Global Health-An Introductory

8012.
book Page 1 Wednesday, October 11, 2006 1:40 PM
Ann Lindstrand Staffan Bergstrm Hans Rosling

Birgitta Rubenson Bo Stenson Thorkild Tylleskr
Global Health
an introductory textbook
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Studentlitteratur
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Cover photo:
Water: Giacomo Pirozzi (UNICEF)
Vaccination: Shehzad Noorani (UNICEF)
Operation: Brian Kelly (BigStockPhoto.com)
Food: Simon van der Berg (BigStockPhoto.com)
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Art.No 8012
ISBN 978-91-44-02198-0
Ann Lindstrand, Staffan Bergstrm, Hans Rosling, Birgitta Rubenson,
Bo Stenson, Thorkild Tylleskr and Studentlitteratur 2006
Illustrator: Niklas Hofvander
Coverdesign: Georg Gtmark & David Herdies
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Printed in Denmark by Narayana Press
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8012.book Page 3 Wednesday, October 11, 2006 1:40 PM
Contents
Preface 5 4 Health transition 123

4.1 Disease transition 124
1 What is development? 9 4.2 Demographic transition 126
1.1 Definitions of development 12 4.3 Global Burden of Disease 130
1.2 Four levels of development 14 4.4 Future projections 132
1.3 Climate 19 4.5 Impact of the health transition on
1.4 Hunters and gatherers (up to health services 134
10 000 years ago) 21
1.5 Agriculture (10 000 to 5 000 years 5 Communicable diseases (30 %) 137
ago) 23 5.1 Acute lower respiratory tract
1.6 Empires (5 000 to 1 000 years infection (6 %) 138
ago) 26 5.2 HIV infection and AIDS (6 %) 143
1.7 European dominance (1 000 to 50 5.3 Diarrhoea (4 %) 153
years ago) 29 5.4 Vaccine-preventable childhood
1.8 Development strategies (the last diseases (3 %) 158
50 years) 34 5.5 Malaria (3 %) 165
1.9 Globalisation (the present) 43 5.6 Tuberculosis (3 %) 168
1.10 A taxonomy of nations 47 5.7 Sexually transmitted infections
1.11 The hopeful future 49 (excluding HIV) (1 %) 171
5.8 Other parasite infections and
2 Health determinants 53 intestinal worms (1 %) 172
2.1 Socio-economic determinants 56 5.9 Other major infections
2.2 Food 70 (0.6 %) 174
2.3 Water 75
2.4 Sanitation 78 6 Nutritional disorders (2 %) 177
2.5 Other environmental 6.1 Nutritionally Acquired Immune
determinants 79 Deficiency Syndrome
2.6 Behaviour 85 (NAIDS) 180
2.7 Health services 89 6.2 Underweight 181
6.3 Child malnutrition 182
3 Health indicators 99 6.4 Micronutrient deficiency 189
3.1 Infant mortality rate 102 6.5 Other nutrition-related risks and
3.2 Under-five mortality rate 103 physical inactivity 196
3.3 Life expectancy at birth 105
3.4 Disease occurrence 107 7 Non-communicable diseases
3.5 Maternal mortality ratio 107 (47 %) 199
3.6 Disability-adjusted life years 7.1 Neuropsychiatric disorders
(DALY) 109 (13 %) 200
C 3.7 Total fertility rate 111 7.2 Cardiovascular diseases
M 3.8 Crude birth rate 113 (10 %) 206
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3.9 Crude death rate 113 7.3 Cancer (5 %) 209
3.10 Population growth rate 116 7.4 Respiratory Diseases (4 %) 212
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3.11 Anthropometrical indicators 116 7.5 Diabetes mellitus (1 %) 215
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7.6 Other non-communicable diseases 11.4 Selective primary health care

(13 %) 217 (1983 to 1992) 270
11.5 Health system reforms (1993 to
8 Injury (12 %) 221 2000) 272
8.1 Road traffic accidents (3 %) 223 11.6 Health status and health care 275
8.2 Falls (1 %) 225 11.7 Health economics 276
8.3 Drowning (1 %) 226 11.8 Health system research 277
8.4 Fires (1 %) 226 11.9 New approach to health
8.5 Poisoning (0.5 %) 227 systems 279
8.6 Homicide and violence (1 %) 227 11.10 Public and private health
8.7 War (0.5 %) 229 care 283
8.8 Suicide (1 %) 229 11.11 Is it possible to construct an
effective health system? 285
9 Sexual and reproductive health
(9 %) 233 12 Global health collaboration 289
9.1 Childlessness and reproductive 12.1 The role of global health
failure 234 collaboration 289
9.2 Maternal mortality: the tip of the 12.2 International organisations 293
iceberg (2 %) 235 12.3 Regional organisations 300
9.3 Maternal morbidity: the base of 12.4 National agencies 301
the iceberg 239 12.5 Non-governmental organisations
9.4 Perinatal morbidity and mortality (NGOs) 302
(7 %) 241 12.6 Philanthropic foundations 303
9.5 Other conditions associated with 12.7 Industry & corporations 304
reproductive ill health 246 12.8 The future of global health
9.6 Sexual and reproductive health: collaboration 304
the human rights issue 249
Abbreviations 309
10 Global population change 251
10.1 Global population growth 253 Appendix 1 311
10.2 Poverty and the demographic Regional summaries in all Unicef
trap 255 statistics referred to in this book
10.3 Population growth and natural
resources 255 Appendix 2 313
10.4 Migration: the push and the Regional summaries of World Health
pull factors 257 Organization statistics referred to in this
10.5 Fertility determinants 257 book
10.6 Will AIDS stop population
growth? 260 Appendix 3 315
10.7 Fertility control: a human right or Regional summaries of the world
a human obligation? 260 according to the World Bank
10.8 Birth control versus motherhood
control 262 Appendix 4 317
Websites
11 Health policy and health systems 265
11.1 The birth of modern public Index 321
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health 265
11.2 Vertical approaches to disease
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control (1946 to 1977) 266
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11.3 Primary health care strategy (1978
K to 1982) 269
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Preface
Preface
The enthusiasm of the students in our glo- ers, advisers to politicians, writers or activ-
bal health course gave us the courage to ists for a better world.
write this book. In the past the training of How can global health be taught? At the
medical doctors and other health profes- University of Bergen in Norway all medical
sionals allocated little time to the global students get one week of training in global
health situation. But student demand and health. At Karolinska Institutet, the medical
new government policy have recently university in Stockholm, Global Health is
yielded global health courses at Swedish jointly taught to medical, nursing and other
Universities. The same is happening in students during five weeks in the elective
many other countries. This book is intended period. The first three weeks cover the theo-
for 510 weeks courses at undergraduate retical content of this textbook, with group
level in medicine, nursing, public health assignments on the health development of
and pharmacy, in the training of other selected countries. During the last two
health professionals and in courses in the weeks, the students are taught in groups of
social sciences. It will hopefully also be use- 20 at medical scools in India, Iran, Tanzania
ful in postgraduate training and as an up- or Cuba. Students study community health
date for those working with international and follow patients at each level of health
health issues. care, from the village to university hospitals.
Why do health professionals need knowl- They gain an experience-based understand-
edge about the world outside national bor- ing of what is possible at each level, and are
ders? Because the daily work in any health taught by much appreciated national teach-
service today includes care for people origi- ers (www.phs.ki.se/ihcar/globalhealth). Over
nating from far away countries. It also in- the coming years other course formats will
cludes care for local residents travelling as emerge according to the context at each uni-
tourists or for work to distant parts of the versity.
world. Health staff must grasp the health The aim of this textbook is to provide an
variations in the whole world. Some may overview of the global health situation for
themselves be working in international or- students taking such courses. It starts with a
ganisations, as volunteers for Mdecins Sans critical review of the concept of human de-
Frontires, as advisers for WHO or as re- velopment (Chapter 1) and of the factors
searchers or managers in multinational that determine the health of the population
pharmaceutical companies. Others will treat in different countries (Chapter 2). Thereaf-
infections originating from the other side of ter, the limitations and merits of the most
the globe. Medical researchers all need to used indicators of health are discussed and
C understand the global variations of the dis- the sources of global health statistics and de-
M ease they spend time studying. Especially mographic data are presented (Chapter 3).
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those that take part in debates and give ad- Past, present and future changes in the dis-
vice on global aspects of their professional ease panorama are explained within the
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knowledge. A few will become political lead- concept of health transition in Chapter 4.
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Preface
In Chapters 5 to 9, we describe the diseases The growing number of international or-

that cause most human suffering. The ganisations promoting global health are
grouping of diseases into five chapters is briefly reviewed in Chapter 12.
mainly based on the classification used in The overall aim of the book is to help read-
the global burden of disease study by Chris- ers acquire an evidenced-based understand-
topher Murray and Allan Lopez: communi- ing of global health. Comments from a
cable diseases, nutritional disorders, non- number of Nordic colleagues have helped us
communicable diseases, injuries and repro- in this impossible task. The authors own be-
ductive health. How changes in health and liefs and preconceived ideas will of course
fertility affect world population is discussed have biased the selection of evidence and the
in Chapter 10. This includes the best an- conclusions presented. Several factual details
swers we can give to the repeatedly asked may be incorrect or omitted. So please read
questions: Will AIDS stop population critically. We invite all readers to provide
growth? and Is family planning effec- critical comments to: hans.rosling@ki.se.
tive? Chapter 11, on health policy and Comments will be made available at
health systems, answers equally burning www.phs.ki.se/ihcar/globalhealth/, and at the
questions, such as: How can world health same Web site we will in due course publish
be improved?. The chapter also explains revisions of selected chapters. Also check for
past and current thinking on how health updated animations of World Health Devel-
service should be organised and financed. opment at: www.gapminder.org.

Preface
Authors ant to Sida, the World Council of Churches

and Save the Children/Sweden. She also has
All authors are attached to the division of a long experience as a teacher and course
international health at the Department of leader in International Health. She is cur-
Public Health Sciences at Karolinska Insti- rently working as the course-leader for the
tutet, the medical university in Stockholm, course in Global Health at Karolinska Insti-
Sweden. tutet.
Ann Lindstrand is a medical doctor special- Bo Stenson is a political scientist with a Mas-
ising in paediatrics, with a Master of Public ter of Public Health from Harvard Univer-
Health from Harvard University. She has ex- sity. He has been head of the Health division
perience of working with MSF in Angola, of the Swedish International Development
Mozambique and Guinea-Conacry, and was Cooperation Agency (Sida) and has had sev-
the President of the Board of MSF Sweden eral assignments in Africa. Currently he is
between 1999 and 2002. She teaches inter- principal officer in the secretariat of the Glo-
national health. She is currently working in bal Alliance for Vaccines and Immunization
French Guiana, responsible for all Maternal in Geneva.
and Child Health (MCH) activities.
Thorkild Tylleskr is a paediatrician and pro-
Staffan Bergstrm is a gynaecologist and pro- fessor of international health at Bergen Uni-
fessor of international health. His research versity, Norway. His focus is on nutritional
concerns reproductive health in low- and disorders in low-income countries. He has a
middle-income countries. He has worked for degree in African linguistics from Sorbonne
many years in Mozambique and other Afri- and a thesis on the phonology of the ki-
can countries. He currently coordinates sakata language, spoken in Congo. He sub-
extensive research and teaching collabora- sequently took a medical degree in Uppsala,
tion with several Asian and African coun- where he also defended his PhD thesis on
tries. the aetiology of the paralytic disease, konzo.
Hans Rosling is a medical doctor and profes-
sor of international health. His research
concerns food security and nutrition in Sub-
Saharan Africa, where he has served as dis-
trict medical officer in Mozambique. He has
Acknowledgements
developed several courses in international Thanks to the Swedish international devel-
health, and the website gapminder.org pre- opment co-operation Agency, (Sida) for sup-
senting world health statistics in an under- port.
standable way.
Thanks to our almost 100 colleagues in in-
Birgitta Rubenson is a nurse tutor with a stitutions abroad and in Sweden and to the
Master of Public Health from Harvard Uni- many hundred students who have given
versity and a PhD in International Health valuable comments during the development
from Karolinska Institutet. She has worked of the manuscript. Through their comments
with primary health care, staff development many weaknesses and inconsistencies have
and HIV/AIDS in low-income countries, been avoided the remaining mistakes are
both at the grass-root level and as a consult- the responsibility of the authors.
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Preface

1 What is development?
Poverty means working for more than 18
hours a day, but still not earning enough to
feed myself, my husband and two children.
A poor woman, Cambodia 1998
Is world health improving? Our answer is thirdly the social consequences of the sud-
Yes! But all aspects of world health are not den transition to market economy in former
going in the right direction! The general communist countries. It can therefore be
health situation is deteriorating in several said that world health is getting better and
countries. Despite this, we find that the pos- worse at the same time, but the improve-
itive health trends dominate in an increas- ment dominates. With the present slow rate
ingly complex world. of overall improvement world health will
Health is a good indicator of human life remain unacceptably bad and unfair for
conditions, and the general development of many decades to come.
a country determines the health of its popu- The unfairness of the world is a colossal
lation. Data of sufficient reliability is avail- political and moral challenge. How large is
able to confirm that the average health sta- the unfairness in the world?
tus of the world population has improved The consumption of an average person in
considerably during the last 50 years. Since the poorest country only corresponds to an
1950 life expectancy at birth in the world expenditure of USD 500 per year, while an
population is estimated to have increased average person in the richest country has an
from less than 50 to more than 65 years annual income of USD 50 000100 times
(WHO 2003). On average 15 years have more!
been added to each human life in the last Three children per thousand live births
two generations. This improvement is a die in the healthiest country, compared to
result of both better welfare and improved 300 child deaths per 1 000 live births in the
health services. Literacy is an important country with most sickness once again 100
health determinant that has increased con- times more!
tinuously in almost all countries. Vaccines The World Health Chart (inside the cover)
and antibiotics have in the last decades displays these income and health variations
become available to most of the world between countries. The huge difference
population. makes it necessary to use inverse logarith-
In spite of the overall improvement, glo- mic scales to show the disparities of the
bal health variations remain very unfair by world. In the new world map on the in-
any standards of morals and justice. The dif- side of the cover healthy & sick replace
ferences in health reflect wide differences north & south, while poor & rich re-
not only between nations but also within place west & east. The chart shows that
nations. Poverty remains the main underly- our world is unfair.
C ing cause of disease in the world. Three This means that the world disparity in
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major setbacks for world health slowed resources per health need (USD per child
down the global health improvement in the death) is 100 100 = 10 000 times. That is
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last decades. The three setbacks are firstly the size of the unfairness, tenthousand
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the HIV epidemic, secondly wars, and times more resources are available to avoid a
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Table 1.1 United Nations Millennium Development Goals and Targets for the period 19902015.
Development Goals Targets

1 Eradicate extreme poverty 1. Reduce by half the proportion of people living on less than a dollar
and hunger a day
2. Reduce by half the proportion of people suffering from hunger
2 Achieve universal primary 3. Ensure that all boys and girls complete a full course of primary
education schooling
3 Promote gender equality 4. Eliminate gender disparity in primary and secondary education
and empower women preferably by 2005, and at all levels by 2015
4 Reduce child mortality 5. Reduce by two thirds the mortality rate among children under five
5 Improve maternal health 6. Reduce by three quarters the maternal mortality ratio
6 Combat HIV/AIDS, malaria 7. Halt and begin to reverse the spread of HIV/AIDS
and other diseases 8. Halt and begin to reverse the incidence of malaria and other major
diseases
7 Ensure environmental 9. Integrate the principles of sustainable development into country
sustainability policies and programmes; reverse loss of environmental resources
10. Reduce by half the proportion of people without sustainable access
to safe drinking water
11. Achieve significant improvement in lives of at least 100 million slum
dwellers by 2020
8 Develop a global partnership 12. Develop further an open trading and financial system that is rule-
for development based, predictable and non-discriminatory. Includes a commitment to
good governance, development and poverty reduction nationally
and internationally
13. Address the least developed countries special needs. This includes
tariff- and quota-free access for their exports; enhanced debt relief for
heavily indebted poor countries; cancellation of official bilateral debt;
and more generous official development assistance for countries com-
mitted to poverty reduction
14. Address the special needs of landlocked and small island developing
States
15. Deal comprehensively with developing countries debt problems
through national and international measures to make debt sustainable
in the long term
16. In co-operation with the developing countries, develop decent and
productive work for youth
17. In co-operation with pharmaceutical companies, provide access to
affordable essential drugs in developing countries
18. In co-operation with the private sector, make available the benefits
of new technologies especially information and communication
technologies
child death in Sweden compared to what is have probably never been wider then they
at hand to save a child in Sierra Leone. are today. Yet there is no longer one single
Note that ethnic, geographic, gender and big gap between countries with healthy and
income disparities within nations are not sick populations. Instead there are rather
shown in the World Health Chart. many health gaps between different groups
Understanding the character and size of of nations, as well as between different pop-
C global disparities is also a major intellectual ulation groups within nations. The health
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challenge, as is the scientific analysis of status of different nations currently lie at all
how, why and for whom life conditions are levels between the extremes. World health is
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changing for the better and for the worse. not only unfair in spite of improvements, it
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The global disparities in health and wealth is also an increasingly complex continuity.

