Global Health: Diseases, Programs, Systems, and Policies PDF Fourth Edition

 FOURTH EDITION GLOBAL HEALTH Diseases, Programs, Systems, and Policies Michael H. Merson, MD Wolfgang Joklik Professor of Global Health Duke Global Health Institute Duke University Durham, North Carolina...

 FOURTH EDITION GLOBAL HEALTH Diseases, Programs, Systems, and Policies Michael H. Merson, MD Wolfgang Joklik Professor of Global Health Duke Global Health Institute Duke University Durham, North Carolina Robert E. Black, MD, MPH Professor and Director Institute for International Programs Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore, Maryland Anne J. Mills, PhD Professor and Deputy Director and Provost London School of Hygiene & Tropical Medicine London, UK 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 © 2020 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. Global Health: Diseases, Programs, Systems, and Policies, Fourth 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. Production Credits VP, Product Management: David D. Cella Cover Design: Scott Moden Director of Product Management: Michael Brown Rights & Media Specialist: Merideth Tumasz Product Manager: Sophie Fleck Teague Media Development Editor: Shannon Sheehan Product Specialist: Danielle Bessette Cover Image (Title Page, Chapter Opener): Production Editor: Kelly Sylvester © Anton Balazh/Shutterstock Senior Marketing Manager: Susanne Walker Printing and Binding: Sheridan Books Manufacturing and Inventory Control Supervisor: Amy Bacus Cover Printing: Sheridan Books Composition: codeMantra U.S. LLC Library of Congress Cataloging-in-Publication Data Names: Merson, Michael H., editor. | Black, Robert E., editor. | Mills, Anne, editor. Title: Global health: diseases, programs, systems, and policies / [edited] by Michael H. Merson, Robert E. Black, and Anne J. Mills. Other titles: Global health (Merson) Description: Fourth edition. | Burlington, Massachusetts: Jones & Bartlett Learning, | Includes bibliographical references and index. Identifiers: LCCN 2018023789 | ISBN 9781284122626 (casebound) Subjects: | MESH: Global Health | Public Health | International Cooperation | Public Health Administration | Health Policy Classification: LCC RA441 | NLM WA 530.1 | DDC 362.1—dc23 LC record available at https://lccn.loc.gov/2018023789 6048 Printed in the United States of America 22 21 20 19 18 10 9 8 7 6 5 4 3 2 1  © Anton Balazh/Shutterstock Brief Contents Acknowledgments ix Contributors xi About the Authors xvii Foreword xix Introduction xxi Chapter 1 Measures of Health and Disease in Populations............ 1 Chapter 2 Culture, Behavior, and Health......................... 43 Chapter 3 Global Health, Human Rights, and Ethics................ 75 Chapter 4 Understanding and Acting on Social Determinants of Health and Health Equity........................... 95 Chapter 5 Reproductive Health................................ 131 Chapter 6 Infectious Diseases................................. 195 Chapter 7 Nutrition.......................................... 259 Chapter 8 Chronic Diseases and Risks........................... 335 Chapter 9 Unintentional Injuries and Violence................... 381 Chapter 10 Global Mental Health............................... 423 Chapter 11 Environmental and Occupational Health............... 477 Chapter 12 Complex Emergencies............................... 537 Chapter 13 The Design of Health Systems........................ 597 Chapter 14 Public Health Infrastructure.......................... 637 Chapter 15 Management and Planning for Global Health........... 679 Chapter 16 Pharmaceuticals................................... 731 iii iv Brief Contents Chapter 17 Innovation, Technology, and Design................... 769 Chapter 18 Evaluations of Large-Scale Health Programs............ 793 Chapter 19 Health and “The Economy”........................... 835 Chapter 20 International Trade and Health....................... 857 Chapter 21 Global Health Governance and Diplomacy.............. 893 Acronyms 923 Index 931  © Anton Balazh/Shutterstock Contents Acknowledgments............................. ix Acknowledgments................................ 69 Contributors.................................. xi Discussion Questions.............................. 69 About the Authors............................ xvii References........................................ 70 Foreword.................................... xix Chapter 3 Global Health, Human Introduction................................. xxi Rights, and Ethics............... 75 Defining Global Health in the Context of Chapter 1 Measures of Health and Human Rights and Ethics........................ 75 Disease in Populations............ 1 Setting the Context: Human Rights and Reasons for and Approaches to Measuring Ethical Approaches to Global Health............. 76 Health and Disease............................... 2 Global Health and Human Rights.................. 79 Summary Measures of Population Health.......... 12 Interpreting the Right to Health.................... 79 Comparisons and Trends in The Challenge in Meeting the Right to Health...... 80 Disease Burden.................................. 27 Rights-Based Approach to Global Health........... 81 Burden of Disease Attributed to Risk Factors....... 35 Global Health and Public Health Ethics............. 82 Conclusion........................................ 37 Case Studies in Global Health, Acknowledgments................................ 38 Human Rights, and Ethics........................ 86 Discussion Questions.............................. 38 Conclusions....................................... 91 Appendix 1........................................ 38 Discussion Questions.............................. 92 References........................................ 40 References........................................ 92 Chapter 2 Culture, Behavior, and Health..... 43 Chapter 4 Understanding and Acting Basic Concepts from Medical Anthropology........ 44 on Social Determinants Theories of Health Behavior and Behavior Change.... 55 of Health and Health Equity...... 95 Common Features of Successful Health Introduction....................................... 95 Communication and Health Conceptual Frameworks for Understanding Promotion Programs.............................60 Social Determinants of Health and Methodologies for Understanding Health Equity.................................... 96 Culture and Behavior............................ 61 Addressing SDH Through Intersectoral Case Study: Use of a Focused Ethnographic Action and Health in All Policies................ 104 Study to Assess the Acceptability of a Implications for Health Systems and Services..... 108 Fortified Infant Cereal in Africa................... 64 Social Exclusion, Social Agency, and Case Study: The Slim Disease—HIV/AIDS Power as a SDH................................. 111 in Sub-Saharan Africa............................ 65 Global SDH, Local Impact: Experiences of Ebola.............................................. 68 Extractive Industries in East and Conclusion........................................ 69 Southern Africa................................. 117 v vi Contents Evaluating Action on the Social Chapter 7 Nutrition...................... 259 Determinants of Health and Health Equity...... 120 Introduction...................................... 259 Conclusion....................................... 124 Spectrum of Malnutrition and Its Acknowledgments............................... 125 Consequences Across the Life Course........... 259 Discussion Questions............................. 125 Causes of Malnutrition............................ 287 References....................................... 125 Policies and Programs to Address Malnutrition in All Its Forms..................... 297 Chapter 5  Reproductive Health............ 131 Discussion Questions............................. 314 Demographic Trends and Fertility References....................................... 315 Determinants................................... 132 Family Planning Programs........................ 147 Chapter 8 Chronic Diseases and Risks....... 335 Impact of Reproductive Patterns Introduction...................................... 335 on the Health of Children....................... 