An Introduction to Global Health

Michael Seear
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 .

AN INTRODUCTION TO
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HE A L
THIRD EDITION

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AN INTRODUCTION TO

THIRD EDITION

Michael Seear and Obidimma Ezezika

CANADIAN
SCHOLARS
Toronto j Vancouver

tinfu
 An Introduction to Global Health, Ihird Edition
by Michael Seear and Obidimma Ezezika

First published in 2017 by

Canadian Scholars
425 Adelaide Street West, Suite 200
Toronto, Ontario
M5V3C1

www.canadianscholars.ca

Copyright © 2007,2012,2017, Michael Seear, Obidimma Ezezika, and Canadian Scholars. All
rights reserved. No part of this publication may be photocopied, reproduced, stored in a retrieval
system, or transmitted, in any form or by any means, electronic, mechanical, or otherwise, without
the written permission of Canadian Scholars, except for brief passages quoted for review purposes.
In the case of photocopying, a licence may be obtained from Access Copyright: 320-56 Wellesley
Street West,Toronto, Ontario M5S 2S3, (416) 868-1620, fax (416) 868-1621, toll-free 1-800-893-
5777, www.accesscopyright.ca.

Every reasonable effort has been made to identify copyright holders. Canadian Scholars would be
pleased to have any errors or omissions brought to its attention.

Library and Archives Canada Cataloguing in Publication

Seear, Michael, 1950-

[Introduction to international health]
An introduction to global health / Michael Seear and Obidimma Ezezika.
— Third edition.

Previous editions published under title: An introduction to international

health.
Includes bibliographical references and index.
Issued in print and electronic formats.
ISBN 978-1-77338-003-2 (softcover).-ISBN 978-1-77338-004-9 (PDF).-
ISBN 978-1-77338-005-6 (EPUB)

1. World health—Textbooks. 2. Poverty—Developing countries—

Textbooks. 3. Public health—Developing countries—Textbooks. I. Ezezika,
Obidimma, author II. Title. III. Title: Introduction to international
health.

RA441.S43 2017 362.1 C2017-906629-3

C2017-906630-7

Cover and text design by Elisabeth Springate

17 18 19 20 21 5 4 3 2 1

Printed and bound in Canada by Webcom

Canada

A
TABLE OF CONTENTS
Acknowledgements vii

Part I What Is Global Health? 1

1 An Overview of Global Health 2
2 A History of International Aid 27

Part II Why Are Poor Populations Less Healthy

Than Rich Ones? 55
3 The Basic Requirements for a Healthy Life 56
4 War and Civil Unrest 81
5 Poverty and Developing World Debt 109
6 Malnutrition 145
7 Governance and Human Rights in Developing Countries 184
8 Water, Sanitation, and Infectious Diseases in Developing
Countries 221

Part III What Are the Types and Extent of 111 Health
in Developing Countries? 259
9 How to Define and Measure Health 260
10 The Diseases of Adults and Children in Developing
Countries 290

Part IV What Can Be Done to Help? 321

11 The Structure of the Foreign Aid Industry 322
12 Primary Health Care Strategies: The Essential
Foundation 360
13 Curative Medical Care and Targeted Programs 384
14 Poverty Reduction. Debt Relief, and Economic Growth 423
15 Building Peace. Good Governance, and Social Capital 462
vi Table of Contents

Part V Other Aspects of Global Health 493

16 Natural and Humanitarian Disasters and Displaced
Populations 494
17 The Health and Rights of Indigenous Populations 530

Part VI Working Safely and Effectively in a Developing

Country 561
18 Planning and Preparing for Safe and Effective
Development Work 562
19 How to Manage a Sustainable Aid Partnership 591

CopyrightAcknowledgements 612
Index 614

,
ACKNOWLEDGEMENTS
I would like to thank the following people who have provided invaluable insights
and comments on various chapters of the manuscript: Mark Brender, Trillium
Chang, Jacqueline Ezezika, Jessica Oh, Vanessa Reddit, and Ken Simiyu.

—Obidimma Ezezika
1

CHAPTER 1
An Overview of Global Health

There are two things which I am confident I can do very well: one is an introduction to
any literary work, stating what it is to contain, and how it should be executed in the most
perfect manner; the other is a conclusion showing from various causes why the execution
has not been equal to what the author promised to himself and to the public.
—Samuel Johnson. 1775

OBJECTIVES
Global health is a rapidly evolving and exciting field with many huge opportunities
to make a difference in the lives of millions. This chapter provides an overview of
global health and how far the field has come in the last century.

