W4R Ess.Ch.1 - ——t—.——._.— LHHHINI: {Intent-:5...

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Unformatted text preview: ——t—.——._.— LHHHINI: {Intent-:5 By the ""1 at this rhapler [he reader will. b;- ahlt- In: I [Jellrlt' Hu— ll‘lm'. Jrlrel'l'n {mt-n; metre. .‘et'td cine-e: 1r.-.;'.r.l- * flfil't-n'. '.:!n‘1'-t' I‘IIII'I:FIII"'.- ttf p_th||| |1|-.t|t|- r'il'enl. 1' i]'i‘.r'.'.'.‘. '.-:Irlit‘ exam-pic, ui gin; LIJI hugull _1e_".'..'.‘_-p-_ I :Jl'L-LH‘LH' LU'IIe ut the neatllnq [.II'II'I1'I1_I!4'-':. rt! publ-t 1.“:3- Her. I ii'i'tf'tblt Um M1l|t~r||1|..n- [:Ir.--.-|-|.t|p|1'n-".'. t;:-..I|.-. .:'::: :I'I'll rn:_1'.'-'_'tt '.n tJIe-Lml hes-HE: I Etiefie dltrn'n. the glut-.1: er'1en'. tc- t‘lfldltflir :r't.1||:te: UIGNEITES l-tut'il.‘ .‘iittitlt ilreti 1n l‘ttrtentuulh. ‘t’lrgtnm. ||'| The l'mred States. She we: fit-Er Iveers. ttlti and had alt-Mfr: bee-It iteditit'~' l.t.l.1 tt'trt'hertll. 'ai'tt.‘ tt‘ltiit' up with at he‘dt‘iitt'itp .: high fever: .ntd .I. very s-tij't' Tied-1. [ALH'iE' were he: -_'-:i:_J-c that she went to “if filflCTEI-‘nf'i' Tt'rfil'n I'd the lit-mi ilt‘rbpflai. ']'!'.-::' phrstemns tlittgnte-ed laurie .15 hat-lug, :tteningitis. .1n inflammatiutt t-r' IhL‘ ITI'PI'I'III'H'i’Hlt" .tmuttd the brain and spine] card: that we:- I .Ilteeri h}- ‘t't’eet Nile virus. This rims ntigtnetet’i lJi ligjrpt 1:1 Ihe Ifififle ttttd ES transmitted [13' a mosquito. Over d. number nr' tit-tallest West “Nile Tint“? spread I'mm Egret It: the Middle 3315-1. Fit-rim. end :‘tfiia. In 1999., [he fired ease: appeared in The l-‘nited Statea, L’tl'lLi it :5 new: flaunt] throughout the L'ntted States. 35 Shawn in Figure 1- 1. H1.‘ 2W5. pull“ was on the verge at being erndieated trnn: every enurttry. Tl'lfl! t'e.tr. hmt'eter. mmun circulated ||| Itnrthern Nigerla thrtt the pniio K'HLLmL' was causing: star Iltmtlltm. [I'I rest‘lmtae I0 theae runture. some entnntunilt' leaders discnuraeed penpie 1-1:.1tn immunizing their children. "-"I"I1|1In r'l'll'l'ltliih. thJIIJ eafies began tn appear tn the .lred CHAPTER 1 \hurtlp' lltt-reJIter. [MIH'I hue-rt hpremi tluttt I1ur1hertt Nieetia I1: hlJIIJI'I. Tettlett. .ttttl ||11I111u--,id_ '11“: Hlulul L;t|:|t|1.1_jgu 1n er.nht.ttt' t'ntiiu had lu'en slurttlttlmen-1'Illtlw..-.It-|11minepartly trnn‘. HJIHHH In IHI1‘ |-.|Hi['ltr‘_r'.l.i‘lt1Lt1lilt'.t“;’He’I.|.‘.-ltl.r.' erl'eerl. “I The tuttt'mef '-i-t'l.5tJ]t"-~' t5. .1 ltJ-fp'eJr 1..||.|.| FlIJitlpmu wit]: III't’. IIi-t die- ed-e: er .ul‘u'etttt'd. i111! lte I't'tt'wen nu treatment I'nr It. He has tubertuit'lm I'J'Hf- MK! II'IIIL-t'it Ui |1I.'i rnnttlh In. etmted with .1 winte. pean- 'rI-.'.l\|. t.tlied lilrllrtit. He ]t.t.-: Inst nture 1|1m] ltJI'Ji'J mt hit but}? weight He Flh'll'lr-IL‘LI. gmrtg In tenth fitflrtlt‘ tttlte 45H.il-iwt'nlIt!-'«r]r:'...l[1tiifituilil'gr' tiej‘lentlrttt tm hi: Ltmily tut Late .H'lLi dey-tu-de)‘ needs. tiemehew :3 um- t:1'.:|muL 1.? mi!— JIUI] [H.‘UPII: It‘- iithinpla With HUI-"f [tt litet. itt MUS uhttttt 3U rstiiit-nn [emf-1e were iit'ing with HW teurldwide_-' The-1;- .tru Ctrut‘attief‘ in Aime. nttt'h .15 flute.th .tt'lrl Leenti‘tel. ll'l witieit .tht'r'tlt .13":- I'rT [iteir ttduite are H W pneitiee and Sw;w,i|5.utti. jn winch .alntest tr terd of the adult-t are HI‘t" pelfiiti'ee.“ 'l'iltere .m- \Lt-IJ'JIIJUHILi-L‘i In Africa in which IFIUITI.‘ teachers are tiring Linn are being train-ed. There are terms in the same areas; that earth-rut he cared For because there are ttttt tew healthy-r Etrtn “writ-3.". Same (thrtttnunitiee .tre collapsing fineiaiit' and em- nt-t11i{.t]l}' i-EIJIII'I the burden rtt'Hll‘Ier and Hi't' E‘Ofiea a threat ttt 5efurttv Il'lreugheut the 'n't‘n'id. Hm Smith i} e high sehnn] etudent in Lundun. Enginnd. Earh; in the :ehnn1 year. he had a fever and enugh that tenuhi nnt 3n .twet'. He did nut feet like eating. He elept bed-Ir and woke ttp every: morning in :1 sweet. Ith itttd T13. .‘tlt'flfilltflt rTlflIJ'I' peep]: tltinE-t that TH her- been eliminated I'mrrs high-income countries. it hm; 1It11. Rather, the hpreed Hf J il‘k' 11.3.5 triggered .1n increatee in 1 it wttrldmde. ]rt :tt'irli- tlrm. II't‘Httieralit‘IH i5 helping in spread the dieease frmtt Iowerdnrorne to higher-income countries. In fact, there are urban areas of the United Kingdom in wide]: the rates of Ti!- are higher than the rates in some low- and middleiincomc en utttries.T WHY STUDY GLfiBAL HEALTH Over the last lift}I years. the world has made significant prog- rEss in improving human health. Since 19513. for mmple. the death rate of children under five years has fallen from 143 deaths per lflflfl children to fewer than 5t} deaths per 1000 children. During that same period. the average life expectancy in developing oountrles has htcreased from all years to so years." Smallpox has been eradicated. polio has been nearly eliminated. and great progress has been made in reducing the burden of vane—preventable diseases in chil— dren and of parasitic infections, such as guinea worm. One reason to stud}r global health is to gain a better understand— ing of the progress rnade so far in addressing global health problems. Another reason to study global health. howexer. is to understood hetter the most important global health chal- lenges that remain and what must he done to address them most effectively. Despite the important progress in improv- ing human health: I mono babies die every do}.r in the Iworld before they are four weeks Ittltil'JI - 5291004: women a year die in childbirth" 1- More than film children die every year of naeaaleam I 1.15 million profile die in the world every year ofTB” In addition, the world is shrinking and the health of people everywhere must he of concern to all of us. This ispar- tieularljr important lie-canoe many diseases are not lil'nittttit by national boundariea Tolaenculosist HIV, and polio. For exam‘ ple. can spread from one country to the men Dengue fe'rer Ire-ted to be concentrated in Southeast Asia but cases are not-tr seen in many more countries as shown in Figure IQ.