It is in the interest of all countries and per- a long-term perspective on global health de-
sons that the global health situation im- velopment. This perspective may lead you
proves at a faster rate. Almost half of UNs to share our view that there is hope for a bet-
Millennium Development Goals relate to ter world. However, the descriptive statistics
health (Table 1.1). The unjust global health provides no information about the causal
disparities are incompatible with global se- relationship between the various dimen-
curity. Better global health will also contrib- sions of development, such as health and
ute to a stable world population, which is economics. Nor can world development be
crucial for the sustainable use of environ- understood solely on the basis of numerical
mental resources. The improvement of information; understanding also requires
world health is largely a political issue, but it knowledge of cultural, social and political
also requires an understanding of which ac- structures, mechanisms and contexts. In
tions will be most effective in improving other words: it is necessary to study and
health in different contexts. This book is a consult a number of academic disciplines to
modest summary of present understanding obtain an evidence-based worldview. The
of global health and how it can be improved. authors of this book only know part of what
This chapter starts by reviewing when and is necessary, so be critical throughout your
why the present injustice of the world reading!
emerged? The historic injustices inflicted on The second difficulty is political. Any con-
the rest of the world during centuries of Eu- clusion about human development, even
ropean colonialism and North American the graphic display of descriptive statistics,
dominance are one important factor in ex- will conflict with a number of ideological,
plaining the present unfairness. However, cultural or moral views. No review of the
our review in this chapter indicates that the world situation is based exclusively on ob-
injustice also has deeper historical causes jective evidence. Some readers may even
that can be traced back through thousands find it irrelevant to make global health de-
of years. The historical causes of todays dis- velopment an area of academic study, point-
parities of the world interact in a complex ing out that urgent action is what is needed
web with contemporary political, social, cul- to improve the world. However, actions for a
tural and economic causes. We will briefly better world will have a greater chance of
review both the historical roots and the con- success if they are based on the best possible
temporary determinants of human develop- understanding of the present situation and
ment. Two particular difficulties arise, how- if they are based on knowledge of actions
ever, when attempting to summarise our that have worked in similar contexts.
present understanding of the broad pattern The analysis of global development easily
of human development. lends itself to the promotion of ones own
The first difficulty is scientific. Global de- favourite political ideas or moral views con-
velopment is determined by a combination cerning, for example, free trade, environ-
of many interacting factors. The analysis, mental conservation, gender equality, social
therefore, requires the involvement of many justice, war on terrorism and nationalism.
academic disciplines and the use of a wide Writing on global health, is often domi-
variety of data, information and theories. nated by skewed arguments for the impor-
You can obtain evidence on which to base tance of more resources for the health sec-
your worldview from the latest develop- tor. The environmentalist will likewise argue
C mental statistics. You can visualise these de- for the importance of environmental pro-
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scriptive statistics using animated graphics tection, the economist for free trade, etc.
by installing the World Health Chart and Few specialists are in a position to provide
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other software that can be downloaded free
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of charge.1 The software enables you to view 1
www.gapminder.org

1.1 Definitions of development
an evidence-based review of the relative im- rough and mortality high during Stone Age.
portance of all major aspects of global devel- The first 100 000 years after the origin of the
opment (Sen 1999). human species saw the human population
We hope that our attempt will stimulate rise to only 10 million. Based on the slow
health professionals to study economics, ar- growth of the human population we must
chaeology, history, demography, geography, conclude that the hunters and gatherers
political sciences, sociology, anthropology that lived during Stone Age had a miserable
and all other subjects that offer explana- health and a short life.
tions for the variation in health conditions Since the development of human lan-
between and within different countries. guage, no innovation has had such a great
Following a discussion of the concept of impact on human development as the in-
development, we present the cases of four troduction of agriculture. This took place
contemporary young women who live at less than 10 000 years ago. Most readers will
very different levels of development. We agree that domestication of the major food
then review different explanations for the crops (wheat, rice, maize, potatoes and cas-
historical origins of the current disparities sava) and the domestication of the main do-
in world health. We briefly discuss national mestic animals (sheep, goats, horses and
developmental strategies of the last 50 cattle) were major achievements for human
years, and the issue of globalisation that has societies. Another important step was the
arisen during the preceding few decades. domestication of dogs and cats. These
We conclude the chapter by providing a animals improved security and reduced the
more evidence-based taxonomy of coun- plague of rats. The spread and adoption of
tries that avoids the old fashioned classifica- all these advancements improved human
tion of all countries into only two groups; welfare. The improved food supply that
developing countries and industrialised agriculture secured improved health: more
countries. An evidence-based view of world children survived and adults lived longer.
health today requires a classification of The longer life that resulted from the de-
countries into more than two groups. We velopment of agriculture allowed the
suggest the classification of countries into number of humans to increase gradually
four groups: high-income, middle-income, from 10 million during the Stone Age to
low-income and collapsed countries. many hundreds of millions before industri-
alisation. The sequence of improvements in
human living conditions that increased
health and in this way led to population
1.1 Definitions of growth during thousands of years of agricul-
ture is widely accepted as development of
development human societies and civilisations. The
The meaning of human development is closer we come to the present, however, the
straightforward, when seen in the light of more controversial the concept of develop-
the changes in daily life that took place dur- ment becomes.
ing the Stone Age. The invention of stone To some, development today means a
tools and the discovery of how to use fire for more or less linear continuation of the his-
domestic purposes were major positive de- torical development of human societies in
velopments for humanity. The same is true the direction of better technologies, in-
C of the invention of baskets for collecting creased consumption, continued economic
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food, and the making of nets for catching growth and greater human choice. To oth-
fish. The invention of pottery led to major ers, development is interpreted as negative
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improvements in food preparation and stor- changes in human life imposed by western
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age. Despite these technologies life was culture upon ethnic groups living a har-

monic life in remote rainforests and high ment is a combined social, economic and
mountains. The populations of such tradi- institutional process with three objectives:
tional societies are considered to live a bet-
to increase the availability of basic life-
ter life, which may be destroyed by devel-
sustaining goods, to generate greater
opment. In contrast to these polarised
individual and national self-esteem, to
views, international debate has seen a con-
expand the range of economic and social
vergence in our understanding of develop- choices.
ment during the past decade. This conver-
gence towards a multidimensional view of
development is largely the result of the work A shorter definition of development is pro-
of Amartya Sen (1999), who won the Nobel vided by the United Nations Development
Prize in Economics in 1999 for his studies of Programme (UNDP 1997):
human development. The present consen-
Development is the process of enlarging
sus is that development may be defined as
peoples choices.
follows:
Development is the desired change
Economic growth is central to the provision
from a life with many sufferings and few
choices to a life with satisfied basic needs of choices in the lives of humans. But even
and many choices, made available for the very poor there is much more to
through the sustainable use of natural development than money (Narayan 2000).
resources. Many argue that human development re-
lates as much to the fulfilment of spiritual
The major basic needs for development are needs and improved self-esteem as it does to
provision of food, water, housing and other economic growth. Prominent non-eco-
forms of basic material welfare. Others nomic dimensions of development are free-
dimensions are health service, education, dom, dignity, self-esteem and protection
human rights and gender equality, freedom from violence and abuse. Amartya Sen
and democracy, and a fair distribution of (1999) emphasises that money is a means to
economic growth combined with a sustain- achieve greater values, rather than an end in
able use of natural resources. Most of these itself. The distribution of income is as im-
dimensions of development are both an end portant as the average income per capita of a
in themselves, and a means of progress. country, if greater human values are to be
Health, for example, is a major end in itself, achieved in a population.
but also a means to accomplish education, The emerging common focus for global
which in turn will contribute to economic development is the reduction and eventual
growth. Economic growth is perhaps the eradication of poverty. Income poverty is
most important means of progress in most only one component of poverty: others in-
of the other dimensions. However, in conclude lack of self-esteem, violations of
trast to most other dimensions, economic human rights, ignorance, and disease. The
growth is not an end in itself. Some regard alleviation of poverty, both in its narrow
the sustainable use of natural resources as an economic sense and in its broader human
end in itself, whereas others regard environ- definition, is both an end in itself, and a
mental protection as a matter of equity in means to increase economic growth. The in-
resource utilisation between those living creased focus on the alleviation of poverty
C today and future generations. by international development agencies may
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The multidimensional understanding of also be seen as a move away from a focus on
development can be expressed in many nations, towards a focus on individuals.
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ways. In his textbook on economic develop- This increased focus on poverty alleviation
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ment, Todaro (2002) states that develop- in the international debate may be seen as

1.2 Four levels of development
part of a globalisation trend that decreases assess whether the broad definition of devel-
the role of nations. opment is a valid concept; and whether the
The understanding of human develop- World Bank, the World Health Organiza-
ment and the alleviation of poverty con- tion, other international organisations and
verged gradually during the 1990s, follow- national governments manage to follow the
ing the end of the Cold War. The eradication new development policy in practice.
of poverty, freedom from hunger, access to Non-governmental organisations, united
safe water, basic education for all children, in networks such as the Peoples Health
equal human rights for women and men, a Movement1, argue that the involvement of
healthy life and the sustainable use of natu- local communities in development is a pre-
ral resources are now regarded as core as- requisite for sustainability, effectiveness and
pects of human development by all con- the achievement of self-esteem and free-
cerned international agencies. The World dom, as well as for the other broader objec-
Bank, the World Health Organization and tives of development. The non-governmen-
most other UN organisations now express tal organisations claim that sustainable mul-
similar views about development. A peculiar tidimensional development is a political
sign of this convergence of international grassroots process, rather than a change in
views of development was the awarding by budget allocations between different sectors
the World Bank (2001) of credit to the of society. As we will see, many researchers
socialist government in Cuba for progress in in economic history and political sciences
education and health in that country. As draw similar conclusions when arguing for
early as 1993, the World Bank stated in its the important role of public institutions and
yearbook that a better life involves more civil society in successful multidimensional
than simply higher income: development.
Development encompasses as ends in
themselves better education, higher
standards of health and nutrition, less
poverty, a cleaner environment, more 1.2 Four levels of
equality of opportunity, greater individ-
ual freedom, and a richer cultural life.
development
We present here four short stories about the
Two decades ago, the World Health Organi- lives of 20-year-old daughters in average
zation argued that good health could be families in countries at four different levels
achieved if the primary health care policy of development. These four women have
was followed, without mentioning how four different degrees of human choice open
much this policy would cost to implement. to them. The first example is the daughter in
Health was mainly expressed as a goal in it- a Swedish family living in a high-income
self. The World Bank had little, if any, inter- country. The yearly income of a person in
est in health at that time. Representatives of this group of countries is around USD
the Bank would have argued, if asked, that 20 000, i.e. about USD 50 per day. One bil-
health improvements would come as a sec- lion out of the six billion people in the
ondary effect of economic growth. Today, world live in high-income countries. The
the World Bank (2004) and the World second example is the daughter in a Brazil-
Health Organization argue jointly that pub- ian family living in a middle-income coun-
C lic investment in improved health for the try, where the average yearly income per
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poor of the world is not only a prerequisite person is between USD 1 000 and 10 000.
for broadly defined human development, The middle-income countries have a com-
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but also a prerequisite for narrowly defined
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economic growth. Readers should critically 1
http://phmovement.org/

Box 1.1
Family in a high-income country (daily income about USD 50 per person)
The Swedish family gathers after the her mothers secret worries, and to comfort
evening meal to discuss the 20-year-old her further she promises to call home daily
daughters holiday plans. Anna has just fin- on her mobile telephone, which she will
ished upper secondary school and has not take with her. Her father suggests that it will
yet decided whether she wants to start uni- be cheaper for her to send SMS messages.
versity studies after the summer holiday. But He reluctantly allows Anna to borrow his
just in case she has applied for the favoura- digital camera. The father reminds Anna to
ble public loans that enable young people send postcards to her grandmother. The
from all socio-economic backgrounds to 80-year-old lady has been admitted to a
study at universities. Her main concern is public nursing home due to advanced
not about her future, but that she is leaving Alzheimers disease. Anna cannot see the
home in less than one week for her first holi- point of sending postcards to her grand-
day trip without her parents. She is going to mother, as the old lady does not remember
travel by train through Germany, France, anything. However, Anna knows her father
Spain and Portugal together with her has a bad conscience for not visiting his
cousin. She had planned to do this trip with mother every week, so she promises to send
her ex-boyfriend, but he left her for another postcards to the nursing home. After all, her
girlfriend two months ago. Her mother is father has agreed to lend her his new digital
not happy about Annas holiday plans. She camera! The daughter is finally reminded by
worries that her daughter may lose the her mother to take enough disposable con-
medicines she needs to take daily to treat tact lenses. For cosmetic reasons, she uses
her asthma. It may be difficult to find the lenses instead of glasses to correct for her
same brands of tablets and inhalation short-sightedness. Anna is happy that she
sprays in foreign countries. Anna comforts can leave her parents just to enjoy travelling
her mother by telling her that she will take to foreign countries. Anna has earned part
enough medicine with her, medicine that of the money needed for the travel by work-
she buys at highly subsidised prices in Swe- ing in the holidays, but most of the money
den. Her mother also worries that her is a gift from her grandfather, who said that
daughter will not eat enough. In her early his pension was high enough to share some
teens, Anna suffered a mild form of ano- of it with his beloved granddaughter.
rexia nervosa. The daughter knows about
bined population of almost three billion in countries or parts of countries with col-
people, nearly half of the worlds popula- lapsed civil administration. They represent
tion. The third example is from Uttar less than 1 % of the worlds population.
Pradesh in India, a state in which the aver- Consider the four fictive conversations after
age income is lower than the average of all the evening meal in these four different
India. The average income per person and families (Boxes 1.1 to 1.4).
year is estimated to be less than USD 1 000. The very different health situations of
Almost 2 billion people in the world live in these four families show that the world
this reality. The fourth example is a family health situation can no longer be described
C in Liberia at the time when the rule of gov- as being that of either a rich country or a
M ernment was replaced by the terror of fight- poor country. The contemporary world
ing warlords. This example presents the sit- health situation is best understood as an ex-
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uation in a few collapsed low-income tremely wide but continuous spectrum of
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countries. Only about 50 million people live health statuses. The life situations of the

Box 1.2
Family in a middle-income country (daily income about USD 10 per person)
The Brazilian family in a small town in cen- installation of a new bathroom in the house
tral Brazil gathers for the evening meal. The was what this familys economy could
20-year-old daughter, Ana, is upset because afford, says the father. Ana must now start
her father has said that he is unable to pay earning her own money.
for her planned university studies. She was In order for her to find a job, she has been
involved in a traffic accident last year, and offered the opportunity to stay with her
her father explains the lack of money by ref- cousins family in Rio de Janeiro. This is on
erence to the high cost of her treatment. the understanding that she helps to care for
She was operated for fractures of both legs. their sick grandmother, who lives with the
Her father took her to a private hospital, cousins family. The 66-year-old lady had
which he believed would provide better one leg amputated last year due to compli-
care than the cheaper government hospital. cations from diabetes, and since then she
Since childhood Ana wears glasses to cor- has had to take regular medication against
rect her short-sightedness. She hates the depression. Ana is told that it is a good offer
glasses for cosmetic reasons, but the family to go to Rio. The cousins family has a new
cannot afford to buy her contact lenses. Ana DVD-player, something that her own family
often takes her glasses off so that she will has not yet been able to afford to buy. Ana
look better when she is walking around is reluctant to leave her hometown because
town. Her father claims that the accident of her new boyfriend, whom she has not yet
occurred because she was not using her introduced to her parents. She would really
glasses that day. Ana says the car hit her be- like to study at the university in her home-
cause the driver was drunk. Anyhow, town instead of working and caring for her
glasses, the treatment of her fractures, and sick and sad grandmother.
first two women, indeed all of the first not mean that all aspects of life are better in
three women can today be found within the richest countries. Undoubtedly, many
the same country, or even in the same town cultural, social and spiritual aspects of life
or village. Fortunately, the tragic life of the are better for the young women in Brazil,
fourth young woman remains relatively India and perhaps even in war-torn Liberia
rare. Such horror is found in only a handful than they are for large parts of the popula-
of collapsed nations in Asia and Africa. The tions in high-income countries.
United Nations has taken wise actions dur- One useful overall indicator of where life
ing the previous decade, and these actions is, on average, better than in other contexts
have assisted countries, such as Mozam- is the direction of human migration in the
bique and Cambodia, to turn prolonged contemporary world. Very few young per-
civil wars into stable peace. sons from rich countries migrate to middle-
The lives of the four young women exem- income or low-income countries. In con-
plify the situation for the average citizen in trast, people migrate overwhelmingly in the
each of four groups of countries. The classi- direction away from poverty, disease, and
fication into high-income, middle-income lack of human rights towards material
C and low-income countries, with the fourth wealth, education, a good health service and
M group of collapsed countries, is useful but human rights. Many foreigners immigrate
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very far from perfect. The statement that to Sweden in spite of the cold weather, the
high-income countries are more developed strange language and the reserved social
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than the countries in the other groups does attitudes in this northern country. The very