• understand the scope of the subjects covered by the term "global health'
• understand how global health relates to the new Sustainable Development Goals
(SDGs)
• understand the design and content of this book and how to get the most out of
the material
• start to apply human faces and experiences to the broad concepts of poverty, mal­
nutrition, and injustice
 Chapter 1 An Overview of Global Health 3

INTRODUCTION
There is simply no good reason why in the 21st century, thousands ofwomen and children
in developing countries should be dying during childbirth and the early years of life.
—Hon.Aileen Carroll, Canadian Minister of International Cooperation, 2005

Global health is, very broadly, the study of the health of populations in a global
context. Although poor levels of health are common in many developing countries,
it is important not to concentrate solely on diseases and to remember that they are
just the most visible result of underlying social disruption. The need to study both
the diseases and their causes means that global health covers a very wide range of
subjects. These vary from tropical medicine and primary health care at one end of
the spectrum to epidemiology and economics at the other end, with a great many
stops in between. The solutions to these problems are, of course, no less complex
than their underlying causes.
Despite widespread improvements in health and prosperity over the last few
decades, malnutrition, poverty, and all the ills that stem from them are still very
common around the world. In fact, to the newcomer, the statistics can be quite
overwhelming. During a period when citizens of industrialized countries are
healthier than at any time in history, hundreds of millions of people in the least
developed countries still live lives of terrible deprivation. There is, of course, a nat­
ural human desire to assist people living under those conditions. Since the end of
World War II, a complex mix of private, governmental, and international organi­
zations has developed with the overall aim of improving the health of populations
in developing countries. While the developing aid industry has had successes, it has
also had its share of trials and considerable errors. Fortunately, the new millennium
seems to have brought a renaissance in aid. Current developments—such as the
Debt Relief Initiative, the Millennium Development Goals (MDGs, which have
now been replaced with the SDGs), several successful disease eradication efforts,
and serious attempts to improve the quantity and effectiveness of foreign aid—have
all combined to bring a sense of great optimism to the field of aid.
Another development has been the growing popular interest in global health
issues. When the world’s seven richest countries first decided to hold annual meet­
ings, about 30 years ago, it is unlikely that the average person paid much attention.
This is in marked contrast to the period leading up to the 2005 Group of Eight
(G8) Conference at Gleneagles, when it seemed as if the whole world was waiting
for the latest word on debt relief. The health of developing populations (particularly
the developing world debt) became a bandwagon that staggered under the weight
of politicians, pop stars, and various other celebrities as they clambered aboard.
 4 PARTI WHAT IS GLOBAL HEALTH?

When Tony Blair announced general agreement on the Multilateral Debt Relief
Initiative, there was a real sense of worldwide excitement. While the agreement
may not quite have lived up to its billing, it cannot be denied that there is now
widespread interest in the broad topic of global health.
This increased awareness of global health issues has probably been fashioned by
events that were large enough to reach news reports. A lot has happened over the
last 20 or 30 years—some of the international issues that caught public attention
included a steady increase in political freedom (South Africa, eastern Europe),
several widely reported famines (Ethiopia, Sudan), destructive civil wars (Rwanda,
Bosnia), and natural disasters (Asian tsunami, Haitian earthquake). Tie current
level of interest was exemplified by the spontaneous public response to the Asian
tsunami. So much money was given by private citizens that the Red Cross actually
asked people to stop sending any more, since it had enough!
Strangely enough, despite the increased demand for courses, books, and general
information on the subject of global health, there is no clearly defined preparato­
ry educational path for entry into the field. Degree and post-graduate courses in
global health can be found in large centres, but there is still a surprisingly limited
amount of educational material considering the level of interest. This book is de­
signed to meet at least some of that demand by providing a broad overview of global
health that nevertheless includes as much detail as possible on key topics, and by

Box 1.1 History Notes

Amartya Sen (1933-)

Amartya Sen is an Indian economist whose work has had a profound effect on the broad sub­
ject of global health. His early work on the origins of famine highlighted what everyone knew
but few had articulated. Superficially 'simple' population health problems such as famine are
far more complex than they initially seem. He showed that starvation is not due just to lack
of food any more than poverty is due only to lack of money. At the root of most complex
problems lies inequity. His later work. Development as Freedom, is also widely quoted. Based
on a wide range of his early research, he further develops his arguments in favour of political
and economic freedom. He outlines five specific types of freedoms: political freedoms, eco­
nomic facilities, social opportunities, transparency guarantees, and protective security, which
are usually viewed as only the ends of development. However, he argues that such freedoms
should be both the ends and the means of development.
Sen was born on a university campus established by the Indian philosopher and previous
Nobel Prize winner, Rabindranath Tagore. He studied economics in India and England. After
serving as master of Trinity College, Cambridge, he recently moved to Harvard University. He
I was awarded the Nobel Prize for Economics in 1998. Please follow the reference for more
details: Nobelprize.org (2011).
 Chapter 1 An Overview of Global Health 5

considering other aspects of global health that are rarely given attention, such
as poverty, wars, humanitarian disasters, and governance. Although the subject
of global health is unavoidably medical in nature, this is not a medical textbook
and is intended for readers with a wide range of interests. Whether you are a pure
researcher tied to a laboratory bench, a nursing student planning a career in de­
velopment work, or a fieldworker in a large aid agency, this book aims to provide
a detailed introduction to global health and its inevitable companion, the modern
aid industry. We would like to wish a warm welcome to anyone opening this book
for the first time, and hope that it will help you find your way through the complex
but fascinating subject of global health.