“ The ‘arn'an do“ first appeared in East Asia bar it. too. is spreading to other regions. Ten years ago. no one in the neighborth of Laurie. mentioned in the 1tigeette. ever thought of getting West Nile virus. Besides the central global health challenges noted show. there are also exceptional disparities in the health of some groups compared to the health of others. Life expec- tancy in Japan. for example. is about 82 years but it is only 51 years in Haiti.u In addition. there are a number of life saving technologies that have been used in high-income countries for many years that are not yet in use in Ion-- income countries. such as the hepatitis B vaccine. In fact. the preyiotis points raise important ethical and humanitar- ian questions about the estertt to which people everywhere Should be concerned about disparities in access to health services and in health status. The important link between health and development is another reason to pay partintlar attention to global health. Poor health of tnothers is linked to poor health ofbalties and the failure of children to reach their full ntental and physical potential. in addition. ill health of children can delay their entry into school and can affect their attendance at school. their performance in school. and. therefore. their future economic prospects. Lhauntries with malor health problems. such as high rates of malaria or HW. have difficulty attractth the investments needed to develop their economy. Moreover. having large numbers ofbadly nourished. unhealthy, and ill- educaled people in any country is destabilizing and a health. economic. and security threat to all countries. The nature of many global health concerns and the need for different actors to work together to address thetn are more reasons why we should be concemed with global health. Although locally relevant solutions are needed to address most health problems. some health issues can only be solved using a global approach. In addition. some problems. such as ensuring access to drugs to treat HW. require more financial resources than any individual country can provide. litill other global health issues require technical cooperation across countries because few countries themselves have the technical capacity to deal with them. Global cooperation might be needed. for example. to estahlish standards for drug safety. to set protocols for the treatment of certain health problems. such as malaria. or to develop an MUS vaccine that could serve the needs of low-income countries. The concepts and concerns of global health are also becoming increasingly prominent worldwide. The spread of E Areas Infutedu-ith Andes eeypb‘ - hearted: Met negotiate-eldeth epidemic aetletnr '. - 'FI'I- rlI'Ir ' so Gnarls of Global Health Hill. the SARS scare. and the fear of the avian flu have alt brought attention to global health. fits you Will read about later in the bottlt. the advocacy efforts of Doctors Without llorders and the rock star Bonn. the establishment of lltc Millennium Development Goals, and the philanthmpy of the Bill at Melinda Gates Foundation have also dramatically raised attention to global health. The topic has become so important that there is a push in many universities tlirough- out the world to ensure that all students have a basic under- standing of key global health issues. HEALTH, PUBLIE HEALTH, AND GLDBAL HEALTH Health 'Hefore starting our review of global health in greater detail. it will be helpful to establish a set of definitions for health. path lie health. and global health that can he used throughout this ltoolt. Most of us thinlt of "health" from our individual per- spective as "not luring sittlt." The World Health Urgentrsitiun. however. set out a broader definition of health in 1943 that is still widely used: "Health is a state of complete physical. men- tal and social Well-lmltlfl and not merely the absence of disease or infirmity."1 This is the delinilion ol'"liea1l.l:t" used in this book. Public Health While the WHt't eoncept of "ht-alth" refers first to inch. vitluals. this hook is mostly about “public health" and the health of populations. C.E..