Global Health: Past, Present,
and Future
Amir Abdul Khaliq and Raymond A. Smego, Jr.
LEARNING OBJECTIVES
• Understand the history of global health and the
public health interventions that have led to the
current state of world health
• Enumerate the major health problems and threats
facing the world today
• Propose solutions for the various problems faced
by health workers around the world
public health n. The science and practice of protect-
ing and improving the health of a community, as by
preventative medicine, health education, control of
communicable diseases, application of sanitary meas-
ures, and monitoring of environmental hazards.
—The American Heritage Dictionary
The collective personal health of a population is the
public health. At the turn of the 20th century, the life
expectancy for a citizen living in the United States was
45.2 years, and the five leading causes of death were
influenza and pneumonia, tuberculosis, diarrhea and
enteritis, heart disease, and stroke (Figure 1-1).
Median survival for persons residing in less developed
regions was even less, and worldwide the most
important pub- lic health problems were largely
infectious in nature. However, 100 years later the public
health for the entire planet had dramatically improved.
In 2004, the average Japanese was living 82 years, the
average American 78 years, and the average Costa Rican
77 years (Figure 1-2). Even impoverished parts of the
world in Africa, Asia, and Latin America saw
tremendous public health gains in the 20th century.
Unfortunately, the gains in some
1
1
developing countries marred by poverty and political
strife have been less than dramatic. In 2004, the average
life expectancy of a person in Kenya was 51 years, in
Bangladesh 62 years, and in Guatemala 68 years. Sadly,
the ongoing human immunodeficiency virus/acquired
immunodeficiency syndrome (HIV/AIDS) pandemic,
with its epicenter in Africa during the 1980s and 1990s,
has contributed to huge setbacks in longevity in much
of the African continent and elsewhere in the 25 years
since its recognition. For example, the life expectancy for
a Ugandan man was approximately 47.4 years in 1980–
1985, 39.7 years in 1985–1990, and 38.9 years in
1995–2000. In 2004, the life expectancy of a Ugandan
man had improved but was still only 48 years.
The leading causes of mortality in the United States
today are heart disease, cancer, stroke, chronic lung dis-
ease, and unintentional injury. Pneumonia, influenza,
and HIV/AIDS account for only 4.5% of the annual
deaths. Globally, both communicable (e.g., pneumonia,
diarrheal disease, HIV/AIDS, tuberculosis, and malaria)
and noncommunicable diseases constitute the list of major
public health priorities as developing countries in Asia,
Africa, and Latin America continue their developmental,
demographic, and epidemiologic transitions (Table 1-1).
In Bayesian fashion, global populations are trading one
set of diseases for another. In many countries, improved
socioeconomic and public health conditions that led to a
reduction in infectious disease–related morbidity and
mortality have resulted in the introduction of lifestyle
diseases such as obesity, coronary artery disease, hyper-
tension, and other diseases related to excessive eating,
smoking, alcohol consumption, and illicit drug use.
Scientific, social, cultural, economic, and political factors
all contribute to the overall wellness of a community, be it
local or international. All around the world, the impact of
disease-oriented medical care on the overall health status of a
country is relatively small compared with the collective con-
tributions made by improved living conditions, including
nutrition, sanitation, housing, education, and income.
Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use.
 GLOBAL HEALTH: PAST, PRESENT, AND FUTURE / 2

1900

Pneumonia

Tuberculosis

Diarrhea and enteritis

Heart disease

Stroke

Liver disease

Injuries

Cancer

Senility

Diphtheria

0 10 20 30 40
Percentage

1997

Heart disease
Cancer
Stroke
Chronic lung disease
Unintentional injury
Pneumonia and Influenza
Diabetes
HIV infection
Suicide
Chronic liver disease

0 10 20 30 40
Percentage

Figure 1-1. The ten leading causes of death as a percentage of all deaths: United States, 1900 and 1997. From the
Centers for Disease Control and Prevention. Achievements in Public Health, 1900–1999: Control of Infectious
diseases. MMWR 48;621–29:1999. (Reproduced with permission.)

PUBLIC HEALTH MILESTONES
From scientific discoveries to public policies, there
have been numerous innovations and advances in public
health throughout human history that have improved the
quality and longevity of life around the globe. Public
health is credited with adding almost 30 years to the
life expectancy of people in the United States in the last
century, and more than 22 years elsewhere in the world.
In 1999, the Centers for Disease Control and Preven-
tion (CDC) formulated its list of ten great public health
achievements in the 20th century as a testament to the
remarkable evolution of the health of the world.1 An
expanded list of public health milestones is shown in
Table 1-2. Dating back to ancient civilizations, there is
evidence of societies working to improve the health of
the general public. The Babylonian sewage systems were
among the first designed to protect the water supply from
 GLOBAL HEALTH: PAST, PRESENT, AND FUTURE / 3

80

Females live longer

Female life expectancy (years)

70

60

50 African region
Region of the Americas
Males live longer Eastern Mediterranean region
European region
40
Southeast Asia region
Western Pacific region

30
30 40 50 60 70 80
Male life expectancy (years)

Figure 1-2. Life expectancy at birth for males and females, countries by WHO region, 2003. From the World Health
Organization. http://www.who.int/healthinfo/statistics/maps_graphshealthstatus/en/index2.html. (Reproduced with
permission.)

Table 1-1. Major global public health problems Table 1-2. Selected public health milestones
and threats, 2006. during the 20th century.

Infectious diseases Immunizations

Tuberculosis (including multidrug-resistant TB) Control of infectious diseases
Malaria Pasteurization
Acute lower respiratory infections in childhood Fluoridation of drinking water
Childhood diarrheas Maternal-child interventions
New and emerging infectious diseases Family planning
‘Transition’ diseases Wastewater systems
Cardiovascular disease Prevention and treatment of heart disease and stroke
Obesity Motor vehicle safety
Other lifestyle diseases related to smoking, alcohol, Workplace safety
illicit drug use, etc. Safer and healthier foods
Mental and psychosocial illnesses Tobacco control
Reducing firearm-related injuries
World hunger Preventing birth defects
Displaced and refugee populations
Maternal mortality
Motor vehicle injury and mortality
Occupational workplace safety contamination and disease. The innovation of pasteuriza-
Landmines tion, discovered by Louis Pasteur in the 1860s, has
Environmental and social determinants of public health helped to ensure the safety of food supplies throughout
Population growth the world and keep them free of disease-causing organ-
Global climate change and natural disasters isms. In 1980, smallpox was officially eradicated from
Pollution (air, water, other) the planet, and although polio and measles have not been
Governmental corruption eradicated yet, the world is making progress towards
Political instability elimination and for protecting children and communities
Regional conflict from these once debilitating diseases.
Nuclear threats In all parts of the globe there is an evolving health tran-
Biological/chemical terrorism sition from first-generation diseases (e.g., common child-
Economic divergence (inequity) hood infections, malnutrition, and reproductive risks) to

