meter) in length. Once the worm is mature, it forms a painful blister on the skin of its host. When the cyst ruptures, the worm begins to emerge from the human host’s body. The blister is often near the foot, but the worm can also emerge from a wrist or another body part. It takes weeks for the worm to be extracted from the body, and a per- son with an emerging guinea worm is usually unable to work or go to school during this time because of the pain. The worm cannot simply be pulled out of the body, because if it breaks and part of the worm is left inside the body, serious Guinea worm extraction.
© CD
C/ Th
e C ar
te r C
en te
r/E . W
olf e
© CD
C/ Th
e C ar
te r C
en te
r/E . S
ta ub
248 Chapter 10 Malaria and Neglected Tropical Diseases
cases were still occurring in Chad, Ethiopia, Mali, and South Sudan, countries that are located in both East Africa and West Africa, which meant that the disease had not yet been contained to a small geographic area.144
Polio, also called poliomyelitis or infan- tile paralysis, is a disease caused by infection with any of the three serotypes of poliovirus, a virus in the enterovirus genus. About 1 in 200 people who contract poliovirus develop a condition called acute flaccid paralysis,
out of water so they do not pass worm eggs to susceptible copepods. Every case of the disease is tracked as part of monitoring progress toward eradication. The number of cases of guinea worm disease diagnosed each year has dropped from an estimated 3.5 million cases in 1986, prior to the start of the eradication program, to less than 100,000 per year by 1997 to just 22 in 2015 (FIGURE 10–11).144 The disease has been elimi- nated from many countries, including India in 2000 and Nigeria in 2013. However, as of 2015,
Oral polio vaccination.
© A
sia ne
t-P ak
ist an
/S hu
tte rst
oc k
FIGURE 10–11 Number of cases of guinea worm globally each year. Data from Eradication of guinea worm disease: Case statement. Atlanta GA: The Carter Center/WHO; 2016.
3,500,000
3,000,000
2,500,000
2,000,000
1,500,000
1,000,000
500,000
1985 1990 1995 2000 2005 2010 2015
0
# of
c as
es
Year
5,000
4,500
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
0
2008 2009 2010 2011 2012 2013 2014 2015
A child paralyzed by polio.
CD C/
Dr . M
ar iam
Fl or
en ce
O go
, N ige
ria
10.15 Eradication 249
Unfortunately, these successes do not necessarily mean that polio is on the verge of eradication. In 2016, Nigeria reported new cases of paralysis from wild poliovirus, and Nigeria was added back to the list of endemic countries.152 Polio vaccination rates are alarm- ingly low in Nigeria; in India, the rates are below the global average even though India has an elevated risk for flare-ups because polio is still occurring in neighboring countries (FIGURE 10–12).153 The expectation is that polio would make a quick resurgence if intensive global vaccination efforts ceased.149 The ini- tial goal of eradicating polio by 2000 was not achieved, and revised target dates have not been met either.154 Sustained effort for many more years will be required to eradicate polio and permanently protect children from the risk of polio- induced disability.
▸ 10.16 Emerging Infectious Diseases
Even as modern science has allowed the control and even eradication of some dis- eases, other infectious diseases are becoming larger threats to human and animal health.
which is a sudden onset of weakness of the legs or a more widespread paralysis that might include weakness of the diaphragm, a muscle essential for breathing.145 Some people who develop polio-related paralysis recover, but some die, some are left with permanent disabilities, and some who appear to recover develop post- polio syndrome years after their infection and have a recurrence of their mus- cle weakness.146 The poliovirus is typically transmitted through fecal-oral transmission, and it can be spread through fecally contami- nated food and water.
There is no cure for polio, but it is vaccine-preventable.147 Oral polio vaccine (OPV) is a live attenuated virus administered by plac- ing a drop of vaccine in the mouth. In very rare cases an OPV recipient can develop vaccine- associated paralytic poliomyelitis (VAPP) or the virus in the vaccine may mutate and become transmissible, causing small outbreaks of circu- lating vaccine-derived poliovirus (cVDPV).148 Several doses of OPV are required for full pro- tection to be conferred. A safe injectable inac- tivated polio virus (IPV) that carries no risk of VAPP is available, but IPV is not as effective as OPV in inducing immunity.
The Global Polio Eradication Initia- tive (GPEI) was launched in 1988 by WHO, The Rotary Foundation, the U.S. CDC, and UNICEF, along with other collaborators. Before the launch of the GPEI, more than 350,000 chil- dren in more than 125 countries were paralyzed by polio every year.149 In 2015, fewer than 100 cases of paralytic polio occurred worldwide, and only two countries were considered to be endemic for polio, Afghanistan and Pakistan.149 India was declared polio-free in 2014, and Nigeria was removed from the list of endemic countries in 2015. The term wild poliovirus (WPV) is used to distinguish naturally acquired cases of polio from vaccine- derived poliovirus cases. In 2015, one of the three strains of wild poliovirus was declared eradicated.150 Trivalent (three-strain) vaccines were replaced by biva- lent (two-strain) OPV formulations that con- tain only WPV1 and WPV3.151
FIGURE 10–12 Percentage of infants receiving three doses of polio vaccine. Data from State of the world’s children 2016. New York: UNICEF; 2016.