Box 1.3
Family in a low-income country (daily income about USD 2 per person)
The Indian family gathers for the evening she has been taking every day for a week,
meal on the veranda outside their small without any effect. Her parents are very
house in rural India. Anas family lives in a concerned about her health, but no one re-
village in the state of Uttar Pradesh. alises that, in addition to anaemia, she has
The 20-year-old daughter, Ana, is today pulmonary tuberculosis. The latter diagno-
visiting her parents to show them her sec- sis was missed due to the limited diagnostic
ond child, a baby who was born the year resources at the health centre where she
before. Ana says she wants to listen to her was very briefly examined.
fathers radio. Her husbands family has a ra- Her grandmother died some years ago,
dio, but has been unable to afford batteries after coughing blood for many months. The
for the radio for several months now. The family thinks she died from tuberculosis, but
reason is that her last delivery was costly for she was never taken to the clinic for diagno-
her and her husband. She is still weak fol- sis. She was instead given traditional medi-
lowing the delivery, and has developed a cines at home. Tuberculosis is considered to
cough in recent months. The cough syrup be a shameful sign of poverty. Conse-
she was prescribed at the public health cen- quently, the word tuberculosis is never
tre did not cure her. The 8-kilometre walk mentioned in the family discussion. The
today from the village where she lives with family knows the possible significance of
her husbands family has tired her. The hid- chronic coughing, but use an old Hindi
den aim of her visit to her parents is to dis- word for chronic cough when talking about
cuss whether they can help to pay for med- Anas disease. Her mother says she should
icines to treat her cough and her weakness. be taken to a private doctor. Her father says
She and her husband hope that her parents it is too expensive; it would be cheaper to
will help to pay for good medicines. She take her to a traditional Ayurvedic clinic.
looks at her small family and thinks: Well, The herbal treatment given at that clinic
at least I still have two healthy children and cured his back pain last year, and he thinks
a kind husband, although we are so poor it also may cure his daughters cough. He is
that we only get enough food to eat every willing to pay for traditional treatment, but
second day. She thinks that it is a shame not for consultation with a private doctor.
that she should be a burden to them. How The reason for his reluctance is that doctors
long will her husband put up with her if she always prescribe very expensive medicines.
remains sick? Ana knows precisely what she would do if
She cannot read, as she had to leave pri- she had her own money and the right to
mary school after only one year. Her father decide for herself. But this is not the case,
said there was no point in continuing, since and she does not want to embarrass her
she could not see what the teacher wrote husband by begging her father for more
on the blackboard. The family could never money. She will try the herbal medicine,
afford to buy glasses for her short-sighted- but the tuberculosis bacteria will continue
ness. The teacher had told her father that to destroy her lungs and infect her children.
glasses were the only thing the clever little Ana does not have any other choice, not
girl needed to learn to read and write. Her even to cry. But she has a secret determina-
younger brother, went to school long tion: I must survive this disease, to make it
enough to learn to read. He is now reading possible for my daughter to go to school!
the text on the bottle of cough syrup that
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Box 1.4
Family in a collapsed country (daily income less than USD 1 per person)
The family in Liberia lived in a rural village not the fact that she was short-sighted. The family
far from the capital Monrovia during the recent could never afford to buy her the glasses that
period when the political and administrative the imam said she needed.
functions of this West African country col- Following the rape, she managed to get
lapsed during a prolonged armed conflict. Li- back to their village with her sick brother. How-
beria is presently in the process of regaining ever, the man who owned a bicycle and used
peace and basic public functions. to bring and sell modern tablets against ma-
The young Liberian woman Ana had never laria had left the village, as had the traditional
been to school. This had always saddened her. healer who sold herbal medicine against fever.
This story begins when her parents returned to The sun set and in the darkness of the night she
what used to be their home before the war. could do nothing but sit beside her young
Anas father had been in hospital close to the brother and try to comfort him. His fever be-
capital for two months. He suffered severe in- came worse, he got convulsions and died in
juries during the fighting that took place be- the middle of the night. The next morning,
tween two armed gangs in their village two some old women who had remained in the vil-
months ago. After the fight, the victorious lage helped her to bury the little body. She
armed gang started to burn down all the now shows her parents the grave, where they
houses in the village. While trying to stop them all pray together.
from burning the family house down, her fa- Ana is relieved that her parents do not blame
ther was badly cut with a big knife. His right her for her brothers death. Although her par-
elbow joint was cut open, but he managed to ents are kind, she does not want to tell them
escape to his family, who were already hiding that she was raped. In spite of all the tragedies
in the forest. The mother told Ana to remain that have affected them, Ana and her mother
with her small brothers in the hiding place in are comforted by the reunion of the family, and
the forest while she tried to help her husband they cook a full meal for everyone. They have
to get to a hospital. They knew of a hospital not eaten much in recent weeks, because one
supported by a humanitarian relief organisa- night someone stole almost all the cassava
tion. It was situated a few days walk away. plants in their field. The children have been ex-
Anas mother had heard that this hospital also tremely hungry, but tonight they will be able
treated poor people who could not pay. Her fa- to eat well. The parents have brought back a
ther reached the hospital in time and recov- sack of maize flour that they were given when
ered, following amputation of his right arm leaving the hospital. Anas two surviving broth-
above the elbow. He now thanks God that he is ers have managed to catch two small birds.
alive and still has his left hand. Ana fries the birds over the fire, while her
Ana lived in the forest with her brothers mother prepares the maize porridge. She and
while their parents were at the hospital. They her brothers are allowed to eat as much as they
ate from the familys cassava field. This produc- want. In silence, they watch their father learn-
tive root crop protected them from starvation. ing to eat with his left hand. The father thinks:
During the second week of hiding, her young- Had we fled in time to the neighbouring
est brother suddenly developed a high fever, country, we would have avoided all these suf-
and she had to return to their village with her ferings. Ana thinks that she is pregnant, as she
sick brother on her back, to look for treatment. has not had any bleedings since the rape. It
The older brothers had to follow. On the path, saddens her immensely that this is not the child
they met a passing gang of armed teenagers, of the man she loved. He was killed in the war
who raped Ana in front of her brothers. She last year. What she will not know until several
C had not recognised the kind of people who years later when peace has returned to her
M were approaching in time to be able to hide. country is that she was infected with HIV dur-
Once, the imam in their village had said that ing the rape. She and her only child will only
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her problem in recognising people was due to have a few years to live together.
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fact that people from all continents are ment must have differed tremendously be-
willing to settle in Sweden shows clearly tween different historic periods.
that wealth, health, education, peace, and A humid, tropical climate is believed to
human rights are highly valued by humans hamper development because it favours the
from all over the world. spread of many parasitic and viral diseases
But how and why did human health and that are transmitted by insects that only live
welfare become so unevenly distributed in in the tropics. The most important of such
the world? As far as we know, there were no diseases is malaria. Humans originated in
major differences in human health between the tropics, but it is assumed that the migra-
the continents during the Stone Age. So tion to sub-tropical climates improved
why and at what point in time during the health and facilitated the growth of the
last 10 000 years did the present differences human population due to a lower incidence
in human health and development emerge? of the parasitic diseases of the tropics
An old hypothesis is that the differences can (McNeill 1976). Studies of the contempo-
be explained by differences in climate rary impact of climate on development also
(Landes 1999). suggest that the burden of malaria is a major
reason for the slow economic growth in
many lowland tropical countries. It is also
possible that malaria contributed to the de-
1.3 Climate cline of ancient civilisations in the humid
None of the early agricultural civilisations tropics. It is remarkable that an emerging
developed in a cold climate, and it was peo- human civilisation was successful in the hot
ple living under a hot sun who invented and dry climate of northern Sudan and
writing and mathematics. The first ad- Egypt along the Nile. However, this civilisa-
vanced civilisations were developed by the tion stopped north of the hot and humid
people living in hot climates along the climate of southern Sudan. The much heav-
Indus River in what is now Pakistan, by the ier burden of malaria in the humid tropics is
Maya Indians in tropical Guatemala and one plausible explanation of this early de-
Mexico, and by the Nile valley populations velopmental demarcation. Today, Egypt has
of what is now Egypt and Sudan. Even completely eradicated malaria, but the dis-
though advanced civilisations arose first in ease remains a major health problem in
the tropics, one explanation of the global southern Sudan.
disparities in human health and welfare that It should be noted that what is commonly
is frequently advanced is that a cold climate called malaria is actually several different
favours planning and development. A hot diseases, all caused by different species of
climate, in contrast, is perceived to hamper the malaria parasite. Falciparum malaria is
activity and to enable people to live with the most severe form, because it affects the
less planning (since there is no winter that brain. This form only exists in humid, trop-
must be lived through). The populations ical countries; whereas a malaria parasite
that now live in the areas of ancient civilisa- that gives a milder form of the disease, Plas-
tions have inherited the hot climate from modium vivax, existed as far north as Sweden
their ancestors. Paradoxically, many of the less than a century ago. The malaria para-
offspring of the great civilisations now live sites that were common in colder countries,
under more modest socio-economic condi- when the countries at these latitudes were
C tions than the descendants of the barbarian poor, survived the winter in a dormant form
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tribes in the cold climates of northern Eu- in the human liver. Malaria disappeared
rope. This suggests that if cold climate has from Sweden following the draining of the
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been a positive determinant for human de- marshlands where the mosquitoes that
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velopment, the climatic effect on develop- acted as hosts for the parasites bred. Better

1.3 Climate
housing also greatly reduced the number of breaks of yellow fever halted the first at-
mosquito bites. The use of quinine, a herbal tempt to construct the Panama Canal be-
drug from South America, for the treatment tween 1881 and 1889. The French company
of malaria also contributed to the disappear- that tried to build the canal housed thou-
ance of the disease. The Anopheles mosquito, sands of workers under miserable condi-
which is capable of transmitting malaria tions. The workers were constantly bitten by
parasites, is still common in Sweden, but it mosquitoes, and the resulting epidemics of
is only a nuisance for humans now, inflict- yellow fever killed a large proportion of the
ing itchy bites during the summer months. workers. It was the Cuban researcher, Carlos
The mosquitoes in Sweden no longer carry Juan Finlay that in 1881 suggested that mos-
malaria parasites, since nobody in the popu- quitoes transmitted yellow fever. Experi-
lation is infected. The climate did not ments on humans carried out by Walter
change, but poverty disappeared. Reed in 1901 proved that the mosquito hy-
In lowland tropical areas, malaria mosqui- pothesis was correct. Reed was at the time a
toes can transmit the parasite from human physician in the US Army during the US oc-
to human all year round. Falciparum ma- cupation of Cuba. He showed, long before a
laria requires transmission between mosqui- vaccine became available, that mosquito
toes and humans in order to continue unin- control could prevent yellow fever. Based on
terrupted all year around. Hence, this severe Reeds findings, an American company
form of malaria only constitutes an obstacle started the second attempt to build the Pan-
to human development in lowland tropical ama Canal in 1907. A substantial invest-
regions. An increase in population density ment was made in sanitary control by qual-
in such areas will inevitably increase the oc- ified public health staff throughout the en-
currence of malaria, if no special measures tire period of work. The company started by
are taken to control the disease. However, draining the swamps. They built mosquito-
even in the most tropical countries all forms free living quarters for the workers, in this
of malaria can be overcome with know- way also contributing to preventing ma-
ledge, resources and political determination. laria. The construction of the Panama Canal
Singapore, Cuba and some other highly de- was successfully completed in 1914. A me-
veloped tropical countries have eradicated morial at the Pacific end of the canal hon-
malaria. The reason that malaria remains a ours Finlay for the discovery that made this
problem in other tropical countries is the major economic investment possible
poverty of these countries, which leads to (Desowitz 1998). The US Army has named
poor human life conditions and insufficient its main medical research institute after
malaria control. But it is fair to conclude Reed, and the Cuban government has
that malaria contributes to the poverty named its vaccine institute after Finlay.
remaining in these countries. The relation- Both governments honour their heroes of
ship between poverty and malaria is recipro- public health. This shows the enormous im-
cal: poverty causes malaria and malaria portance of medical advances for develop-
causes poverty. The alleviation of poverty in ment in tropical regions. The climate ham-
countries with hot, humid climates requires pers economic development in tropical
extra resources for the control of malaria regions by facilitating the spread of some in-
(McMichael 2001). fectious diseases, but with extra investments
Another example of a disease that ham- these infectious diseases can now be con-
C pers development in tropical areas is yellow trolled, and this will promote economic
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fever, which is a viral disease. The virus is development in the tropics.
transmitted by a number of mosquito spe- A cold climate has also been an obstacle to
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cies, most readily by Aedes aegypti, which is development, by favouring the transmission
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common in tropical areas. Epidemic out- of infectious diseases that thrive when poor

people live under cramped conditions in advancing technologies? We shall ask why
frosty and miserable houses. Prominent ex- European colonialism, followed by North
amples are tuberculosis and leprosy. Leprosy American dominance, has ruled the world
is also known as Hansens disease, after the for the last 500 years. If we can identify the
Norwegian researcher Armauer Hansen, period at which the developmental and
who identified the leprosy bacterium in health differences emerged and increased,
1874. His studies were conducted among we may identify the major causes of these
poor patients in the leprosy hospital in the differences.
town of Bergen in western Norway. At that
time, leprosy was common among the poor
in Norway. Leprosy was transmitted when 1.4 Hunters and gatherers
many persons survived the cold winter
packed into cold and miserable cottages.
(up to 10 000 years ago)
The Center of International Health at Ber- Different academic disciplines study the de-
gen University is situated in Armauer velopment of human living conditions over
Hansen Building. In this way the country very different time scales. Evolutionary biol-
with cold climate also honors its conqueror ogy covers many millions of years. Archae-
of the poverty diseases that were specifically ology studies the human development that
prevalent in the cold climate. has taken place during the last one million
Climate has undoubtedly affected the de- years. Historians are only concerned about
velopment of societies. Some scholars at- written history, approximately the last 5 000
tribute a major role to climate (Landes 1999) years since the art of writing was invented in
when explaining the present lower level of present Iraq. Economists study the last few
human development in tropical climates. hundred years. Political science focuses
Others mention that tropical climate also mainly on the last 200 years, and its sub-dis-
has favoured economic development, as a cipline development studies focuses on
number of very valuable crops, such as world development during the last 50 years.
spices, sugar cane and tobacco, can only Historical documentation of human dis-
grow in warm climates. It is clear that differ- eases exists already in ancient Chinese, Per-
ent climates can stimulate or hamper devel- sian, Indian, Arabic, and Greek texts. How-
opment, but it cannot be convincingly dem- ever, reasonable quantitative documenta-
onstrated that climate is the main explanation of disease occurrence and mortality are
tion for the great differences in living limited to the last two centuries. We must
conditions and health status in todays therefore depend on research in demogra-
world. phy, history and archaeology to assess indi-
We will search for the major causes of con- rectly human health in earlier historical pe-
temporary developmental differences by re- riods. An estimate of the health of pre-his-
viewing history and identifying the period torical and historical populations can be
during which the great differences in devel- obtained from the population growth. Peo-
opment emerged. We commence where all ple must have been healthier where more of
humans originated, in Africa. We shall them survived and the number of people in-
briefly review human society from a time creased. From this follows that there must
when all our ancestors were hunter-gather- have been long periods when people were
ers in Africa until they had eventually healthier in India and China than anywhere
C spread to all corners of the world. What de- else in the world.
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termined the spread of agriculture among But let us start from the beginning.
our stone-age ancestors, and what deter- Present scientific consensus is that humans
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mined the formation of the great empires originated from Africa (Kaessmann & Paabo
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and civilisations with written languages and 2002). Human ancestors started to spread

1.4 Hunters and gatherers (up to 10 000 years ago)
from Africa more than 100 000 years ago. for food and sufficient animals to hunt, hu-
Several waves of early human ancestors mans remained in one place and their num-
managed to adopt to the environment in bers grew in the newly occupied areas.
the Middle East and on the Eurasian con- When food supplies became insufficient,
tinent. The evolutionary origin of modern some migrated to new places. The main
Homo sapiens has not been resolved. Accord- driving force was probably the gradual in-
ing to the multiregional hypothesis, mod- crease in the number of people. The average
ern human populations inherited their number of children born to each woman in
genes from different waves of human ances- the hunter-gather populations is estimated
tors that came out of Africa at widely differ- to have been at least six. If four of these died
ent periods. A different hypothesis proposes during childhood, the population would
that one isolated population of early hu- not grow. If less than four children died, the
mans evolved into modern Homo sapiens. population would grow. Human popula-
This population succeeded in spreading tions are capable of a more than two-fold in-
across Africa, Middle East, Europe, Asia, Aus- crease in their numbers in one generation
tralia, and eventually to the Americas. They and a more than 16-fold increase in a cent-
displaced, killed and eventually replaced all ury. In periods of good availability of food,
early human populations as they spread. the health of our ancestors may have been
Support for this hypothesis comes from mo- relatively good during some generations.
lecular biology, especially studies of DNA. They ate a variety of foods. The population
These methods date the time of divergence density was low, which minimised the trans-
from the common ancestor of all modern mission of infectious diseases. In spite of
human populations to less than 200 000 this, the human population increased very
years ago. This date is incompatible with the slowly following the exodus from Africa.
multiregional hypothesis, since it gives a This means that the good periods were few
human species that is too young for the and the harsh periods many. Our Stone Age
waves of migration to have occurred. ancestors suffered many injuries and lived a
Whichever model (if either) is correct, the risky and hazardous life. During long peri-
oldest fossil evidence for anatomically mod- ods they had a very low life expectancy due
ern humans is about 130 000 years old in Af- to frequent early deaths.
rica, and 90 000 years old outside Africa. The The increase in numbers that occurred as
present differences in external traits in hu- soon as most children survived made the
mans from different geographic regions, local life of hunter-gatherers unsustainable.
sometimes referred to as human races, have That is why they had to move on, gradually
thus existed for less than 100 000 years. The and in stages, until they filled the world.
genetic variation that lies behind these dif- During good periods, their numbers dou-
ferences constitutes less than 1 % of the evo- bled in a generation. When humans crossed
lutionary history that all people have in from Asia into the Americas and arrived at
common (Boyd & Silk 2000). the prairies of North America, they found
Humans advanced to using stone tools many wild animals to hunt. This probably
and the creation of art about 40 000 years led to a period of plenty, and the number of
ago. This marked the start of the older Stone hunters multiplied. The humans caused in
Age, which ranged from 40 000 to 10 000 this way the extinction of many of the ani-
years BC. During this period all our ances- mal species in North America. The same
C tors lived from gathering edible plants and happened in all areas where humans found
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hunting animals. Humans slowly increased an excess of easily-hunted animals.
in number, filled new areas, and parts of the By the end of the last Ice Age, about
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population migrated to new locations. As 10 000 years ago, human populations had
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long as there was enough plants to gather reached every continent. Following Europe,

Asia and Australia, they moved on via Alaska All human populations lived in similar
to North, Central and South America. Ar- ways 10 000 years ago, but why did human
chaeological evidence indicates that the societies develop differently during the last
present genetic variations between human 10 000 years? Why and when did the
groups had already been formed. The present large differences in levels of devel-
human population of the world 10 000 years opment and health emerge?
ago is estimated to have been less than 10
million people, approximately the same as
the present population of Sweden. All 1.5 Agriculture (10 000 to
groups on all continents still lived from
gathering edible wild plants, catching fish
5 000 years ago)
and hunting wild animals and birds. No The introduction of agriculture was un-
major differences in development or doubtedly the first major reason for the dif-
health emerged in the period during which ferences in health and living conditions be-
humans spread to all continents. tween different human societies that we
Why was the world population so small find today. Agriculture improved health
10 000 years ago? Why did the human pop- through its more efficient ways of producing
ulation not exceed 10 million people in the food and clothing. But due to new social or-
course of the first 90 000 years of human ganisations agriculture also gave rise to
life, equal to about 4 000 generations? The health differences between groups in the
growth rate of the human population was same society.
less than 0.02 % per year during the older Agriculture enabled the size of the human
Stone Age, which corresponds to adding less population to multiply by a factor of 100,
than one person to a group of 1 000 during from ten million at the end of the Stone Age
one generation. to about one billion at the start of the indus-
Very few human groups that live prima- trial revolution (1820). However, agriculture
rily from hunting and gathering remain to- did not improve human health in a straight-
day. These few remaining groups are inte- forward way. More food improved health
grated into the world economy in several but by increasing population density, agri-
ways. However, before such integration culture also resulted in many cases to the
takes place the capacity of the ecological spread of new and lethal infectious diseases,
system in each area to provide edible wild such as measles and smallpox. Agriculture
plants for the gatherer and game for the often resulted in a more monotonous diet,
hunter determines the size of the hunting- resulting in iron deficiencies and other nu-
gathering populations. Research among tritional deficiencies. However, the overall
these groups reveals their harsh living con- effect of agriculture on health and survival
ditions, with high mortality among both was favourable, as indicated by the steady
children and adults. Each woman on aver- increase in the global population. This in-
age gives birth to six to eight children dur- crease in population was, of course, inter-
ing her life. Pre-agricultural societies were rupted by many catastrophic events, such as
able to regulate their birth rate through pro- famine, war and epidemics, but agriculture
longed breastfeeding, abstinence and the provided much better chances for survival
expulsion of young adults from the commu- for more people in the world.
nity. Many also used infanticide, the inten- There is clear evidence that agriculture
C tional killing of a newborn, to maintain ec- emerged independently in a few areas of the
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ological balance. However, the main expla- world between 9 000 BC and 2 000 BC
nation for the slow growth of the human (Figure 1.1). The cultivation of food crops
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population before agriculture is that the was independently invented by the ances-
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death rate was very high (Livi-Bacci 1995). tors of todays Indians in South and Central