second-generation diseases (e.g., cardiovascular and cere-
brovascular diseases, cancers, and degenerative diseases)
and to third-generation diseases (e.g., violence, drug abuse,
and mental and psychosocial illness).2
Control of Infectious Diseases
The 19th century shift in population from countryside
to cities that accompanied industrialization and immi-
gration led to overcrowding in poor housing served by
inadequate or nonexistent public water supplies and
waste-disposal systems. These conditions resulted in
repeated outbreaks of cholera, dysentery, tuberculosis,
typhoid fever, influenza, yellow fever, and malaria. This
global urbanization accelerated dramatically during
the last four decades of the 20th century. In 1960, an
estimated 70% of the world’s population lived in rural
areas; today, almost the same percentage live in cities
and large metropolitan areas and are at risk for large-
scale disease outbreaks. In 1994, the city of Shanghai,
China, experienced an outbreak of viral hepatitis A in-
volving more than 400,000 cases. Throughout the Indian
subcontinent, virtually every major city has experienced
outbreaks of viral hepatitis E linked to contaminated
municipal water systems, involving up to 200,000 persons
per outbreak.
Public health control of infectious diseases after 1900
was based on the 19th century discovery of microorgan-
isms as the cause of many serious diseases such as cholera
and tuberculosis.3,4 Disease control resulted from im-
provements in sanitation and hygiene, the discovery of
antibiotics, and the implementation of universal child-
hood vaccination programs. Scientific and technologic
advances played a major role in each of these areas and are
the foundation for today’s disease surveillance and control
systems. In Western countries, the incidence of many in-
fectious diseases began to markedly decline by 1900 be-
cause of public health improvements, implementation of
which continued into the 20th century.
In many urban and rural areas of Asia, Africa, and
Latin America, basic public health services such as provi-
sion of clean drinking water, sewage and solid waste dis-
posal, food safety, and public education about hygienic
practices (e.g., food handling and handwashing) are still
lacking or inadequate. These deficiencies contribute to
a continued global burden of major waterborne and
foodborne diseases such as acute diarrheal illness (re-
sponsible for approximately 1.9 million deaths every
year), viral hepatitis, enteric fever, and brucellosis. One-
third of the world’s population suffers from diseases
caused by unsafe food, and many of these people expe-
rience long-term complications or death. Furthermore,
animal and pest control programs are inadequate
worldwide and contribute to the persistence of diseases
such as malaria, rabies, viral encephalitis, trypanosomia-
sis, plague, and anthrax.
GLOBAL HEALTH: PAST, PRESENT, AND FUTURE / 4
In Western countries, deaths from infectious diseases
declined markedly during the 20th century. In particular,
there has been a sharp drop in infant and child mortality
and a 29.2-year increase in life expectancy. For example,
in the United States in 1900, 30.4% of all deaths oc-
curred among children younger than 5 years; in 1997,
that percentage was only 1.4%. In 1900, the three lead-
ing causes of death were pneumonia, tuberculosis, and
diarrhea and enteritis, which (together with diphtheria)
caused one-third of all deaths. Of these deaths, 40%
were among children younger than 5 years. In 1997,
heart disease and cancers accounted for 54.7% of all
deaths, with less than 5% attributable to pneumonia, in-
fluenza, and HIV infection.
Despite this remarkable progress, infectious diseases
remain among the greatest threats to persons living in
poorer developing regions of the world. 60 percent of
children who die under the age of five die because of
pneumonia, diarrhea, or measles. Even as the number
of tuberculosis cases is at an all-time low in the United
States, the global prevalence of tuberculosis is at an all-
time high, with about 8 million new cases and 3 million
deaths annually. HIV/AIDS has become the most devas-
tating epidemic in human history, supplanting the 1918
influenza pandemic that resulted in 20 million deaths.
Since 1981, an estimated 30 million lives have been lost
to HIV/AIDS, and almost 40 million more persons are
believed to be infected worldwide, especially in sub-Saha-
ran Africa, India, and Southeast Asia. This pandemic is
still in progress. In addition, more than 20 new diseases
were discovered in the last 25 years (Table 1-3), demon-
strating the volatility of infectious diseases and the unpre-
dictability of disease emergence. Many of the emerging
infectious diseases, such as avian flu, severe acute respira-
tory syndrome (SARS), and hemolytic uremic syn-
drome, are zoonotic.
Immunizations
Vaccines are probably the greatest achievements of bio-
medical science and public health in history. At the be-
ginning of the 20th century, infectious diseases exacted
an enormous toll on the global population. Currently,
vaccine-preventable diseases remain prevalent causes of
child and adult mortality in Asia, Africa, and parts of
Latin America.
In 1900, few effective measures existed to treat
and prevent infectious diseases. Although the first vac-
cine against smallpox was developed in 1796, more than
100 years later its use was not widespread enough to fully
control the disease. Four other vaccines—against rabies,
typhoid, cholera, and plague—were developed late in the
19th century but were not used widely by 1900. Since
1900, vaccines have been developed or licensed against 22
other diseases (Table 1-4). In 1974, when the Expanded
Programme on Immunization (EPI) was launched by the
 GLOBAL HEALTH: PAST, PRESENT, AND FUTURE / 5
Table 1-3. Newly recognized pathogens or Table 1-4. Vaccine-preventable diseases, by
diseases since 1981. year of vaccine development or US licensure,

1798–2005.
Avian influenza
Acanthamebiasis Disease Year
Australian bat Lyssavirus
Babesiosis Smallpoxa 1798b
Bartonella henselae Rabies 1885b
Coronaviruses/Severe acute respiratory syndrome (SARS) Typhoid 1896b
Ehrlichiosis Cholera 1896b
Hantavirus pulmonary syndrome Plague 1897b
Helicobacter pylori Diphtheriaa 1923b
Hendra or equine morbilli virus Pertussisa 1926b
Hepatitis C virus Tetanusa 1927b
Hepatitis E virus
Tuberculosis 1927b
HIV/AIDS
Influenza 1945c
Human herpesvirus 8
Yellow fever 1953c
Human herpesvirus 6
Poliomyelitisa 1955c
Human T-cell lymphotropic virus I
Human T-cell lymphotropic virus II Measlesa 1963c
Borrelia burgdorferi Mumpsa 1967c
Microsporidia Rubellaa 1969c
Encephalitozoon cuniculi Anthrax 1970c
Encephalitozoon hellem Meningitis 1975c
Enterocytozoon bieneusi Pneumococcal 1977c
Nipah virus disease Adenovirus 1980c
Parvovirus B19 Hepatitis Ba 1981c
Variant Creutzfeldt-Jakob disease Haemophilus influenzae type ba 1985
Japanese B encephalitis 1992c
World Health Organization (WHO), less than 5% of the Hepatitis A 1995c
world’s children were immunized against the six initial Varicellaa 1995c
target diseases—diphtheria, tetanus, pertussis (whooping Lyme disease 1998c
cough), polio, measles, and tuberculosis—during their Rotavirusa 1998c,2006d
first year of life. Until then, immunization programs had Human Papilloma virus 2005c
been largely restricted to industrialized countries, and aVaccine recommended for universal use in US children. For small-
even there were only partially implemented. By 1990, pox, routine vaccination ended in 1971.
and again in the most recent statistics (after a slight in- bVaccine developed (i.e., first published results of vaccine usage).
terim drop in coverage rates), almost 80% of the 130 cVaccine licensed for use in the United States. Withdrawn from the

million children born each year were immunized before
their first birthday. As coverage for each of the childhood
vaccines has increased—now involving over 500 million
immunization contacts with children every year—there
has been a corresponding drop in the incidence of dis-
ease. The EPI (which today includes yellow fever and
hepatitis B vaccines) now prevents the deaths of at least
3 million children a year. In addition, at least 750,000
fewer children are blinded, physically disabled, or men-
tally retarded as a result of vaccine-preventable diseases.
During the 20th century, substantial achievements were
made in the control of many vaccine-preventable diseases.5
The dramatic 95% or greater decline in morbidity from
nine vaccine-preventable diseases (smallpox and the EPI
diseases mentioned previously for which vaccines had been
recommended for universal use in children as of 1990)
and their complications attest to the remarkable efficacy of
immunizations. Poliomyelitis caused by wild-type viruses
market in 2001.
dLive oral pentavalent vaccine.
From Centers for Disease Control and Prevention. Achievements
in public health, 1900–1999: impact of vaccines universally recom-
mended for children—United States, 1990–1998. MMWR 1999;48;
243–248. (Reproduced with permission.)
has been nearly eliminated, and cases of measles and
Haemophilus influenzae type b (Hib) invasive disease
among children younger than 5 years have been reduced
to record low numbers. As is true for other public health
interventions, national and international efforts to pro-
mote vaccine use depend on public health infrastructure,
economics, and political stability and political will. With
the proper mind-set and establishment of priorities,
even large or poor countries can achieve remarkable
rates of vaccination coverage for their populations.