-'t. Winslow. considered to be the founder of modern public health in the United States. formulated a definition of public health in I'll}! that is still commonly.r used today. in his definition. public health is: - I a - i - 'I‘be-prom‘otion-oflamyfledga” " um tolerates: ' . the-we - 'roiarm'uresniioesfiiHM.. _ fo- . . . the science and the art ofpreven ting disease. prolonging life. and promoting physical health and mental health and efficiency through orga- Itittcd community efforts toward a sanitary envi- ronment; the control of community infections: the education of the individual in principles of personal hygiene: the urganiration of medical and nursing service for the early diagnosis and treatment of disease: and the development of the social machinery to ensure to every indi- vidual in the community a standard of living adequate lor the maintenance of health. “' According to Winslcnv's definition. some examplesofpuhlic health activities would include the developn'ient of .1 campaign to promote child ianntuiiiratiori iii a particular country. an effort to get people in a city to use seat belts when they drive. and actions to get rlctrple in a specific setting to eat healthier treads and to stop smoking, in .aidition. most levels of piveriiment also carry out certain public health functions. Theat- include the management of a. puth health clinic. the operation of a public health labora— tory. and the numtenarice of a disease surveillance system. tlther examples are shtnvn in Table l- I . 'liiere are a number of guiding principles to the practice of public health That have been articulated. for example. by the .‘Lfllttlltitlfl Public l'lcalth Assaeiation in itsr "Public Health limit! of Ethics.""' These principles focus on prevention of disuse. respect for the rights of individuals. and a commitr nient to developing public health efforts in conjunction with communities. They also highlight the need to pay particular attention to disenfranchised people and communities and to working in public health on the basis of data and evidence. In addition. they note the importance of taking account of a wide range of disciplines and appreciation for the lollies. beliefi. and cultures ofcliverse grouper. Finally. they put con— siderable emphasis on engaging in public health. practice in a way that “enhances the physical and social environment" and that builds on collaborations across public health actors. These themes are at the foundation of this book and will recur throughout it. Many people confuse "public health" and "medicine." although they have quite different approaches. Table 1—2 outlines these tlilll'erenees.‘= To a large extent. the biggest dif— ference between the medical approach and the public health approach is the focus in public healdr on the health of pop ula— tictns rather than on the health of indisiduals. Exaggerating somewhat for cilia. we could say. for example. that a phy— '-Iiciltt cans for an individual patient whom he irnn'iunircs Disease prevention and hunt: penetration tar Disease diagnosis. treatment. and care hummuoltles for individuals ll'mdspearomtiutmpurgetthemfimnment. En’aphlailnnmflllnlm hum-In belie-ion “Entries and medical care Source.- Modified aim; Hollth. lib-mu. HSl'l'It met-indium Bmeen Public Health and Medicine. hwdahle lit unweth. own-WW-m Mae 1?. mos. against a particular disease. while a public health specialist is .‘i-onte examples of Important global health concerns lllv'tti‘l'ftt'l focus on how Uttc ensures that the whole colttntunilft' would include: the [actors that contribute to women (lying gets vaccinated. i't phs-siciaat will counsel an individual patient of pregnancsurelaled causes in so many countries: the on the need to exereise and avoid obesity: 4 public health sper exceptional amount of malnutrition among young children. citIIist 1will wort: with a program meant to help a communin capo:tu in South Asia and Africa; the burden of different stas' itI.tl'l'-tt:lt:t'ltl1i-I active tu a'r‘oid obesity. In addition. there are infectious and non-communicable dismees wurldwitlc and branches of public health. such as epidflniflittg't‘. that form what can be done In control those diseases. The impact of specifically on studying patterns and causes of disease in the environment on health globally and the effects of natural specific pupuiatioos and the application of this information disasters and conflicts are 3131: important to global health. to controlling health problems." Finally, we should note the flther significant global health issues inciude honr countries exceptional attention which public health approaches patr In can organize and manage their health systems to enable the prevention ofhealth problems. heaithicst population they can attain with the resources avail- Elolial Health What catacth is glohol' health? The United States Institute of Medicine defined global health as “health problems, issues. and concerns that transcend national boundaries and mag.- best be addressed by cooperative actions . _ _"" It The lsifit rates of death another group defined what we would now call global 553 health as “the application of the principles of public hesith ' Masksth flu” to health problems and challenges that transcend national mmdmnnhm'wmmmn iniundaa-ias and to the complex array of global aod local ' mm "fHTVl‘P‘EE-‘EW forces that afiect them."“‘ "1mm mm“ also important point cooceming the stud? of global Tn ' health is that it implies that one considers health problems MM i from a global perspective. rather than from the point ofview moms .' of antr inditriduai country. In addition, the phrase “global hmmmumm _ health” implies that countries work together not only to mm ': understand critical health issues but also to solve them- To a large extent. the expression “global health" has replaced the '_ terrn “international health."