0%
20%
40%
60%
80%
100%
USA
Ger m
an y
Ira n
Bra zil
Chin a
In dia
Nige ria
Eth iop
ia
global average
250 Chapter 10 Malaria and Neglected Tropical Diseases
new risks and risk groups. Advanced medical therapies like the immunosuppressive drugs used by people who have had organ transplants and the technology for keeping premature infants alive have created new populations of highly susceptible people (#2). Healthcare- associated infections may be very hardy and difficult to treat, and antimicrobial resistance is increasing (#1). Other technological advances have created new places for infectious agents to grow and new methods of dispersion.
New infectious diseases can emerge any- where in the world and spread quickly, so the distinction between local public health prob- lems and global ones is increasingly limited. Nipah virus, which causes encephalitis, was
Outbreaks of emerging infectious dis- eases (EIDs) occur when a new pathogen begins to affect human populations or an existing pathogen changes the kind of dis- ease it causes. The agent might evolve in a way that makes it easier to transmit to a sus- ceptible person (increased transmissibility) and, therefore, more common (increased incidence). It might change so that it causes a new set of symptoms or more severe symp- toms (increased virulence). In some cases, an infectious agent that usually affects only nonhuman hosts may adapt in a way that makes it infectious to humans. Sometimes, an infectious agent may change in a way that allows for a different portal of entry, perhaps developing the ability to spread through air- borne transmission. Other infections, called reemerging infections, were controlled at some point in the past but are becoming problematic again.155
The U.S. Institute of Medicine has con- cluded that these new health threats derive from a complex interaction of genetic, biolog- ical, environmental, ecological, social, political, and economic factors (FIGURE 10–13).156 As the world population increases (#6), humans and domestic animals move into previously unin- habited natural environments (#5) and are exposed to new plants, animals, and microbes. Alteration of the environment (#4), such as deforestation, dam building, and manipulation of wetlands, creates new environmental reser- voirs for infectious agents and their hosts, and natural disasters (#3) like floods and droughts can alter the landscape and introduce new infec- tious agents to a region. Changes in dietary and other behaviors (#6) that become trendy and spread globally may also facilitate transmission. Urbanization facilitates emergence as people with different strains of infections interact with one another (#2) and create new habitats for vectors (#5). Technology is also speeding up the rate of emergence. Modern transportation (#8) has made it possible for an infectious person to travel nearly anywhere in the world within hours. Healthcare innovations (#7) have created
1 Microbial adaptation and change
2 Human susceptibility to infection
3 Climate and weather
4 Changing ecosystems
5 Economic development and land use
6 Human demographics and behavior
7 Technology and industry
8 International travel and commerce
9 Breakdown of public health measures
10 Poverty and social inequality
11 War and famine
12 Lack of political will
13 Intent to harm
FIGURE 10–13 Risk factors for EIDs as identified by the U.S. Institute of Medicine. Data from Smolinski, MS, Hamburg MA, Lederberg J, editors. Committee on Emerging Microbial Threats to Health in the 21st Century. Institute of Medicine. Microbial threats to health: Emergence, detection, and response. Washington: The National Academies Press; 2003.
10.16 Emerging Infectious Diseases 251
the Sustainable Development Goals. Int Health. 2016;8(Suppl 1):i15–18.
9. Molyneux DH. The ‘neglected tropical diseases’: Now a brand identity; responsibilities, context and promise. Parasit Vectors.2012;5:23.
10. Reaching the unreached: 4th progress report of the London Declaration. London: Uniting to Combat Neglected Tropical Diseases; 2016.
11. An innovative approach to R&D for neglected patients: Ten years of experience & lessons learned by DNDi. Geneva: DNDi; 2014.
12. Chosidow O. Scabies and pediculosis. Lancet. 2000;355:819–26.
13. Severe malaria. Trop Med Int Health. 2014;19(Suppl 1): 7–131.
14. World malaria report 2015. Geneva: WHO; 2015. 15. Aly ASI, Vaughan AM, Kappe SHI. Malaria parasite
development in the mosquito and infection of the mammalian host. Annu Rev Microbiol. 2009;63: 195–221.