The success of vaccination programs in the United States
and Europe inspired the 20th century concept of disease
eradication—the idea that a selected disease could be elimi-
nated from all human populations through global coopera-
tion. In 1980, after a decade-long campaign involving
33 nations, smallpox was eradicated worldwide, approxi-
mately a decade after it had been eliminated from the
United States and the rest of the Western Hemisphere. Polio
and dracunculiasis have the possibility of being eradicated in
the near future.
Despite the dramatic declines in vaccine-preventable
diseases, such diseases persist, particularly in developing
countries, and several challenges face vaccine delivery
worldwide. National treasuries and vaccine delivery sys-
tems must be capable of successfully implementing an in-
creasingly complex vaccination schedule. An American
child requires 15 to 19 doses of vaccine by age 18 months
to be protected against 11 childhood diseases.6 In addi-
tion, future immunization challenges are presented by the
recent licensure of new vaccines such as the seven-valent
conjugated pneumococcal vaccine, tetravalent meningo-
coccal vaccines, and the human papilloma virus vaccine.
Anticipated new vaccines include those for influenza,
parainfluenza, and chronic diseases (e.g., gastric ulcers, and
cancer caused by Helicobacter pylori, and rheumatic heart
disease that occurs as a sequel to group A streptococcal
infection). In the 1990s, given constrained national
health care resources, many developing countries were
forced to analyze their infectious diseases epidemiologies
and choose between adding Hib or hepatitis B vaccine to
their national EPI programs.
Clinical trials are under way for a vaccine to prevent
and/or treat HIV infection. The global immunization
challenge of this century will be finding a way to fi-
nance provision of an effective HIV vaccine for the
world’s masses who need it most. Creative and innova-
tive strategies to fund the worldwide distribution of an
effective HIV vaccine, when it becomes available, are
being aggressively discussed with potential funders such
as the World Bank, the World Monetary Fund, and
the Gates foundation. The number of persons who will
be candidates for an HIV vaccine will depend on
whether the immunobiologic is strictly preventive or is
therapeutic.
International partnerships involving affluent indus-
trialized nations, the WHO, and Rotary International
are seeking to eradicate polio in the near future. Efforts
to accelerate control of measles, which causes approxi-
mately 1 million deaths each year, and to expand rubella
vaccination programs are also under way around the world.
The use of existing vaccines in routine childhood vacci-
nation programs worldwide must be expanded, and
successful introduction of new vaccines must occur as
they are developed. Such efforts regarding infectious
disease control and prevention can benefit both rich
and poor countries by decreasing disease importations
GLOBAL HEALTH: PAST, PRESENT, AND FUTURE / 6
from developing countries. In the West, millions of cases
of potentially preventable influenza, pneumococcal dis-
ease, and hepatitis B occur each year in adolescent and
adult populations. Many new vaccines will be targeted
at these age groups.
Antimicrobial Drug Resistance
Antibacterial antibiotics have been in civilian use for
more than 60 years and have saved the lives of millions of
persons with streptococcal and staphylococcal infections,
gonorrhea, syphilis, and other infections. Drugs have also
been developed to treat viral diseases (e.g., herpes and
HIV infection), fungal diseases (e.g., candidiasis and as-
pergillosis), and parasitic diseases (e.g., malaria). Peni-
cillin, discovered fortuitously by Sir Alexander Fleming
in 1928, was not developed for medical use until the
1940s, but it soon changed the face of medicine. The
drug quickly became a widely available medical product
that provided effective treatment of previously incurable
bacterial illnesses, with a broader spectrum and fewer
side effects than sulfa drugs.
The increased development and use of antimicrobial
agents has hastened the development of drug resistance.
The emergence of drug resistance in many microorgan-
isms is reversing some of the therapeutic miracles of the
last 50 years and underscores the importance of disease
prevention. Antimicrobial multidrug resistance is a se-
rious and growing problem worldwide for commu-
nity-based infections caused by Plasmodium species,
Mycobacterium tuberculosis, Streptococcus pneumoniae,
Salmonella and Campylobacter species, Neisseria gonor-
rhoeae, Helicobacter pylori, and HIV, as well as for noso-
comial infections due to staphylococci, enterococci,
Enterobacteriaceae, Clostridium difficile, and systemic
fungi. (See Chapter 12 for more information.)
Future Challenges to the Control
of Infectious Diseases
Successes in reducing morbidity and mortality from in-
fectious diseases during the first three quarters of the
20th century led to complacency about the need for
continued research into the treatment and control of
infectious microbes. However, the global appearance of
AIDS, the emergence of multidrug-resistant tuberculo-
sis (MDR-TB), and an overall increase in infectious dis-
ease mortality during the 1980s and early 1990s have
provided additional evidence that as long as microbes
can evolve, new diseases will appear.
Molecular genetics has provided valuable insights
into the remarkable ability of microorganisms to evolve,
adapt, and develop drug resistance in an unpredictable
and dynamic fashion. Resistance genes are transmitted
from one bacterium to another on plasmids, and viruses
evolve through replication errors and reassortment of

ZIMBABWE: A CASE STUDY OF AN HIV-RAVAGED COUNTRY
As mentioned previously, public health is generally the result of a
summation of the scientific, social, cultural, economic, and political
variables within a population. The HIV/AIDS pandemic has had an
unprecedented impact on the fabric of individual nations and on
the evolution of the planet as a whole because it has targeted the
most economically and socially productive members of society as
well as claimed the futures of maternally infected infants. This case
study of one country in sub-Saharan Africa, Zimbabwe, illustrates
the interplay of national and international factors that can lead to
public health devastation.
Zimbabwe (formerly Rhodesia) achieved its independence
from Britain in 1980; since that time, the Zimbabwe African Na-
tional Union-Patriotic Front has been in power under the presi-
dency of Robert Mugabe. Officially, Zimbabwe has a population of
13 million people, although actual population figures are thought
to be much lower. 56 percent of the population live on less than
US $1 a day, and 80% live on less than US $2 a day.
Zimbabwe is experiencing one of the world’s worst HIV epi-
demics, and the level of HIV infection is one of the highest in the
world, with about 25% of 15 to 49-year-olds infected. About
1.82 million of the nation’s 14 million people are living with HIV or
AIDS. The overall HIV prevalence, once as high as 34% in 2000, has
recently declined to 21.6%. Over 3,200 people die each week from
AIDS, and AIDS-related illnesses account for about three-fourths of
hospital admissions. As a result, life expectancy in Zimbabwe has
fallen to 33 years, from a historical high of 61 years in 1990. An esti-
mated 1.3 million orphans and 1.8 million Zimbabweans are living
with HIV and AIDS. Approximately one-third of all the country’s
teachers and over half of Zimbabwe’s soldiers are HIV seropositive.
Since the late 1990s, the decline of Zimbabwe’s once flourishing
economy, in spite of well-developed infrastructure and financial sys-
tems, has gravely affected a large segment of the population. Unem-
ployment is reportedly more than 70%, and the number of people liv-
ing in poverty, also currently estimated at more than 70%, is
increasing. Hyperinflation has reduced purchasing power. Real gross
domestic product (GDP) has declined by 30% in the last 5 years, and
annual inflation rates reached a record 1,000% in May 2006. Such con-
tinued high inflation hampers development, hitting the poor hardest.
Agricultural production has plummeted in the last 6 years; for exam-
ple, between 2000 and 2004, the national cattle herd shrank by 90%,
and the production of flue-cured tobacco declined from 237 million
kilograms to 70 million kilograms. The frequency of acute malnutri-
tion declined in 2004, partly as a result of large-scale food aid, although
the situation in some areas continues to worsen.On the Human Devel-
opment Index, Zimbabwe ranks 147th of 177 countries.
gene segments and by crossing species barriers. Re-
cent examples of microbial evolution include the de-
velopment of a virulent strain of avian influenza in
Hong Kong (1997–1998) and the multidrug-resistant
W strain of M. tuberculosis in the United States in
1991. The emergence of Vancomycin-Intermediate
GLOBAL HEALTH: PAST, PRESENT, AND FUTURE / 7
Agriculture is the most important sector of the Zimbabwean
economy but has been severely disrupted by land resettlement.
This has led to a collapse in investor confidence and the flight of
capital. Lack of foreign exchange has led to critical shortages in fuel
and other imported commodities, including power. The cost of
schooling has risen dramatically, posing serious challenges for low-
income families. The decline in inward investment and develop-
ment assistance is further compromising the prospects for economic
recovery.
Food shortages affect up to half the population of Zimbabwe.
A national vulnerability assessment in November 2005 estimated
that 2.8 million Zimbabweans would face food shortages in the
“hungry season” (January through March) leading up to the next
harvest. Following much better rains, the harvest in 2006 was ex-
pected to be better than that in 2005. Due to hyperinflation, even
when food is available it is unaffordable to many. However, the im-
pact of chronic illness, localized flooding, and the high price of
seeds and fertilizer will mean that many people will require assis-
tance later in the year.
The International Monetary Fund (IMF) suspended payments
to Zimbabwe in 2000, following the government’s decision to
abandon IMF public spending guidelines (including payments
to war veterans, the cost of which amounted to 3% of GDP). The
country went into arrears at the World Bank in 2000 and at the
IMF the following year, effectively cutting off cooperation with
either institution. The country is crippled by governmental cor-
ruption up to the presidential level; according to Transparency
International’s 2003 Corruption Perception Index, Zimbabwe
ranked 106 of 133 on the global list of most corrupt
nations.
Despite these obstacles, Zimbabwe is on track to achieve the
Millennium Development Goal (MDG) target on HIV and AIDS,
namely, to “have halted by 2015, and begun to reverse, the spread
of HIV/AIDS.” Declining HIV prevalence is likely to be a result of
high mortality rates and changes in sexual behavior. Most of
Zimbabwe’s other MDGs are unlikely to be achieved by 2015 un-
less the political and social situation improves dramatically. Child
and maternal mortality indicators show a steadily worsening situ-
ation, exacerbated by HIV/AIDS.
Current foreign aid priorities include tackling HIV/AIDS
(including increasing access to antiretroviral therapy), food inse-
curity (including increasing individuals’ access to seeds and fertil-
izers, nutrition gardens, and safe water), and support to orphans
and vulnerable children (including school feeding and home-
based care programs).
Staphylococcus aureus (VISA) and vancomycin-resistant
S. aureus (VRSA) has become a major cause of global
concern among clinicians and microbiologists.
For continued success in controlling infectious dis-
eases, the global public health system must prepare to ad-
dress diverse challenges, including the emergence of new