“ Goals of Global Health able to them: the search for new technologies to improve important global health problems: and. how different actors can worh together to solve health problems that are too significant for auv countrv or actor to solve on their own. Another global health matter oi importance would he the relationship hetween globalization and the health ol'dil’l'erent communities. Someadditinnal global health issues ot'unput- t-ance are shown in Table l 3. CRITICAL GLDBAL HEALTH CDNCEPTS In order to understand and to help address he; glottal health issues. like those noted previously. tltere are .1 number ol concepts concerning global health With which one must he litmiliar. liottte til the most Important include: I Tlte delet'n'tit'tattts of health I The measurement ltl—l'l-t'dllll states I The itttput'tance of culture to health I- The glottal hurdcn of disease l The lteji' tislc Factors for different health conditions IIII The demographic and epidemic-logic transitions I The organization and functions nt- health s‘lr'stems It is also essential to understand the links between health and education and health. equity. povertv. and development. Eluiltlinpr tilt the pres-ions concepts. those interested Ill. global health also need to have an understanding ofhnw he}- health iraaies ail-eel different parts of the world and the world as a Whole. These include: - Environmental health 1 Nutrition I Reproductive health I llChild health 'I Infectious diseases I Hon—communicable diseases I Injuries Finally. it is important to understand glol'utl health issues that are generally.t addressed through cooperation. Some of these mncern conflicts. natural disasters. and humanitarian emergen- cies. Others relate to the medianisms in which different actors in global health activities snarl-t together to solve global health problems. Harnessing. the power of science and technology to serve global health needs also reclaim cooperation THE UBJECTI‘JES BF THE EDDK This book aims to introduce readers. in a clear and simple manner. to the most important issues and concepts related to global health. as outlined previously. It provides an introduc- tion to global health for people who have little or no previous exposure to this field. At the same time. it is intended to set a foundation for those who rnav pursue additional course erotic and professional activities in public health. global health. medicine. or development. THE DRGAHIIATIIJH 0F THE EDGE This hmlc is organised in several parts thal close-iv follow the topics mentioned previouslv. Part l introduces the reader to the basic principles of glolttll health. he?! I'llt'tltttll'fla til health. and the concepts of the health and the development lint. tiltattter t introduces readers to some kev principles. themes. and goals of global health. lihapter .‘-.‘ cit-amines the determinant. til" health. how health is ttieasuretli. and how health condtttous change over ttttte and .15 countries develop eti'innmicallp. (:hnpler .‘u looks it! ll‘tt.‘ l'lllultb l'ltlth'tlll ltthtlllt and development. teiuc'l'ttttl."r upon the cnrtntac'titins hetweett health and education. count. and poverty. l'att ll revues-vs cross-cutting. themes in pitthal health. tfhapter 4 examines human rights and ethical issues itt glulial health. t'iliapter it covers ltealth :t'r'steil'lai. This chapter reviews the putp-ttse and goals of health systems and how different countries have organised their health systems. The chapter also reviews the he; challenges that health ss‘stettts titce. the costs and consequences of those challenges. and ltfl'ln' :iIEIlfllE countries have addressed health system challenges. Culture plavs an extremer important part in health. and Chapter ti examines the links between culture and health. This dtnpler reviews the importance of culture to health. how health is perceived in different groups. the manner in Iwhich different culture groups seelc health care and engage in health prac- tices. and how one can promote change in health behavior. Part III reviews the most important causes of illness. disability. and death. particularly in low- and middle—income countries. The chapters in this part of the book will examine environmental issues. nutrition. reproductive health. and child health. The book then looks at infectious diseases. non— communicable diseases. attd unintentional injuries. Part 1T total-nines hotv cooperative action can address global health issues. Chapter l-l reviews the impact on health of conflicts. nannal disasters. and other health emergencies. Chapter ‘1 5 examines how different actors in the global health field work both individually and cooperativelv to address key global health problems. Finally. Chapter lo reviews how sci- ence and technology have helped to improve public health and how further advances in science and technologv could help to address some of the most important global health challenges that remain. Each chapter follows a similar outline. The chapters begin with vignettes that relate to the topic to he covered and wl-tich are intended to matte the topic “real” for the reader. Some of these vignettes are not true in the literal sense. However. each of them is based on real events that occur regularly in the countries discussed in thts book. Most chapters then explain ltey concepts. terms. and definitions. The chapters that deal with cross-cutting issues in the scennd and fourth parts of the hook tl‘ten examine the importance of the mph: to enhancing global health. some key challenges in further improving global health. and what can he done to add reset those challenges. The chapters that focus on health conditions look at the importance of tlte topic to tlte burden of disease. key issues related to this cause of illness. disability. and death. and the costs anti consequences of these issues for individuals. cont- ntunities. and the world. 