16. Management of severe malaria: A practical handbook (3rd edition). Geneva: WHO; 2012.
17. Ghosh K, Ghosh K. Pathogenesis of anaemia in malaria: A concise review. Parasitol Res. 2007;101:1463–9.
18. Idro R, Marsh K, John CC, Newton CR. Cerebral malaria: Mechanisms of brain injury and strategies for improved neurocognitive outcomes. Pediatr Res. 2010;68:267–74.
19. Idro R, Jenkins NE, Newton CR. Pathogenesis, clinical features, and neurological outcomes of cerebral malaria. Lancet Neuro. 2005;4:827–40.
20. Doolan DL, Dobaño C, Baird JK. Acquired immunity to malaria. Clin Microbiol Rev. 2009;22:13–36.
21. Desai M, ter Kuile FO, Nosten F, et al. Epidemiology and burden of malaria in pregnancy. Lancet Infect Dis. 2007;7:93–104.
22. Steketee RW, Nahlen BL, Parise ME, Menendez C. The burden of malaria in pregnancy in malaria-endemic areas. Am J Trop Med Hyg. 2001;64(Suppl):28–35.
23. Chima RI, Goodman CA, Mills A. The economic impact of malaria in Africa: A critical review of the evidence. Health Policy. 2003;63:17–36.
24. Sachs J, Malaney P. The economic and social burden of malaria. Nature. 2002;415:680–5.
25. Shretta R, Liu J, Cotter C, et al. Malaria elimination and eradication (Chapter 12). Disease control priorities. 3rd ed. Major infectious diseases (Volume 6). Washington DC: IBRD/World Bank; 2017.
26. Achieving the malaria MDG target: Reversing the incidence of malaria 2000–2015. Geneva: WHO /UNICEF; 2015.
27. Plowe CV. The evolution of drug-resistant malaria. Trans R Soc Trop Med Hyg. 2009;103(Suppl 10):S11–14.
28. Hemingway J, Shretta R, Wells TNC, et al. Tools and strategies for malaria control and elimination:
first identified in 1999 when cases occurred in people in Malaysia and Singapore. In 2001, and in many years since then, Nipah virus caused outbreaks in Bangladesh and India.157 Middle East respiratory syndrome (MERS) coronavirus was first identified in Saudi Arabia in 2012,158 and the virus sparked an outbreak in South Korea in 2015.159 The strain of H1N1 influenza that was first detected in Mexico in February 2009 had spread to doz- ens of countries by May of that year.160 Some NTDs are also considered to be EIDs, such as dengue, which is occurring more often than it did in the past and has an increasing geographic range.161 Systems for identifying and controlling emerging threats to human health no matter where they first occur are an important part of protecting the health of all of the world’s people.
▸ References 1. Keusch GT, Kilama WL, Moon S, Szlezák NA,
Michaud CM. The global health system: Linking knowledge with action—Learning from malaria. PLoS Med. 2010;7:e100179.
2. Parascandola J. From MCWA to CDC: Origins of the Centers for Disease Control and Prevention. Public Health Rep. 1996;111:549–51.
3. Hotez PJ, Fenwick A, Savioli L, Molyneux DH. Rescuing the bottom billion through control of neglected tropical diseases. Lancet. 2009;373:1570–5.
4. Investing to overcome the global impact of neglected tropical diseases: 3rd WHO report on neglected tropical diseases. Geneva: WHO; 2015.
5. Feasey N, Wansbrough-Jones M, Mabey DCW, Solomon AW. Neglected tropical diseases. Br Med Bull. 2010:93:179–200.
6. Bhutta ZA, Sommerfeld J, Lassi ZS, Salam RA, Das JK. Global burden, distribution, and interventions for infectious diseases of poverty. Infect Dis Poverty. 2014;3:21.
7. Fitzpatrick C, Nwankwo U, Lenk E, de Vlas SJ, Bundy D. An investment case for ending neglected tropical diseases (Chapter 17). Disease control priorities. 3rd ed. Major infectious diseases (Volume 6). Washington DC: IBRD/World Bank; 2017.
8. Fitzpatrick C, Engels D. Leaving no one behind: A neglected tropical disease indicator and tracers for
252 Chapter 10 Malaria and Neglected Tropical Diseases
45. Sadasivaiah S, Tozan Y, Breman JG. Dichlorodiphenyltrichloroethane (DDT) for indoor residual spraying in Africa: How can it be used for malaria control? Am J Trop Med Hyg. 2007;77(Suppl 6): 249–63.
46. Indoor residual spraying: An operational manual for indoor residual spraying (IRS) for malaria transmission control and elimination (2nd edition). Geneva: WHO; 2015.
47. The use of DDT in malaria vector control: WHO position statement. Geneva: WHO; 2011.
48. Tediosi F, Lengeler C, Castro M, Shretta R, Wells T, Tanner M. Malaria control (Chapter 13). Disease control priorities 3rd ed. Major infectious diseases (Volume 6). Washington DC: IBRD/World Bank; 2017.