infectious diseases, the reemergence of old diseases (some-
times in drug-resistant forms), large foodborne outbreaks,
and acts of bioterrorism. Continued protection of health
requires improved capacity for disease surveillance and
outbreak response at the local, state, national, and global
levels; the development and dissemination of new labora-
tory and epidemiologic methods; continued antimicrobial
and vaccine development; and ongoing research into envi-
ronmental factors that facilitate disease emergence.7 The
global public health response to the SARS outbreak in
2004 demonstrated unprecedented cooperation in surveil-
lance and the dissemination of information. Ongoing re-
search into the possible role of infectious agents (e.g.,
Chlamydia trachomatis, viruses) in causing or intensifying
certain chronic diseases such as type 1 diabetes mellitus,
some cancers, and atherosclerotic heart disease is also
imperative.
MAJOR PUBLIC HEALTH CHALLENGES
FOR THE FUTURE
World Hunger and Poverty
In 2000, WHO’s Millennium Development Goals to be
achieved by 2015 were endorsed by 189 countries; these
goals include reducing by half the 1.2 billion people in the
world who live on less than US $1 per day and the 852
million people who suffer from hunger on a daily basis.8 It
is estimated that every day more than 16,000 children die
from hunger-related causes (one child every 5 seconds).
Hunger is the most extreme manifestation of poverty,
where individuals or families cannot afford to meet their
most basic need for food. Hunger manifests itself in
many ways other than starvation and famine. Under-
nourishment negatively affects people’s health, produc-
tivity, sense of hope, and overall well-being. Lack of food
can stunt growth, heighten susceptibility to illness, slow
thinking, sap energy, hinder fetal development, and con-
tribute to mental retardation. Economically, the constant
securing of food consumes valuable time and energy, al-
lowing less time for work and earning income. Socially,
the lack of food erodes relationships and feeds shame so
that those most in need of support are often least able to
call upon it.
Poor nutrition and caloric deficiencies cause nearly
one in three people to die prematurely or have disabili-
ties, according to the WHO.9 Pregnant women, nursing
mothers, and children are among the groups most at risk
for undernourishment. Every year, nearly 11 million chil-
dren die before they reach their 5th birthday. Almost all
of these deaths occur in developing countries, three-
fourths of them in sub-Saharan Africa and South Asia,
the two regions that also suffer from the highest rates of
hunger and malnutrition. Most of these deaths are attrib-
uted not to outright starvation but to diseases that oppor-
tunistically afflict vulnerable children with host defenses
GLOBAL HEALTH: PAST, PRESENT, AND FUTURE / 8
weakened by hunger. Each year, more than 20 million
low-birth-weight babies are born in developing countries.
These babies risk dying in infancy, and those who survive
often suffer lifelong physical and cognitive disabilities.
The four most common childhood illnesses are diar-
rhea, acute respiratory illness, malaria, and measles. Each
of these illnesses is both preventable and treatable. Yet,
poverty interferes with parents’ access to immunizations
and medicines. Chronic undernourishment superimposed
on insufficient treatment greatly increases a child’s risk of
death. In the developing world, 27% of children younger
than 5 years are moderately to severely underweight, 10%
are severely underweight, 10% are moderately to severely
wasted or seriously below weight-for-height, and an over-
whelming 31% are moderately to severely stunted or seri-
ously below normal height-for-age.10
HIV/AIDS
The HIV/AIDS epidemic has become a major obstacle
in the fight against hunger and poverty in developing
countries. Because the majority of HIV-infected persons
with AIDS are young adults who normally harvest crops,
food production has dropped dramatically in countries
with high HIV/AIDS prevalence rates. In half of the coun-
tries in sub-Saharan Africa, per capita economic growth is
estimated to be falling by between 0.5% and 1.2% each
year as a direct result of AIDS. Infected adults also leave
behind children and elderly relatives who have little means
to provide for themselves. In 2003, 12 million children
were newly orphaned in southern Africa, a number ex-
pected to rise to 18 million in 2010.11 Since the epi-
demic began, 30 million people have died from AIDS,
and more than 15 million children have lost at least one
parent to the disease. The UNICEF term child-headed
households, meaning minors orphaned by HIV/AIDS
who are raising their siblings, illustrates the gravity of
the situation.11,12 Approximately 60% of the 40 million
HIV-infected people in the world today live in sub-
Saharan Africa (Figure 1-3).
Each year, another 5 million people become infected
with HIV and more than 3 million people die of AIDS.
Despite these figures, only a small minority of persons
in need are receiving antiretroviral therapy (Figure 1-4),
although the situation has improved since the advent of
generic antiretroviral drug production and national scale-
up drug distribution programs. WHO’s Millennium
Development Goal was to provide 3 million people in
developing countries with antiretroviral treatment by the
end of 2005.
Infant and Maternal Mortality
Child mortality is closely linked to poverty. Improve-
ments in public health services are critical to childhood
 GLOBAL HEALTH: PAST, PRESENT, AND FUTURE / 9

Adult prevalence (%)

15.0–34.0%
5.0–<15.0%
1.0–<5.0%
0.5–<1.0%
0.1–<0.5%
<0.1%

Figure 1-3. Adults (15–49 years of age) living with HIV (%), end 2005. From the World Health Organization. 2006
report on the global AIDS epidemic. (Reproduced with permission.)