THE SCOPE AND DEFINITION OF GLOBAL HEALTH

There can be no real growth without healthy populations. No sustainable development
without tackling disease and malnutrition. No international security without assisting
crisis-ridden countries. And no hope for the spread of freedom, democracy, and human
dignity unless we treat health as a basic human right.
—Gro Brundtland, Director General ofthe World Health Organization, 2003

Providing a concise, inclusive definition for a subject as varied as global health is

a challenge. This is reflected in the common questions that newcomers ask: What
is global health? How does it differ from international health? Where do tropical
medicine, epidemiology, and public health fit in? An all-inclusive definition of glob­
al health would be similar to the description of an elephant by the blind philoso­
phers—there are lots of parts, but no coherent whole. It is perhaps more useful to
define the subject using its broad basic aims. Taking that approach, global health can
be defined as a subject that tries to find practical answers to the following questions:

• Why is population health so poor in many developing countries?

• What is the extent of the problem?
• What can be done about it?

Those questions have dictated the general layout of this book and their answers will
cover varied and interesting topics. Global health has been defined as “collaborative
trans-national research and action for promoting health for all” (Beaglehole 6c
Bonita, 2010). Global health has “health equity among nations and for all people”
as its major objective (Koplan et al., 2009).
Before World War II, global health was largely the preserve of doctors and
missionaries. As the industry has grown, ever-increasing numbers of new special­
ists have been added to the list. Investigating the causes and extent of ill health
I 6 PARTI WHAT IS GLOBAL HEALTH?

requires researchers, biostatisticians, and epidemiologists. Addressing the last

question—-What can be done about it?—requires a small army. Health initiatives
may include economic interventions (economists, business specialists, agrono­
mists, small-scale bankers, etc.), medical initiatives (doctors, nurses, pharmacists,
nutritionists, etc.), and human rights initiatives (politicians, rights activists, and
constitutional lawyers). Increasingly, standards of project management are im­
proving, which requires accountants, project managers, and the full range of
support staff associated with any large company. Finally, a large part of many
aid projects consists of trying to get people to change their behaviour, so projects
now also include psychologists, anthropologists, popular public figures, and even
directors of soap operas. While a successful project certainly requires money and
well-trained staff, it must always be remembered that the most important people
in the whole process are the target population. No initiative stands a chance
unless local people are included (and listened to) at every stage of planning and
implementation.

FROM MILLENNIUM DEVELOPMENT GOALS TO

SUSTAINABLE DEVELOPMENT GOALS
Learn from the past, set vivid, detailed goals for the future, and live in the only moment
of time over which you have any control: now.
—Denis Waitley

Established following the Millennium Summit of the United Nations in 2000, the
Millennium Development Goals (MDGs) helped guide the global health devel­
opment community for 15 years. Hie eight MDGs were:

1. To eradicate extreme poverty and hunger

2. To achieve universal primary education
3. To promote gender equality
4. To reduce child mortality
5. To improve maternal health
6. To combat HIV/AIDS, malaria, and other diseases
7. To ensure environmental sustainability
8. To develop a global partnership for development

Important strides have been taken at the global level toward achieving many of the
health-related MDGs. For example, the targets for both malaria and tuberculosis
 Chapter 1 An Overview of Global Health 7

were met. In addition, substantial progress was made in reducing child under-
nutrition, child mortality, and maternal mortality. There was also recorded progress
in increasing access to improved sanitation (WHO, 2015).
While the MDGs have promoted increased health and well-being in many
countries, progress toward reaching these goals has been uneven across countries.
Studies have pointed out that the MDGs were prepared by only a few stakeholders
without adequate involvement by developing countries and overlooked develop­
ment objectives previously agreed upon and not appropriately adapted to national
needs (Fehling et al., 2013).
Overall, the outcome of the MDGs has been incredible, particularly in the
areas of poverty reduction, increased access to safe drinking water and education.
For example, extreme poverty has declined significantly over the last two decades.
In 1990, nearly half of the population in the developing world lived on less than
US$1.25 a day; that proportion dropped to 14 percent in 2015. There has also been
advancement on the three health goals and targets. For example, between 1990
and 2015, the global under-five mortality rate has declined by more than half,
dropping from 90 to 43 deaths per 1,000 live births, and HIV, tuberculosis, and
malaria epidemics were staved.
The transition from the MDGs to the Sustainable Development Goals
(SDGs) is premised on building a sustainable world where environmental sus­
tainability, social inclusion, and economic development are equally valued. There
were a number of shortcomings or challenges in the MDGs that left out issues
such as disasters, conflict situations, the epidemic of non-communicable diseases,

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Photo 1.1: The Sustainable Development Goals

Source: Image courtesy of the Global Goals for Sustainable Development, www.globalgoals.org.
r !
8 PARTI WHAT IS GLOBAL HEALTH?