49. The Global Malaria Action Plan for a malaria-free world. Geneva: Roll Back Malaria Partnership; 2008.
50. Berdud M, Towse A, Kettler H. Fostering incentives for research, development, and delivery of interventions for neglected tropical diseases: Lessons from malaria. Oxford Rev Econ Pol. 2016;32:64–87.
51. Birkett AJ. Status of vaccine research and development of vaccines for malaria. Vaccine. 2016;34:2915–20.
52. Turner JW, Robinson JD. Malaria no more: Nothing but nets. Health Commun. 2014;29:1067–8.
53. Global technical strategy for malaria 2016–2030. Geneva: WHO; 2015.
54. Simmons CP, Farrar JJ, Nguyen V, Wills B. Dengue. N Engl J Med. 2012;366:1423–32.
55. Guzman MG, Halstead SB, Artsob H, et al. Dengue: A continuing global threat. Nat Rev Microbiol. 2010;8(Suppl 12):S7–16.
56. Bhatt S, Gething PW, Brady OJ, et al. The global distribution and burden of dengue. Nature. 2013;496:504–7.
57. Messina JP, Brady OJ, Scott TW, et al. Global spread of dengue virus types: Mapping the 70 year history. Trends Microbiol. 2014;22:138–46.
58. Schwartz LM, Halloran ME, Durbin AP, Longini IM Jr. The dengue vaccine pipeline: Implications for the future of dengue control. Vaccine. 2015;33:3293–8.
59. Vannice KS, Durbin A, Hombach J. Status of vaccine research and development of vaccines for dengue. Vaccine. 2016;34:2934–8.
60. Johansson MA, Vasconcelos PFC, Staples JE. The whole iceberg: Estimating the incidence of yellow fever virus infection from the number of severe cases. Trans R Soc Trop Med Hyg. 2014;108:482–7.
61. Monath TP, Vasconcelos PF. Yellow fever. J Clin Virol. 2015;64:160–73.
62. Simons H, Patel D. International Health Regulations in practice: Focus on yellow fever and poliomyelitis. Hum Vaccin Immunother. 2016;12:2690–3.
63. Hayes EB. Zika virus outside Africa. Emerg Infect Dis. 2009;15:1347–50.
What do we need to achieve a grand convergence in malaria. PLoS Biol. 2016;14:e1002380.
29. Guidelines for the treatment of malaria (3rd edition). Geneva: WHO; 2015.
30. Universal access to malaria diagnostic testing: An operational manual. Geneva: WHO; 2011.
31. Menéndez C, D’Alessandro U, ter Kuile FO. Reducing the burden of malaria in pregnancy by preventive strategies. Lancet Infect Dis. 2007;7:126–35.
32. WHO policy brief for the implementation of intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP). Geneva: WHO; 2013.
33. Eisele TP, Larsen DA, Anglewicz PA, et al. Malaria prevention in pregnancy, birthweight, and neonatal mortality: A meta-analysis of 32 national cross- sectional datasets in Africa. Lancet Infect Dis. 2012;12:942–9.
34. Conteh L, Sicuri E, Manzi F, et al. The cost- effectiveness of intermittent preventive treatment for malaria in infants in sub-Saharan Africa. PLoS One. 2010;5:e10313.
35. WHO Global Malaria Program. Insecticide-treated mosquito nets: A WHO position statement. Geneva: WHO; 2007.
36. Lengeler C. Insecticide-treated bed nets and curtains for preventing malaria. Cochrane Database Syst Rev. 2004; (2):CD000363.
37. Bousema T, Okell L, Felger I, Drakeley C. Asymptomatic malaria infections: Detectability, transmissibility and public health relevance. Nat Rev Microbiol. 2014;12:833–40.
38. Bhatt S, Weiss DJ, Cameron E, et al. The effect of malaria control on Plasmodium falciparum in Africa between 2000 and 2015. Nature. 2015;526:207–11.
39. Chen-Hussey V, Behrens R, Logan JG. Assessment of methods used to determine the safety of the topical insect repellent N,N-diethyl-m-toluamide (DEET). Parasit Vectors. 2014;7:173.
40. Yasuoka J, Levins R. Impact of deforestation and agricultural development on anopheline ecology and malaria epidemiology. Am J Trop Med Hyg. 2007;76:450–60.
41. Nájera JA, González-Silva M, Alonso PL. Some lessons for the future from the Global Malaria Eradication Programme (1955–1969). PLoS Med. 2011;8:e1000412.
42. Mendis K, Rietveld A, Warsame M, Bosman A, Greenwood B, Wernsdorfer WH. From malaria control to eradication: The WHO perspective. Trop Med Int Health. 2009;14:802–9.