8012 01 Chapter 1 Page 24 Wednesday, November 1, 2006 10:46 AM
1.5 Agriculture (10 000 to 5 000 years ago)
Figure 1.1 The spread of humans to all continents and the areas of domestication of the main staple crops.
America, by the ancestors of Africans and changed forever human life in this world.
Arabs, and by the ancestors of populations The ten animals were the cow, horse, sheep,
in India and China. The crucial events of goat, pig, camel, lama, chicken, duck and
this agricultural revolution were the domes- turkey.
tication of the ten plants that have re- But why did agriculture emerge and de-
mained the major staple crops of humans velop in particular locations? Was it because
until this day. The first of these events was the humans living in these places were
the cultivation of wheat. It was probably a smarter than those living elsewhere? Were
Turkish, Kurdish and/or Arabian female an- the ancestors of Chinese rice growers
cestor in what is now Syria, Turkey or Iraq smarter than the ancestors of the Australian
who started the cultivation of cereals about aborigines? Were the Aztec Indians who do-
10 000 years ago. She used seeds from a wild mesticated maize in what now is Mexico
grass that grew in the region. The farmers smarter than the Indians on the colder
that followed gradually selected better and plains of North America, who never domes-
better varieties of what became wheat. The ticated any major crop? Were the ancestors
domestication of rice took place in China, of people living at the sources of Euphrates
maize in Mexico, the potato in Peru, and and Tigris rivers smarter than the ancestors
cassava in what is now Brazil. These are of the Swedes?
now the five most important staple crops in Jared Diamond (1997) has published a
the world. Sorghum, millet, sweet potato, general hypothesis about the major trends
C yams and plantains (cooking banana) are in human development. His hypothesis is
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the other major staple crops. These ten that the major determinant of the global de-
plant species were all domesticated more velopment of the human societies on differ-
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than 4 000 years ago. In combination with ent continents was access to plants and ani-
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the domestication of ten animal species this mals that could be domesticated, and how
8012 01 Chapter 1 1 November 2006 10.46:47 sida 24 av 52

Box 1.5
Why did the Aborigines of Australia not colonise England?
A thought-provoking question is why the domestication in the flora of Australia. The

level of development of the Aborigines of inhabitants of the British Isles were origi-
Australia in the 18th century differed so nally hunters and gatherers, living a life sim-
much from that of the British occupiers, ilar to that of the Aborigines in Australia. In
who arrived in 1788. In other words: why the course of history, those who lived in the
did the Aborigines remain hunters and British Isles acquired wheat from the Middle
gatherers, and thus succumb to cruel colo- East. It was the wheat from the Middle East
nisation by the British, and why were there that the British eventually took across the
only an estimated 300 000 Aborigines living oceans and that eventually made agricul-
in Australia when the British occupation ture such a success in Australia. Australias
started? isolation from the rest of the world meant
The Aborigines arrived in Australia long that wheat did not reach Australia until the
before any humans settled in the British arrival of the Europeans. The simple expla-
Isles. Australia lost its land connection with nation for the society of the Aborigines re-
Asia due to geological events after their ar- maining pre-agricultural is thus that there
rival 40 000 years ago. The Aborigines sub- was nothing to domesticate in Australia.
sequently lived in Australia without contact It should be noted that the only impor-
with the rest of the world. In many parts of tant domestication that took place in Eu-
Australia, the soil is fertile and the rainfall is rope was that of the olive tree. Europe got
suitable for agriculture. Why did the Aborig- agriculture from the Middle East and Asia.
ines not develop agriculture during these The Europeans had land connections at
40 000 years? There must have been many similar latitudes, while the unfortunate Abo-
Aborigine families who were very, very hun- rigines were isolated from all plant domesti-
gry many times during those 40 000 years. cations that occurred in the rest of the
If we can understand why they did not start world. Their hunting and gathering could
agriculture, we will also understand why only sustain about 300 000 people. The
they did not develop an alphabet, mathe- decimation that took place during the Brit-
matics, shipbuilding and weapons to pro- ish occupation decreased the Aborigine
tect themselves against the British. population to about 60 000 people in 1930.
The reason is that the Aborigines did not Thereafter the size of the Aborigine popula-
find any plant to cultivate. The natural flora tion has increased. Today there are more
and fauna of Australia do not contain any than 400 000 Aborigine people, probably a
wild plant or animal that can be domesti- higher number than ever before during
cated. European immigrants to Australia their 40 000-year-long history.
have also failed to find any plant suitable for
these plants and animals could be spread plants and animals for domestication, people
across the globe. There is no convinsing evi- developed agriculture!
dence that differences in intelligence deter- The main support for this theory is that
mined where agriculture started and where all the major domestic crops and animals
it was later adopted. The current belief is were already in use 4 000 years ago. Since
C that hunter-gatherer populations must have then an increasing number of people have
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tried desperately many times to find new passed through every part of every forest
ways to feed their starving children in times during the last 4 000 years, but no-one has
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of unsuccessful hunting and gathering of found one single additional plant or animal
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wild plants. Where nature provided suitable that became an important new crop or do-

1.6 Empires (5 000 to 1 000 years ago)
mestic animal. Many have tried. One exam- basis for the development of urban life. The
ple is the attempts to domesticate the zebra. ability to create a storable food surplus was
This has repeatedly proven impossible, as essential in allowing human societies to
zebras bite anybody who tries to treat them form cities. The storage of food surplus and
as domesticated animals. the foundation of urban life are believed to
The Swedish botanist, Carl Linn, classi- be the basis for major inventions, such as
fied all plants and animals in a scientific mathematics and alphabets. No human so-
manner. Yet neither he nor any of the thou- ciety developed an alphabet before adopting
sands of botanists and zoologists that fol- agriculture as their main form of food sup-
lowed have found any additional plant or ply. At the time of the arrival of Europeans
animal that could become a major staple in the Americas, the agricultural empires of
crop or domestic animal. The only explana- the Incas, Mayas and Aztecs had developed
tion for the failure to find new plants and cities, and some had developed a basic sign
animals for domestic use is that our human alphabet. The Native Americans on the
ancestors as early as 4 000 years ago had at- northern plains had no cities and none
tempted to domesticate all existing plants could read or write. Most of the disparities
and animals in the world in their struggle to in development that were created by the
survive (Box 1.5). adoption of agriculture persist to this day.
Jared Diamond suggests on the basis of This is a consequence of the population of
several pieces of evidence that the subse- agricultural societies obtaining more food,
quent development of human history was better health and lower mortality. Their
determined by how agriculture and animal numbers increased, and eventually the
husbandry spread from the few sites of do- farmers became a hundred times more nu-
mestication. Domesticated plants and ani- merous than neighbouring hunters and
mals were adapted to a specific climate. For gatherers. The farming populations devel-
this reason, populations living at the same oped new cultures, institutions and technol-
latitudes east or west of a site of domestica- ogies; whereas the societies of the hunters
tion, and thus having similar climate, could and gatherers remained relativety similar
rapidly adopt the domesticated plants and over the centuries, as did their high mortal-
raise the domesticated animals. Due to the ity rates and the small populations that re-
east-west direction of the longest geographi- sulted from this. On all continents, societies
cal axis of their continent the peoples on based on agriculture and cattle-herding
the Eurasian continent were very successful have come to dominate over neighbouring
in exchanging the fruits of domestication. hunters and gatherers. This domination has
There are similar agro-ecological zones ex- often resulted in cruel and catastrophic re-
tending from what is now Portugal in Eu- ductions through genocide and diseases of
rope to Eastern China. The highlands of the already small populations of hunter-
Central Asia constituted less of a barrier to gatherers.
the transfer of domesticated crops and ani-
mals than the hot, dry Sahara of Africa, and
the tropical Panama peninsula in the Amer- 1.6 Empires (5 000 to 1 000
icas. In Eurasia, the domesticated crops and
animals could relatively easily be spread and
years ago)
adapted to areas outside their sites of do- One process by which agriculture expanded
C mestication. Wheat spread relatively rapidly was the spread of domesticated plants and
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to both Asia and Europe following its do- animals to populations that had not previ-
mestication around 8,500 BC. ously practised agriculture. However, agri-
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Agriculture and the ability to store carbo- cultural expansion probably occurred main-
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hydrates in the form of cereals, were the ly through the occupation of the lands of

gatherers and hunters by rapidly growing oping partial resistance to most of them.
farming populations from other areas. The The populations of the Americas, who met
last major example of this was the occupa- these viruses for the first time during the
tion by northern European farmers of the European colonisation, remained suscep-
fertile lands of the hunting native Ameri- tible. The viruses became as deadly to the
cans, as described in a series of well-known people of the Americas as were the weapons
Swedish novels, first published in 1949 of the European invaders (Diamond 1997).
(Moberg 1995). Agriculture, trade and the rise of an urban
Agriculture gradually resulted in larger lifestyle had major impact on human
populations and larger kingdoms, and even- health. New infectious diseases emerged due
tually in several major civilisations and em- to the higher population density at which
pires. China, India, Iran, Egypt and Mexico people lived and closer contacts between
are examples of modern nations that ap- humans and domesticated animals. The cul-
proximately correspond to the areas of an- tural aversion to living with and eating pigs
cient empires that emerged thousands of that is observed in many parts of the world
years ago. The major civilisations and emis based on rational considerations. The pig
pires that developed on the Eurasian conti- is the domestic animal that is physiologi-
nent gradually came into more frequent cally most similar to humans. It is therefore
contact with each other. The size of a partic- more likely than other domestic animals to
ular population and the wealth of a particu- transmit diseases to humans. The pig tape-
lar empire changed as a result of wars, worm, which can cause neurological dam-
which were numerous. However, contacts age and epilepsy in humans, is a prominent
between the empires and kingdoms also in- example. The origin of several major epi-
cluded trade. The agricultural civilisations demic infectious diseases, such as smallpox,
improved agricultural methods, transport measles and influenza, is genetically traced
systems and other technologies in a step- to diseases among domestic animals (cows,
wise fashion. These civilisations exchanged pigs and ducks). The increase in food supply
goods, technology, institutional organisa- that agriculture made possible resulted in
tions, knowledge and culture through trade denser human settlements and much closer
contact. The kingdoms of Sub-Saharan contacts between animals and humans. The
Africa were involved in this exchange to a exchange of infectious diseases between hu-
limited degree. East-west contacts were al- mans also increased considerably through
ways easier than north-south contacts. The the introduction of agriculture. Human so-
ancient civilisations on the American conti- ciety responded by developing sanitary
nent: the Incas, the Mayas and the Aztecs, rules, hygienic practices and water supply
were not only isolated from those in technology.
Europe, Asia and North Africa; they were The provision of safe drinking water, the
also isolated from each other. disposal of urine and faeces, and improve-
One explanation for the later domination ments in personal hygiene became major
of the world by the populations of Eurasia determinants for the success of urban socie-
are the waves of epidemic infectious diseases ties. The storage of food also made rat-con-
that spread through the contact between trol a major task of ancient public health.
European and Asian populations. Trade Bacterial diseases spread across the Eurasian
within and between the major agricultural continent. The Plague, a bacterial disease
C regions of the Eurasian continent allowed that uses the rat louse as a vector, reached
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viral diseases such as smallpox and measles Europe in 1347. The first epidemic of this
to spread in epidemics across the continent. plague had a devastating effect on the Euro-
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Exposure to these diseases probably resulted pean population. The effects of plague were
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in the surviving Eurasian population devel- less severe when the disease returned in

1.6 Empires (5 000 to 1 000 years ago)
smaller epidemics in subsequent centuries. Africa and the Americas. The Roman Empire
This was probably partially due to greater re- was the principal example in Europe. The
sistance among the surviving population, Romans built impressive aqueducts to pro-
and to the use of more rational actions to vide cities with fresh water. The major dis-
stop the epidemics. Cholera, a bacterial diseases were kept under control and the popu-
ease that causes the most severe form of lation grew. Two thousand years ago, the
acute diarrhoea, has occurred for thousands Roman Empire had a population of 50 mil-
of years in Bengal. The cholera bacteria are lion. This was more than one fifth of the es-
transmitted directly from human faeces to timated world population of 230 million.
the human mouth, and have a very short in- The majority of the population of the
cubation time. Therefore cholera reached Roman Empire lived in the Middle East and
Europe as late as 1832, as a result of the in- North Africa (McMichael 2001).
creased speed of transport brought by the How did human development differ in the
industrial revolution. world 1 000 years ago, when the Roman Em-
The agricultural revolution and the cul- pire had split and largely collapsed? Agricul-
tural and technological developments in the ture, and the institutional and technological
great empires had both positive and nega- improvements that followed, had yielded a
tive effects on human health. These socie- slight improvement in health that had in-
ties had striking health differences between creased the world population to more than
the ruling classes and slaves, but the net ef- 250 million. Differences in human living
fect must have been improved health as the conditions had emerged. However, the
size of the populations grew. Population greatest disparities in health were found
growth was fastest in China and India, since within the empires, rather than between
these two countries for long periods had them. The most significant determinant for
slightly better health than the rest of the a persons health was whether he or she be-
world. The successful development of their longed to the ruling class or was a slave. The
agricultural civilisations many thousands of ability to read and to make decisions about
years ago thus explains why these countries ones own life was still a privilege of a few
today are the most populous in the world male members of the ruling classes. Ethnic
(Table 1.2). Agricultural civilisations, and differences remained throughout the world
the accompanying improved health that re- between agricultural societies and hunter-
sulted in population growth, also developed gatherer societies. It is difficult to assess how
in South-East Asia, Persia, the Middle East, gender differences in living condition
Table 1.2 Estimated population (in millions) of the main world regions.
Year 0 1000 1500 1600 1700 1820 1870 1913 1950 1973 1998
Asia (excl. Japan) 171 175 268 360 375 680 731 926 1 298 2 139 3 390
Japan 3 8 15 19 27 31 34 52 84 109 126
Western Europe 25 25 57 74 81 133 188 261 305 358 388
Eastern Europe* 9 14 31 38 46 91 141 236 267 360 412
North America** 1 2 3 2 2 11 46 111 176 251 323
Latin America 6 11 18 9 12 21 21 40 81 166 508
C Africa 17 33 46 55 61 74 90 125 228 388 760
M World 230 268 438 556 603 1 041 1 270 1 791 2 525 3 913 5 907
Y * Includes former Soviet Union. ** Includes Australia & New Zealand.
K Source: Maddison 2001.

changed with the transition to an agricul- 1.7 European dominance

tural society and later to a feudal agricultural
society. We have reasons to assume that the
(1 000 to 50 years ago)
life situation for the majority of the human It is difficult to explain why the economic,
population in the empires on the Eurasian social and military development of Western
continent was relatively similar 1 000 years Europe surpassed that of Asia and the Mid-
ago. Europe had no clear developmental ad- dle East in the last Millenium. It is easier to
vantage in comparison with other empires at explain why the populations of Western Eu-
that time. Estimates of economic develop- rope, and their offspring in North America,
ment 1 000 years ago (Table 1.3) indicate became much healthier than most of the
that Asia lay slightly ahead of the rest of the people in the rest of the world. This was a
world. China was also ahead of Japan at that consequence of the socio-economic advan-
time. Knowledge, technology and social tages that followed the Western European
institutions were more advanced in the Ara- world dominance.
bian and Islamic cultures of the Middle East The last 1000 years of European colonial-
than they were in Europe. ism and world dominance has seen a
Our brief search for the origin of contem- twenty-fold increase in world population,
porary developmental differences between with most of this increase taking place dur-
the western countries and Japan, on the ing the last 500 years (Table 1.2). The last
one hand, and the rest of the world on the 500 years have seen a ten-fold increase in
other hand shows that these differences the average per capita GDP in the world
must have emerged during the last 1 000 (Table 1.3). This undoubtedly reflects an im-
years. However, development on the Eura- provement in the average living conditions
sian continent lay ahead of that of the rest for the world population. This improve-
of the world 1 000 years ago. The people of ment has taken place despite the numerous
America, Africa and Australia were already wars and genocides and other cruelties that
destined to succumb to the cruel occupation European dominance has inflicted on the
of people from Eurasia. However, Western peoples of other continents. However, the
Europe was by no means ahead of the rest of health improvements for the majority of
the Eurasian continent. The origin of the the populations of the colonial powers and
global dominance of Western Europe from their allies only came gradually, being in
1500 to 1950 must be found between the fact concentrated in the last one or two cen-
years 1000 to 1500. turies. The related improvements in North
Table 1.3 Gross domestic product per capita in international US dollars (i.e. purchasing power parity).
Year 1000 1500 1820 1870 1913 1950 1973 1998

Asia (excl. Japan) 500 600 600 500 600 600 1 200 2 900
Japan 400 500 700 800 1 400 2 000 11 400 20 400
Western Europe 400 800 1 200 2 000 3 500 4 600 11 500 17 900
Eastern Europe* 400 500 700 900 1 500 2 600 5 700 4 400
North America** 400 400 1 200 2 400 5 300 9 300 16 200 26 100
Latin America 400 400 700 700 1 500 2 600 4 500 5 800
C Africa 400 400 400 400 600 900 1 400 1 400
M World 435 600 700 900 1 500 2,100 4 100 5 700
Y * Includes former Soviet Union. ** Includes Australia & New Zealand.
K Source: Maddison 2001.