Table 1.1: Sustainable Development Goals

Goall End poverty in all its forms everywhere
Goal 2 End hunger, achieve food security and improved nutrition and promote
sustainable agriculture
Goal 3 Ensure healthy lives and promote well-being for all at all ages
Goal 4 Ensure inclusive and equitable quality education and promote lifelong learning
opportunities for all
Goal 5 Achieve gender equality and empower all women and girls
Goal 6 Ensure availability and sustainable management of water and sanitation for all
Goal 7 Ensure access to affordable, reliable, sustainable, and modern energy for all
Goal 8 Promote sustained, inclusive and sustainable economic growth, full and
productive employment and decent work for all
Goal 9 Build resilient infrastructure, promote inclusive and sustainable industrialization
and foster innovation
Goal 10 Reduce inequality within and among countries
Goal 11 Make cities and human settlements inclusive, safe, resilient, and sustainable
Goal 12 Ensure sustainable consumption and production patterns
Goal 13 Take urgent action to combat climate change and its impacts

I
Goal 14 Conserve and sustainably use the oceans, seas and marine resources for
sustainable development
Goal 15 Protect, restore and promote sustainable use of terrestrial ecosystems,
sustainably manage forests, combat desertification, and halt and reverse land
degradation and halt biodiversity loss
Goal 16 Promote peaceful and inclusive societies for sustainable development, provide
access to justice for all and build effective, accountable and inclusive institutions
at all levels
Goal 17 Strengthen the means of implementation and revitalize the Global Partnership for
Sustainable Development

mental health disorders, and large inequalities in all parts of the world. The
SDGs (Table 1.1) address many of these shortcomings and posit a new all-inclu­
sive health goal (“Ensure healthy lives and promote well-being for all at all ages”)
with a broad set of targets (Table 1.2).
This book makes references to these SDGs (Photo 1.1), which are officially
known as Transforming Our World: The 2030Agendafor Sustainable Development.
I The SDGs are considered a successor to the MDGs. There are 17 SDGs and 169
core targets that relate to them. The goals are contained in paragraph 55 United
Nations Resolution A/RES/70/1 of25 September 2015 (UN, 2015c).
The SDGs are far reaching and applicable to all countries. They also include
a broad range of socio-economic environmental and equity objectives, and offer
the prospect of more peaceful and inclusive societies. Issues like poverty erad­
ication, health, education, and food security and nutrition remain priorities in
the SDGs.
 Chapter 1 An Overview of Global Health 9

Table 1.2: Targets for Goal 3: Ensure healthy lives and promote
well-being for all at all ages
3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000
live births
3.2 By 2030, end preventable deaths of newborns and children under 5 years of age,
with all countries aiming to reduce neonatal mortality to at least as low as 12 per
1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births
3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical
diseases and combat hepatitis, water-borne diseases and other communicable
diseases
3.4 By 2030, reduce by one third premature mortality from noncommunicable
diseases through prevention and treatment and promote mental health and
well-being
3.5 Strengthen the prevention and treatment of substance abuse, including narcotic
drug abuse and harmful use of alcohol
3.6 By 2020, halve the number of global deaths and injuries from road traffic
accidents
3.7 By 2030, ensure universal access to sexual and reproductive health-care services,
including for family planning, information and education, and the integration of
reproductive health into national strategies and programmes
3.8 Achieve universal health coverage, including financial risk protection, access to
quality essential health-care services and access to safe, effective, quality, and
affordable essential medicines and vaccines for all
3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous
chemicals and air, water and soil pollution and contamination
3.a Strengthen the implementation of the World Health Organization Framework
Convention on Tobacco Control in all countries, as appropriate
3.b Support the research and development of vaccines and medicines for the
communicable and noncommunicable diseases that primarily affect developing
countries, provide access to affordable essential medicines and vaccines, in
accordance with the Doha Declaration on the TRIPS Agreement and Public
Health, which affirms the right of developing countries to use to the full the
provisions in the Agreement on Trade-Related Aspects of Intellectual Property
Rights regarding flexibilities to protect public health, and. in particular, provide
access to medicines for all
3.c Substantially increase health financing and the recruitment, development, training
and retention of the health workforce in developing countries, especially in least
developed countries and small island developing States
3.d Strengthen the capacity of all countries, in particular developing countries, for
early warning, risk reduction and management of national and global health risks

SDGS AND HEALTH

The 13 targets of the SDG goal on health are shown in Table 1.2. You will notice
that some of the MDGs have been reflected in the SDG framework, such as mater­
nal mortality (target 3.1), child mortality (target 3.2) and infectious diseases (target
!
:
10 PARTI WHAT IS GLOBAL HEALTH?