43. Dunn R. In retrospect: Silent Spring. Nature. 2012;485:578–9.
44. Attaran A, Roberst DR, Curtis CF, Kilama WL. Balancing risks on the backs of the poor. Nat Med. 2000;6:729–31.
References 253
Leishmaniases, Geneva, 22–26 March 2010. Geneva: WHO Technical Report Series; 2010.
84. King CH. Toward the elimination of schistosomiasis. N Engl J Med. 2009;360:106–9.
85. Colley DG, Bustinduy AL, Secor WE, King CH. Human schistosomiasis. Lancet. 2014;383:2253–64.
86. Honeycutt J, Hammam O, Fu CL, Hsieh MH. Controversies and challenges in research on urogenital schistosomiasis-associated bladder cancer. Trends Parasitol. 2014;30:324–32.
87. Steinmann P, Keiser J, Bos R, Tanner M, Utzinger J. Schistosomiasis and water resources development: Systematic review, meta-analysis, and estimates of people at risk. Lancet. 2006;6:411–25.
88. Rollinson D, Knopp S, Levitz S, et al. Time to set the agenda for schistosomiasis elimination. Acta Trop. 2013;128:423–40.
89. Taylor MJ, Hoerauf A, Bockarie M. Lymphatic filariasis and onchocerciasis. Lancet. 2010;376:1175–85.
90. Global programme to eliminate lymphatic filariasis: Progress report, 2015. Wkly Epidemiol Rec. 2016;91:441–60.
91. Lymphatic filariasis: Managing morbidity and preventing disability: An aide-mémoire for national programme managers. Geneva: WHO; 2013.
92. Ramaiah KD, Ottesen EA. Progress and impact of 13 years of the Global Programme to Eliminate Lymphatic Filariasis on reducing the burden of filarial disease. PLoS Negl Trop Dis. 2014;8:e3319.
93. Boatin B. The Onchocerciasis Control Programme in West Africa (OCP). Ann Trop Med Parasitol. 2008;102(Suppl 1):13–7.
94. Progress report on the elimination of human onchocerciasis, 2015–2016. Wkly Epidemiol Rec. 2016;91:505–14.
95. Tekle AH, Zouré HG, Noma M, et al. Progress toward onchocerciasis elimination in the participating countries of the African Programme for Onchocerciasis Control: Epidemiological evaluation results. Infect Dis Poverty. 2016;5:66.
96. WHO Expert Committee on Leprosy: 8th report. Geneva: WHO; 2012.
97. Rodrigues LC, Lockwood DNJ. Leprosy now: Epidemiology, progress, challenges, and research gaps. Lancet Infect Dis. 2011;11:464–70.
98. Suzuki K, Akama T, Kawashima A, Yoshihara A, Yotsu RR, Ishii N. Current status of leprosy: Epidemiology, basic science and clinical perspectives. J Dermatol. 2012;39:121–9.
99. Merritt RW, Walker ED, Small PLC, et al. Ecology and transmission of Buruli ulcer disease: A systematic review. PLoS Negl Trop Dis. 2010;4:e911.
100. Treatment of Mycobacterium ulcerans disease (Buruli ulcer): Guidance for health workers. Geneva: WHO; 2012.
64. Mlakar J, Korva M, Tul N, et al. Zika virus associated with microcephaly. N Engl J Med. 2016;374:951–8.
65. D’Ortenzio E, Matheron S, Yazdanpana Y, et al. Evidence of sexual transmission of Zika virus. N Engl J Med. 2016;374:2195–8.
66. Murray KO, Mertens E, Desprès P. West Nile virus and its emergence in the United States of America. Vet Res. 2010;41:67.
67. Petersen LR, Brault AC, Nasci RS. West Nile virus: Review of the literature. JAMA. 2013;310:308–15.
68. Lindsey NP, Staples JE, Lehman JA, Fischer M. U.S. CDC. Surveillance for human West Nile Virus disease—United States, 1999–2008. MMWR Surveill Summ. 2010;59:1–17.
69. Kilpatrick AM. Globalization, land use and the invasion of West Nile virus. Science. 2011;334:323–7.
70. Campbell GL, Hills SL, Fischer M, et al. Estimated global incidence of Japanese encephalitis: A systematic review. Bull World Health Organ. 2011;89:766–74.
71. Ikegami T, Makino S. The pathogenesis of Rift Valley fever. Viruses. 2011;3:493–519.
72. Weaver SC, Lecuit M. Chikungunya virus and the global spread of a mosquito-borne disease. N Engl J Med. 2015;372:1231–9.
73. Global strategy for dengue prevention and control 2012–2020. Geneva: WHO; 2012.
74. Rassi A Jr, Rassi A, Marin-Neto JA. Chagas disease. Lancet. 2010;375:1388–402.
75. Bern C. Chagas’ disease. N Engl J Med. 2015;373:456–66. 76. Pereira Nunes MC, Dones W, Morillo CA, Encina
JJ, Ribeiro AL; Council on Chagas Disease of the Interamerican Society of Cardiology. Chagas disease: An overview of clinical and epidemiological aspects. J Am Coll Cardiol. 2013;62:767–76.