166 The Burden of Chronic Disease: Causes Impact of Reproductive Patterns and Impacts.................................... 335 on the Health of Women....................... 170 Categories of Chronic Disease.................... 342 Mechanisms to Reduce Maternal Global Costs and Consequences Morbidity and Mortality in Low- and of Chronic Diseases............................. 351 Middle-Income Countries...................... 178 Impact on Sustainable Development Conclusion....................................... 185 and the Environment........................... 353 Discussion Questions............................. 185 Stakeholder Responses to the Growing References....................................... 186 Burden of Chronic Disease...................... 353 Future Drivers for Prevention and Chapter 6  Infectious Diseases............. 195 Management of Chronic Diseases.............. 361 Overview......................................... 195 Summary......................................... 372 Control of Infectious Diseases..................... 196 Discussion Questions............................. 372 Childhood Vaccine-Preventable Diseases: References....................................... 373 The Expanded Program on Immunization....... 198 Enteric Infections and Acute Chapter 9 Unintentional Injuries Respiratory Infections........................... 207 and Violence.................. 381 Bacterial Meningitis............................... 214 Introduction...................................... 381 Mycobacterial Infections.......................... 217 The Global Burden of Unintentional Sexually Transmitted Infections and AIDS......... 223 Injuries and Violence............................ 382 Viral Hepatitis..................................... 229 Risk Factors for Unintentional Injuries and Violence................................... 393 Malaria and Other Arthropod-Borne Diseases...................... 232 Interventions to Prevent Unintentional Injuries and Violence............................ 399 Helminthiasis..................................... 236 Advancing the Injury and Violence Prevention Zoonoses......................................... 239 Agenda: Opportunities and Challenges......... 410 Viral Hemorrhagic Fevers......................... 241 Conclusion....................................... 414 Infectious Causes of Blindness.................... 246 Discussion Questions............................. 414 Antimicrobial Resistance.......................... 248 Acknowledgments............................... 414 Emergence of New Infectious Disease Threats.... 249 Disclaimer........................................ 414 Global Health Security Agenda................... 251 References....................................... 414 Conclusion....................................... 251 Acknowledgments............................... 252 Chapter 10 Global Mental Health.......... 423 Discussion Questions............................. 252 Introduction...................................... 423 References....................................... 252 Historical Development of Global Mental Health..... 425  Contents vii Culture and Mental Disorders..................... 428 Communicable Disease Control.................. 578 The Determinants of Mental Disorders............ 434 Noncommunicable Diseases...................... 584 The Burden of Mental Disorders................... 437 Role of International, National, and Interventions..................................... 445 Nongovernmental Organizations............... 584 Global Mental Health: Looking Ahead............. 461 Conclusion....................................... 590 Discussion Questions............................. 465 Discussion Questions............................. 591 References....................................... 466 References....................................... 591 Chapter 11 Environmental and Chapter 13 The Design of Occupational Health........... 477 Health Systems............... 597 Introduction...................................... 477 Understanding the Health System................ 598 The Burden and Distribution of Disease from Historical Development of Health Systems........ 603 Environmental and Occupational Hazards...... 478 The Role of the State.............................. 605 Methods for Environmental Health Governance and Regulation...................... 608 Research and Practice.......................... 488 Financing......................................... 613 Assessment of Environmental Health Resource Allocation.............................. 620 Impacts and Risks.............................. 495 Provision of Services.............................. 625 Occupational Health.............................. 498 Performance of Different Types of Systems........ 628 Major Issues in Environmental Health............. 505 Universal Health Coverage and The Future of Environmental Health Global Health Security.......................... 630 in an Unequal World............................ 525 Conclusion....................................... 631 Conclusion....................................... 527 Discussion Questions............................. 632 Discussion Questions............................. 528 References....................................... 632 Acknowledgments............................... 528 References....................................... 528 Chapter 14 Public Health Infrastructure.... 637 Chapter 12 Complex Emergencies......... 537 Introduction...................................... 637 Essential Public Health Functions................. 639 Introduction...................................... 537 Strengthening Public Health Systems............ 640 Direct Public Health Impact of War................ 541 Health Security................................... 657 Indirect Public Health Impact of Civil Conflict..... 544 Conclusion....................................... 671 The Effects of Armed Conflict and Political Violence on Health Services.................... 547 Acknowledgments............................... 671 Specific Health Outcomes........................ 549 Discussion Questions............................. 672 Prevention and Mitigation of Complex References....................................... 672 Emergencies................................... 558 Responses to Complex Emergencies.............. 560 Chapter 15 Management and Planning Rapid Assessment................................ 561 for Global Health.............. 679 Health Information Systems...................... 563 What is Management and Planning?.............. 679 Shelter and Environment......................... 565 The Context of Management Water and Sanitation............................. 566 and Planning................................... 682 Food Rations and Distribution.................... 567 Organizing....................................... 686 Nutritional Rehabilitation......................... 570 Planning.......................................... 689 Health Services: Response to Complex Management of Resources....................... 699 Emergencies................................... 572 Transport Management........................... 712 Reproductive Health.............................. 576 Key Themes in Management and Planning........ 715 viii Contents Conclusion and Challenges for Managers Disseminating Evaluation Findings and and Planners................................... 723 Promoting their Uptake......................... 829 Discussion Questions............................. 725 Working in Large-Scale Evaluations............... 829 References....................................... 726 Acknowledgments............................... 831 Discussion Questions............................. 831 Chapter 16 Pharmaceuticals.............. 731 References....................................... 831 Introduction...................................... 731 Chapter 19 Health and “The Economy”..... 835 Pharmaceutical Availability: Upstream Issues...... 732 Availability: Country-Level Distribution Systems Introduction...................................... 835 and Pharmaceutical Management.............. 738 A Macroeconomic Focus......................... 836 Affordability...................................... 746 The Household as the Nexus of the Safe and Effective Use of Medicines............... 749 Health–Wealth Relationship.................... 