survival, including safe water, better sanitation, and (es-
pecially for girls and mothers) education. In the United
States from 1915 through 1997, the infant mortality
rate declined more than 90%, to 7.2 per 1,000 live
births; from 1900 through 1997, the maternal mortal-
ity rate declined almost 99%, to less than 0.1 reported
death per 1,000 live births (7.7 deaths per 100,000 live
births in 1997)—and the United States ranks only
25th among developed countries in infant mortality and
21st in maternal mortality (Figure 1-5). In stark contrast,
in the Central African Republic in 2000, for every
1,000 live births 120 infants died and 179 children
under age 4 died, and 1,100 of every 100,000 women
died of pregnancy-related complications. Each year
worldwide, almost 10.5 million children die before their
5th birthday.13

Number of people receiving ARV therapy Estimated

Geographical region Coverage
(lowestimate – high estimate) need

Sub-Saharan Africa 810,000 (730,000–890 000) 4,700,000 17%

Latin America and the Caribbean 315,000 (295,000–335 000) 465,000 68%

East, South and South-East Asia 180,000 (150,000–210 000) 1,100,000 16%

Europe and Central Asia 21,000 (20,000–22 000) 160,000 13%

North Africa and the Middle East 4,000 (3,000–5 000) 75,000 5%

Total 1 330,000 (1,200,000–1 460 000) 6.5 million 20%

Figure 1-4. Antiretroviral coverage in low- and middle-income countries, by region, as of December 2004. From the
World Health Organization. Progress on global access to antiretroviral therapy. March 21, 2007. http://www.who.int/hiv/
facts/cov1205/en/index.html. (Reproduced with permission.)
 GLOBAL HEALTH: PAST, PRESENT, AND FUTURE / 10

200 185
172

150
126
105
100 90
83 78 86 87 88
77 78
68
60 54
46 38 48
50 37 32
21 21

0
Sub-Saharan

Northern

America

Developing
CIS, Asia

Southeast

Eastern
Southern Asia

Oceania

Western Asia

and the

Europe
Africa

Latin
Asia

regions
CIS,
Asia
Africa

1990 2003 2015 target

Figure 1-5. Under-five mortality rate per 1,000 live births, 1990 and 2003.

Worldwide, in 1960 one child in five died before age 5. East, central and eastern Europe, the former Soviet Union,
By 1990, the rate had fallen to one in ten. Such and South Asia (around a 30% reduction between 1990
progress gave hope that child mortality could be cut and 2004). Unfortunately, substantial progress has not
by two-thirds by 2015. But advances slowed in the been observed in Africa, with only a 10% decline since
1990s, and only northern Africa, Latin America, the 1990 and much less than that observed between 1970
Caribbean, and Southeast Asia maintained their rapid and 1990. Almost 100 countries, including over 40 in
pace. In these regions, economic growth, better nutri- sub-Saharan Africa, are not on track to reach WHO’s
tion, and better access to health care have helped spur 2015 Millennium Development Goal of two-thirds
improvements in child survival (Table 1-5). Regional reduction in the under-five mortality rate observed in
averages, however, mask differences from country to 1990.
country and disparities among socioeconomic groups. One hundred years ago, most obstetrical deliveries
Important progress has also been observed in the Middle and surgical interventions around the world were per-
formed without following the principles of asepsis. As
a result, large numbers of maternal deaths were caused
by sepsis following delivery or illegally induced abor-
tion, with the remaining deaths primarily attributed to
hemorrhage and toxemia. Today, the complications of
Table 1-5. Environmental and medical pregnancy and childbirth are still a leading cause of
interventions contributing to the decline death and disability among women of reproductive age
in infant mortality in the 20th century. in the poorest regions of the world.14,15 It is estimated

that around 529,000 women die each year from ma-

Improvements in standards of living ternal causes (especially intractable hemorrhage,. sepsis,
Reduction in vaccine-preventable diseases complications of unsafe abortion, prolonged or ob-
Control of milkborne diseases structed labor, and eclampsia), and many more suffer
Improvements in nutrition injuries, infection, and disabilities during pregnancy or
Declining fertility rates childbirth.
Longer birth spacing Poor obstetrical education and delivery practices
Advances in clinical medicine are mainly responsible for the high numbers of mater-
Discovery of antibiotics and fluid and electrolyte therapies nal deaths, most of which are preventable. In many
Technologic advances in neonatal medicine poor countries, obstetrical services are primarily pro-
Improvements in access to health care vided by poorly trained or untrained medical practi-
Increases in surveillance and monitoring of disease tioners (for example, in the Central African Republic
Placing of infants on their back only 44% of babies are delivered by skilled atten-
Regionalization of perinatal services dants). Most births occur at home with the assistance
Improvements in education levels
of midwives or traditional birth attendants. In much

of the world, consistent access to antenatal and postnatal
care, which benefits both mother and fetus, is inadequate
or lacking.
The foundations for maternal risk are often laid in
girlhood. Women whose growth has been stunted by
chronic malnutrition are vulnerable to obstructed labor.
Anemia predisposes to hemorrhage and sepsis during
delivery and has been implicated in at least 20% of post-
partum maternal deaths in Africa and Asia. The risk of
childbirth is even greater for women who have under-
gone female genital mutilation; an estimated 2 million
girls are mutilated every year.
Motor Vehicle Safety
Each year, road traffic accidents claim 1.2 million lives
worldwide and injure or disable as many as 50 million
more.16 Road traffic accidents are the second leading cause
of death worldwide among persons aged 5 to 29 years.
Previous studies have shown that casualty and fatality
rates in developing countries are higher than in the
West. Furthermore, in the Middle East gulf countries,
injury and death rates are much higher than in develop-
ing countries with comparable vehicle ownership levels.
For example, in the United Kingdom and United States
in 2004 there were 0.72 and 1.51 road traffic fatalities
per hundred million vehicle kilometers, respectively,
whereas the United Arab Emirates recorded a dispropor-
tionate 3.33 deaths per hundred million kilometers.17 In
2004, road traffic mortality in Oman was 28 per 100,000
population, far in excess of the global average of 19 per
100,000 persons, and more than one-third of those who
died were younger than 25 years.
Over the past two decades, research has provided a
clear understanding of the circumstances surrounding
motor vehicle injuries in children and the demographic
risk and protective factors that influence the likelihood
that a child will be injured. Riding unrestrained is the
single most important risk factor for death and injury
among children in motor vehicle accidents. In the United
States in 2000, 47% of motor vehicle fatalities among oc-
cupants younger than 5 years involved children who were
not restrained. In most developing countries, infant and
child safety seat usage is even lower.
Occupational Workplace Safety
Workplace safety is a serious concern in many parts of
the world, where workers face significant health and
safety risks during the course of trying to earn a living.
Major unintentional occupation-related illnesses, in-
juries, and deaths occur as a result of motor vehicle–
related accidents, mining-related exposures and accidents,
machine-related accidents, construction exposures and
accidents, agriculture/forestry/fishing-related accidents,
transportation/communications/public utilities–related
GLOBAL HEALTH: PAST, PRESENT, AND FUTURE / 11
incidents, electrocutions, falls, and homicides. Workplace
fatalities, injuries, and illnesses remain at unacceptably
high levels and involve an enormous unnecessary health
burden, suffering, and economic loss amounting to 4%
to 5% of global GDP.18
In the United States, data from the National Safety
Council from 1933 through 1997 indicate that deaths
from unintentional work-related injuries declined 90%,
from 37 per 100,000 workers to 4 per 100,000.19,20 The
corresponding annual number of deaths decreased from
14,500 to 5,100. During the same period, the workforce
more than tripled, from 39 million to approximately
130 million. Workers in developing countries, however,
have not achieved the same levels of workplace protec-
tion as in the West. Globally, workers continue to die
from preventable injuries sustained on the job. According
to the latest International Labor Organization estimates
for the year 2000, there are 2.0 million work-related
deaths worldwide each year. WHO estimates that only
10% to 15% of workers have access to a basic standard of
occupational health services. Mining remains the most
hazardous industry worldwide.
Coronary Heart Disease and Stroke
An estimated 16.7 million deaths—or 29.2% of total
global deaths—result from the various forms of cardiovas-
cular disease (CVD): ischemic or coronary heart disease,
cerebrovascular disease or stroke, hypertension, heart fail-
ure, and rheumatic heart disease. Of these, 7.2 million
deaths are due to ischemic heart disease, 5.5 million to
stroke, and an additional 3.9 million to hypertensive
and other heart conditions.21 At least 20 million people
survive heart attacks and strokes every year, with a sig-
nificant proportion of them requiring costly clinical
care, which puts a huge burden on long-term care re-
sources. CVD affects people in their midlife years, un-
dermining the socioeconomic development not only of
affected individuals but also of families and nations.
Lower socioeconomic groups generally have a greater
prevalence of risk factors, diseases, and mortality in de-
veloped countries. A similar pattern is emerging as the
CVD epidemic matures in developing countries as well.
Cardiovascular diseases are no longer only diseases of
the developed world. In 2005, some 80% of all CVD
deaths worldwide took place in developing low- and
middle-income countries, and these countries accounted
for 86% of the global CVD disease burden. More than
60% of all coronary heart disease occurs in developing
countries, partly as a result of increasing longevity, urban-
ization, and lifestyle changes. It is estimated that by
2010, CVD will be the leading cause of death in devel-
oping countries. Furthermore, CVD is responsible for
10% of disability-adjusted life years (DALYs) lost in
low- and middle-income countries and 18% in high-
income countries. DALYs represent healthy years lost