Table 1.3: SDG targets related to health

1.3 Implement nationally appropriate social protection systems and measures for all.
including floors, and by 2030 achieve substantial coverage of the poor and the
vulnerable
2.2 By 2030, end all forms of malnutrition, including achieving, by 2025, the
internationally agreed targets on stunting and wasting in children under five
years of age. and address the nutritional needs of adolescent girls, pregnant and
lactating women and older persons
4.2 By 2030, ensure that all girls and boys have access to quality early childhood
development, care and pre-primary education so that they are ready for primary
education
4.a Build and upgrade education facilities that are child, disability and gender
sensitive and provide safe, non-violent, inclusive, and effective learning
environments for all
5.2 Eliminate all forms of violence against all women and girls in the public and
private spheres, including trafficking and sexual and other types of exploitation
5.3 Eliminate all harmful practices, such as child, early and forced marriage and
female genital mutilation
5.6 Ensure universal access to sexual and reproductive health and reproductive
rights as agreed in accordance with the Programme of Action of the International
Conference on Population and Development and the Beijing Platform for Action
and the outcome documents of their review conferences
6.1 By 2030, achieve universal and equitable access to safe and affordable drinking-
water for all
6.2 By 2030, achieve access to adequate and equitable sanitation and hygiene for all
and end open defecation, paying special attention to the needs of women and
girls and those in vulnerable situations
6.3 By 2030, improve water quality by reducing pollution, eliminating dumping and
minimizing release of hazardous chemicals and materials, halving the proportion
of untreated wastewater and substantially increasing recycling and safe reuse
globally
10.4 Adopt policies, especially fiscal, wage and social protection policies, and
progressively achieve greater equality
11.5 By 2030, significantly reduce the number of deaths and the number of people
affected and substantially decrease the direct economic losses relative to global
gross domestic product caused by disasters, including water-related disasters,
with a focus on protecting the poor and people in vulnerable situations
16.1 Significantly reduce all forms of violence and related death rates everywhere
16.2 End abuse, exploitation, trafficking, and all forms of violence against and torture
of children
16.6 Develop effective, accountable and transparent institutions at all levels
16.9 By 2030, provide legal identity for all, including birth registration
17.18 By 2020, enhance capacity-building support to developing countries, including
for least-developed countries and small island developing States, to increase
significantly the availability of high-quality, timely and reliable data disaggregated
by income, gender, age, race, ethnicity, migratory status, disability, geographic
location, and other characteristics relevant in national contexts

i
 Chapter 1 An Overview of Global Health 11

3.3). However, the SDG framework is expanded to include neonatal mortality and
other infectious diseases beyond HIV/AIDS, such as hepatitis.
Due to increasing recognition of the burden of disease arising from non-com­
municable diseases, injuries, and other burdens beyond HIV/AIDS, malaria, and
tuberculosis, the SDGs now include new targets on non-communicable diseases,
mental health (target 3.4), substance abuse (target 3.5), injuries (target 3.6), and
health impact from environmental pollution (target 3.9).
Although only Goal 3 directly concerns health, all other 16 SDGs are indirect­
ly related to health. For instance, poverty and hunger as referred to in Goals 1 and
2, respectively, relate to health both as a cause of ill health and as a consequence
of ill health. The goal of inclusive and equitable quality education and lifelong
learning opportunities for all can only be possible if populations are well enough to
enrol in classes, attend school, and have the capacity to learn. The aim of achieving
gender equalities in Goal 5 is important to health issues that affect women globally
and related to empowerment. Goal 6 on clean water and sanitation is an import­
ant element and cause of ill health and the spread of many infectious diseases.
Employment, referred to in Goal 8, is an important social determinant of health

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Photo 1.2: A 10-minute film introducing the Sustainable Development Goals

is projected onto the UN Headquarters, 22 September 2015.
Source: UN Photo/Cia Pak, with kind permission of the UN Photo Library (www.unmultimedia.
org/photo).
 12 PARTI WHAT IS GLOBAL HEALTH?

(i.e., a person’s socio-economic status). The inequities referred to in Goal 10 are

important in creating equitable health for all—and as you would see in the course
of this book, health inequities are one of the major component challenges. Goals 11
and 12 deal with living conditions such as safety and health, while climate change
impacts on health in Goal 13. Goals 14 and 15 refer to making ecosystems and
environments more safe and preventing their distortion, which are important for
population health. Goal 16 focuses on justice and peace, which in its absence leads
to strife, civil wars, and wars. Finally, in order to “strengthen the means of im­
plementation and revitalize the Global Partnership for Sustainable Development”
as enunciated in Goal 17, different national and international partners must work
collaboratively to help countries improve their health status.
Forming an idea of the standards ofpopulation health in developing countries,
based purely on available statistics, is difficult; the numbers are simply too large
to comprehend. However, no matter how bad health indicators might be today,
they are all a great deal better than they used to be. In the six decades since the
end of World War II, life expectancy in many countries has increased by over 25
years (Figure 1.1) and infant mortality rates have fallen steadily (Figure 1.2). The
aid industry that grew during this same period can probably claim some credit for

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Figure 1.1: Global trends in life expectancy at birth with time

Source: World Bank. 2016a. Data from the World Bank. World Development Indicators: Life
expectancy at birth, total (years). Retrieved from: http://data.worldbank.org/indicator/SP.DYN.LEOO.IN/
countries?display«=graph (Accessed February 29. 2016).