838 Antimicrobials and Antimicrobial Resistance...... 755 Macroeconomics and Risk Factors for Disease...................................... 843 Pharmaceuticals for Noncommunicable Diseases........................................ 759 The Macroeconomy and the Healthcare Sector.............................. 847 Conclusion....................................... 762 Conclusion....................................... 850 Discussion Questions............................. 762 Acknowledgments............................... 852 References....................................... 763 Discussion Questions............................. 852 Chapter 17 Innovation, Technology, References....................................... 853 and Design................... 769 Chapter 20 International Trade Introduction...................................... 769 and Health................... 857 Innovation: A Catalyst for Change Introduction...................................... 857 in Global Health................................ 769 Relationship Between Trade and Health........... 858 Technology Platforms Impacting the The Impact of Trade on Health: Global Health Landscape....................... 771 Different Pathways............................. 861 Global Health Innovation Processes............... 777 Trade and Its Effects on Health Systems........... 870 Technological Opportunities: Filling the Conclusion: From Conflict Between Gaps in Global Health.......................... 785 Trade and Health to Coherence................. 885 Conclusion....................................... 789 Discussion Questions............................. 887 Discussion Questions............................. 790 References....................................... 887 References....................................... 790 Chapter 21 Global Health Governance Chapter 18 Evaluations of Large-Scale and Diplomacy............... 893 Health Programs.............. 793 Introduction...................................... 893 Why We Need Large-Scale Impact Evaluations.... 793 Globalization and Global Health Needs........... 894 Planning the Evaluation.......................... 796 What Is Global Health Governance?............... 897 Developing an Impact Model..................... 800 Mapping Existing Institutional Arrangements Stepwise Approach to Impact Evaluations........ 801 Governing Global Health....................... 904 Types of Inference and Choice of Design.......... 803 Conclusion....................................... 919 Defining the Indicators and Discussion Questions............................. 919 Obtaining the Data............................. 810 References....................................... 919 Incorporating Equity in the Evaluation............................... 822 Acronyms.................................... 923 Carrying Out the Evaluation...................... 822 Index....................................... 931  © Anton Balazh/Shutterstock Acknowledgments We would like to acknowledge the technical and editorial assistance of Michelle Pender and Rachel Genego. ix  © Anton Balazh/Shutterstock Contributors Stuart Anderson, MA, PhD, FRPharmS, FHEA Gillian P. Christie, MPhil, MA Emeritus Professor of History of Pharmacy, London Doctor of Public Health Candidate School of Hygiene & Tropical Medicine Harvard T.H. Chan School of Public Health London, United Kingdom Cambridge, Massachusetts Abdulgafoor M. Bachani, PhD, MHS Alex Cohen, MA, PhD Assistant Professor, International Health Visiting Scientist Director, Johns Hopkins International Injury Department of Epidemiology Research Unit Harvard T.H. Chan School of Public Health Health Systems Program, Department of Boston, Massachusetts International Health & Johns Hopkins Bloomberg School of Honorary Associate Professor Public Health Department of Population Health Baltimore, Maryland London School of Hygiene & Tropical Medicine London, United Kingdom David E. Bloom, MA, PhD Clarence James Gamble Professor of Economics and Osman A. Dar, FRCP Edin, FFPH Demography Consultant in Global Health Chair, Department of Global Health Global Public Health Division and Population Public Health England Harvard School of Public Health London, United Kingdom Boston, Massachusetts Jessica Fanzo, PhD Chris Beyrer, MD, MPH Bloomberg Distinguished Associate Professor Desmond M. Tutu Professor and Director Department of International Health Center for Public Health and Human Rights Bloomberg School of Public Health Johns Hopkins Bloomberg School of Public Health Berman Institute of Bioethics Baltimore, Maryland Johns Hopkins University Baltimore, Maryland Alexander Butchart, MA, PhD Coordinator, Violence Prevention Andrew Green, BA, MA, PhD Department for Management of Professor Emeritus Noncommunicable Diseases, Disability, Nuffield Centre for International Health and Violence and Injury Prevention Development, Leeds Institute of Health Sciences World Health Organization University of Leeds Geneva, Switzerland Leeds, United Kingdom David Canning, PhD Aubree Gordon, PhD Professor of Economics and International Health Assistant Professor Department of Global Health and Population Department of Epidemiology Harvard School of Public Health School of Public Health Boston, Massachusetts University of Michigan Ann Arbor, Michigan Rupa Chanda RBI Chair Professor in Economics Johanna Hanefeld, BA, MSc, PhD Indian Institute of Management Associate Professor Bangalore, India Health Policy and Systems Research xi xii Contributors London School of Hygiene and Tropical Medicine Nancy Kass, ScD London, United Kingdom Vice Provost for Graduate and Professional Education Kara Hanson, MPhil, SD Phoebe R. Berman Professor of Bioethics and Public Professor of Health System Economics Health Faculty of Public Health and Policy Deputy Director of Public Health in the Berman London School of Hygiene and Institute of Bioethics Tropical Medicine Johns Hopkins University London, United Kingdom Baltimore, Maryland David J. Heller, MD, MPH Assistant Professor Berit Kieselbach, MSc, MPH Arnhold Institute for Global Health Technical Officer, Violence Prevention Icahn School of Medicine at Mount Sinai Department for Management of Noncommunicable New York, New York Diseases, Disability, Violence and Injury Prevention David L. Heymann, MD World Health Organization Professor of Infectious Disease Epidemiology Geneva, Switzerland London School of Hygiene & Tropical Medicine London, United Kingdom Tord Kjellstrom, MEng, PhD (Med) Visiting Fellow Adnan A. Hyder, MD, MPH, PhD Australian National University Professor & Associate Chair, International Health Canberra, Australia Director, Health Systems Program, International Health Brandon A. Kohrt, MD, PhD Director, Johns Hopkins International Injury Charles and Sonia Akman Associate Professor in Research Unit Global Psychiatry Department of Psychiatry and Associate Director, Johns Hopkins Berman Institute Behavioral Sciences of Bioethics The George Washington University Johns Hopkins Bloomberg School of Public Health Washington, DC Baltimore, Maryland Sandra D. Lane, PhD, MPH Brady Hunt Laura J. and L. Douglas Meredith Professor PhD Candidate Professor of Public Health and Anthropology Richards-Kortum Laboratory Syracuse University Department of Bioengineering & Rice University Research Professor Houston, Texas Obstetrics and Gynecology Upstate Medical University Dean T. Jamison, MS, PhD Syracuse, New York Professor, Global Health Adjunct Professor, Health Services Kelley Lee, BA MPA, MA, DPhil, FFPH, FCAHS Institute for Health Metrics and Evaluation Professor Department of Global Health Faculty of Health Sciences University of Washington Simon Fraser University Seattle, Washington Burnaby, British Columbia, Canada Benjamin Johns, PhD Siobhan Leir, MSc Senior Associate / Scientist Research Assistant in Global Public Health International Development Division London School of Hygiene & Tropical Medicine Abt Associates, Inc. London, United Kingdom Rockville, Maryland Henry Lishi Li, MA, MSc Sandeep P. Kishore, MD, PhD, MSc PhD Candidate Associate Director Department of Health Services Research and Policy Arnhold Institute for Global Health London School of Hygiene & Icahn School of Medicine at Mount Sinai Tropical Medicine New York, New York London, United Kingdom  Contributors xiii Tonya Littlejohn, MBBS, MA