and indicate the total burden of a disease as opposed to
simply the resulting death. The global burden of coro-
nary heart disease is projected to rise from 46 million
DALYs in 1990 to 82 million in 2020. The rise in CVD
reflects a significant combination of unhealthy dietary
habits, reduced physical activity levels, and increased to-
bacco consumption worldwide as a result of industrial-
ization, urbanization, economic development, and food
market globalization.
More than half of the deaths and disability from heart
disease and strokes each year can be reduced by a combi-
nation of simple, cost-effective, national efforts and indi-
vidual actions to reduce major risk factors such as high
blood pressure, diabetes mellitus, high cholesterol, obe-
sity, and smoking. Obesity is one of the newest global epi-
demics, especially in developed and transitional countries.
Because of obesity’s association with cardiovascular disease
and diabetes, obesity control and weight loss must be con-
sidered an important global strategy to improve the health
and well-being of people all over the world.
In the West, major milestones in the management of
angina pectoris and heart attack, including expensive or
invasive interventions such as diagnostic coronary an-
giography, thrombolytic therapy, statins, IIb/IIIa platelet
receptor blocker drugs, percutaneous transluminal coro-
nary angioplasty, coronary artery stenting, coronary ar-
tery bypass grafting, and ventricular assist devices, have
resulted in impressive declines in mortality from these
conditions in the past two decades. The technologic fu-
ture holds even more promise for cardiovascular disease
treatment. However, these diagnostic and therapeutic
services are largely inaccessible to the majority of popu-
lations living in Asia, Africa, and Latin America. No mat-
ter what advances are made in high-technology medicine,
major global reductions in death and disability from car-
diovascular disease will only come from preventive meas-
ures involving modification of risk factors, not from cure.
The most cost-effective methods of reducing risk are pop-
ulation-wide interventions combining effective economic,
educational, and broad health promotion policies and
programs emphasizing the dietary intake of fats, cessation
of smoking, and salt restriction.
The WHO, in collaboration with the CDC, is
presently working to provide actionable information to
develop and implement appropriate national and inter-
national policies related to the global epidemic of heart
attack and stroke. As part of such efforts, the WHO has
produced The Atlas of Heart Disease and Stroke, which
addresses the problem of heart disease and stroke in a
clear and accessible format for a wide audience. This
highly valuable reference material has been designed for
use by policy makers, national and international organi-
zations, health professionals, and the general public.
This picturesque atlas is in six parts: cardiovascular dis-
ease, risk factors, the burden, action, the future and the
past, and world tables.22
GLOBAL HEALTH: PAST, PRESENT, AND FUTURE / 12
Displaced and Refugee Populations
Under the United Nations (UN) Convention on the
Status of Refugees, a refugee is defined as a person who,
“owing to a well-founded fear of being persecuted for
reasons of race, religion, nationality, membership in a
particular social group, or political opinion, is outside
the country of his nationality, and is unable to, or,
owing to such fear, is unwilling to avail himself of the
protection of that country.” Internally displaced persons
(IDPs) are people who have similarly been forced from
their homes but have not crossed an internationally rec-
ognized state border. At the beginning of 2005, 13.4
million refugees were recognized by the UN. Although
the overall number of refugees worldwide has decreased
in recent years, increases have occurred in Africa, Asia,
and the Pacific. Together, women and children make up
approximately 80% of the refugee population.23 The UN
High Commissioner for Refugees (UNHCR) reports
that, on average, refugees will spend 17 years outside of
their home country.
In 2004, approximately 25,000,000 IDPs were dis-
placed by conflict in 48 countries: 36% were located in
camps or centers, 15% were living in urban areas, and
49% were either dispersed in rural areas or living in an
unknown type of settlement.24 More than half of the
world’s displaced people live in Africa, and nearly half
live in countries experiencing ongoing conflict. Children
and adolescents under the age of 18 account for nearly
half this number, with 13% being under the age of 5.
Refugees and internally displaced individuals face
daunting economic, social, and health risks that accom-
pany displacement (Table 1-6). Relief programs target
Table 1-6. Factors that place refugees and
internally displaced persons at risk for serious
public health and humanitarian consequences.
Displacement and separation from families
Social instability
Increased mobility
Sexual and gender-based violence
Exploitation and abuse (including HIV/AIDS)
Poverty and food insecurity
Lack of access to health services, education, and
basic assistance
Lack of linguistically and culturally appropriate health
information
Forced labor or slavery
Forcible recruitment into armed groups
Trafficking
Abduction
Detention and denial of access to asylum or family-
reunification procedures