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 Chapter 1 An Overview of Global Health 13

these improvements (particularly due to immunizations and other public health

interventions), but developed countries improved at much the same rate without
receiving any aid, so some caution is required in drawing simple conclusions. The
final report on the achievements of foreign aid is a mixed one (Easterly, 2006) and
will be discussed in detail later in the book.
It must be remembered that global health statistics—typically Millennium
Development Goals (MDGs)—are often expressed in reports as weighted average
values based on results from studies in many different countries. Consequently,
they are heavily influenced by public health improvements in the largest countries,
particularly China and India. When poverty and health statistics are broken down
by region, a more accurate view is obtained. For example, India and China have
been able to elevate many of their people out of poverty. However, this obscures
the point that other regions of the world, particularly sub-Saharan Africa, have
seen little or no improvement over many years.
The term “developing world” covers a large range of countries in different
regions of the world, with each country having its own complex mixture of social
and economic challenges. Problems differ between countries and, as the HIV/
AIDS epidemic has shown, new challenges also appear with time. While there is

1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2013 2014 2015

World «— Middle income —High income ^^"Low income

Figure 1.2: Global trends in infant mortality with time

Source: World Bank. 2016a. Data from the World Bank. World Development Indicators: Life
expectancy at birth, total (years). Retrieved from: http://data.worldbank.org/indicator/SP.DYN.LE00.lN/
countries?display=graph (Accessed February 29. 2016).
r

14 PARTI WHAT IS GLOBAL HEALTH?

no simple cookie-cutter list of problems applicable to every one of these diverse ar-
eas. there are recurring themes. Of these, poverty and malnutrition stand out well
above the crowd as both affect hundreds of millions of people around the world. It
should always be remembered that wherever severe poverty and malnutrition are
found, some form of serious injustice will always be close behind. When it comes
to the spectrum of diseases affecting developing world populations, there have
been profound changes over the last 20 years. The emergence of an increasingly
prosperous global middle class has shifted the emphasis away from infectious dis­
eases and more toward those associated with a “Western” lifestyle. Problems such
as childhood obesity, motor vehicle accidents, smoking-related illnesses (particu­
larly heart attacks and strokes), mental illness, and substance abuse are already at
epidemic levels in some middle-income developing countries. Some of the major
topics encountered within the subject of global health are listed below.

Poverty

Although global poverty has declined significantly over the past two decades and
the MDG target for poverty was achieved ahead of the 2015 deadline, there are still
about 836 million people who live in extreme poverty. The overwhelming majority of
these people live in two regions—South Asia and sub-Saharan Africa—and they ac­
count for about 80 percent of the global total of extremely poor people (UN, 2015a).
Poverty traps populations within a vicious cycle of poor education, limited job op­
portunities, and chronic ill health. Wherever there is widespread poverty, there will
inevitably be inequity and injustice as two of the principal contributory causes.

Malnutrition

Although there have been slow improvements in global nutrition over time, the sta­
tistics concerning the extent of undernutrition are still startling. At a time of great
prosperity for developed countries, there are currently 795 million people suffering

t from malnutrition, with the vast majority living in the developing regions (FAO,
2016). Increased food prices and global recession have combined to slow progress in
reaching the MDGs for malnutrition. Again, global averages show a decline, but in
Africa and parts of Asia, there has been little progress. Apart from areas of severe
social chaos, large-scale famines are, fortunately, now much less common. Death
from starvation has largely been replaced by the debilitating effects of chronic mal­

i nutrition, which sap the energy and the potential of huge numbers of the world’s
population. Through its effects on a child’s immune response, malnutrition greatly
increases mortality from diseases such as gastroenteritis and measles.
 Chapter 1 An Overview of Global Health 15

Photo 1.3: An undernourished child drinks a fortified milk formula at a

feeding centre in Madaoua, Niger.
Source: Photo by Thorsten Muench, courtesy of the European Community Humanitarian Office
(ECHO: http://ec.europa.eu/echo).
i
Childhood Illnesses

Child mortality from avoidable diseases is an area where there has been much
progress (Figure 1.2), much of it attributable to aid. Since 1990, annual deaths of
children under five have fallen from 12.4 million to 5.9 million. Many countries
have seen mortality rates halved over that time. The leading causes of death include
preterm birth complications (18 percent), pneumonia (15 percent), birth asphyxia
and trauma (12 percent), and diarrhea (9 percent) (WHO, 2016). While this is
great news, it is far too early for celebrations. Almost 6 million deaths still mean
that 16,000 are occurring every single day, many ofwhich strike babies that are not
even a month old. These deaths leading to loss of human potential is made even
worse by the fact that most of these children would have survived had they lived
in a developed country. Not only are most of these cases treatable, but many are
also completely avoidable with simple and affordable interventions. For example,
roughly 100,000 children still die from measles every year, a disease for which there
is a 99 percent effective vaccine costing roughly US$1 per child.
r 16 PARTI WHAT IS GLOBAL HEALTH?