Melinda K. Munos, PhD Affiliated Scholar Assistant Professor Center for Public Health and Human Rights Department of International Health Johns Hopkins Bloomberg School of Public Health Bloomberg School of Public Health Baltimore, Maryland Johns Hopkins University Rene Loewenson, PhD, FRSPH Baltimore, Maryland Director Mary Natoli Training and Research Support Centre PhD Candidate Harare, Zimbabwe Richards-Kortum Laboratory Department of Bioengineering Crick Lund, PhD Rice University Professor of Global Mental Health and Development Houston, Texas Centre for Global Mental Health Institute of Psychiatry, Psychology, and Neuroscience Maria Oden King’s College London Teaching Professor London, United Kingdom Department of Bioengineering & Rice University Professor of Public Mental Health Houston, Texas Alan J. Flisher Centre for Public Mental Health Marsha Orgill, BAdmin (Hons), MPhil Department of Psychiatry and Mental Health Senior Researcher University of Cape Town Health Policy and Systems Division, School of Public Cape Town, South Africa Health and Family Medicine Alexandra Macmillan, MBChB, MPH, PhD, FNZCPHM University of Cape Town Senior Lecturer Environmental Health Cape Town, South Africa University of Otago Benjamin Palafox, MSc Dunedin, New Zealand Research Fellow, Pharmaceutical Policy and Melisa Martinez-Alvarez, BSc, MSc, PhD Economics Senior Scientist Department of Global Health and Development MRC Unit at The Gambia London School of Hygiene & Tropical Medicine London School of Hygiene & Tropical Medicine London, United Kingdom Barbara McPake, PhD Vikram Patel, MSc, MRCPsych, PhD, FMedSci Professor of Health Economics and The Pershing Square Professor of Global Health and Director, Nossal Institute for Global Health Wellcome Trust Principal Research Fellow Melbourne School of Population and Global Health Harvard University University of Melbourne Boston, Massachusetts Melbourne, Australia Margaret Peden, BSc Nurs, BSc Med Hons, PhD Jane Menken, MS, PhD Senior Research Fellow & Head of Distinguished Professor of Sociology Injury Programme Research Professor, Institute of Behavioral Science The George Institute for Global Health University of Colorado, Boulder Oxford University Boulder, Colorado Oxford, United Kingdom Dipak Kumar Mitra, MBBS, MPH, PhD Ajay Pillarisetti, MPH, PhD Associate Professor of Epidemiology Lecturer and Postdoctoral Scholar School of Public Health Environmental Health Sciences Independent University, Bangladesh (IUB) University of California, Berkeley Dhaka, Bangladesh Berkeley, California Tolib Mirzoev, MD, MA, PGCertLTHE, PhD Jennifer Prah Ruger, BA, MA, MSc, PhD, MSL Associate Professor Amartya Sen Professor of Health Equity, Economics, Nuffield Centre for International Health and and Policy Development, Leeds Institute of Health Sciences School of Social Policy & Practice University of Leeds University of Pennsylvania Leeds, United Kingdom Philadelphia, Pennsylvania xiv Contributors M. Omar Rahman, MD, MPH, DSc Sarah Simpson Vice Chancellor and Dean Conjoint Lecturer School of Public Health UNSW Sydney Independent University, Bangladesh (IUB) Sydney, Australia Dhaka, Bangladesh Director Michael Kent Ranson, MD, MPH, PhD EquiACT Senior Economist (Health) Montluel, France The World Bank Washington, DC Kirk R. Smith, MPH, PhD Professor Global Environmental Health Arthur Reingold, MD University of California, Berkeley Professor and Division Head, Epidemiology and Berkeley, California Biostatistics School of Public Health Richard Smith, BA, MSc, PhD, HonMFPH University of California, Berkeley Professor of Health System Economics Berkeley, California Dean of Faculty of Public Health and Policy Eric Richardson London School of Hygiene and Associate Professor of Practice Tropical Medicine Department of Biomedical Engineering London, United Kingdom Duke University Durham, North Carolina Christine P. Stewart, MPH, PhD Associate Professor Rebecca Richards-Kortum, PhD Department of Nutrition Malcom Gillis University Professor Program in International and Community Nutrition Department of Bioengineering University of California, Davis Rice University Davis, California Houston, Texas Michael J. Toole, BMedSc, MBBS, DTM&H Sakib Rokadiya, MRCP, DTMH Principal Research Fellow Specialist Registrar in Infectious Diseases & General Burnet Institute Medicine Professor, School of Public Health Barts Health NHS Trust Monash University London, United Kingdom Melbourne, Australia Giuliano Russo Lecturer in Global Health Cesar G. Victora, MD, PhD Centre for Global Public Health Emeritus Professor of Epidemiology Queen Mary University of London Federal University of Pelotas in Brazil London, United Kingdom Pelotas, Brazil Susan C. Scrimshaw, PhD Ronald J. Waldman, MD, MPH Nevin Scrimshaw International Nutrition Professor of Global Health Foundation, Tufts University, & Former Milken Institute School of Public Health President of The Sage Colleges and The George Washington University of Simmons College Washington, DC Thornton, New Hampshire Keith P. West, Jr., DrPH, MPH Rima Shretta, MSc, PhD George G. Graham Professor, Infant and Child Associate Director Nutrition Malaria Elimination Initiative Department of International Health Global Health Group Bloomberg School of Public Health University of California, San Francisco Johns Hopkins University San Francisco, California Baltimore, Maryland  Contributors xv Harvey Whiteford, MBBS, MPH, PhD Alistair Woodward, MB BS, MMedSci, PhD, FNZCPHM Professor of Population Mental Health Professor Epidemiology and Biostatistics School of Public Health, The University of University of Auckland Queensland Auckland, New Zealand Brisbane, Australia Derek Yach, MBChB, MPH James Whitworth, MD, FMedSci Chief Health Officer Professor of International Public Health The Vitality Group London School of Hygiene & Tropical Medicine New York, New York London, United Kingdom  © Anton Balazh/Shutterstock About the Authors Michael H. Merson, MD, is the Wolfgang Joklik benefits of zinc supplements in prevention and treat- Professor of Global Health at Duke University. He ment of childhood diarrhea and pneumonia. His joined the Duke faculty in November 2006 as the other interests are related to the use of evidence in pol- founding director of the Duke Global Health Insti- icy and programs, including estimates of the causes of tute and served in that role through 2017. In addition, child mortality, the development of research capacity, Dr. Merson was Vice President and Vice Provost for and the strengthening of public health training. Global Affairs from 2011 until 2018, and Vice Chan- As a member of the U.S. National Academy of cellor for Duke-National University of Singapore Medicine and advisory bodies of the World Health Affairs from 2010 until 2016. Organization, the International Center for Diarrheal Dr. Merson has held leadership positions at the Diseases Research, Bangladesh, and other interna- Centers for Disease Control and Prevention and the tional organizations, Dr. Black assists with the devel- International Center for Diarrheal Diseases Research, opment of research and policies intended to improve Bangladesh; served as Director of the World Health child health. He chaired the Child Health and Nutri- Organization’s Diarrheal and Acute Respiratory Con- tion Research Initiative and serves on the governing trol Programs and Global Program on AIDS; and boards of Nutrition International and Vitamin Angels. was the first Dean of Public Health at Yale University. He has more than 700 scientific journal publications. Dr. Merson’s research and writings have been primar- Dr. Black is the recipient of the Programme for Global ily on the etiology of diarrheal diseases in low- and Paediatric Research Award for Outstanding Contri- middle-income countries, AIDS prevention and pol- butions to Global Child Health in 2010, the Prince icy, and academic global health. He has served as an Mahidol Award for Public Health in 2010, the Canada advisor to a number of international organizations and Gairdner Global Health Award in 2011, the Nutrition advisory bodies; is an elected member of the National Leadership Award from Sight and Life in 2013, and Academy of Medicine; and has received two honor- the Jimmy and Rosalynn Carter Humanitarian Award ary degrees and the U.S. Surgeon General’s Exemplary