'i'hese chapters then examine what has been learned abour how to deal with thrse health burdens in the most costaeflectivr ways. the future challenger. in each of these areas. and some specific cases of successful efforts at addressing such challenges. Most chapters contain Several case: studies. Some of these deal with well-knottnt caster that have already proven to be models for global health ellorts. til-then. however. are based on experiences that show good promise. both for success and for providing lessons. but which have tttit yet print-en themselves. Each chapter concludes with a summary of the main tttessages in the chapter and a set of study questions that can assist the reader in reviewing the materials included in the chapter. Each chapter also contains endnotes with citations for the data that is used in the book. The book does not cort- tain any additional lists of reference materials. 'l‘hose wishing tn explore topics in greater depth will find ample suggestions for additional reading in the endrtotes. The reader should note that the chapters are not in order of importance. Nutrition. for example. is fundamental to all health concerns. However. it only makes sense to cover nutri— tion in this hoolt afte't establishing the contest for studying global health and after covering some cross—cutting global health issues. In addition. you will note that there is no chap- ter called "globalization and health." Rather. you will find that the relationships bettveesl globalization and health are integrated into all of the chapters. THE PERSPECTIVE 'llF THE Blllllt The book wfll talte a global perspective to all that it covers. Although the book includes many country case studies. top- lot will he examined from the perspective of the world as a whole. The book also pays particular attention to the linlrs between poverty and health and the relationship between health and equity. Special attention will also he given to gender and ttt ethnicity and their relation to health. Another theme that runs through the hook is the connection between health and development. The book follows the point of 1-"ictv that health is a human right. The book is written with the prestttttption that governments have an obligation to try to ensure that all of their people have access to an affordable package of healthcare services and that all people are protected from the costs of ill health. The book is also based on the premise. however. that the development of a health system by any country. as discussed further in tihapter 5. is inextricably linked to the valur system and the political structure of that country.” The book covers lie-y global health topics. including those that affect developed and dt'velopittg coutttrtes‘. how; ever. the book pays particular attention to developing count tries and to poor people within them. The rationale for this is that improving health status indicators within 'ttlltl across countries can only be accomplished if the health of the tutor and other disadvantaged groups is int proved. to addition. the idea of social justice is at the core of public health. The basic tenet of socialjustice in relation to health "is that the knowl- edge obtained on how to ensure a healthy population must he extended equally to all groups in any society . . ."" SDHE KEY TERMS The boot: will often speak of "developed countries" and “developing countries.“ These terms are not precise. “l‘letetnped countries" are those. Slit'l't as the United States. France. Australia. and the United Kingdom. that have rela— tively high income per capita and that are often thought of as *industrialized." ‘Developirtg countries" are those. such as Haiti. Liberia. Laos. and Papua New Guinea. that have relatively low per capita incomes and that are not heavily industrialized. Although the book will use the terms "developed" and “developing countries.” it will also use the terms “low— income." “middleaincome.” and “high—income“ to refer to countries. "these terrns will follow the definitions used by the World llaolc. which divides countries into four income groups. based on their gross national income per person:“ $315 or less—low—ioconte $816 to BESS—lower middlevincome $3256 to $ltl.[r65—upper middle-income 510.066 or abovefihigl't-inoarne iii. Much of the data discussed in this book will be broken down by the geographic regions used by the 1t't'orld Bank {see Table I—t l. ._-_. .tr .:- and Steals of Elohal Health I [last t'tsia and the Pacific Ii Europe and (Senlral r'tsia e Latin America and the Caribbean I Middle East and North Africa I South Asia. I Bob-Saharan Mrica Occasionally. however. data will be discussed according to the regions that are used by the World Health Organization. For compamtive pnrpteres. data is sometimes also shown for high- ioeorne countries that belong to the Organization for Economic (".otiperation and Development [HECDL THE MILLENNIUM DEVELDPHENT GDALS This book will malte cononu ous references to the Millen niorn Development Goals tMIJllsl. 