77. Schmunis GA, Yadon YE. Chagas disease: A Latin American health problem becoming a world health problem. Acta Trop. 2010;115:14–21.
78. Franco JR, Simarro PP, Diarra A, Jannin JG. Epidemiology of human African trypanosomiasis. Clin Epidemiol. 2014;6:257–75.
79. Brun B, Blum J, Chappuis F, Burri C. Human African trypanosomiasis. Lancet. 2010;375:148–59.
80. Lutje V, Seixas J, Kennedy A. Chemotherapy for second-stage human African trypanosomiasis. Cochrane Database Syst Rev. 2013; (6):CD006201.
81. Leishmaniasis is high-burden countries: An epidemiological update based on data reported in 2014. Wkly Epidemiol Rec. 2016;91:287–96.
82. Alvar J, Vélez ID, Bern C, et al. WHO Leishmaniasis Control Team. Leishmaniasis worldwide and global estimates of its incidence. PLoS One. 2012;7:e35671.
83. Control of the leishmaniases: Report of a meeting of the WHO Expert Committee on the Control of
254 Chapter 10 Malaria and Neglected Tropical Diseases
118. Preventable epilepsy: Taenia solium infection burdens economies, societies and individuals: A rationale for investment and action. Geneva: WHO; 2016.
119. García HH, Gonzalez AE, Evans CAW, Gilman RH. Cysticercosis Working Group in Peru. Taenia solium cysticercosis. Lancet. 2003;362:547–56.
120. Coral-Almeida M, Gabriël S, Abatih EN, Praet N, Benitez W, Dorny P. Taenia solium human cysticercosis: A systematic review of sero-epidemiological data from endemic zones around the world. PLoS Negl Trop Dis. 2015;9:e0003919.
121. Ndimubanzi PC, Carabin H, Budke CM, et al. A systematic review of the frequency of neurocysticercosis with a focus on people with epilepsy. PLoS Negl Trop Dis. 2010;4:e870.
122. Thomas LF. Landscape analysis: Control of Taenia solium. Geneva: WHO; 2015.
123. Mandal S, Mandal MD. Human cystic echinococcosis: Epidemiologic, zoonotic, clinical, diagnostic, and therapeutic aspects. Asian Pac J Trop Med. 2012;5:253–60.
124. Macpherson CNL. Human behaviour and the epidemiology of parasitic zoonoses. Int J Parasitol. 2005;35:1319–31.
125. Budke CM, Deplazes P, Torgerson PR. Global socioeconomic impact of cystic echinococcosis. Emerg Infect Dis. 2006;12:296–303.
126. Marks M, Solomon AW, Mabey DC. Endemic Treponema diseases. Trans R Soc Trop Med Hyg. 2014;108:601–7.
127. Mitjà O, Asiedu K, Mabey D. Yaws. Lancet. 2013;381: 763–73.
128. Mitjà O, Marks M, Donan DJ, et al. Global epidemiology of yaws: A systematic review. Lancet Glob Health. 2015;3:e324–31.
129. Asiedu K, Fitzpatrick C, Jannin J. Eradication of yaws: Historical efforts and achieving WHO’s 2020 target. PLoS Negl Trop Dis. 2014;8:e3016.
130. van de Sande WWJ, Maghoub ES, Fahal AH, Goodfellow M, Welsh O, Zijlstra E. The mycetoma knowledge gap: Identification of research priorities. PLoS Negl Trop Dis. 2014;8:e2667.
131. van de Sande WW. Global burden of human mycetoma: A systematic review and meta-analysis. PLoS Negl Trop Dis. 2013;7:e2550.
132. Fürst T, Keiser J, Utzinger J. Global burden of human food-borne trematodiases: A systematic review and meta-analysis. Lancet Infect Dis. 2012;12:210–21.
133. Keiser J, Utzinger J. Emerging foodborne trematodiasis. Emerg Infect Dis. 2005;11:1507–14.
134. Torgerson PR, Mastroiacovo P. The global burden of congenital toxoplasmosis: A systematic review. Bull World Health Organ. 2013;91:501–8.
101. Trachoma control: A guide for programme managers. Geneva: WHO; 2006.
102. Emerson P, Frost L, Bailey R, Mabey D. Implementing the SAFE strategy for trachoma control: A toolbox of interventions for promoting facial cleanliness and environmental improvement. Atlanta GA: The Carter Center/International Trachoma Initiative; 2006.
103. Eliminating trachoma: Accelerating towards 2020. Geneva: WHO Alliance for the Global Elimination of Trachoma by 2020; 2016.