in 2016. Service Medal. Anne J. Mills, PhD, is Deputy Director and Provost Robert E. Black, MD, MPH, is Professor and Direc- of the London School of Hygiene & Tropical Medi- tor of the Institute for International Programs of the cine (LSHTM), and Professor of Health Economics Johns Hopkins Bloomberg School of Public Health in and Policy. She has degrees from Oxford University Baltimore, Maryland. Dr. Black is trained in medicine, (MA), Leeds University (Diploma), and London Uni- infectious diseases, and epidemiology. He has served versity (PhD). After two years as Overseas Develop- as a medical epidemiologist at the Centers for Disease ment Institute Fellow and Economist in the Ministry Control and Prevention and worked at institutions in of Health in Malawi, she spent three years at the Bangladesh and Peru on research related to childhood University of Leeds studying health planning in the infectious diseases and nutritional problems. He was National Health Service; she moved to the LSHTM Chair of the Department of International Health of in 1979. the Bloomberg School of Public Health from 1985 to Dr. Mills has researched and published widely 2013. in the fields of health economics and health systems Dr. Black’s current research includes field trials in low- and middle-income countries and continues of vaccines, micronutrients, and other interventions; to be involved in research on financial protection in effectiveness studies of health programs; and evalu- South Africa, Tanzania, India, and Thailand. She has ation of preventive and curative health service pro- had continuing involvement in supporting capac- grams in low- and middle-income countries. In the ity development in health economics in universities, last 20 years, he has led work that demonstrated the research institutes, and governments. She has been xvii xviii About the Authors involved in numerous policy initiatives, including Dr. Mills received the Prince Mahidol Award in the the World Health Organization’s Commission on field of medicine. In 2013, she was elected a Fellow of Macroeconomics and Health. She is a Foreign Asso- the Royal Society; and in 2015, she was made a Dame ciate of the U.S. Institute of Medicine and a Fellow in the Queen’s New Year’s Honours, for services to of the U.K. Academy of Medical Sciences. In 2009, international health.  © Anton Balazh/Shutterstock Foreword T he philosophy, skills, and knowledge essential of the environment. Evolution is evident in humanity’s for global health practice continue to improve responses to its global health problems. with experience. The objective, of course, is the No global health decision stands alone. Instead, improvement of health for everyone in the world, or such decisions are always dependent on political global health equity. The means to achieve that objec- decisions and compromises. It is difficult enough to tive require harnessing every resource and skill pos- gain agreement on a local level, where groups are sible in every country. When it comes to health, no acquainted and share many experiences. It is many country is more important than any other. times more difficult to achieve agreement across polit- The United States has direct experience with the ical and cultural divides. Global health workers are returns of global investment in health. When Pres- forced to learn diplomatic skills and to understand ident Lyndon Johnson provided funds for global the art of cross-cultural transactions. Despite such smallpox eradication in 1966, the United States had difficulties, some of my best professional memories not had a case of smallpox for 17 years. It would have involve meetings, discussions, and field activities been easy to say this was not an American problem. involving people of various cultures and languages. Yet the investment to eliminate smallpox in the rest Successful approaches thrive on the shared knowledge of the world had immediate financial benefits because of people with different life experiences. treating Americans with adverse effects caused by the For all of the improvements, there are, neverthe- vaccine was no longer necessary. We did not have to less, areas of concern. The rapid expansion of academic tolerate 6 to 8 deaths each year due to the vaccine. programs in global health presents practical problems And savings were realized in foreign quarantine pro- for students. We need more teachers who have actu- cedures as well. This country recoups its investment ally worked in resource-poor situations. I attended a in smallpox eradication every 3 months—more than superb tropical public health program 50 years ago, 150-fold, to date, and it will continue forever, an but not a single faculty member had actually lived in infinite ­benefit–cost ratio. tropical areas, although they were frequent consul- Because of the increasing number of global health tants to field programs. The training of pediatricians, programs, health benefits continue to accrue for every surgeons, or internists involves hands-on experiences. country. More than 35,000 deaths are averted each day Likewise, we need to increase the ability of students to in children younger than the age of 5, as compared to have problem-solving experiences in poor areas, while 60 years ago, when my interest in global health was they are still in school. kindled. In addition to smallpox, we stand at the brink This text also addresses the very real shortcomings of eradicating Guinea worm disease and polio. The of how global health is organized. We are often critical number of measles deaths has declined by more than of the World Health Organization (WHO) and other 95% and, according to the World Bank, 250,000 peo- agencies without acknowledging that we organized ple move out of poverty every day. It is a miraculous them to be dysfunctional. WHO has regional offices time for global health. that can undercut the WHO headquarters decisions And science marches on, in ways that promise because the United States insisted, 70 years ago, on even more benefits in the next decade. Immuniza- strong regional offices in its attempt to protect the Pan tion rates are improving, new vaccines are becoming American Health Organization. We imposed the bur- available, and the world is slowly moving to address den of 195 health ministers as WHO’s board of direc- chronic diseases, environmental health problems, and tors, and annually tell WHO to reduce its budget. Then injury control in larger geographic areas. Even the we condemn WHO for an inadequate response to the health problems associated with global warming now Ebola virus. It is time to ask what has been learned engage many countries, including the largest polluters in 70 years and how we can use that experience to xix xx Foreword improve our global organizations to better protect the departments in every country. Moreover, keeping health of all. people healthy helps to keep them productive. The Finally, WHO promoted primary health care world will not be a great place for any of us until it is at the Alma Ata conference 40 years ago, yet we a great place for all of us. are still struggling to implement village-level inter- Drs. Merson, Black, and Mills have again brought ventions and better understand the social deter- us a comprehensive text that helps to make sense of minants of health. This year the world will again an enlarging and challenging field. It is an enormously come together at a conference in Kazakhstan to valuable guide for students, teachers, practitioners, recommit to strengthening primary health care in and researchers alike, which helps to map out the jour- order to achieve universal health coverage and the neys of those who will change the future and make our Sustainable Development Goals. No risk factor is planet a healthier one. as great as poverty. Nevertheless, while progress is being made and the World Bank has championed William Foege the cause, deliberate action to reduce poverty is still Professor Emeritus, Rollins School of Public Health, an underdeveloped tool in the daily lives of health Emory University  © Anton Balazh/Shutterstock Introduction Michael H. Merson, Robert E. Black, and Anne J. Mills T he three of us are privileged to serve as faculty determinants of health and develop strategies that will at universities that provide education every