'l1ie MDGs were formulated in Ztitltl at the United Nations Millennium Summit and were articulated in the Millennium Declaration.“ There are a hill-Us and 15 core targets that relate to them. The countries that signed the declaration pledged to meet the hiDtis by EDIE. Keeping the Ml‘tt‘ls in mind as you read this book is important because the Mllfis are an explicit statement of the goals that many countries have set for an important part of their development efiorts and. therefore. are an iroponant part of the contest for understanding global health issue-s. The MDGs and their related targets are noted in Table 1—5. As you can see. all eight of the MDGs relate to health. The goals of reducing child mortality. improving maternal heath. and combating HIWMDE. malaria. and other diseases directly concern health. However. each of the other goals also relates to health. Hunger and poverty. referred to in goal 1. are intimately lioltcd with health status. both as causes. of ill — health and as consequences of ill health. The goal of univer- sal primary education can only he met if children are well enough nourished and healthy enough to enroll in school. attend school. and have a good capacity to learn 1while they are there. As you “fill read throughout the hook. the gender disparities referred to in goal 3 are central to the health issues that affect women globally. many of which relate to their lacls of empowerment. lioal I is meant to address the need For safe water and sanitation. the lack of which is '.I t'ttainr cause till ill health and death. The last chapter of the book discusses how different actors in global health can work together to help countries improve health status. as indicated in goal ti on partnerships for develop rne nt. ADIlIIIflHAL CUHHENTS fiN THE CASE STUDIES Many of the case studies in this I-molr Iarere provided by the tTenter for Global Development and are elaborated upon funher in .t comp-mien piece to this book entitled L'rtse hirlreflrj in Global Health: Millions Soveo‘.‘ That bnols provides detailed case studies of It] successhal interventions in global health. The cases were carefully selected on the basis of five selection criteria: scale. importance. impact. duration. and cost-effectiveness. When considered together. the cases sug- gest a number of important lessons that rarill be reflected throughout this horde - Success in addressing important health problems is possible. even in the poorest countries I Governments in poor connotes can manage major pub— lic health W and often can fund them as well a Technology docs enable progress in health: how- ever. many successes stem from basic changes in _ arose om or wear aunts. out: one! nanny Grown. hillside a: liliThEThflSflCfiflmszHflhpafiePfi-fllfilmlfllfie-IIHEIMHHMHMHL Gull THEE GoaliefirndimteEm-emeflflnxa-HJM Target t.Hun.betwm199onnd2ots.rhepmpmtenefpewte when ittcome-ii'lese than it a tiny Target 1. Helen. between I99!) ant! EDIE. tbeptoponiett ofpeupieswbe wife: from lttt —-—-—-—-——-—-—-—-—-———-—EEL———__—_. Goal 2; Adele-Ire Unit-end Primary Education Title! 3. Enter: tint. by 1015, children net-mm. boyx'nnd girls alibi.- willbeebleto mmefltfleeumelm‘ Er ttltooling Gael hflbmmfiemierfiqueflty end limpet-u Women Tll'fil‘l t. Filmioate gentler displr'l‘tr in pr'etttnrtr and secondary ' edueeliott. preferably by 2005. and in. all levels ofetltttitlon no lilifl.‘ thin llllS Gee“: Mime ottte Mortality rm 5. Reduce by two thirds. between test: and tots. the under-five nut-mfg: fltt Goalie-Item Meter-oat Hit-em: Tull! t5. Reduce by three quutten. between 1990 and 2.015. the mammal month ntio Goal to. Combat 31mins, Melanie. mt etho- diets-m rug: r. it“. halted by ems mt begun to mm the ttpfeiltl e't'tt'trt one. Tee-let 3. Hm halted by Juli Ind begun to meme the incidence of mini: and other mht'disflfl! Goal 5".- Ettuttefinvire-mentdl Satin-inability Target 9. integrate the printile of mm deteloptttett'itt‘t'o country petiole: and pfflfil'll'fll- end ton-me the loss ol'ettvitottmefttnl ruourou Target 10. Halt-e. b1! 1015.1he proportion of people without sustainable lee-eta tn “Ill drinking water and basic sanitation I Tug: 11. Here achieved by 2:13] : tigoifieent improvettteot in the lite; of ll. lent 1m million slum dweller: omtooqetepeotehtmmfiromm Target mom-top fitt‘l‘htrmopcm t't-Ile-ltmd. predictable. nontlieeziminemqr ruling and l'mttndttl system . Target 13. Address the needs ofthe least Dotteth Cotmttlfl' Target 14. tit-idem the special mat neonatal-tree dmm._mmo mmmmwgm "" Tea-get l5. Dee] oomptebentively 1r'titls. the debt tit-ht Mable in the begun: - ' Soto-oer Data fi-am Millennium Praia-:1: God: end Tatum. Arm :1 hutrJim.mtnilenniumpeoj-eemflyu|y§nlmhbnt lune-{EL people‘s behavinr. such as filtering rater. thine SHALLFflK ERABIEATIOH—THE Hoar FAMOUS infants oral reht'drotion for diarrhea. and cessation SUCCESS 511111? of smoking *- Cooperation anlong gJobal health aetors can make a it is fitting to end this introductory- ehttpter with a sumon I'I'Iflj-UI diilerence lo the achievement of health aim: of the most famous public health success story ofol]. the cost: I it is possible to find Widen-It? oft-that works and does of smallpox; eradication. 