1.7 European dominance (1 000 to 50 years ago)
America and Japan have taken place even combination with direct public health
later. It is the health improvements for the actions that improved health in Western
general population of the richest countries Europe.
during the last century that have caused In his long-term study of the history of
health to be so extremely unevenly distrib- the world economy, Angus Maddison (2001)
uted throughout the world. The wide health estimates that the total size of the world
disparities as measured by life expectancy economy has increased nearly 300-fold dur-
are only to a minor extent due to a deterio- ing the last 1 000 years. This means that the
ration of the health status of the population value of all goods and services produced in
in the rest of the world. the world has increased by a factor of 300.
During the first eight centuries of the pre- However, most of this increase is due to a
vious millennium, until industrial develop- 20-fold increase in the world population
ment started to make an impact around from 0.3 billion in 1000 AD to 6 billion
1820, most people living in rural or urban today (Table 1.2). The economic increase per
societies in the world experienced approxi- capita is thus 15-fold. An improved econ-
mately the same miserable level of health. omy means that humans work more effi-
Most citizens of the colonial powers did not ciently, but its effect on health depends on
have significantly longer lives than the how the economic resources are distributed
inhabitants of the colonies, at least not dur- and used. Maddison (2001) identifies three
ing the first few hundred years of European main reasons for strong economic growth,
colonialism. There are, of course, many which benefited the populations of Western
exceptions. Europeans inflicted severe hor- Europe, North America and Japan. It is clear
rors onto the Native American population. that the increased survival and improved
The Native Americans were either annihi- health of the populations in these regions
lated or greatly reduced in number follow- during the last 200 years are partly ex-
ing the European invasion (Table 1.2). plained by economic growth, and partly by
Another exception is the impact of the slave the social changes that both preceded and
trade on the health of Africans. Severe followed this economic growth.
oppression was a constant aspect of Euro-
pean dominance of the world. However, the
majority of the population of Western 1.7.1 Trade and capital
Europe also continued to live in misery and The principal reason for world economic
illiteracy, until the last two centuries. This growth was increased international trade
was largely due to the effects of frequent and the movement of capital. The start of
wars within Europe. Life expectancy in Eng- Western European international trade on a
land, France and the Netherlands was less large scale can be dated to 992 AD. In this
than 40 years at the start of the industrial year the Republic of Venice signed its first
revolution in 1800. One century and an trade agreement with the Byzantine Em-
industrial revolution later life expectancy in peror in Constantinople (now Istanbul). The
these countries had only increased to 50 Republic of Venice, and the other major
years in 1900. Further economic growth and North Italian city-states of Milan, Florence
the establishment of democracy and welfare and Genoa, established and maintained a
policy led to an increase in life expectancy very profitable Mediterranean trade with
to 70 years in 1950. Public investment in the Middle East. These city-states also estab-
C education and sanitation, in parallel with lished overland trade between Northern
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popular movements for social justice, gradu- Italy and several towns in Flanders, in what
ally led to the creation of the European wel- is now Belgium. The economic importance
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fare states. It was these social changes, of Flanders gradually increased. The trading
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which followed the industrial revolution, in houses of Northern Italy developed the cap-

italist system that emerged as the driving consumption of potatoe grew from negli-
force of economic development in Western gible levels in the year 1800 to almost 300 kg
Europe. Portugal and Spain replaced North- per person per year in 1850. Potatoes were
ern Italy as the dominant economic region more productive than any crop previously
around 1500, following successful transoce- grown in Sweden. The potato put an end to
anic voyages by Columbus and Vasco da famine in Sweden. The last major famine oc-
Gama. In the following centuries, the Neth- curred in 1863. Sweden, indeed all of Eu-
erlands, followed by France and Britain, rope, owes a debt of gratitude to the natives
took over most of the transoceanic world of the Andes who had domesticated the po-
trade. This world trade was based on the su- tato thousands of years earlier, and to the
periority of the European warships. The Eu- sailors who brought the potato to Europe.
ropeans frequently used armed attacks on One of the first and most noticeable positive
other countries to support their trade, and effects of the globalisation of agriculture
in this way favoured the economic growth that followed transoceanic European coloni-
of Western Europe. The countries that were alism was the spread of all major staple crops
attacked, and later colonised, often suffered from the agricultural revolution to all conti-
devastating effects from the same trade that nents where they could be grown. This
gave economic growth in Europe. The most spread occurred between 1500 and 1800, be-
dramatic example is the transatlantic slave fore the start of the industrial revolution. It
trade by which 13 million Africans were for- should be noted that the benefits of growing
cibly transported to the Americas, to work maize and cassava also spread across Africa
mainly on sugar and coffee plantations many centuries before the European colo-
(Thomas 1998). Undoubtedly, European co- nists penetrated the continent.
lonial dominance of the rest of the world
was a prerequisite for what was to come, but
it was only after the industrial revolution 1.7.3 Technology and institutions
that the wide economic, social and health The third reason for the world economic
disparities emerged between the popula- growth of the last 1 000 years was techno-
tions of the world. logical and institutional innovation. Until
500 years ago, Europe advanced mainly by
importing technology that had been devel-
1.7.2 Agriculture and crops oped in China, India or the Middle East.
The second reason for world economic Only during the last 500 years was Europe
growth during the last thousand years was the world centre for technological and
the introduction of agriculture into new fer- scientific development, a status that has
tile areas, and the introduction of new crops now been taken over by North America and
into areas where agriculture was already Japan.
practised. Both of these processes took place The explanation of Western Europes
mainly by the migration of agriculture from world dominance lies in the period between
northern to southern China, and from Eu- the years 1000 and 1500. The gradual devel-
rope to North America and Australia. Many opment of Western European agriculture re-
important crops were transferred between sulted in a steady population growth during
continents in the agricultural globalisa- these medieval centuries. Agricultural devel-
tion that took place from 500 to 200 years opment was accompanied by gradual devel-
C ago, as a result of European colonisation. opment in culture, architecture and knowl-
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Maize and cassava were transferred from the edge. This development was largely related
Americas to Africa, wheat from Europe to to the spread of the institutions of the Cath-
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Australia and North America, and the potato olic Church, and universities associated
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from the Americas to Europe. In Sweden the with the Church, and to a gradual improve-

1.7 European dominance (1 000 to 50 years ago)
ment in the system of trade and its financ- gressive colonial policy towards Korea and
ing. Western European development was se- China, and later towards other parts of
verely retarded by the Plague epidemic South East Asia.
around 1350, but the effects of this epi-
demic were eventually overcome. Centres of
development grew in a crescent from North- 1.7.4 The industrial revolution
ern Italy via France to the Netherlands, and The industrial revolution started in Europe
later crossed the sea to Britain. The estab- around 1820. The economic level of Europe,
lishment of social institutions, such as uni- North America and Japan were at the time
versities and banks, was as important as approximately only twice that of the rest of
technological advances in shipbuilding and the world. This difference has now increased
book printing. to its current level of seven to one. Asian
In the centuries before 1500, Western Eu- countries have started to close the gap in
rope had developed a slight technological recent decades, but the total economic dis-
lead over Asia in weapons technology and parity between the richest and the poorest
in shipbuilding technology. The European nations of the world continues to grow.
lead in maritime technology was largely due Major technological and socio-economic
to wide differences in political and eco- advances occurred in Western Europe fol-
nomic priorities in Europe and Asia. Chi- lowing the industrial revolution. These ad-
nese ships did sail to East Africa before 1500, vances continued for more than a century.
but China made a political decision not to Advances were driven as much by institu-
invest further in transoceanic dominance. A tional development as by technological in-
simplistic explanation for this is that the novation. Core elements were the mechani-
wealthy of Europe were keener to obtain silk sation of production, the use of new raw
from China than the wealthy of China were materials, and the replacement of human
to obtain woollen cloth from Europe. Simi- energy by mechanised energy from steam
larly, Europe was keener to obtain spices engines and improved hydroelectric energy.
from India than India was to obtain salted The mechanisms of the industrial revolu-
herring from Europe. European trade with tion are well-documented (Landes 1999).
Asia after 1500 was combined with repeated Table 1.3 shows the effects of the industrial
armed attacks and, whenever possible, the revolution on the economic growth of
use of military and political dominance to Europe and other parts of the world. The
improve European trade conditions. The Eu- economic benefits of the industrial revolu-
ropean powers skilfully used political con- tion were extremely unevenly distributed,
flicts in Asia to gain dominance in trade. and thus it was during industrialisation that
Only Japan managed to maintain fully its European dominance of the world created
independence from Europe, which it first the present economic disparity in the world.
achieved by isolating itself! However, Japan This resulted from the direct control that
entirely changed its policy towards Europe Western European countries exerted over
around 1830. A very active process started to colonized countries, and from the strong in-
obtain European technology and knowledge direct control that they exerted over coun-
for the industrialisation of Japan. Japan also tries such as China, whose foreign trade lay
invested early in general primary education completely under Western European con-
for both boys and girls. This multidimen- trol. European colonisation expanded dur-
C sional Japanese strategy was successful. Edu- ing the industrial revolution into Africa and
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cation, health and wealth improved in Ja- Asia. The European colonisation of Africa
pan. In 1905 Japan won the war against Rus- was relatively late, and the territorial parti-
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sia. Thereafter Japan also copied European tion and domination of African societies
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colonial ambitions and started its own ag- took place largely after the Berlin confer-

ence of 1885. Due to strong resistance it nomical, social and institutional develop-
took several decades for Europeans to gain ment varied greatly. Due to very different de-
control of the occupied territories in Africa. velopments in these countries in recent dec-
Mozambique was dominated by Portugal ades, the variations are even greater today.
for more than four centuries. However, the The communist revolutions in Russia in
Mozambican territory was not effectively 1917 and in China in 1949 were important
controlled by Portugal until after the First developments in the 20th century. All the
World War. The period of colonial adminis- nations with communist regimes and cen-
tration of the territory of Mozambique, and trally planned economies developed ini-
of many other African countries, lasted only tially in similar ways. The similarities were
60 to 80 years. The developmental chal- seen in social advances, slow economic
lenges for the newly independent African growth and limitations of human rights.
countries thus relate both to the structure The rapid transition from centrally planned
and institutional systems of the pre-colonial economies to market economies in the
societies and to the effects of less than a cen- countries that emerged from the former
tury of colonial administration. Soviet Union during the 1990s gave rise to
The European colonialism and North different socio-economic developments
American dominance that followed the in- than those that emerged from the transition
dustrial revolution gave the impression of a to market economies by the ruling commu-
homogeneous situation for the majority of nist parties in China and Vietnam. These
the world population, who lived under this different changes combined with the main-
dominance. However, the differences in tenance of centrally planned economies in
health development that have arisen during Cuba and North Korea has further contrib-
recent decades suggest that the precolonial uted to the widely differing socio-economic
situation is an important determinant for situations in the former group of commu-
the present developmental situation in nist countries.
many countries. The transformation of almost all coun-
tries and territories into national states
with widely different development, and the
1.7.5 The end of colonialism diversity of the transformations of commu-
The colonial period started to come to an nist regimes, have given rise to a world
end in 1776 with the independence from with tremendous variations in develop-
Britain of the United States of America. De- ment. The health disparities between and
colonisation continued with countries of within the countries of the world are today
Latin America becoming independent dur- related to these enormous disparities, as
ing the next century, and most countries in shown by the World Health Chart on the
the Middle East, Asia and Africa becoming back cover of this book. The wide differ-
independent after the Second World War. ences in the progress of former colonies are
Most African nations became independent linked both to the prerequisites that were
between 1960 and 1980. Following the fall available for development at independence
of the apartheid regime in South Africa the and to the chosen developmental strategy.
county received its true independence from The progress of each former colony does, in
colonialism. With the return of Hong Kong fact, depend on how the chosen strategy
to China, and the independence of East suits the situation in each country. We
C Timor, the world today consists almost en- summarise in subsequent sections ideas
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tirely of independent nations. The newly in- about the determinants of the development
dependent states were initially seen as a ho- of nations during the last 50 years, and
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mogenous group referred to as developing opinions about the ongoing globalisation
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countries or the Third World, but their eco- of the world.

1.8 Development strategies (the last 50 years)
1.8 Development strategies reference list (de Vylder 2002, Todaro 2002,
Middleton 2001, Allan & Thomas 2000,
(the last 50 years) Gunnarsson 1995).
The debate about what determines the de-
velopment of nations is as old as social sci-
ence and economics. Adam Smiths classic 1.8.1 Import substitution (1950 to 1985)
work published in 1776, An Inquiry into the Most newly independent countries em-
Nature and Causes of the Wealth of Nations, barked on rapid industrialisation based on a
may be regarded as the start of the modern strategy of import substitution. They chose
debate. Smith argued that wealth came from this strategy based on a number of develop-
the accumulation of capital for investment ment theories known collectively as struc-
through savings, the division of labour and turalism. The goal of import substitution
free trade. Another classic work that dis- was to improve the terms of trade for the
cussed the development of human societies, newly independent countries. Prices of ex-
a work that constituted the foundation of ported raw materials kept falling, and this
communism, was Karl Marx's Capital, pub- meant that such countries could never afford
lished in 1867. to improve welfare by paying for imported
Most analysis of economic and social de- industrial goods with the earnings from the
velopment before 1950 was focused on the export of raw materials. The decision to
driving forces in the richest and most indus- focus on government planning and protec-
trialised countries. Following the independ- tion from the international market was
ence of the former colonies, an increasing based on the premise that free trade would
amount of research has been focused on the only benefit the rich countries. Instead, the
development situations of the newly inde- newly independent countries founded in-
pendent countries. This change of focus has dustries that were supported by government
generated a number of development theo- subsidies or directly owned by the state.
ries and new research areas, such as devel- High customs duties on imported goods pro-
opment economics and development stud- tected the new domestic industries. In con-
ies. These theories are based on the observa- trast, the domestic industries could import
tion that the situations for the newly machinery without customs duties.
independent developing countries differ Many economists criticised this strategy,
from the historic situations of the contem- but many new national governments fa-
porary high-income countries. The new na- voured it. The governments gained a central
tions have had to develop under the contin- role in the national economy through the
ued dominance of a world economy con- import substitution strategy. All new govern-
troled by richer countries. Therefore it may ments also, to different degrees, invested in
still be relevant to divide the world into two public education, health services and infra-
types of countries when considering solely structure, such as roads. However, the subsi-
economic and military power. Theories for dised industry did not become sufficiently
the development of the newly independent profitable. The heavy public investment and
countries have differed considerably during subsidies to industry soon eroded the econ-
the last half-century. We will review the omy of many newly independent countries.
strategies for development that emerged A large part of the national investment was
from the different development theories by made with borrowed money. Countries for
C describing some major trends in the process which the import substitution strategy did
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that have dominated the strategy of govern- not pay off were caught in a debt crisis.
ments and international organisations. Ref- A striking example of the import substitu-
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erences to further information on the deter- tion strategy is provided by the investment
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minants of development are given in the made in pharmaceutical industries by many

African countries. This investment was dependence was replaced by total depend-
based on the observation that the costs of ence on international banks and economic
drug imports were increasing rapidly, due to organisations. Economic failure meant that
both population growth and improved cov- governments could no longer maintain the
erage of the health service. The solution was quality of public schools and health service
to make this import unnecessary by the systems. The low salaries of teachers and
rapid development of a national pharma- health staff prohibited them from working
ceutical industry. The Ministry of Health full-time, and health centres and hospitals
was expected to buy cheaper drugs from the often lacked the drugs and equipment
national industry in the future. However, needed to treat the patients. The currency of
the pharmaceutical industry proved to be an indebted country lost most of its value. It
technologically complex to operate, and can be said, somewhat simplified, that the
productivity was low. It was also found that import substitution policy ended in the debt
the making of tablets and ampoules for in- crisis of the 1980s. More and more countries
jection was a very minor part of the cost of were forced to renegotiate their debts with
drugs. The main cost was the purchase of the International Monetary Fund and the
active substances, and these substances still World Bank, at annual meetings known as
had to be imported from countries with the Paris Club. The debt crisis was particu-
more advanced chemical industries. It then larly severe in Sub-Saharan Africa and in
turned out that sometimes tablets made in Latin America, but it also affected several
the country were even more costly than Asian countries. Consequently, interna-
imported tablets. Import substitution con- tional economic institutions soon dictated
tributed to fewer drugs being available in the development policies of the indebted
the health service and to an increased debt countries. They correctly diagnosed that
that could not be repaid. The increasingly something was wrong, but the treatment
competitive world market in generic drugs they prescribed, known as structural adjust-
from middle-income countries provided ment programmes, often caused more
tablets at lower price, and the national problems than it solved.
industry could not compete. A West African
pharmaceutical consultant summarised the
plans for a pharmaceutical industry in 1.8.2 Structural adjustment programmes
Angola in the 1980s as follows: The govern- (19851997)
ment wants to construct a pharmaceutical The International Monetary Fund (IMF)
temple, on the altar of which it will burn and the World Bank reacted at the end of
large amounts of dollars in honour of the the 1980s to the increasing debts and fre-
young nation. A rational economic analy- quent failures of government intervention
sis showed that an effective means of reduc- in most low-income and many middle-in-
ing the cost of drugs for low-income coun- come countries. The standardised reactions
tries was to buy annual drug requirements of these international organisations, how-
through a competitive and non-corrupt in- ever, did not take differences in local con-
ternational tender system. The import sub- texts in each country into consideration.
stitution strategy was often based on a mix- The IMF and the World Bank enforced simi-
ture of insufficient economic analysis and lar neo-liberal so-called structural adjust-
excessive political prestige. ment programmes (SAPs) in all countries.
C When many of the attempts at rapid in- In brief, SAP meant more market economy
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dustrialisation failed, the poor countries be- and a smaller public sector. This new policy
came unable to pay back their loans. Indeed, was largely supported by the international
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many countries became unable to pay even development agencies in the high-income
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the interest on their loans. Their recent in- countries. The governments of the indebted

several severe side-effects. SAP did not

Purchasing Power Parity (PPP) achieve rapid economic growth, particularly
(= International Dollars) not in the low-income countries of Sub-Sa-
haran Africa, where economic growth was
The domestic currency is converted to US
and is most desperately needed. The educa-
dollar by an exchange rate at which all
the goods and services that comprise the tion systems and health services that had
gross domestic product will cost the been weakened by economic chaos were not
same to buy in the country as in United improved by SAP. It is, however, simplistic
States. As PPP conversion reflects the to blame the whole crisis in the economy
services and goods that inhabitants can and public health services on SAP.
buy in their own country, the GDP/capita Printing more banknotes in an economy
expressed in international dollars (= PPP) with severe inflation and increasing interna-
is the best estimates of the economic dif- tional debt could no longer finance a grow-
ferences between the countries in the ing government health service. This became
world.
obvious to many African governments dur-
ing the 1980s, and the problem was unoffi-
cially noted long before SAP was introduced.
The value of staff salaries had fallen to neg-
countries were obliged to apply SAP if they ligible levels and the supply of drugs and
were to have their debts renegotiated. consumables was insufficient to maintain
The philosophy of SAP was that the state even a minimum quality of the service. In
should do less, but do it better. The impov- many low-income countries in Africa, pa-
erished nations were to achieve macroeco- tients only received treatment in a govern-
nomic balance by cutting public expendi- ment hospital if informal fees were paid di-
ture. They had to privatise formerly state- rectly to the staff, and if the relatives bought
owned industry and they had to open their the drugs, gloves and other equipment that
countries to free trade. However, the eco- was needed for the treatment from private
nomic growth that was expected as a result pharmacies. Relatives even had to bring
of these measures did not materialise in water for the surgeons to wash before sur-
many countries. In those countries in which gery in some hospitals, since the hospital
economic growth was achieved, the new was incapable of maintaining a water sup-
wealth did not benefit the majority of the ply. The structural adjustment programmes
population, at least not in the short term. did not destroy functional economies, but
How was it that the treatment prescribed by neither did the programmes improve the
the main economic institutions of the world faltering economies in the way that was in-
did not achieve what was promised? tended. This neo-liberal policy did not re-
The diagnosis on which the launch of the store the basic functions of the health and
SAP was based was to a large degree correct. education sectors.
Most of the indebted countries were in mac- The movement in high-income countries
roeconomic chaos. They could no longer for debt relief in poor countries failed to
pay for public health services by printing recognise fully the catastrophic economic
more banknotes. SAP brought inflation situation that had caused the debts and the
under better control, and the reforms re- introduction of SAP. It has now been
established reasonable stability of the ex- acknowledged in most countries that it was
C change rate of the national currencies. The the combination of imposed blue print
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macroeconomic balance was a positive re- type of SAP and poor national governance
sult of the SAP policy in several countries. that resulted in the crises for the public sec-
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Yet the treatment that was prescribed cured tor (Bhutta 2001). In many low-income and
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only a small part of the problem, and it had middle-income countries in Africa, Asia and