104. Knobel DL, Cleaveland S, Coleman PG, et al. Re-evaluating the burden of rabies in Africa and Asia. Bull World Health Organ. 2005;83:360–8.
105. Hampson K, Coudeville L, et al. Estimating the global burden of endemic canine rabies. PLoS Negl Trop Dis. 2015;9:e0003709.
106. Fahrion AS, Mikhailov A, Abela-Ridder B, Giacinti J, Harries J. Humans rabies transmitted by dogs: Current status of global data, 2015. Wkly Epidemiol Rec. 2016;91:13–20.
107. WHO Expert Consultation on Rabies (2nd report). Geneva: WHO Technical Report Series; 2013.
108. Rabies vaccines: WHO position paper. Wkly Epidemiol Rec. 2010;85:309–20.
109. Global elimination of dog-mediated human rabies: Report of the Rabies Global Conference 10–11 December 2015. Geneva: WHO/OIE (World Organization for Animal Health); 2016.
110. Bethony J, Brooker S, Albonico M, et al. Soil-transmitted helminth infections: Ascariasis, trichuriasis, and hookworm. Lancet. 2006;367:1521–32.
111. Bundy DA, Walson JL, Watkins KL. Worms, wisdom, and wealth: Why deworming can make economic sense. Trends Parasitol. 2013;29:142–8.
112. Knopp S, Steinmann P, Keiser J, Utzinger J. Nematode infections: Soil-transmitted helminths and trichinella. Infect Dis Clin North Am. 2012;26:341–58.
113. Pullan RL, Smith JL, Jasrasaria R, Brooker SJ. Global numbers of infection and disease burden of soil transmitted helminth infections in 2010. Parsit Vectors. 2014;7:37.
114. Bartsch SM, Hotez PJ, Asti L, et al. The global economic and health burden of human hookworm infection. PLoS Negl Trop Dis. 2016;10:e0004922.
115. Helminth control in school age children: A guide for managers of control programmes. 2nd ed. Geneva: WHO; 2011.
116. Hotez PJ, Molyneux DH, Fenwick A, et al. Control of neglected tropical diseases. N Engl J Med. 2007;357: 1018–27.
117. Preventive chemotherapy for helminth diseases: Progress report, 2014. Wkly Epidemiol Rec. 2016;91: 93–103.
References 255
150. Apparent global interruption of wild poliovirus type 2 transmission. MMWR Morb Mortal Wkly Rep. 2001;50:222–4.
151. Patel M, Orenstein W. A world free of polio: The final steps. N Engl J Med. 2016;374:501–3.
152. Roberts L. New polio cases in Nigeria spur massive response. Science. 2016;353:738.
153. State of the world’s children 2016. New York: UNICEF; 2016.
154. Polio eradication & endgame strategic plan 2013– 2018. Geneva: WHO; 2013.
155. Morens DM, Folkers GK, Fauci AS. The challenge of emerging and re-emerging infectious diseases. Nature. 2004;430:242–9.
156. Smolinski, MS, Hamburg MA, Lederberg J, editors. Committee on Emerging Microbial Threats to Health in the 21st Century. Institute of Medicine. Microbial threats to health: Emergence, detection, and response. Washington DC: The National Academics Press; 2003.
157. Lo MK, Rota PA. The emergence of Nipah virus, a highly pathogenic paramyxovirus. J Clin Virol. 2008;43:396–400.
158. The WHO MERS-CoV Research Group. State of knowledge and data gaps of Middle East respiratory syndrome coronavirus (MERS-CoV) in humans. PLoS Curr. 2013;5:1.
159. Cowling BJ, Park M, Fang VJ, Wu P, Leung GM, Wu JT. Preliminary epidemiologic assessment of MERS- CoV outbreak in South Korea, May–June 2015. Euro Surveill. 2015;20:21163.
160. Neumann G, Noda T, Kawaoka Y. Emergence and pandemic potential of swine-origin H1N1 influenza virus. Nature. 2009;459:931–9.
161. Mackey TK, Liang BA, Cuomo R, Hafen R, Brouwer KC, Lee DE. Emerging and reemerging neglected tropical diseases: A review of key characteristics, risk factors, and the policy and innovation environment. Clin Microbiol Rev. 2014;27:949–79.
135. Accelerating work to overcome the global impact of neglected tropical diseases: A roadmap for implementation. Geneva: WHO; 2012.
136. Dowdle WR. The principles of disease elimination and eradication. Bull World Health Organ. 1998;76(Suppl 2): 22–5.
137. Hopkins DR. Disease eradication. N Engl J Med. 2013;368:54–63.
138. Morens DM, Holmes EC, Davis AS, Taubenberger JK. Global rinderpest eradication: Lessons learned and why humans should celebrate too. J Infect Dis. 2011;204:502–5.