'l'ltis ("Fl—on was not only a great tri— not work in global health efforts umph of publjt: health. but we also a great accompliohtnent for It Success comes in all thapes—djflermt types. of pro- menltimi In addition. the history ot'smollpox eradicationisweil grams in different types of settings have been and can know to etertrone who Works in public health. and it provides be successful tttatttr Imam that can be applied to other public health eiTorts. The history of smallpox eradication and the lessons learned from dealing with it also remain very important because ofthc new threat of smailpox lacing used as a biological weapon. Background In Hon. sttiallpoa ravaged over EU countries. slice-ting ltl tnillion to i5 million people. of whom almost 1 ntillion died each year.“ lit the time. smallpox ltiiled as manv as 30% of those infected. Those who survived might suffer deep pitted scars nttd blindness as a result of their illness.“ The Intervention r‘tithough a vaccine against Mllilllpux was created by Edward Jenner in I'F‘itl. eradication of smallpox. became .I practical goal only.r in The I‘Jfiils when the vaccine could be mass pro- duced and stored without refrigeration. .i't later breakthrough came itt the form of the bifurcated needle. a marvel of simple leehluilogj.r that dramatically reduced costs hv allowing entl~ less reuse after sterilisation. and by rcqalrtng a far sntaller amount of vaccine per patient. The needle also made vain cinatinn easy. thereby reducing tlte time .tttd effort required to train villagers in its use. In [959. the 1et'nrtl I lealth Organirarton {W HtTIi adopted a proposal to eradicate smallpox through compulsorv vac- oinatiott. but the program languished until toss. when the United States stepped in with technical and financial sup port. a Smallpox Eradication Unit was established at the Wl-iC‘t. headed bv Dr. tho. Henderson of the Centers for Disease Control and Prevention [CDC] in the United States. As part of the smallpox eradication put-grant. all WHO member countries were required to manage progtam funds effectivelv. report smallpox cases. encourage research on smallpox. and maintain flexibility in the implementation of the smallpox program to suit local conditions. The Smallpox Eradication Unit proved to be a small but committed team. supplying vaccines and specimen hits to those countries that still had smallpox. Although wars and civil unrest caused disruptions in the program's progress. momentum was always regained with new methods and extra resources that focused on containing outbreaks b}.- speeding wid't motorized teams to seelt out new cases. isolate new cases. and vaccinate everyone in the vicinitv of the new cases. This military—style approach proved effective even in the most difficult circumstances. It also took practical account of the facts that: til it would have been extraordinarily dif- ficult to immunize the whole world against smallpox. and {1] the transmission of the smallpox virus could he stopped by focusing vaccination efforts around new com. The Impact In I??? the last endemic case of smallpox in the world was recorded In Somalia- It1 I981]. after two vears of surveillance and searching. the l-‘t-'H|ti|I declared smallpox the first disease in history to have been eradicated. Smallpox had previouinr been eradicated to Latin America in 19?] and in Asia itt HTS." Costs and Benefits The annual cost of the eradication carrtpatgtt between 19st and 19?“! was $2.1 million. For the wltole campaign. inter- national donors provided 593 million. while Elfin million carne front the endemic countries." The llnltccl bit-ates saves the total of all its Lttfllrihllllt'tl'la evcrv in days because it no longer need- to spend money on vaccination or treatment. malttng stttullpos eradication one of the best values it: health interventions ever achieved? Esttmales for economic loss due to 'ttttallpn'r: to a developing country are avail-aisle only I'or lndis. its.th on these. it has been estimated that develr oping countries as a whole suffered economic losses related to smallpox of about it hilltntt each year at the start of the nttensified campaign.J Lessons Learned The success of the program can be attributed to the political commitment and leadership exemplified in the partnership between WHO and the US- Centers for Disease Control and Prevention. Success in individual countries hinged on having someone who was responsible. preferainr solely. for the eradication effort. In addition. small WHO teams made frequent field trips to review progress. and a small number of committed people working in the program were able to motivate Large numbers of staff. Moreover. in the days before the Internet and email. the program managers held a monthly meeting in which their exchanged information about the progress of the campaign and the lessons learned fmm working on it in different countries. hio two national campaigns were alilce. which makes flexibility essential in program design. The plan for eradicat- ing n-nalipox used existing