the Middle East, opposition to the neo-lib- ment. While sound economic policies are
eral policy of the 1980s was not dominated necessary, economic policies are far from
by the traditional political left, but by other sufficient to achieve socio-economic devel-
movements. A movement known as the opment in poor countries. The 1993 Nobel
Peoples Health Assembly effectively Laureate in Economics, Douglass North, elo-
voiced health-focused opposition. The Peo- quently summarised that neo-classical eco-
ples Health Assembly is an international nomic theory is simply an inappropriate tool to
grassroots network of organisations and analyze and prescribe policies that will induce
individuals with thousands of participants. development. The reason for this is that classi-
It arose spontaneously in 2000 at a meeting cal and neo-liberal economists have been con-
in Bangladesh. The participants defend cerned with the operation of markets, not with
public investment in the health service and how functioning markets are developed.
debt relief for poor countries.1 A simplified analogy is that neo-liberal
Improved macroeconomic stability re- economists are excellent Formula 1 drivers
mains a favourable effect of the SAP pro- that can drive established market economies
grammes. The dominance of the neo-liberal well. However, the same economists do not
strategy ten years ago is now being replaced know how to construct the cars that they
by a more multidimensional development love to drive (some times so fast that they
strategy, of which the macroeconomic re- cause crashes). The question arises concern-
forms are only one component. The SAP ing what it takes to construct a market that
erred in trying to achieve development by can be driven by economists with sufficient
isolated economic reforms. Its failures led to safety? Four principal non-economic di-
a general recognition of the multi-dimen- mensions of development are today widely
sional character of development and a recognized as being necessary for a func-
deeper understanding of the complex links tioning and safe market economy. A sum-
between the economic, social and institu- mary is given in Box 1.6.
tional aspects of development, as well as of The first dimension is public investment
the crucial role of good governance in in improved health and basic education,
achieving an optimal balance between the termed investment in human capital in
different development dimensions. economic jargon. When the structural ad-
justment programmes reduced government
investment in human capital, construction
1.8.3 Prerequisites for economic growth of the foundation for a functioning modern
(1998 ) market economy a healthy and educated
Several non-economic dimensions of devel- population stopped.
opment are now recognised as being crucial The second dimension is the creation and
for economic progress and human develop- maintenance of well-functioning public in-
stitutions. This requires public funding,
1
http://phmovement.org human capital and good governance.
Box 1.6
Non-economic requirements for economic growth

C 1 Human capital = A healthy and educated population
M 2 Public institutions = Police, courts, tax authority, legal property register, etc.
3 Civil society = Trades unions, religious organisations etc, with strong values.
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4 Good governance = Ruling in the interest of the majority without corruption
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The third dimension has been termed The fall of the Berlin Wall ended more
civil society. This term refers to the range than a century of political competition
of social organizations, of varying degrees of between capitalism and communism.
formality that are autonomous from the Capitalism stands alone as the only feasi-
ble way to rationally organize a modern
state, market and family, and are formed
economy. At this moment in history, no
through voluntary association. Prominent
responsible nation has a choice. As a
examples are trades unions, sports associa-
result, with varying degrees of enthusi-
tions, development NGOs, human rights asm, Third World and former commu-
groups, womens groups, religious and other nist nations have balanced their budgets,
faith-based organizations, social move- cut subsidies, welcomed foreign invest-
ments, advocacy networks, etc. Many spe- ment, and dropped their tariff barriers.
cific values, norms and cultural patterns are Their efforts have been repaid with bitter
transferred through these organizations. disappointment.
Current research attributes a considerable
role to such organizations in the develop-
ment of nations. Much of the successful de- De Sotos hypothesis is that the informal
velopment of the market economy in West- economic sector is much larger and more
ern Europe is attributed to the social envi- important in most middle-income and
ronment created by the combination of a low-income countries than has been real-
strong civil society and well-functioning ised. This informal sector is sometimes re-
public institutions. ferred to as the black market, but it in-
The fourth dimension has been termed cludes all economic activities that occur out-
good governance. Good governance de- side of the control of tax authorities and
scribes a government that is doing the right without legal protection and documented
things in the right way. Leaders make opti- property rights. Investments in the informal
mal decisions for the benefit of the majority sector by small entrepreneurs, such as fisher-
with due respect to the interests of minori- men and tailors, are not protected by the
ties. Human rights are protected, gender legal system of the state. Small entrepre-
equality is advanced and the mass media are neurs are unable to mobilize capital for fur-
free to inform and debate national and in- ther investment by using their property as
ternational issues. A government ruling security for needed loans. De Soto claims
with good governance rules in the interest that a market economy will not function
of the majority, not in the interests of a until the state serves the interests of the
wealthy minority. whole population. The correct enforcement
The continued unfair trade conditions im- of laws and property rights is needed for a
posed by the richer countries continue to free market to create prosperity. To put it
hamper development in the world. How- simply, governments must fight corruption,
ever, researchers also increasingly empha- permit a free flow of information, and de-
size important internal reasons for the slow fend the rights of small-scale enterprises in-
socio-economic development in many stead of acting as the guardians of a small
low-income and middle-income countries. traditional elite. Studies of the successful
The Peruvian economist Hernando de Soto Asian tiger economies, such as Taiwan and
has analysed the failure of a market econ- South Korea, have shown that it is the abil-
omy to generate rapid economic growth and ity of a government to provide these public
C welfare improvements in so many countries functions that gives rapid economic growth.
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in Africa, Middle East, Asia and Latin Amer- De Soto criticises the form of globalisation
ica. His book The Mystery of Capital: Why that is currently being developed because it
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Capitalism Triumphs in the West but Fails Eve- interconnects only the elite groups of the
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rywhere Else (2001) starts as follows: different countries. His recommendation to

the governments in low-income and mid- Later, a rapid aging of the population will
dle-income countries is to make capitalism take place. The population composition
function for all citizens by creating func- during the decades between a population
tioning public institutions. His underlying with many children and that with many
argument is that capitalism is the only old people has a low dependency ratio.
game in town that can create the massive There are many people who produce goods
surplus value that is needed to eradicate and services, relative to the number who
poverty. need to be supported. This favourable age
Consensus about the prerequisites for a distribution has been found to provide a
functioning market economy is emerging demographic gift that facilitates economic
from economic research. Gunnarsson and growth. The former communist countries in
Rojas (1995) identify three main reasons for Eastern Europe did not receive a demo-
the success of the Asian tiger economies. graphic gift when they converted from a
These reasons are (1) an egalitarian social planned economy to a market economy.
structure; (2) an autonomous state; and (3) Economic growth is a major factor pushing
socio-cultural coherence in the civil society. the demographic transition, but the demo-
The egalitarian social structure means that graphic transition can also help to push
all parties are treated equally in the courts economic growth during a period of a few
and by public authorities. Both South Korea decades. This period has already passed in
and Taiwan gave everyone access to land for Eastern Europe.
farming, and achieved a reasonably fair dis- Contemporary development policy corre-
tribution of income. The differences in in- sponds to Amartya Sens broad definition of
come between rich and poor in these suc- development (see Section 1.2). Develop-
cessful Asian economies are smaller than ment policy takes into consideration that
they are in Sweden, and many times smaller development is driven by a number of mu-
than they are in Africa and Latin America. tually reinforcing dimensions, of which eco-
Income equality seems to be good for economic growth is just one. Other major di-
nomic growth. The autonomy of the state mensions are education, health and free-
means that the government acts in the in- dom. Increased gender and economic
terests of the whole nation, and does not equality are also widely recognised as being
focus on the protection of the wealth of a crucial for socio-economic and health devel-
small elite. Socio-cultural coherence refers opment (Sen, 1999). The social conflict in
to the shared values in the civil society. Eco- Bolivia that in 2003 stopped planned gas ex-
nomic growth is greatly facilitated in coun- ports provides a dramatic example of how
tries in which citizens enjoy not only the economic inequalities and social distrust
protection offered by law, but also trust each can stop economic growth.
other, due to shared values originating from There is now a clear agreement among
different social networks. international agencies that public invest-
Development in eastern Asia is also ment in the health service and wise govern-
related to the interplay between economic ment health policies are crucial to human
and demographic factors. A rapid fall in fer- development and to economic develop-
tility in eastern Asia has created a favoura- ment. The 1993 yearbook of the World Bank
ble dependency ratio in the population. was entitled Investing in Health. The
The decline in family size and in mortality World Bank announced in 1993 for the first
C rates, will cause a distinctive sequence of time that expenditure on public health serv-
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effects on the population composition. The ices was an investment. The World Health
number of adults relative to the number of Organization has recently reinforced this
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children and old people in the population view with a report from its Commission for
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will be very high during the initial decades. Macroeconomics and Health published in

2001.1 This report is based on commis- the government plans to use the money
sioned research that shows that investment made available when it is no longer obliged
by the international community in im- to pay the debts. The rich countries are will-
proved health in low-income countries will ing to write off the loans if the money is to
increase economic growth in these coun- be spent in ways that will relieve poverty.
tries. It predicts that health investment in Furthermore, the General Secretary of the
the poorest countries will produce an eco- United Nations, Kofi Annan, has convinced
nomic return that is to the benefit of the the rich countries to contribute to a global
global world economy. The report estimates fund to fight AIDS, tuberculosis and malaria.
that public funding at a level of the ex- This fund would make drugs and vaccines
change rate of USD 35 per person per year is cheaper for low-income countries.3
needed to provide essential health services. A particularly striking development fail-
Low-income countries in Africa currently ure can be seen in Sub-Saharan Africa,
allocate only USD 5 to 10 per person, and which is also the region of the world that
these countries receive only about USD 2 in has been worst hit by HIV/AIDS. Most coun-
development aid per person for the health tries in this region have lagged behind world
sector. The WHO now states that if govern- development throughout the last 20 years
ments double their investment, the interna- (Table 1.4). This is considered to be mainly
tional donor agencies must increase their due to the failure to provide the institu-
support, in order to achieve the improve- tional structures and governance that are
ments in health that are needed to enable needed for positive national development.
economic growth where it is most needed. During the last two decades, most Sub-Saha-
(The cost estimates given above are quoted ran African countries have become margin-
in current US dollars, i.e. at the 2004 ex- alised in the world economy. Africa is yet to
change rates of the national currency.) benefit from the demographic gift. Analy-
It has been recognised for many years that sis of this failure with a longer development
debt relief is a prerequisite for development perspective and placing more emphasis on
of the poorest countries. It remains to be the civil society and institutional factors re-
decided, however, under what conditions veal clearly why post-colonial development
debt relief should be provided. Low-income has been less successful in Sub-Saharan Af-
countries must present to the World Bank rica than it has in Latin America, the Middle
and the International Monetary Fund Pov- East and most parts of Asia.
erty Reduction Strategy Papers (PRSP).2 This The Latin American countries are off-
PRSP process implies that debt relief is of- spring of Western Europe, and the relative
fered in exchange for a description of how failure of their socio-economic development
1
www.cmhealth.org
2 3
www.imf.org/external/np/prsp/prsp.asp www.theglobalfund.org
Table 1.4 General economic development in groups of countries.
Countries 1960s 1970s 1980s 1990s

High-income countries Good Relatively bad Good Relatively good*
Africa Good Fair Very bad Bad
Latin America Good Fair Very bad Fair
C
China & South East Asia Fair Good Very Good Good
M
India & South Asia Fair Fair Good Good
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* With great variations: very good in USA, reasonable in Europe and bad in Japan.
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Source: Adapted from de Vylder (2002).

when compared to offspring of Britain such Although national leadership and govern-
as Australia and New Zealand is surprising. ance is crucial for positive development, it
This is especially so as Argentina, Uruguay may be an error to attribute the develop-
and Cuba in many ways were on a par with ment crisis in many Africa countries to the
large parts of Western Europe during the occurrence of less capable leaders. Post-colo-
first part of the past century. nial nation-building may rather be regarded
The Middle East and most of Asia are as a much greater challenge in Sub-Saharan
descendents of ancient civilisations that Africa than elsewhere in the world. It seems
knew how to read and write long before the that the immense challenge in Africa has
Europeans learnt these skills. These coun- yielded both the best and the worst of lead-
tries have a stronger coherence in their civil ers. The best leaders include persons like
societies and a much better institutional Mandela, Annan and Nyerere; while Amin,
base for the modern state than is the case in Bokassa and Mobutu form a stark contrast.
Sub-Saharan Africa. The recent successful The labelling of most of the world as col-
socio-economic development in Asia and onies gave the impression that the poten-
the Middle East may be seen as a reversion tial and difficulties facing development was
to the more homogenous development level similar when the new nations rather sud-
of the Eurasian continent that existed before denly became known as developing coun-
the European colonial expansion during the tries or the third world. The importance
last centuries. of the widely different historical and cul-
At the beginning of the European territo- tural backgrounds of these developing
rial occupation, the present nations in countries was not sufficiently appreciated
Sub-Saharan Africa were mainly small polit- during the last decades. Labels such as the
ical units of subsistence farmers and cat- third world gave the impression that the
tle-herders. These small units had advanced development challenges were similar in Ar-
and ancient social organisations and cul- gentina and Mozambique. Both countries
tures, but there were few large civilisations had the same unfair trade barriers of the
that used an alphabet. Ethiopia was an high income countries, but Argentina had
exception. Contemporary Sub-Saharan Afri- without doubt a much higher socio-eco-
can nations have much less of civil society nomic development than Mozambique.
coherence and weaker social institutions on However, given the situation in these coun-
which to build the present nations than is tries 50 years ago, it is more surprising that
generally the case for the countries of Asia Argentina has not achieved the same level
and the Middle East. of development as Western Europe than it is
The farming systems in much of Sub- that Mozambique is still struggling with se-
Saharan Africa are still based on rain-fed vere poverty and ill health. In contrast, one
agriculture using shifting cultivation. This can admire the leaders of Mozambique for
involves cultivating land for three to four having achieved independence, and for
years and then leaving it fallow for a gener- bringing a peaceful end to the brutal civil
ation. Women largely carry out the agricul- war that followed. Mozambique now faces
ture labour in these systems. This is quite enormous challenges with widespread pov-
different from the system of irrigated rice erty, weak public institutions, prevalent cor-
cultivation that was used for thousands of ruption and increasing HIV prevalence, but
years and that formed the basis of many given the history of the country this is not
C Asian civilisations. The kingdom of Thai- surprising. Good governance thus involves
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land thus had a much better chance of suc- making the best out of a countrys situation
ceeding in the modern world than the at any given moment. Although there is
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republic of Tanzania had when it became an agreement on the main components of a
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independent country in 1960. good national development policy, a coun-

try still needs excellent politicians who are The debate about the relationship be-
able to implement these policies in a contin- tween human development and the envi-
uously changing context. ronment has been highly polarised (Sarre &
The emerging consensus on national Blunden 2000). The biologists fear that hu-
development policy does not include how manity is irreversibly changing the biologi-
to balance socio-economic development cal basis for its own survival. This is now
against environmental sustainability. This supported by clear scientific evidence that
debate remains extremely polarised, and global warming is taking place. Recent re-
will be reviewed below. search has shown that the climate of the
world has warmed by about 0.6 C com-
pared to earlier average, and that this
1.8.4 Sustainable development change corresponds to observed changes in
The term sustainable development is the the natural ecology (Gian et al. 2002). It has
established term for the concern that devel- been predicted that a number of health
opment must maintain natural resources for effects will result from this warming
coming generations. The human species has (Patz & Kovatz 2002). The diseases that are
had a tremendous impact on the ecology of expected to increase range from an increase
the whole world. Hunters have driven ani- in malaria due to more favourable condi-
mals to extinction, and farmers have tions for the mosquitoes to an increase in
changed vegetation and caused erosion. skin cancer in populations with deficient
Industrialisation and the increased energy skin pigmentation.
consumption that followed have changed It is also possible to interpret the links
the chemical composition of the atmos- between human activity and environmental
phere. The enormous increase in the change by assuming that humanity will be
number of humans that these revolutions able to adapt to changing conditions
gave rise to has also had profound environ- through a series of mechanisms. This view
mental effects. The way in which human finds support in the fact that earlier catastro-
societies use and protect the natural phe scenarios have not come true. Three
resources while they improve their liveli- decades ago, Paul Ehrlich published a book
hood is one criteria for good develop- entitled The Population Bomb. He forecast
ment. Paul Harrison (1993) argues that that human population growth would result
contemporary human development is com- in lack of raw materials and food (Ehrlich
pelling us to stage a third revolution, the 1968). He was wrong. Six billion people are
sustainable use of natural resources. The Rio today being fed by increased agricultural
Conference in 1992 converted environmen- output, and population growth is slowing.
tal concern into global and national policies The prices of many raw materials have
known as Agenda 21. The need for the fallen. There is firm evidence that agricul-
sustainable use of natural resources makes it tural development will be able to feed an
necessary to include a biological dimension expected stable world population of about
in the definition and analysis of develop- 10 billion, 50 to 100 years from now (Evans
ment. The understanding of global develop- 2000).
ment involves a progressively more com- The very definition of global environmen-
plex system analysis. Peace & conflict tal problems is controversial. Many argue
research and meteorology play a more cen- that a lack of latrines, poor hygiene and un-
C tral role than health sciences, but more evi- safe water remain the main environmental
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dence about the relationship between cli- problems of mankind. Many families can-
mate change and health is one component not avoid drinking water that contains their
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of the global system analysis that is now neighbours faeces, and this is responsible
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required. for millions of child deaths each year. The