year address these determinants, thereby sharing goals to to hundreds of graduate and undergraduate improve the health of populations. These disciplines students motivated to learn about global health issues and professional fields include social and behavioral and challenges. Many of these students plan to or have sciences (including sociology, economics, psychol- already begun careers in global health research, policy, ogy, anthropology, political science, and international practice, teaching, or administration. This text is writ- relations), biomedical and environmental sciences, ten for these students around the world, as well as for engineering, business and management, public policy, those who teach and mentor them. In this Introduc- law, history, and divinity. Furthermore, while efforts to tion, we define global health, provide a brief history reduce health disparities should focus on prevention, of the field, and summarize its many accomplishments treatment, care, and curative strategies must also be and challenges. We then explain how we put this Fourth addressed when developing solutions to global health Edition together and how we think it can best be used. challenges. This call for multipronged action further emphasizes the need for a multidisciplinary approach. ▸▸ What Is Global Health? In addition, while social justice must continue to be a central pillar of health, the approach to achiev- Global health is a burgeoning field, which has seen a ing health equity and finding solutions to reducing major surge of interest as an area of academic study in health disparities must now much more strongly the last decade. Essentially, global health has replaced emphasize global cooperation. Rather than following international public health in both concept and reality. a model that transfers ideas and resources from high-­ International public health focuses on the application income countries, organizations, or funding agencies of the principles of public health to health problems to low- and middle-income settings, it is imperative and challenges that affect low- and middle-income to pursue “a real partnership, a pooling of experience countries (LMICs) and to the complex array of global and knowledge, and a two-way flow between devel- and local determinants that influence them. Global oped and developing countries” when implementing health maintains this focus, but places much greater health interventions or programs (Koplan et al., 2009, emphasis on health issues that concern many coun- p. 1995). tries or that are affected greatly by transnational deter- Today we live in an increasingly connected world, minants, such as climate change or urbanization. but the challenges to reduce health disparities are This greater emphasis on the scope and location of considerable, and the tenets of global health provide health problems provides the opportunity to address a unique insight and strategic approach to addressing cross-border issues as well as domestic health dispari- them. Given this evolution in our thinking, there has ties in high-income countries. been an understandable interest in defining global While international public health primarily health. In 1997, the U.S. Institute of Medicine (IOM) applies the principles of public health, there is now released a report that broadly defined global health agreement that success and progress in improving as “health problems, issues, and concerns that tran- health around the world requires a multidisciplinary scend national boundaries, may be influenced by cir- and interdisciplinary approach that includes, yet cumstances or experiences in other countries, and are extends beyond, public health. Professionals from best addressed by cooperative actions and solutions” many disciplines and academic fields possess the skills (Board on International Health, 1997, p. 1). More than and knowledge needed to understand the various 10 years later, IOM amended its definition, describing xxi xxii Introduction global health “not just as a state but also as the goal of helps to draw out global health’s distinctive qualities. improving health for all people by reducing avoidable (EXHIBIT I-1). disease, disabilities, and deaths” (Committee on the U.S. Commitment to Global Health, 2009, p. 5). Although a number of other definitions for global ▸▸ A Brief History of Global Health health have been proposed, we prefer the definition of global health that was adopted by the Consortium of Tracing the roots of global health brings us to the Universities for Global Health (CUGH). CUGH was history of international public health. This history formed to promote, facilitate, and enhance the growth encompasses the origins of public health and can be of global health as an academic field of study. It has viewed as the story of how populations experience defined global health as follows: health and illness; how social, economic, and polit- ical systems create the possibilities for healthy or [A]n area for study, research, and practice unhealthy lives; how societies create the preconditions that places a priority on improving health for the production and transmission of disease; and and achieving equity in health for all people how people, both as individuals and as social groups, worldwide. Global health emphasizes trans- attempt to promote their own health or avoid illness national health issues, determinants, and (Rosen & Morman, 1993). A number of authors have solutions; involves many disciplines within documented this history (Arnold, 1988; Basch, 1999; and beyond the health sciences and promotes Leff & Leff, 1958; Rosen & Morman, 1993; Winslow & interdisciplinary collaboration; and is a syn- Hallock, 1933). A brief history is presented here pri- thesis of population-based prevention with marily to provide a perspective for the challenges that individual-level clinical care. (Koplan et al., face us today (EXHIBIT I-2). 2009, p. 1995) When providing this definition, an effort was The Origins of Public Health made to explain the differences between public health, It is difficult to select a date for the origins of the field international health, and global health. While these of public health. Some would begin with Hippocrates, terms certainly share areas of overlap, this comparison whose book Airs, Waters, and Places, published around EXHIBIT I-1 Global Health, International Health, and Public Health Global Health International Health Public Health Focuses on issues that directly or Focuses on health issues of countries Focuses on issues that impact indirectly impact health but can other than one’s own, especially the health of the population of a transcend national boundaries. those of LMICs. particular community or nation. Development and implementation Development and implementation Development and implementation of solutions often require global of solutions usually involve of solutions usually do not involve cooperation. binational cooperation. global cooperation. Embraces both prevention in Embraces both prevention in Mainly focused on prevention populations and clinical care of populations and clinical care of programs for populations. individuals. individuals. Health equity among nations and for Seeks to help people of other Health equity within a nation or all people is a major objective. nations. community is a major objective. Highly interdisciplinary and Embraces but has not emphasized Encourages multidisciplinary multidisciplinary within and beyond multidisciplinarity. approaches, particularly within health sciences. health sciences and with social sciences.  A Brief History of Global Health xxiii EXHIBIT I-2 History of Global Health: A Summary 400 BC: Hippocrates presents the causal relationship between environment and disease. First century AD: Romans introduce public sanitation and organize a water supply system. 14th century: The “Black Death” (bubonic plague) leads to quarantine and cordon sanitaire. Middle Ages: Colonial expansion spreads infectious diseases around the world. 1750–1850: The Industrial Revolution results in extensive health and social improvements in cities in Europe and the United States. 1850–1910: Knowledge about the causes and transmission of communicable diseases is greatly expanded. 