healthcare systems. and it also forced man]-r countries to improve their health services. This benefited irnmua'timiiun programs more generally and offset the cost of the initial smallpox campaign. Monitoring standards were established across the pro— gram to constantiv evaluate the progress of the program against agreed benchmarks. The participation of communi— ties provided strategic lessons for later community-based prniects. The value of publicity about the program was highlighted when news alt-out the program's progress trig- gered large donations in 1934 to complete eradication in five remaining countries. r'tt't important discovery made «duringr the campaign was that immunization programs could vac- cinate people with more than one vaccination at a time. This helped to pave the way for later programs of routine immu- nization. about which you will read later. The eradication of smallpox continues to inspire efforts against other diseases. but it must be remembered that the particular features of smallpox made it a prime candidate for eradication. The disease was passed directly between people. Without an intemning vector. so there were no reservoirs: the distinctive rash of smallpox made diagnosis easy: survivors gained lifetime immunity: and. the severity of ryrn ptonts. once tlte disease became infectious. matte patients tttl-te to their beds arid infect few others. {Rood vaccina- tion coverage could therefore disrupt transmission entirely. Unfortunately. almost it} years after eradication. funds are still allocated to preorntionary measures against the disease because of the continuing tltreat of smallpox being used as In agent ofhia—terrorisnt. CENTRAL MESSAGES OF THE EDUK Because this is tlte introductory chapter of the book. it will not end with a summary. as the other chapters do. Rather. it will be moat valuable to end this chapter by highlighting some of the central messages of the boot: as a whole. they are pro-tented below in outline form. without citations or recitation ol'the evidence behind them. That evidence will be provided and cited in the chapters that follow. It will be very important to keep these messages in mind as you go through the boots. I There are strong linl'rs between health. human develi opntent. labor production-r. and economic develop- meat. I Health status is determined by a variety of factors. including income, education. knowledge of healthy behaviors. social status. sex. genetic makeup. and access to health services. I There has been enormous progress in improving healdt status over the last ED years in many countries. This is reflected in the substantial increases these countries have witnessed in that period. for example. in life expectancy. I Some of this progress has come about as 'a Imdt of overall economic development and improvements in income. However. much of it is due to improvements at public hygiene. better water supply and sanitation. and better education. Increased nutritional status has also had a large impact on improvements in health status Technical progress in some areas, such as the development of vaccines against childhood diseases and the development of antibiotics. has also improved human health. The progress in heald-i status. however. has been very uneven. Hundreds of millions of people. especially poorer people in low and middle-income countries. continue to get sick. be disabled by. or die from preventable causes of disease. In many countries. nutritional status and health status of lflWETelttcomc people have Improved only slowly. In addition. lilW AIDS is causing a decline in health and nutritional status and life expectancy in a number of countries in Stilt-Saharan Africa. There are enormous disparities in health status and access to health services both within and across coun- tries. I|i't'ealthier people in most countries have better health status and better access to health services than poorer people. in general. urban dwellers and ethnic majorities enjoy better health status than rural people and disadvantaged ethnic minorities. in addition. women face a number of unique challenges to their health. Countries do not need to be high—income to enioy good health status. By contrast. there are a number of examples. such as ltlhina. t'losta Rica. Cuba. Kerala state in tndia. and Sri Lanlta. that malice clear that low— income countries or low—income areas within coun— tries can help their people to achieve good health. even in the absence ofestensive financial resources to invest in health. However. this requires strong politi- cal will and a focus on public hygiene. education. and investing in low-cost but higlt yielding investments in nutrition and health. Some global health issuin can only be solved through the cooperation of various actors in global health. This could include. for example. the development of an MUS vaccine. However. an important part of health status is determined by an individuals and families" own knowledge of health and hygiene. People and com- munities have tremendous abilities to enhance their own health status. The world continues to shrinit at a very rapid pace. For health. security. and humanitarian reasons. each of us should be concerned about the health ofevery- one else. ...
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