Photo 1.4: A young boy receives a meningitis vaccine in Nigeria.

Source: Photo by Claire Barrault, courtesy of the European Community Humanitarian Office
(ECHO: http://ec.europa.eu/echo).

Pregnancy-Related Deaths

It is only within the last decade that serious attention has been paid to the health
of women around the world. Prior to this time, the best available estimates sug­
gest that well over 500,000 women died each year from pregnancy-related causes
(WHO, 2010); 99 percent of these occurred in developing countries.
In 2015, developing regions still accounted for approximately 99 percent
(302,000) of the global maternal deaths, with sub-Saharan Africa alone accounting
for roughly 66 percent (201,000), followed by South Asia (66,000) (WHO, 2016).
Almost all of these deaths are completely avoidable with improved standards of
care. For example, a quarter of the total simply bled to death (Say et al., 2014). Until
the impetus of the MDGs in 2000, there was a great deal more talk than action,
but latest figures suggest that deaths are finally falling. However, in some areas of
the world, women still face a 1-2 percent chance of dying with every delivery and
a nearly 10 percent lifetime risk of dying from a pregnancy-related cause. Although
statistics are not accurately collected, it is widely believed that for every woman who
dies, 10 times that number are left with disabling injuries such as bowel or bladder
fistulas, chronic infection, or permanent pain. This statistic can only be improved
by provision of better maternal health care.

i
 Chapter 1 An Overview of Global Health 17

Photo 1.5: Members of a Kirghiz family living at the foot of the Kongur
Mountains in Xinjiang, China. They are 1 of nearly 50 Indigenous minority
groups living in China.
Source: Photo/F. Charton, with kind permission of the UN Photo Library (www.unmultimedia.org/
photo).

Indigenous Health

From Canadian Inuit in the North to Australian Aboriginals in the South, there
are roughly 370 million Indigenous peoples around the world that form at least
5,000 separate groups in over 90 countries (Photo 1.5). Although their back­
grounds are widely diverse, they frequently share a history of conquest and varying
degrees of subsequent discrimination (UNPFII, 2010). As a result of this poor
treatment, Indigenous peoples also share surprisingly common health problems
that often include high rates of substance abuse, diabetes, family violence, and sui­
cide. Wherever records are available, Indigenous health lags far behind the average
levels of the dominant population. For example, life expectancy is usually at least 5
to 10 years shorter than national averages. The non-binding UN Declaration on the
Rights of Indigenous Peoples, signed in 2007, has improved the visibility of such
minority groups. After a very long time, Indigenous peoples are finally gaining an
international voice, particularly in the area of self-determination.
If

18 PARTI WHAT IS GLOBAL HEALTH?

Photo 1.6: Former Secretary-General Ban Ki-moon (on the right) visits a
Syrian family that has been living in a refugee camp in the Beqaa Valley of
' eastern Lebanon for five years, 25 March 2016.
Source: UN Photo/Mark Garten, with kind permission of the UN Photo Library (www.
unmultimedia.org/photo).

War

From Bosnia to Guatemala and from Somalia to Sudan, modern war has changed.
Fighting between countries has largely been replaced by internal wars marked by
high levels of violence against civilian populations, usually further complicated by
progressive economic and social collapse. This situation has given rise to the term
“humanitarian disaster.” Apart from the millions of people who have been killed over
decades ofwar, there is also an incalculable cost for the survivors in terms ofland mine
injuries, the terrible legacy of child soldiers, confinement to a refugee camp, and the
destruction of a country’s entire socio-economic structure (Chen et al., 2007). For ex­
ample, the current civil war in Syria has led to at least 300,000 deaths as of September
2016 and has displaced millions of people, with civilians bearing the brunt of the
on-going violence and with rising numbers ofpeople killed or injured (SOHR, 2016).

Natural Disasters

Natural catastrophes, such as earthquakes, hurricanes, and volcanoes, are not rare.
During the last decade, the world has witnessed two of the most lethal disasters in

m*.
 Chapter 1 An Overview of Global Health 19

Photo 1.7: Devastated area of Port au Prince after Haiti's 2010 earthquake.
Source: Phuong Tran/Integrated Regional Information Network photo library (www.irinnews.
org/photo).

history (the Asian tsunami and the Haitian earthquake) and also the most costly di­
sasters in history (Hurricane Katrina and the Kobe earthquake). As the world pop­
ulation grows, more and more people live in vulnerable areas of the world, so death
rates from disasters climb steadily each decade (Guha-Sapir et al., 2010). Apart from
the immediate loss of life, the cost for survivors is enormous in terms of property
destruction and loss oflivelihood (Photo 1.7). Although disasters cannot be prevent­
ed, their effects can be mitigated by planning and preparation. The United Nations’
recent International Strategy for Disaster Reduction is an attempt to improve the
preparedness of developing world communities to face unexpected disasters.