1910–1945: Significant reductions in child mortality occur. Schools of public health and international foundations and intergovernmental agencies interested in public health are established. 1945–1990: The World Bank, World Health Organization (WHO), and other United Nations agencies are created. WHO eradicates smallpox. The Alma Ata conference gives emphasis to primary health care. The HIV/AIDS pandemic begins. The United Nations Children’s Fund (UNICEF) leads efforts to ensure universal childhood immunization. Greater attention is given to noncommunicable diseases (NCDs). 1990–2000: Priority is given to health-sector reform, the impact of and responses to globalization, cost-effectiveness, and public–private partnerships in health. 2000–2010: Priority is given to equity, social determinants of health, health and development, use of innovative information and communications technologies, declaration of the Millennium Development Goals (MDGs), and response to influenza. 2010–2020: Priority is given to climate change’s impact on health, growing burden of NCDs, increasing threat of emerging and re-emerging diseases, global health security, universal health coverage, proliferation of innovative technologies for delivery of prevention and care services, and the declaration of the Sustainable Development Goals (SDGs). 400 BC, was the first systematic effort to present the and other institutions to provide medical care and causal relationships between environmental factors social assistance. At the same time, many European and disease and offer a theoretical basis for an under- countries began to expand their horizons abroad, standing of endemic and epidemic diseases. Others by exploring and colonizing new lands. The travel- would cite the introduction of public sanitation and ers brought some diseases with them (e.g., influenza, an organized water supply system by the Romans in measles, smallpox), and those who settled in these the first century AD. Many would select the bubonic colonial outposts were forced to confront diseases plague (“Black Death”) pandemic of the 14th century, that had never been seen in Europe (such as syphi- which began in Central Asia; was carried on ships to lis, dysentery, malaria, and sleeping sickness). Euro- Constantinople, Genoa, and other European ports; pean explorers also carried pathogens from one part and then spread inland, killing 25 million persons of Africa to another, and from one area of the globe to in Europe alone. In responding to this devastating another (e.g., from Africa to North America through infectious disease, the Great Council of the city of the slave trade). On long voyages, the greatest enemy Ragusa (now Dubrovnik, Croatia) followed a conta- of the sailor was often scurvy—at least until 1875, gion theory, which recommended the separation of when the British government issued its famous order healthy and sick populations; it issued a document that all men-of-war should carry a supply of lemon stating that outsiders entering the city must spend juice as a preventive measure. 30 days in the restricted location of nearby islands The Age of Enlightenment (1750–1830) was a piv- (Stuard & NetLibrary, 1992). The length of time for otal period in the evolution of public health. It was a this isolation period, dubbed trentino, was eventually time of social action in relation to health, as reflected increased from 30 to 40 days, introducing the con- by the new interest taken in the health problems of cept of the modern quarantine (Gensini, Yacoub, & specific population groups. During this period, rapid Conti, 2004). advances in technology led to the development of fac- The Middle Ages was also the period when many tories. In England and elsewhere, this industrialization cities in Europe, particularly through the formation was paralleled by expansion of the coal mines. The of guilds, took an active part in establishing hospitals Industrial Revolution had arrived. During this period, xxiv Introduction sanitaire the populations of the cities of England and communicable diseases were discovered in laborato- other industrialized nations grew enormously, with ries in North America and Europe. The development overcrowded, unsanitary conditions in these urban of this knowledge base was paralleled by related dis- areas leading to outbreaks of cholera and other epi- coveries in the sciences of physiology, metabolism, demic diseases, which ultimately resulted in high rates endocrinology, and nutrition. Dramatic decreases of child mortality. Near the end of this period, signif- were soon seen in child and adult mortality thanks to icant efforts were made to address these problems. improvements in social and economic conditions, dis- Improvements were made in urban water supplies and covery of vaccines, and implementation of programs sewerage systems, municipal hospitals arose through- in health education. The way was now clear for the out cities in Europe and the east coast of the United development of public health administration based on States, laws were enacted limiting children’s ability to a scientific understanding of the principles involved in work, and data on deaths and births began to be sys- the transmission of communicable diseases. tematically collected in many places. The first two decades of the 20th century wit- As industrialization continued, it became obvious nessed the establishment of three formal intergovern- that more efforts to protect the health of the public mental public health bodies: the International Sanitary were needed. These changes occurred first in England, Bureau to serve nations in the western hemisphere regarded as the first modern industrial country, (in 1904); l’Office Internationale d’Hygiene Publique through the efforts of the noted social reformer Edwin in Paris, which was concerned with prevention and Chadwick. Beginning in 1832, he headed up the royal control of the main quarantinable diseases (in 1909); Poor Law Commission, which undertook an extensive and the League of Nations Health Office (LNHO) in survey of health and sanitation conditions throughout Geneva, Switzerland, which provided assistance to the country. The work of this commission led in 1848 countries on technical matters related to health (in to the Public Health Act, which created a General 1920). In 1926, LNHO commenced publication of Board of Health that was empowered to appoint local Weekly Epidemiological Record, which evolved into a boards of health and medical officers of health to deal weekly publication of the World Health Organization effectively with public health problems. The impact of (WHO) and still is published today. LNHO also estab- these developments was felt throughout Europe and lished many scientific and technical commissions, especially in the United States, where it stimulated cre- issued reports on the status of many infectious and ation of health departments in many cities and states. chronic diseases, and sent its staff around the world Cholera, which in the first half of the 19th to assist national governments in dealing with their ­century spread in waves from South Asia to the Mid- health problems. dle East and then to Europe and the United States, In North America and countries in Europe, the did the most to stimulate the formal international- explosion of scientific knowledge in the latter part of ization of public health. The policy of establishing a the 19th century and the belief that social problems cordon ­sanitaire—­an action applied by many Euro- could be solved stimulated universities, such as Johns pean nations in an effort to control the disease—had Hopkins, to establish schools of public health. In become a major restraint on trade, necessitating an France, public subscriptions helped to fund the Insti- international agreement. In 1851, the First Interna- tut Pasteur (named in honor of Louis Pasteur) in Paris, tional Sanitary Conference was convened in Paris to which subsequently developed a network of institutes discuss the role of quarantine in the control of cholera, throughout the francophone world that produced sera plague and yellow fever, which were causing epidem- and vaccines and conducted research on a wide variety ics throughout Europe. Although no real agreement of tropical diseases. Another significant development was reached, the conference laid the foundations for during this period was the