the specific needs of women, children and adolescents,
older refugees, and particular ethnic or social groups.
Unaccompanied children and those with only one par-
ent are at greatest risk, since they lack the protection,
physical care, and emotional support provided by the
family.25,26 Safety and well-being is especially difficult
in the presence of armed elements among displaced or
refugee populations. Furthermore, many IDPs and self-
settled refugees are in countries where the government
is either indifferent or actively hostile to their assis-
tance and protection needs. In at least 13 countries in
recent years, including Myanmar, Sudan, Uganda, and
Zimbabwe, state forces or government-backed militia
have attacked displaced and other civilian populations.
Landmines
More than 80 countries, located in every region in the
world, are affected by landmines or unexploded ordnance
or both. Some of the most mine-contaminated countries
include Afghanistan, Angola, Burundi, Bosnia and Herze-
govina, Cambodia, Chechnya, Colombia, Iraq, Lebanon,
Nepal, and Sri Lanka.27,28 Other countries with land-
mines, such as Myanmar, India, and Pakistan, provide little
public information about the extent of their problem.
Over the past decades, landmine deaths and injuries
have totaled in the hundreds of thousands. The precise
number of still-buried, undetonated explosive devices
is unknown. An estimated 15,000 and 20,000 new
landmine-related casualties occur each year, translating
into 1,500 new casualties each month, more than 40
new casualties a day, or at least 2 new casualties per hour.
Most casualties are civilians, and most live in countries
that are now at peace. In Cambodia, for example, over
45,000 landmine injuries were recorded between 1979
and 2005, and some 20,000 people were killed by land-
mines during this same period. More than 75% of the
total casualties were civilians.
Landmines indiscriminately kill or maim civilians,
soldiers, peacekeepers, and aid workers alike. Antiper-
sonnel landmines are still being laid today, and together
with mines from previous conflicts, claim victims each
day in every corner of the globe. The situation has im-
proved in recent years, but a global mine crisis remains
and a mine-free world is a long way off.
Environmental and Social Determinants of
Public Health
POPULATION GROWTH
Population structures and dynamics have profound po-
tential implications for world health in the 21st century.
In the last century the world experienced an unprece-
dented increase in population, from 1.7 billion in 1900
to almost 6.5 billion in 2000. By the end of the present
GLOBAL HEALTH: PAST, PRESENT, AND FUTURE / 13
century, growth projections suggest that world popula-
tion will be between 8 to 20 billion persons. Urbaniza-
tion will be accelerated, and international migration
may be the most important demographic feature of the
21st century.
In the ensuing decades, aging of the population in
America, Japan, China, India, and elsewhere will have
dramatic social and economic ramifications on health
and health care. Demographic changes worldwide will
affect every aspect of the quality of life, including the en-
vironment, food, economy, schools, jobs, and health. In
all countries there will be a further health transition from
first-generation diseases to second- and third-generation
diseases. The ability of the world to feed itself will de-
pend not only on food production but also on “popula-
tion choices in the quality, style, distribution, and pattern
of human consumption”.2
GLOBAL CLIMATE CHANGE AND NATURAL DISASTERS
Global Warming The earth’s surface has undergone
unprecedented warming over the last century, particu-
larly over the last two decades. Every year since 1992
has been on the current list of the 20 warmest years on
record. In its 2001 report, the Intergovernmental Panel
on Climate Change (IPCC) stated that “there is new
and stronger evidence that most of the warming ob-
served over the last 50 years is attributable to human
activities”29 and that global warming has altered natural
patterns of climate.
Carbon dioxide from the burning of fossil fuels and
clearing of land has been accumulating in the atmos-
phere, where it acts like a blanket keeping the earth warm
and heating up the surface, oceans, and atmosphere (the
greenhouse effect). Current levels of carbon dioxide are
higher than at any time during the last 650,000 years.
The world’s oceans have absorbed about 20 times as
much heat as the atmosphere over the past half-century,
leading to higher temperatures not only in surface waters
but also in water 1,500 feet below the surface. Some ob-
served climatic, physical, and ecological changes include
an increase in global average surface temperature of
about 0.8°C (1.4°F) in the 20th century, a rise in
global
average sea level and an increase in ocean water tempera-
tures, and increased rainfall and other precipitation levels
in certain regions of the world.30,31 Scientists predict that
continued global warming on the order of 1.4°C to
5.8°C (2.5°–10.4°F) over the next 100 years (as
pro-
jected in the IPCC’s Third Assessment Report) is likely
to result in the following:
• A rise in sea level between 3.5 and 34.6 inches
(9–88 cm), leading to more coastal erosion, flooding
during storms, and permanent inundation
• Severe stress on many forests, wetlands, alpine re-
gions, and other natural ecosystems
 GLOBAL HEALTH: PAST, PRESENT, AND FUTURE / 14
• Greater threats to human health as mosquitoes and ENVIRONMENTAL POLLUTION
other disease-carrying insects and rodents spread dis-
eases over larger geographic regions Indoor Air Pollution More than 3 billion people
worldwide continue to depend on solid fuels, including
• Disruption of agriculture in some parts of the world biomass fuels (wood, dung, straw, and agricultural residues)
due to increased temperature, water stress, and sea- and coal, for their energy needs. Cooking and heating with
level rise in low-lying areas such as Bangladesh or the solid fuels on open fires or traditional stoves results in high
Mississippi River delta. levels of indoor air pollution. Indoor smoke contains a
range of health-damaging pollutants, such as small parti-
Natural Disasters Natural disasters have been impor-
cles, carbon monoxide, nitrous oxides, sulfur oxides (espe-
tant sources of human morbidity and mortality throughout
cially from coal), formaldehyde, and carcinogens (such as
history, in every region of the world. Floods, earthquakes,
benzo[a]pyrene and benzene). Particulate pollution levels
hurricanes, tornadoes, fires, and other disasters wreak havoc
may be 20 times higher than accepted guideline values.
on global populations each year. The tsunami that struck
There is consistent evidence that exposure to indoor air
11 countries in South Asia in December 2004 resulted in
pollution can lead to acute lower respiratory infections
devastation of staggering proportions: more than 150,000
(ALRIs) in children younger than 5, particularly pneumo-
people dead (especially in Indonesia and Sri Lanka), tens of
nia (ALRIs represent the single most important cause of
thousands of people missing, thousands of miles of de-
death in children younger than 5 years and account for at
stroyed coastline, and loss of livelihood for millions of dis-
least 2 million deaths annually in this age group), and to
traught survivors. Although this catastrophe was unusually
chronic obstructive pulmonary disease and lung cancer
vast, it was a classic natural disaster in several ways, uncom-
(where coal is used) in adults.
plicated by war or terrorism. The short-term public health
According to The World Health Report 2005, indoor
needs of the surviving population were familiar (albeit
air pollution is responsible for 1.6 million deaths,
massive): water, sanitation, food, shelter, and appropriate
mostly of women and children, in developing coun-
medical care administered to persons remaining in place
tries, and is estimated to cause 3.1% of the overall bur-
and the thousands who were living in self-settled displaced
den of disease in developing countries and 2.7% glob-
communities. 32
ally (Figure 1-6).33 In most societies, it is women who
In addition to the instantaneous devastation, in
many natural disasters the number of casualties may
increase by as much as twofold as a result of the spread
Deaths attributable to solid fuel use
of communicable diseases in the crowded communities
that are often created in the aftermath. The public 24%

Africa
health model for natural disasters highlights a cycle of 31%
preparedness, mitigation, response, and recovery. The Americas
Short-term interventions after large-scale natural disas- Eastern Mediterranean
2%
ters include supplying the recommended 20 liters of Europe
water per person per day and ensuring that there are 7%
Southeast Asia
adequate, culturally appropriate sanitation facilities to 1%
prevent outbreaks of cholera, dysentery, and hepatitis Western Pacific
A; targeted measles vaccination in unvaccinated popu- 35%
lations, with vitamin A supplementation when indi-
cated; control of vector-borne illnesses such as malaria

and dengue through early treatment and mosquito- DALYs attributable to solid fuel use
control measures; early diagnosis and treatment of
acute respiratory and gastrointestinal infections, partic- 26% Africa
ularly among infants and young children; delivery of The Americas
adequate amounts of culturally appropriate emergency
Eastern Mediterranean
food rations; counseling for survivors experiencing 0% 54%
grief, loss, and guilt; and epidemic surveillance to de- 2% Europe
tect the early appearance of communicable diseases. Southeast Asia
15%
The longer-term recovery and rehabilitation needs in Western Pacific
disaster-affected areas are less understood than the 3%
short-term needs, but are typically strategic rather than

logistic in nature and involve a transition from emer- Figure 1-6. Deaths and disability adjusted life years
gency relief activities to sustainable reconstruction and (DALYs) attributable to solid fuel use. From (Reproduced
development activities. with permission.)