most important contribution that health many measurements of development show-

sciences have made to the discourse on glo- ing favourable trends. His conclusion is that
bal ecology is demonstrating that basic san- the common image of the state of the world
itation and health services result in a decline is a mix of prejudice and deficient analysis.
in child mortality. This decline, in turn, His book has been met with attacks from
leads to lower birth rates, giving a stable both scientists and cake-throwing environ-
population. This corresponds to the inven- mentalists.1 The Danish Committee on Sci-
tion of the two-child family, which will entific Dishonesty stated in January 2003
yield stable human populations. It is note- that Lomborg had been systematically
worthy that 30 years ago the growth of the one-sided, while Lomborg has replied that
human population was regarded as the the Committee had failed to give one single
major threat to sustainable development. example of this.2 We find the review of data
Fertility reduction is today not included and the conclusions of his short chapter on
when the United Nations defined in 2000 its global health development to be accurate.
Millennium Development Goals (Table 1.1) Interested readers may engage in the debate
to be achieved by 2015. The reason is that about The Skeptical Environmentalist through
the number of children born per woman has the websites mentioned below. It remains
already fallen to three or less in most parts difficult to draw a line between scientific
of the world, with the exception of the reviews and advocacy statements in the
countries in Sub-Saharan Africa and a few debate about global environmental change
other countries. The average number of chil- and human development. It is also difficult
dren born per woman in India has decreased to draw such a line in the intense debate on
from 6.5 to 2.9 during the last four decades. how global political governance should be
This huge nation has thus in a few decades organised in the present period of economic
achieved more than 75 % of the require- globalisation.
ment for changing unsustainable family We conclude that global warming now
sizes with six children to sustainable should be regarded as a fact, but that the de-
two-child families. This is a neglected suc- gree and the future distribution and charac-
cess in human development! World opin- ter of impacts of this warming remain un-
ion, instead of celebrating a problem known, as well as to what degree it is wise to
solved, rapidly changed its focus to a new invest in halting the warming or in adapting
alarm. This is probably unavoidable, but for to the consequences, respectively.
those in despair it is good to know that the
global problems of past decades have been
largely solved.
It is impossible to reach scientific consen-
1.9 Globalisation (the present)
sus about how to handle the links between The term globalisation is much used but
human development and the global envi- rarely defined. To some, it designates the
ronment. The book The Skeptical Environ- goal of world development. Globalisation,
mentalist, by the Danish statistician Bjrn they argue, has been around for a long time.
Lomborg is a prominent example of the con- The current phase is just an intensification
troversy regarding sustainable development. that will strengthen market economy and
Lomborg (2001) reviewed the available data bring more wealth to the world. To others,
underlying not only the assessment of envi- globalisation designates the evil forces that
C ronmental change but also other aspects of increase the unfairness of the contemporary
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world development. He concluded that world, leading to further dominance by the
most of the debate in high-income countries
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concerning global development constitutes 1
www.anti-lomborg.com
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of a litany of pessimistic forecasts, despite 2
www.lomborg.com

United States and its closest allies. To a third The increased interconnectivity not only
group, the term globalisation is a descriptive between remote parts of the world but also
term for the present state of world affairs: an between local communities within a nation
increasingly neo-liberal world economy is blurring the distinction between domes-
with increasing movement of capital across tic and foreign politics. Globalisation has
national borders, and with decreasing power been described as a process of denationalisa-
of local communities and nations to regu- tion following a century in which the na-
late these economic activities. As a description-state had considerably more impor-
tive term, globalisation, however, also tance than the local and global communi-
includes a growing global commitment for ties (Cooper 2003). The Nobel Prize winner
the environment and for joint human Joseph Stiglitz (2003) argues that globalisa-
values. The future may bring a free trade tion can be a positive force for the poor
that in the end benefits the poor in both around the world, but only if the IMF,
low-income and middle-income countries, World Bank, and WTO dramatically alter
or it may bring just a continuation of the the way they operate. After having worked
neo-liberal merging of global elites, with in these organizations he has become their
increased suffering for the poor. The descrip- main critic, but remains positive to eco-
tive interpretation refers to globalisation as nomic globalisation. Another leading econ-
an open-ended and contradictory process omist and UN adviser (Bhagwati 2004)
that generates forces that act in both good claims that globalisation has reduced pov-
and bad directions. erty in China from 28 % of the population
We use the term globalisation as a de- in 1978 to only 9 % in 1998. Nevertheless,
scription of a number of changes in the he recommends that continued globalisa-
world that have accelerated in the last dec- tion should be better managed. He suggests
ade following the end of the Cold War. The taxing of skilled workers who leave poor
term globalisation refers to more than the countries for jobs abroad, using non-gov-
dominance of neo-liberal policy in the glo- ernmental organisations as corporate watch-
bal economy. The present process of change dogs, slowing financial liberalisation and
in the world is both wider and deeper than loosening intellectual property safeguards.
an expansion of western economic domi- The globalisation process may be seen as
nance. From an Asian perspective globalisa- comprised of at least eight components:
tion may even be seen as the beginning of
the end of European and North American 1 The economic forces of transnational capital-
dominance. ism have induced a process of economic
In short, the descriptive term globalisa- investment with progressively fewer links
tion refers to an increased interconnectivity to nationally owned companies. Nations
of remotely living populations. The life situ- are today adapting to companies, rather
ation of people in one part of the world has than companies adapting to nations.
an increasing direct significance for the There is an increasing deficit of global
well-being of populations in very distant democratic governance that can match
parts of the world. A dramatic example of the global capital movements. Capitalism
this was the terrorist attack on World Trade has become global at a much faster rate
Centre on 11 September 2001. This attack than democracy.
was originally planned in a remote part of 2 New communication technologies for satel-
C rural Afghanistan and killed thousands lite-meditated TV, the Internet, e-mail
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people in downtown Manhattan in New and cheap telephone connections have
York. The reciprocal attack on Afghanistan revolutionised communications between
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that followed probably killed even more remote parts of the world. Through the
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civilians. application of new technologies and

commercial mechanisms that require issue for the World Trade Organization
only limited involvement of state-owned (WTO). It was agreed at the last WTO
telephone networks, connections are meeting that poorer countries with pub-
being established to remote parts of rural lic health emergencies should be given
Africa in ways that were impossible only the right to obtain drugs at the lowest
a few years ago. possible production cost. A major reason
for this change in policy was that the
3 National governments increasingly share
United States broke the patent rules with
power, not only with transnational com-
respect to the best antibiotic needed to
panies but also with other types of organ-
control a minor anthrax epidemic in
isations, such as agencies of the United
2001. This is a prominent example of a
Nations, international voluntary organi-
case in which global health interests are
sations such as Greenpeace, and mass
attempting to limit the negative health
media, such as CNN, which are becoming
effects of a neo-liberal trade policy. The
increasingly international.
outcome remains unclear.
4 A growing global cultural identification of
7 Intellectual property rights go beyond nations
the national elites in most countries, i.e. a
when scientific advances in molecular ge-
cultural identification by rich, well-edu-
netics have made plant genes the property
cated and powerful social groups. With
of transnational companies. An intense
this comes an increasing global cultural
struggle about the right to patent genes is
conformity, especially in youth culture.
currently raging between national institu-
The habit of eating hamburgers and lis-
tions and transnational companies.
tening to MTV music is rapidly spreading
across most national borders. But a global 8 Global ethical values and human rights are
culture is also promoted by an expanding further issues confronting the principles
non-commercial global civil society. This of sovereign national states. An organisa-
has resulted in world music, a global envi- tion such as Mdicines Sans Frontire
ronmental movement and a growing (MSF) bears the principle of denationali-
integration of cultures and ethnic groups sation in its name, and hence constitute a
from other continents into local cultures. prominent feature of globalisation. The
Another aspect is the growing importance humanitarian organisation MSF was
of diasporas, i.e. people of the same origin founded during the civil war in Nigeria,
and culture who live in a large number of when the International Red Cross was not
local communities across the globe. allowed by its national Nigerian counter-
part to assist the population in the break-
5 Global environmental changes, such as glo-
away territory of Biafra in 1968. Assist-
bal warming, know no borders. This com-
ance from the International Red Cross
pels nations to negotiate about global
was refused because one of the fighting
regulations to protect a shared global
fractions did not have a recognised na-
environment. The world must also deal
tional Red Cross organisation. The Red
more efficiently with the common global
Cross was formed in 1863 to act in armed
microbiological environment, as exem-
conflicts between recognised nations. A
plified by infectious diseases such as HIV
number of relief workers did not accept
and SARS, and by resistant strains of older
that national borders should stop them
microbes (WHO 2003).
C from relieving the suffering of people.
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6 Patents are questioned on global level. An These workers founded MSF. This is a clear
example of the uncertainty with respect example of global ethical values being
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to patenting can be found in pharmaceu- awarded greater significance than na-
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tical drugs, which have become a central tional integrity.

Globalisation is thus characterised by simul- not allow free trade. This was the reason the
taneous changes in several social, economic, meeting of the World Trade Organisation in
technological, political and cultural dimen- Mexico in 2003 did not reach an agreement
sions. The effects that globalisation has had on the conditions for world trade. China,
and will have on health are a topic of heated India and Brazil lead a united front against
debate at the time of writing this textbook, the high-income countries. They demanded
and opinions differ as much as the defini- trade that was truly free trade that included
tions of globalisation do. The nation state is agricultural products. Looked upon in this
beneficial for health by providing the public way, fair globalisation may open new oppor-
investment that is needed for health promo- tunities for low-income and middle-income
tion, the provision of primary health care, countries to receive foreign investment and
and public hospital services. Many claim to sell their products on the world market.
that globalisation threatens the health serv- Good governments will thus gain greater tax
ice that is provided by the welfare states, and revenues, which they can invest in the
prevents poorer nations from building wel- health sector.
fare states. Commercial globalisation is cata- A contrasting prediction is that nations
strophic for health by facilitating the free will lose power, and that health services in
promotion of tobacco, alcohol and other poor countries will be organised to serve a
health-threatening goods. Others conclude rich minority in a neo-liberal economy with
that globalisation increases economic private health care. There are several exam-
growth and in this way mainly benefits the ples of this happening (WHO 2003). It may
global health situation (Feachem 2001). One confuse some readers that the communist
line of thinking also suggests that globalisa- parties currently in power in China and Vi-
tion may apply pressure on the richest coun- etnam are leading the international transi-
tries to support the alleviation of poverty for tion of health service to out-of-pocket pay-
the sake of joint security and global stability. ment and private-for-profit provision. A
The agricultural subsidies in high-income strong voice in the global health debate for
countries correspond to a lack of globalisa- free primary health care is the Peoples
tion, i.e. the national governments use tax Health Movement, which in 2000 presented
revenues to subsidise national agricultural the Peoples Health Charter (Box 1.7). The
products that could be purchased at lower charter argues strongly for a publicly fi-
prices on the world market. The agricultural nanced health service and for development
policies of the European Union and US do policies that favour health. The charter ad-
Box 1.7
The Peoples Health Assembly and the Charter
The idea of a Peoples Health Assembly (PHA) The present Charter builds upon the
has been discussed for more than a decade. views of citizens and peoples organisations
A number of organisations launched the from around the world, and was first ap-
PHA process in 1998 and started to plan a proved and opened for endorsement at the
large international Assembly meeting, which Assembly meeting in Savar, Bangladesh, in
was subsequently held in Bangladesh at the December 2000.
end of 2000. A range of pre-Assembly and The Charter is an expression of a vision of
C post-Assembly activities were initiated, in- a better and healthier world, and calls for
M cluding regional workshops, the collection radical action. It is a tool for advocacy and a
of peoples health-related stories and the rallying point for a global health movement.
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drafting of a Peoples Charter for Health. http://phmovement. org
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vocates strongly against the commercial as- trary, such lines must be arbitrarily chosen,
pects of globalisation. This network, pres- as the world health situation constitutes a
ently led from Bangalore in India, is a lead- continuum between two extremes that are
ing representative for NGOs in the global wider apart than ever.
health debate. This global network is in it- Most authors who review global health
self a new aspect of globalisation. and social development no longer use the
previous concept of two types of countries
(Cooper 2003; Allen 2000). This is not a
trendy change of terminology, but rather a
1.10 A taxonomy of nations delayed reflection of a major change in the
There is a strong association between so- pattern of global health and social develop-
cio-economic development and the health ment. We suggest that the use of terms such
status of the population in each country of as industrialised and developing coun-
the world. There is also a strong association tries, or north and south, should be
between the socio-economic situation of dif- avoided when discussing global health. The
ferent population groups within countries most used alternative taxonomy is a division
and the health status of each of these groups. based on economic level into high-income,
The old division of countries into two middle-income, and low-income countries.
groups, industrialised and developing, or A group of collapsed nations, with pro-
north and south, may remain relevant longed complex emergencies due to armed
with respect to political, economic and mil- conflicts, may be added to these three groups.
itary considerations. However, we find that Most previous taxonomies of nations have
the old division into two groups of countries grouped countries into two groups. This has
today constitutes an irrelevant taxonomy for been true ever since the ancient empires con-
an evidence-based view of the contemporary ceived the world as being composed of the
global health situation. This is because there empires and the barbarian territories. Both
is today a continuous spectrum of health sta- the Chinese and the Roman Empire saw the
tus across the populations of the more than borders between the two groups as a line,
200 nations of the world. There are countries often in the form of a wall cutting across con-
with all levels of child mortality. The worst tinents to divide mankind (Table 1.5). Hu-
child health situation corresponds to coun- manity seems very prone to divide itself into
tries with several hundreds of children dying a we group and a them group. Under-
per one thousand born; while the best child standing of the modern world requires
health situation corresponds to countries higher ambitions.
with only three young children dying per The dichotomisation of mankind was
one thousand born. Countries are found that prominent during the European colonisa-
have all different levels of economic devel- tion of the world. It was expressed linguisti-
opment. There is no longer one single big gap cally in terms of civilised and primitive
between two types of countries (see World cultures. Many concepts of world health re-
Health Chart on back cover). main influenced by this colonial division of
A division of countries into more than countries into two groups. During decoloni-
two groups is therefore long overdue when sation, colonial powers and former colonies
analysing the global health situation. This became industrialised and developing
new pattern of social and health situations countries. The frequent use of the term de-
C favours the division of nations into three, veloping country is surprising, as this cate-
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four or more groups, based on their levels of gory lacks definition. The limitation of the
socio-economic development. This does not term is notable in many ways, especially
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imply that clear dividing lines can be easily within the UN system and in various agen-
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found between such groups. On the con- cies for international development co-oper-

1.10 A taxonomy of nations
Table 1.5 Taxonomy of nations based on their level of development.
Time period Taxonomy of countries into named groups

Early Historic Empires Barbarians
Colonial Colonial Powers Colonies
19461960 Developed Underdeveloped
19601990 Industrialised Developing
1975 North South
1946 First Second Third World
1983 Industrialised Newly industrialised Developing Least developed
1990 High-income Middle-income Low-income *
countries Countries countries
* Collapsed or war-torn nations.
ation. It seems that these organisations do tries with a subgroup called least developed
not want to recognize progress in formerly countries. The human development index
developing countries. In UNICEFs Year- (HDI), which is composed of measures of na-
book, State of the Worlds Children 2004, tional economy, life expectancy and literacy
Singapore is still labelled a developing coun- rate of a country, offers an alternative divi-
try (UNICEF 2004, page 136.). Yet Singapore sion of countries. The HDI for all countries is
in the same book is ranked as having the published annually in the Human Develop-
second lowest child mortality in the world, ment Report by the United Nations Devel-
and Singapores gross national product per opment Programme, UNDP.1 The human de-
capita is also on a par with that of the rich- velopment index has become used mainly
est countries in the world. The use of coun- for ranking countries, rather than for divid-
try labels without definitions is a result of ing them into groups. This provides further
subconscious prejudice when trying to evidence that the development of all of the
make sense of the world situation. The use countries in the world today are found on a
of the terms north and south also suffers continuum.
from the problem that there is no definition The World Bank launched in the 1990s a
regarding which country should belong to classification into high-income, mid-
which group. The terms first world, sec- dle-income and low-income countries,
ond world and third world reflected a first based on well-defined cut-off values of the
attempt to construct a new form of categori- gross national product expressed in current
sation, namely one in which countries may US dollars (this measure thus considered the
belong to more than one group. However, exchange rate of the currency against the
only the term third world became widely dollar, and not its purchasing power)
used, and it remains unclear whether South (Box 2.2). We have added to these three cat-
Korea, Turkey, Russia, Saudi Arabia, Poland, egories a distinct, small group of war-torn,
Mexico and Singapore, for example, are low-income countries, which in the last dec-
third world countries today. ade have been designated as collapsed
Taxonomies with more than two groups of countries or failed states. It should be
C countries were first devised by the United noted that the cut-off levels used to classify
M Nations. The UN introduced a new taxon- countries are arbitrary, but they are at least
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omy in the 1980s that grouped countries well-defined values, and this taxonomy al-
into industrialised countries, newly indus-
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1
trialised countries, and developing coun- www.undp.org

lows for countries to change group from one tant to note how he summarises the
year to the next. The World Bank adds a multi-dimensional development consensus
caveat to their income taxonomy: into diplomatic language. Later he lays
The use of these three terms is not in- down the concrete Millennium Develop-
tended to imply that all countries in one ment goals that are to be used for monitor-
group are experiencing similar developing. Kofi Annan spoke as follows to the
ment, or that other economies have gathered national leaders:
reached a preferred stage of develop- We recognise that, in addition to our sep-
ment. Classification by income does not arate responsibilities to our individual socie-
represent development status. ties, we have a collective responsibility to
This taxonomy is, of course, far from per- uphold the principles of human dignity,
fect, but we have found it to be a convenient equality and equity at the global level. As
description of the present variations in de- leaders we have a duty therefore to all the
mographic patterns, disease panoramas and worlds people, especially the most vulnera-
health statuses of the countries of the world. ble and, in particular, the children of the
The World Bank1 provides the latest world, to whom the future belongs.
cut-off values. Countries divided according We reaffirm our commitment to the pur-
to their 2002 gross national income (previ- poses and principles of the Charter of the
ously known as gross national product, see United Nations, which have proved timeless
Box 2.2) per capita in current US dollars at and universal. Indeed, their relevance and
levels calculated by the World Bank Atlas capacity to inspire have increased, as na-
method form the following groups: low-in- tions and peoples have become increasingly
come, 735 USD or less; lower middle-income, interconnected and interdependent. We are
7362 935 USD; upper middle-income, 2 936 determined to establish a just and lasting
9 075 USD; and high-income, 9 076 USD or peace all over the world in accordance with
more. This classification gives Indonesia as the purposes and principles of the Charter.
the richest low-income country and Ukraine We rededicate ourselves to support all ef-
as the poorest middle-income country. Saudi forts to uphold the sovereign equality of all
Arabia is the richest middle-income country States, respect for their territorial integrity
and Slovenia is the poorest high-income and political independence, resolution of
country. Until a better taxonomy is pro- disputes by peaceful means and, in con-
posed and widely used, the classification of formity with the principles of justice and in-
countries into three groups based on eco- ternational law, the right to self-determina-
nomic performance remains useful, because tion of peoples which remain under colo-
this classification departs from the previous nial domination and foreign occupation,
worldview with only two types of countries. non-interference in the internal affairs of
A display of countries according to both eco- States, respect for human rights and funda-
nomic and social performance is available in mental freedoms, respect for the equal
the World Health Chart on the back cover. rights of all without distinction as to race,
sex, language or religion and international
co-operation in solving international prob-
1.11 The hopeful future lems of an economic, social, cultural or hu-
manitarian character.
The Secretary General of the United Nations
We believe that the central challenge we
outlines the challenge to the world in the
C face today is to ensure that globalisation be-
UN Millennium Declaration.2 It is impor-
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comes a positive force for all the worlds
1
people. For while globalisation offers great
Y www.worldbank.org/data/countryclass/
countryclass.html
opportunities, at present its benefits are very
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2
www.un.org/millennium unevenly shared, while its costs are une-