founding of the Rockefel- international cooperation in health. ler Foundation (in 1909) and its International Health The latter part of the 19th century was distin- Commission (in 1913). During its 38 years of opera- guished by the enormous growth of knowledge in tion, the commission cooperated with many govern- the area of microbiology, as exemplified by Louis ments in campaigns against endemic diseases such as Pasteur’s proof of the germ theory of disease, Robert hookworm, malaria, and yellow fever. The Rockefeller Koch’s discovery of the tubercle bacillus, and Walter Foundation also provided essential financial support Reed’s demonstration of the role of the mosquito in to help establish medical and public health schools transmitting yellow fever. Between 1880 and 1910, the around the world; and later international health etiologic causes and means of transmission of many programs in a number of American and European  A Brief History of Global Health xxv schools of medicine and public health. All of these eliminated the disease in 1981 and stimulated the developments were paralleled by the development and establishment of the Expanded Program on Immu- strengthening of competencies in public health among nization, which focused on the delivery of effective the militaries of the United States and the countries vaccines to infants. Also, during the 1970s, two large of Europe, stimulated in great part by the buildup to international research programs were initiated under and realities of World War I. Following the war, there the co-sponsorship of various United Nations agen- was increasing recognition that much ill health in the cies: The Special Program for Research on Human colonial world was not easily solvable with medical Reproduction (focusing on development and testing interventions alone, but rather was intractably linked of new contraceptive technologies) and the Tropical to malnutrition and poverty. Disease Research Program (providing support for the Some historians would date the beginning of development of better means of diagnosis, treatment, international public health to the end of World War II. and prevention of six tropical diseases, including The ending of European colonialism, the need to malaria). Greater attention also was gradually given reconstruct the economies of the United States and the to chronic diseases, commonly known as noncom- countries of Western Europe, and the rapid emergence municable diseases (NCDs), such as cardiovascular of newly independent countries in Africa and Asia and cerebrovascular diseases and cancer. were all forces that led to the creation of many new In 1978, WHO organized a conference in Alma intergovernmental organizations. The United Nations Ata in the former Soviet Union that prioritized the Monetary and Financial Conference, held in Bretton delivery of primary healthcare services and set the goal Woods, New Hampshire, in 1944 and attended by rep- of “health for all by the year 2000.” Rather than focus- resentatives from 43 countries, resulted in the estab- ing solely on control of specific diseases, this confer- lishment of the International Bank for Reconstruction ence called for international efforts to strengthen the and Development (more commonly known as the capacities of LMICs to extend their health services World Bank) and the International Monetary Fund. to populations with poor access to prevention and The former initially lent money to countries only at care. The concerns of tropical medicine, which were prevailing market interest rates, but in 1960 it began to concentrated on the infectious diseases of warm cli- provide loans to poorer countries at much lower inter- mates, were replaced by an emphasis on the provision est rates and with far better terms through its Interna- of health services to reduce morbidity and premature tional Development Association. It was not until the mortality in resource-poor settings (De Cock, Lucas, early 1980s, however, that the World Bank began to Mabey, & Parry, 1995). Given the limited financial and accelerate greatly its provision of loans to countries for managerial capacities of many governments, increased programs in health and education. By the end of that attention was paid to the role of nongovernmental decade, these loans had become the greatest source of organizations (NGOs) in providing these services. foreign assistance to LMICs (Ruger, 2005). As a result, many mission hospitals, particularly in In the decade after World War II, many other sub-Saharan Africa, expanded their activities in their United Nations organizations (e.g., UNICEF) and local communities, the number of local NGOs began specialized agencies (such as WHO) were formed to to increase, and a number of international NGOs (e.g., assist countries in strengthening their health, social, Save the Children, Oxfam, Médecins Sans Frontières) and economic sectors. In addition, most of the wealth- greatly expanded their services, often with support ier industrialized countries established agencies or from bilateral agencies. Disease-specific efforts—most bureaus that funded bilateral projects in specific notably UNICEF’s Child Survival Program, with its LMICs. Among the historical colonial powers, such acronym GOBI (growth charts, oral rehydration, assistance was most often provided to their former breastfeeding, immunization) and its goal of univer- colonies. sal childhood immunization by 1990—were seen by Many of the international health efforts in the many as programs that both focused on specific health 1960s and 1970s were dedicated to the control of spe- problems and provided a means of strengthening cific diseases. A global effort to control malaria was health systems. hampered by a number of operational and technical The emergence of what is sometimes called difficulties, including the vector’s increasing resis- “the new public health” was heralded by the Ottawa tance to insecticides and the parasite’s resistance to Charter of 1986, which was meant to provide a plan available antimalarial drugs. In contrast, the cam- of action to achieve the “health for all” targets set paign to eradicate smallpox, led by WHO, successfully forth at Alma Ata. The Ottawa Charter pioneered the xxvi Introduction definition of health as a resource for development, on health-sector reform, cost-effectiveness as an rather than merely a desirable outcome of develop- important principle in the choice of interventions, and ment. The prerequisites for health that were outlined public–private partnerships in health, paralleled by a in the charter were diverse and included peace, shelter, rapid expansion of innovative technologies. education, food, income, a stable ecosystem, sustain- Although rising incomes have long been known able resources, social justice, and equity. Moreover, the to improve health status, increased attention has been charter emphasized the importance of structural fac- paid to the relationship between health and pov- tors that affect health on a societal level, rather than erty, and the importance of a healthy population for focusing only on the risk behaviors of individuals. It achieving economic development. Participation of called on the worldwide health community to address sectors other than the health sector is now viewed health disparities by engaging and enabling peo- as essential for achieving a healthy population. More ple to take charge of their health at community and and more countries are experiencing the demographic ­policy-making levels. This shift from a “risk behavior” transition to societies with rapidly increasing num- focus to an emphasis on “risk environment” contin- bers of middle-aged and older adults, and in turn are ues to resonate in contemporary public health practice being challenged with providing preventive and care and research. services that address health problems of both the poor One hugely influential development in the 1980s and the wealthy simultaneously. Increasing life expec- was the onset of the human immunodeficiency virus tancy, urbanization, and resultant changing lifestyles (HIV)/acquired immunodeficiency syndrome (AIDS) have contributed to an ever-increasing burden of pandemic. By the time a simple laboratory test to NCDs. India and China, for example, now have high detect HIV was discovered in 1985,