cook and spend time near the fire, and in developing
countries they are typically exposed to these very high
levels of indoor air pollution for between 3 and 7 hours
per day over many years. Young children are often
carried on their mother’s back during cooking. Conse-
quently, they spend many hours breathing smoke from
early infancy. Emerging evidence suggests that indoor
air pollution in developing countries may also increase
the risk of other important child and adult health prob-
lems, including asthma, otitis media and other acute
upper respiratory infections, low birth weight and
perinatal mortality, tuberculosis, nasopharyngeal and
laryngeal cancer, cataracts (blindness), and cardiovascular
disease.
Clearly, some of the world’s regions rely heavily on
solid fuel use at the household level, whereas others have
made an almost complete transition to cleaner fuels, such
as gas and electricity. For example, more than 75% of the
population in India, China, and nearby countries and
50% to 75% of people in parts of South America and
Africa continue to cook with solid fuels. These differ-
ences in household solid fuel use patterns are reflected in
an unequal share of the disease burden due to indoor air
pollution, with Africa, Southeast Asia, and the Western
Pacific region shouldering the biggest death toll. More
than half of the total DALYS lost due to exposure to in-
door air pollution occur in Africa, highlighting the urgent
need to intervene. WHO has developed a comprehensive
Program on Indoor Air Pollution to support developing
countries.
Water Pollution An important fraction of the bur-
den of water-related diseases (in particular, water-re-
lated vector-borne diseases) is attributable to the way in
which water resources are developed and managed. In
many parts of the world, the adverse health impacts of
dam construction, irrigation development, and flood
control include an increased incidence of malaria,
Japanese encephalitis, schistosomiasis, lymphatic filaria-
sis, and other diseases. Other health issues indirectly
associated with water resource development include nu-
tritional status, exposure to agricultural pesticides and
their residues, and accidents/injuries. The WHO’s Water,
Sanitation and Health Program focuses on drinking
water quality, bathing waters, water resources quality,
and wastewater use.
Water-related infectious diseases are a major cause of
morbidity and mortality worldwide, and newly recog-
nized pathogens and new strains of established pathogens
are being discovered that present important additional
challenges to both the water and public health sectors.
Between 1972 and 1999, 35 new agents of disease were
discovered, and many more have reemerged. Among these
are several pathogens that may be transmitted through
water.
GLOBAL HEALTH: PAST, PRESENT, AND FUTURE / 15
POLITICAL INSTABILITY, REGIONAL CONFLICT, AND
GOVERNMENTAL CORRUPTION
Some have suggested that improvement in the health
status of populations, particularly those in developing
countries, can occur only through sociopolitical
change, a global outlook, and local empowerment.
International aid agencies and voluntary groups are
important partners in this effort. However, lack of na-
tional and international political will and geopolitical
stability are major barriers in this regard. At all levels,
there has been a global failure to address the root
causes of poverty, disease, and homelessness. Even
though there is widespread recognition of the inextri-
cable link between health and development, global and
national efforts to address the challenges of access to
and distribution of resources have fallen woefully
short.
Effective public health infrastructure depends criti-
cally on strong economies. Unfortunately, developing
countries around the globe have track records of wide-
spread corruption that siphons billions of dollars from
their economies each year, thereby diverting valuable fi-
nancial assets that could be used for preventive and cur-
ative health care services. Various forms of corruption
are generally related to nondemocratic political systems
and political instability.34 Protracted civil and regional
conflicts lead to the socioeconomic instability of a na-
tion, which invariably affects the health and welfare of
its citizens.
BIOLOGIC AND CHEMICAL TERRORISM
For decades, but especially since the attacks of
September 11, 2001, the world has been preparing itself
for bioterrorism, that is, the deliberate release of viruses,
bacteria, or other biologic agents designed to cause illness or
death in people, animals, or plants. Biologic agents can be
spread through air, water, or food; some potential bioterror-
ism agents, such as smallpox virus and hemorrhagic fever
viruses, can be spread from person to person. These agents
are classified into three categories according to their trans-
missibility and the severity of illness or death they cause
(Table 1-7).35 Category A agents are microorganisms or
toxins that pose the highest risk to public health and global
security, and category C agents are those that are consid-
ered emerging threats.
Category A
• Many are easily spread or transmitted from person to
person
• Result in high death rates and have the potential for
major public health impact
• Might cause public panic and social disruption
• Require special action for public health preparedness
 GLOBAL HEALTH: PAST, PRESENT, AND FUTURE / 16
Table 1-7. Microbial agents with bioterrorism potential.
Category A
Bacillus anthracis (anthrax)
Clostridium botulinum (botulism)
Yersinia pestis (plague)
Variola major (smallpox) and other pox viruses
Francisella tularensis (tularemia)
Viral hemorrhagic fever viruses
Arenaviruses
LCM, Junin, Machupo, Guanarito, and Lassa fever
viruses
Bunyaviruses
Hantaviruses
Rift Valley fever virus
Flaviviruses
Dengue virus
Filoviruses Ebola
virus Marburg
virus
Category B
Burkholderia pseudomallei (melioidosis)
Coxiella burnetii (Q fever) Brucella
species (brucellosis) Burkholderia
mallei (glanders) Ricin toxin (of
Ricinus communis)
Epsilon toxin (of Clostridium perfringens)
Staphylococcal enterotoxin B
Rickettsia prowazekii (typhus fever)
Food- and waterborne pathogens
From National Institute of Allergy and Infectious Diseases (NIAID) Biodefense Research. NIAID category A, B, and C pathogens.
http://www3.niaid.nih.gov/biodefense/bandc_priority.htm.
Category B
• Are moderately easy to spread
• Result in moderate illness rates and low death rates
• Require specific enhancements of existing laboratory
capacity and enhanced disease monitoring
Category C
• Are easily available
• Are easily produced and spread
• Have the potential for high morbidity and mortality
rates and major health impact
Chemical terrorism refers to the intentional release of a
hazardous chemical into the environment for the purpose
of public harm. Types and categories of potential chemical
warfare agents include biotoxins, blister agents/vesicants,
blood agents, caustics (acids), choking/lung/pulmonary
agents, incapacitating agents, long-acting anticoagulants,
metallic poisons, nerve agents, organic solvents, toxic
Category B (cont.)
Bacteria
Diarrheagenic Escherichia coli, pathogenic Vibrio spp.,
Shigella spp., Salmonella spp., Listeria monocyto-
genes, Campylobacter jejuni, Yersinia enterocolitica
Viruses
Caliciviruses, hepatitis A virus
Protozoa
Cryptosporidium parvum, Cyclospora cayetanensis,
Giardia lamblia, Entamoeba histolytica, Toxoplasma
gondii, microsporidia
Viral encephalitis viruses
West Nile, LaCrosse, California encephalitis, Venezuelan
equine encephalitis, Eastern equine encephalitis,
Western equine encephalitis, Japanese B encephalitis,
and Kyasanur forest viruses
Category C
Nipah virus and additional hantaviruses
Tickborne hemorrhagic fever viruses
Crimean-Congo hemorrhagic fever virus
Tickborne encephalitis viruses
Yellow fever
Multidrug-resistant Mycobacterium tuberculosis
Influenza
Other rickettsiae
Rabies virus
Severe acute respiratory syndrome–associated coronavirus
(SARS-CoV)
alcohols, and vomiting agents. Protection of the global
public heath from biologic and chemical terrorism
involves well-orchestrated disaster preparedness includ-
ing improved education, disease recognition, surveil-
lance, and emergency notification by first responders,
clinicians, laboratories, and public health workers.
NUCLEAR THREATS
The possibility of regional or global nuclear conflict looms
as an ominous public health threat in the 21st century.
Major industrialized countries such as the United States,
Russia, England, France, and Germany have had nuclear
capabilities for decades, but it is likely that newer nuclear-
capable nations such as India, Pakistan, and Israel and nuclear-
striving North Korea and Iran pose much greater nuclear
risks to world populations.
ECONOMIC DISPARITIES
The world is witnessing huge economic transformations
in all countries. Private markets and free trade, although

highly efficient, are never equitable, and the 21st century
will continue to see both a convergence in the rates of
improvement of life expectancies and a divergence in the
capacity for income generation between countries, as the
rich become richer and the poor get poorer. Finally,
global health will be influenced by national debates re-
garding the inclusion of education and health care in the
concept of basic human rights, similar to social, political,
and religious rights.
STUDY QUESTIONS
1. Trace the rise and fall of the importance of infec-
tious diseases to global health and enumerate the
new infectious threats in the world.
2. How have sanitation, environmental health, and
attention to basic necessities such as food and
water improved global health, and how are they
threatened today?
3. Take one global health challenge from this chapter
and expand on its causes, trends, and the correc-
tive action needed, taking into account resources
in the developing world.
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