Human Rights Abuses

Abuses of basic human rights are not confined to the developing world; they can
be found, to some degree, in almost every country. However, the worst examples of
abuse are found in developing countries, particular those in the very poorest areas
of the world. Examples include discrimination and oppression based on gender
(e.g., female genital mutilation, exclusion of girls from school) or violence against
h
20 PART I WHAT IS GLOBAL HEALTH?

Photo 1.8: The International Criminal Court in the Hague

Source: Photo by Hanhil, courtesy of Wikimedia Commons.

particular ethnic and religious groups (some examples include the Rwandan geno­
cide, the humanitarian crisis in Darfur, and the collapse of the former Yugoslavia).
The full list is, unfortunately, a very long one. In the past, human rights have been
looked on as a separate issue that stands on its own, but with the establishment of
the International Criminal Court in 2002 (Photo 1.8), this attitude has changed.
It is now realized that peace and prosperity (and also successful aid projects) de­
pend on a fundamental foundation of benign governance that respects the rights
of individuals (Annan, 2005). Beneficial changes in human rights are increasingly
being included as a central feature of large-scale aid projects.

NOTES ABOUT THE THIRD EDITION

There must be an ideal world, a sort ofmathematician’s paradise where everything happens
as it does in textbooks.
—Bertrand Russell, 1914
 Chapter 1 An Overview of Global Health 21

Using This Book

Global health is a rapidly changing subject even at the best of times. Yet, over
the last decade that pace of change has accelerated. This third edition has been
rewritten in light of the emerging health trends and ongoing discussions on the at­
tainment of the new SDGs. New graphs have been added throughout the textbook,
and new pedagogical tools such as discussion questions and chapter summaries
have been included at the end of each chapter that further provide readers with
feedback and discussion points.
As we have already seen, global health covers a wide range of subjects; it does
not lend itself to a neat, linear narrative. That has not changed in the last few years,
so while the book has been well updated, the basic form of the first edition has been
maintained. Chapters are still grouped into sections based on their relevance to the
three main questions set at the beginning of this introduction: Why is population
health so poor in developing countries? What is the extent of the problem? What
can be done about it? The final section of the book is devoted to other aspects of
global health such as refugees, disasters, and Indigenous health. Finally, advice
is given on the planning requirements needed for a successful project and also on
working effectively in overseas partnerships. Although the subject matter is often
medical in nature, it should be stressed that this is not a medical text and is written
for a mixed audience (no previous medical training is necessary).
Enough information has been included within the text to allow readers to
gain a good grasp of the subject without the need for extra research. However, for
those who are interested in further information on particular subjects, there are
over 1,000 references and recommended books spread throughout the chapters.
Tables and graphs are often used to illustrate points, and references are added for
the original data sources. Conventional notation is used for books (author, date,
title, publisher) and scientific journals (authors, date, title, volume, pages):

CDC. 2005. Health informationfor international travel\ 2005-2006. Pub: Elsevier

Press.
Jha, P., et al. 2006. Low male-to-female sex ratio of children born in India: National
survey of 1.1 million households. The Lancet, 367: 211-218.

Other references will include websites for large organizations that are likely to
remain unchanged:

National Aboriginal Health Organization (NAHO) website. Retrieved from:

www.naho.ca/english/.

I
■

22 PARTI WHAT IS GLOBAL HEALTH?

Some reports, manuals, and booklets can be obtained by downloading them

from the relevant websites:

Lavizzari, L. 2001. A guidefor project management and evaluation: Managingfor

impact in rural development. May be downloaded from International Fund for
Agricultural Development website at: www.ifad.org/evaluation/guide/.

The modern aid industry has a reasonably long history and has, as a result, accu­
mulated its own share of interesting characters. Under the heading “History Notes,”
each chapter includes a briefmention of someone who has made a major contribution
to the field ofglobal health. Finally, in the modern world, the rich are so rich and the
poor are so poor that it is fairly simple to find incongruous examples of the differences
in the lives lived by these two groups. In order to give some insight into the harsh
reality of life in a developing country, most chapters include an example under the
heading “Moment ofInsight.” Although some ofthe comparisons may seem surpris­
ing, they are all true (original information sources are provided).

Check Your Sources

For my part, I consider that it will be found much better by all parties to leave the past to
history, especially as I propose to write that history myself.
—Winston Churchill, speech to the House ofCommons, 1948

Whether you prefer Churchill or the blunter style of Henry Ford (“History is
more or less bunk”), the message is the same: do not believe everything you read,
particularly when it comes to complex social problems. Modern communications

Box 1.2 Moment of Insight

Amount of revenue generated at the Cost of smallpox eradication program,

$ domestic box office within five days for 1967-1979 (total, not annual):
the movie Star Wars Ep. VII: The Force
Awakens:

US$300 million US $300 million

(The movie set the record for fastest to

reach this milestone.)

Source: www.the-numbers.com/movie/records/ Source: Glynn, I., & Glynn, J. 2004. The life and
Fastest-to-300-million-at-the-Box-Office death of smallpox. Pub: Cambridge University
Press.

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