139. Moore ZS, Seward JF, Lane JM. Smallpox. Lancet. 2006;367:425–35.
140. Breman JG, Henderson DA. Diagnosis and management of smallpox. N Engl J Med. 346:1300–8.
141. Henderson DA. Principles and lessons from the smallpox eradication programme. Bull World Health Organ. 1987;65:535–46.
142. Henderson DA, Inglesby TV, Bartlett JG, et al. Smallpox as a biological weapon: Medical and public health management: Working Group on Civilian Biodefense. JAMA. 1999;281:2127–37.
143. Cairncross S, Muller R, Zagaria N. Draculculiasis (guinea worm disease) and the eradication initiative. Clin Microbiol Rev. 2002;15:223–46.
144. Eradication of guinea worm disease: Case statement. Atlanta GA: The Carter Center/WHO; 2016.
145. Hinman AR, Foege WH, de Quadros CA, Patriarca PA, Orenstein WA, Brink EW. The case for global eradication of poliomyelitis. Bull World Health Organ. 1987;65:835–40.
146. Howard RS. Poliomyelitis and the postpolio syndrome. BMJ. 2005;330:1314–18.
147. Polio vaccines: WHO position paper—March, 2016. Wkly Epidemiol Rec. 2016;91:145–68.
148. Minor P. Vaccine-derived poliovirus (VDPV): Impact on poliomyelitis eradication. Vaccine. 2009;27:2649–52.
149. Polio Global Eradication Initiative: Annual report 2015. Geneva: WHO; 2016.
256 Chapter 10 Malaria and Neglected Tropical Diseases
© Xinzheng. All Rights Reserved/Moment/Getty
CHAPTER 11
Reproductive Health Reproductive health services help babies get their healthiest start in life, keep women from dying during pregnancy and childbirth, and enable adults and adolescents to make informed decisions about family planning. They also support demographic goals, especially in lower-income countries where increased access to modern contraceptives has slowed the rate of population growth. However, limited access to skilled birth attendants in many lower-income countries means that many babies and mothers are still dying each year from preventable causes. Global goals for improving maternal and neonatal survival will not be met unless more resources are invested in reproductive health interventions.
▸ 11.1 Reproductive Health and Global Health
Reproductive health encompasses issues of fertility and infertility, contraception, pregnancy and childbirth, gynecologic and urologic health, and the prevention and treat- ment of sexually transmitted infections. Many reproductive health services are provided under the broader umbrella of maternal and child health (MCH) or maternal, new- born, and child health (MNCH) programs that promote health for pregnant women, newborns, infants, children, and adolescents. MCH programs often focus on helping babies and young children get their healthiest start in life. Women are included in MCH initia- tives because the healthiest babies are born to women who were healthy before they conceived their offspring, who had access to
health services during pregnancy, and who had skilled birth attendants assist with deliv- ery and the postnatal period. But reproductive health is not just about pregnancy, and it is rel- evant to both women and men of all ages. All adults and adolescents need to have access to reproductive health care and the tools to main- tain their reproductive health.
Although there is nearly universal consen- sus on the merit of improving infant and child health, reproductive rights have long been a controversial global health topic because they require frank discussions about sexual behav- iors and gender issues. Sustainable Develop- ment Goal (SDG) 3 focuses on health, and one of its targets is to “ensure universal access to sexual and reproductive health-care services, including for family planning, information, and education, and the integration of repro- ductive health into national strategies and programs” (SDG 3.7) (FIGURE 11–1).1 SDG 5 focuses on gender equality, and one of its tar- gets is to “ensure universal access to sexual and
257
reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the ICPD and the Beijing Plat- form for Action and the outcome documents of their review conferences” (SDG 5.6).1 The International Conference on Population and Development (ICPD) was a United Nations (UN) meeting held in Cairo, Egypt, in 1994.2 The Cairo Conference program of action
emphasized reproductive rights, calling for women and their partners to have the freedom to decide how many children they want without interference from governments or other orga- nizations.3 This agenda raised concerns among a diversity of religious and social groups, with the Roman Catholic Church especially vocal about the promotion of contraception and possible increases in the number of abortions.4
3.1.1 Maternal deaths per 100,000 live births
3.1.2 Proportion of births attended by skilled health personnel
3.7.1 Percentage of women of reproductive family age (aged 15–49) who have their need for family planning satisfied with modern methods
3.7.2 Adolescent birth rate (aged 10–19) per 1000 women in that age group
5.2.1 Proportion of ever-partnered women and girls aged 15 years and older subjected to physical, sexual, or psychological violence by a current or former intimate partner in the past 12 months
5.2.2 Proportion of women and girls aged 15 years and older subjected to sexual violence by persons other than an intimate partner in th