1.11 The hopeful future
venly distributed. We recognise that devel- Respect for nature

oping countries and countries with econo- Prudence must be shown in the manage-
mies in transition face special difficulties in ment of all living species and natural re-
responding to this central challenge. Thus, sources, in accordance with the precepts
only through broad and sustained efforts to of sustainable development. Only in this
create a shared future, based upon our com- way can the immeasurable riches pro-
mon humanity in all its diversity, can glo- vided to us by nature be preserved and
balisation be made fully inclusive and equi- passed on to our descendants. The current
table. These efforts must include policies unsustainable patterns of production and
and measures, at the global level, which cor- consumption must be changed in the in-
respond to the needs of developing coun- terest of our future welfare and that of our
tries and economies in transition and are descendants.
formulated and implemented with their ef-
Shared responsibility
fective participation.
Responsibility for managing worldwide
We consider certain fundamental values
economic and social development, as well
to be essential to international relations in
as threats to international peace and secu-
the twenty-first century. These include:
rity, must be shared among the nations of
Freedom the world and should be exercised multi-
Men and women have the right to live laterally. As the most universal and most
their lives and raise their children in dig- representative organisation in the world,
nity, free from hunger and from the fear of the United Nations must play the central
violence, oppression or injustice. Demo- role.
cratic and participatory governance based
on the will of the people best assures these
rights. 1.11.1 Millennium Developme nt Goals
(MDGs)
Equality
The United Nations Millennium Summit in
No individual and no nation must be de-
2000 agreed on a set of time-bound and
nied the opportunity to benefit from
measurable goals and targets for combating
development. The equal rights and op-
poverty, hunger, disease, illiteracy, environ-
portunities of women and men must be
mental degradation and discrimination
assured.
against women.1 These 8 goals and the corre-
Solidarity sponding 18 targets and 48 monitoring indi-
Global challenges must be managed in a cators concern the main advances to be
way that distributes the costs and burdens made in the major development dimensions
fairly in accordance with basic principles between 1990 and 2015. In other words the
of equity and social justice. Those who MDG tells how much to do during one gen-
suffer or who benefit least deserve help eration of 25 years.
from those who benefit most. The statistical data for the 48 indicators is
available at the web page of the UN Statisti-
Tolerance
cal Division.2 The goals, targets and indica-
Human beings must respect one other, in
tors have been selected such that they make
all their diversity of belief, culture and
global policy concrete to national govern-
language. Differences within and be-
ments and in peoples lives by showing what
C tween societies should be neither feared
can and must be achieved within one gener-
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nor repressed, but cherished as a precious
asset of humanity. A culture of peace and 1
Y www.un.org/millenniumgoals
dialogue among all civilisations should be 2
http://millenniumindicators.un.org/unsd/mi/
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actively promoted. mi_goals.asp

ation. The definition of development in mension. These goals can be criticised for
the millennium declaration is also a confir- including indicators for which no reliable
mation of a global acceptance of the multi- data is available. They can also be criticised
dimensional view of development. The for not taking into consideration the possi-
goals show the ambitions of the Secretary bility that a country in 1990 may have had
General of UN, Kofi Annan, to improve an uneven development profile, while all
co-ordination within the UN organisation, countries are assumed to advance at an
both in action and in monitoring the equal rate in all dimensions. Thus, a country
impact of the actions taken. Three of the that was doing very badly in 1990 may show
eight UN Millennium Development Goals the best progress in fulfilling each goal. For
(MDGs) to be achieved by 2015 directly con- example, China already had low child mor-
cern health (Table 1.1). tality in 1990, while that of Egypt was high.
The goals make the general aims of the Egypt is, therefore, in a better position to
global community operational. However, fulfil goal number four, since this goal is ex-
there are obviously no binding agreements pressed as a relative improvement. However,
in this area, and no agency has been given these are technical issues that need to be ad-
ultimate responsibility for reaching the tar- dressed without calling the MDG concept as
gets. The UN emphasises that countries such into question.
should monitor their own development Kofi Annans basic approach in the Millen-
goals. This process is being co-ordinated by nium Declaration and in the Millennium
the UN development group.1 The MDGs Development Goals is firmly based on the
constitute an ambition to reach shared re- best current understanding of how multidi-
sponsibility between national governments, mensional development can be achieved.
international organisations and other part- The fact that the United Nations develop-
ners in development. Some of the goals and ment policy is evidence-based and will be
targets are impossible to monitor for several monitored brings hope for a better global
countries because the 1990 value is too un- future! You may be surprised that the World
certain. However, the way in which the tar- Bank has done advanced analyses on how to
gets have been defined involves rates of de- improve global health.
velopment, rather than absolute levels. The
rates of development set down in these tar-
gets are not impossible. The goal to reduce
child mortality by two thirds in 25 years has References and suggested further reading
already been achieved during the past 25 Allen T, Thomas A. (Eds.) Poverty and devel-
years in several countries, including Egypt, opment into the 21st century. Oxford
South Korea, Mauritius, Malaysia, Chile and University Press; 2000.
Iran. Many other countries have reached the Bhagwati J. In Defense of Globalization.
rates of development specified by other tar- Oxford University Press; 2004.
gets. An animation on Human Development Bhutta ZA. Structural adjustments and their
Trends and MDGs is available at the gap- impact on health and society: a perspec-
minder site.2 tive from Pakistan. Int J of Epidemiology
The world and the countries are advised 2001;30:71216.
to simultaneously keep track of several di- Boserup E. Population and Technology
mensions of development. The MDG ap- Change, a study of long-term trends. The
C proach does actually not set a fixed goal, but University of Chicago Press; 1981.
M
rather a rate for development in each di- Boyd R, Silk JB. How humans evolved.
Norton; 2000.
Y
1
www.undg.org
Cohan JE. How many people can the world
K
2
www.gapminder.org support? Norton; 1995.

1.11 The hopeful future
Cooper R. The Breaking of Nations: Order McMichael T. Human Frontiers, environ-

and Chaos in the Twenty-first Century. ments and disease. Cambridge University
London: Atlantic Books; 2003. Press; 2001.
de Soto H. The Mystery of Capital: Why McNeill W. Plagues and People. Anchor
Capitalism Triumphs in the West and Press; 1976.
Fails Everywhere Else. Times Books; 2001. Middleton N, O'Keefe P, Visser R. (Eds.)
Desowitz, R. Tropical diseases from 50 000 Negotiating Poverty. London: Pluto Press;
BC to 2500 AD. Flamingo; 1998. 2001.
de Vylder S. The driving forces of develop- Moberg W. The Emigrants. Penguin Books;
ment (in Swedish). Forum Syd; 2002. 1995.
Diamond J. Guns, Germs and Steel. A short Narayan D. Voices of the poor Can anyone
history of everybody for the last 13 000 hear us? Oxford University Press; 2000.
years. London: Vintage; 1997. Patz JA, Kovats RS. Hotspots in climate
Ehrlich PR. The Population Bomb. New change and human health. BMJ 2002;
York: Ballentine Books; 1968. 325:10948.
Evans LT. Feeding the 10 billion plant and Roberts JM. The Penguin History of the
population growth. Cambridge Univer- World. Penguin Books; 1995.
sity Press; 2000. Sarre P, Blunden J. An Overcrowded World?
Feachem RG. Globalisation is good for your Oxford University Press; 2000.
health, mostly. BMJ. 2001;323:5046. Sen A. Development as Freedom. Oxford
Gian R, et al. Ecological responses to recent University Press; 1999.
climatic change. Nature 2002;416:389 Sen G, George A, stlin P. Engendering
95. International Health the Challenge of
Gunnarsson C, Rojas M. Growth, stagna- Equity. MIT Press; 2002.
tion, chaos (in Swedish). SNS; 1995. Stiglitz JE. Globalization and its discontents.
Harrison P. The Third revolution popula- W.W. Norton & Company; 2003.
tion, environment and a sustainable Thomas H. The Slave Trade. The History of
world. Penguin Press; 1993. the Atlantic Slave Trade 14401870.
Kaessmann H, Paabo S. The genetic history Papermac; 1998.
of humans and the great apes. J Intern Todaro M, Smith SC. Economic develop-
Med 2002;251:118. ment, 8th edition. Addison Wesley; 2002.
Landes DS. The Wealth and Poverty of UNDP, Human Development Report 1997.
Nations: Why Some Are So Rich and UNDP, Human Development Report 2003.
Some So Poor. Norton; 1999. UNICEF, State of the worlds children 2004.
Livi-Bacci MA. Concise History of World WHO, World Health Report 2003.
Population. Blackwell; 1995. World Bank, World Development Report
Lomborg B. The sceptical environmentalist. 1993.
Cambridge University Press; 2001. World Bank, World Development Report
Lutz W. The future population of the earth: 2001.
what can we assume today? Earthscan; World Bank, Responsible Growth for the
1996. New Millennium: Integrating Society,
Maddison A. The World Economy: A Millen- Ecology, and the Economy; 2004.
nial Perspective. OECD; 2001.

2 Health determinants
Poverty is pain; it feels like a disease. It
attacks a person not only materially but
also morally. It eats away ones dignity and
drives one into total despair.
A poor woman, Moldavia 1997
The basic requirements for good health in factors, which is far away from the actual
human populations are not so many, but disease at the other end of the web of deter-
they interact in a very complex way. Since mining factors. Primary schooling for all
the degree of fulfilment of these require- will reduce the occurrence of many diseases.
ments determines health status, they are In fact primary schooling for all children
jointly designated health determinants. The appears to be the most effective health inter-
determinants can be grouped and labelled vention of all, but it will take half a century
in various ways. We group the determinants before it has full effect.
under seven headings: Poverty and ignorance are underlying
1 socio-economic causative factors that act upon many inter-
2 food mediate causative factors, such as insuffi-
3 water cient food supply and unsafe water supply.
4 sanitation Each causative chain is ultimately linked to
5 other environmental determinants the direct biological cause of a specific dis-
6 behaviour ease. One example is how a polluted water
7 health services supply results in poliovirus infection, as
virus particles from the faeces of one in-
Any grouping of health determinants is a fected person are transmitted via drinking
simplification of the complex web of factors water to the gut of a previously healthy
that jointly determine the health status of child. If the child has been vaccinated, she
human populations. This web is composed will manage to resist the virus and remain
of many mutually interacting socio-eco- healthy. But if the health service has been
nomic, cultural and environmental factors, inadequate, the unvaccinated child who
which, through various links with individ- drinks water that has been contaminated
ual behavioural and genetic factors, deter- with poliovirus may be at risk. This child
mine the health of a human being. Public can thus acquire an acute infection with the
health is about understanding the role of poliovirus, which causes high fever and may
each factor in this web and about how to lead to permanent paralysis in one or both
modify factors or to intervene with new fac- legs. In poverty-related diseases such as po-
tors in ways that improve the health status lio, the effect of one determinant is strongly
of a population. dependent on the other determinants.
The cause of each of the main diseases in The provision of vaccination services in
the world can also be regarded as a long poor communities, where few mothers have
chain of causative factors within a wider attended school, will not have the same ef-
C web of interlinking factors. The causative fect as if the same service is provided in
M chain behind a specific disease may start in communities where all women are literate
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underlying poverty or ignorance. Interven- and conversant with how infectious diseases
tions like primary schooling for all children may be prevented by an injection at an early
K
will affect one of these underlying causative age. In many communities, a high propor-

tion of children will remain unvaccinated spite of free elementary schooling being de-
although the health service provides safe clared a human right in 19481.
vaccinations, because of reluctance by many Another example of interactions between
illiterate mothers to have their children vac- different health determinants can be found
cinated. Many factors may thus be regarded in contemporary Sweden. An increasing
as the cause of the paralysis of one of the proportion of highly educated parents ab-
legs of the little girl mentioned previously: stain from vaccinating their children
the poverty of her family and community; against infectious diseases, e.g. measles, due
the unsafe water supply in that community; to the influence of new cultural values orig-
the poorly functioning health system that inating from anthroposophy and related
failed to vaccinate her; or the virus itself. philosophical trends. There are two main
Hypothetically speaking, the individual reasons as to why the unvaccinated Swedish
childs genetic susceptibility to developing children are very rarely infected with the
paralysis when exposed to poliovirus infec- measles virus. A minor reason is that good
tion may also be put forward as the cause of housing standards decrease the risk of mea-
the paralysis, as paralysis only occurs in a sles transmission in Sweden. However, the
few percent of those infected with this virus. main reason is that the vast majority of
All of these factors can intellectually be re- Swedish parents do continue to have their
garded as causes, although some may, in cer- children vaccinated. The vaccination of
tain circumstances, be easier and less costly most of the children provides herd immu-
to prevent than others. nity, meaning that an infectious disease
We may go even deeper in analysing the will not spread in a population in which the
cause of paralysis in the child. This requires vast majority are vaccinated. Acting in com-
a study of how the global political and eco- bination, these two factors reduce the risk of
nomic situation relates to the occurrence of measles epidemics in Sweden to almost zero
the underlying determinants of diseases among vaccinated and unvaccinated alike.
within the poor community of the victim. The advice from parts of the anthroposophy
Global economic and health policy may al- movement that vaccination is unnecessary
leviate or aggravate the poverty of the fam- will continue to be supported by empirical
ily and thus affect their access to safe water evidence only as long as it is not followed by
and health service. too many. If an unvaccinated Swedish child
The satisfying message in relation to polio travels to a low-income country where mea-
infection is that the international commu- sles occur, she will be at great risk of acquir-
nity has taken up its responsibility. Techni- ing the disease and hence to transmit it to
cal and financial resources have been made other children. This demonstrates the fact
available for polio vaccination of all chil- that the health effect of one and the same
dren throughout the world. The disease has determinant may be different in different
already been eradicated from Latin America. contexts.
The eradication of the poliovirus from the The scientific evidence for the relative im-
world is now within our grasp through con- portance of each determinant in a web of
certed international action and funding. It causation is surprisingly limited. The reason
is interesting to note that the contemporary is that the strong interdependence between
global health governance is successful in the different factors makes it very difficult to
dealing with health problems that can be separately quantify the effect of each factor
C solved by highly technical interventions in observational studies. Many factors
M
such as vaccination. In sharp contrast to would also only exert their positive effects if
such technical achievements stands the fact another factor changed at the same time.
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that the world is still far from providing pri-
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mary schooling for all its children. This is in 1
www.un.org/Overview/rights

Table 2.1 Major preventable risk factors for disease in the world in 2000.
Risk factors % of total disease burden*

**
Under nutrition 15
Over nutrition*** 13
Unsafe sex 6
Tobacco 4
Alcohol 4
Unsafe water, sanitation and hygiene 4
Indoor smoke from solid fuels 3
Occupation**** 2
* (attributable DALYs see chapter 3 for definition)

** including: underweight, iron-VitA-and Zinc deficiency
*** including: hypertension, high cholesterol, overweight, low fruit and vegetable intake and physical inactivity
**** including: risk factors of injury, carcinogens, airborne particles, ergonomic stressors, noise
Source: World Health Report 2002. WHO.
Provision of safe tap water in a village will disease is caused by each preventable risk
only reduce the occurrence of diarrhoea if factor. The eight most common risk factors
health education is simultaneously pro- are together responsible for half of the
vided and if poor households have the healthy life years lost in the world.
means to maintain the water clean when The difficulty in defining causes and best
storing and drinking it in their homes. In preventive actions against ill health also re-
addition many causative factors, such as lit- lates to difficulties in defining health. A dis-
eracy, are not possible to study in ran- cussion of health determinants must include
domised controlled trails. It is therefore dif- an attempt to define health (Box 2.1). The
ficult to answer questions such as: How
much healthier would country X be if every
Box 2.1
household gained access to clean, safe wa-
ter? How much would child survival im- Definitions of health
prove in country Y if malnutrition was erad-
The definition of health agreed upon in
icated among children?
1948 at the foundation of the World
The World Health Report 2002 presents
Health Organization:
the first coherent attempt (Table 2.1) to esti-
Health is a state of complete physical,
mate at a global level the relative importance
mental, and social well-being and not
of each major preventable risk factor respon-
merely the absence of disease or infirmity.
sible for the loss of disability adjusted life
years (DALY, see chapter 3). It is estimated This eloquent holistic definition encom-
that the world at the beginning of the new passes a broad psychosocial view on the
millennium has reached the point where the health of humans. However, it is useless
degree of ill health due to being overweight, for monitoring the effect of health pro-
eating foods with a high dietary fat content motion and disease prevention. When
and lack of physical activity is almost as WHO in 1977 reformulated its overall
C great as the ill health resulting from lack of goal a more practical health definition
food. Too much food accounts for 13 % and was included.
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too little food 15 %, of lost healthy years in Health permits a socially and economi-
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the world today. Table 2.1 also shows the es- cally productive life.
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timates of how much of the global burden of

2.1 Socio-economic determinants
health aspirations of the poorest people in 2.1 Socio-economic

the world remain a matter of survival and a
hope of living without disability. The promo-
determinants
tion of world health in the last 50 years has It is agreed that the poverty of households
also focused on improving survival. Mortal- and individuals, as a result of the level and
ity statistics have thus been the main means distribution of economic resources of each
of monitoring the result of health promo- nation, is the most important determinant
tion, as will be discussed further in chapter 3. of health. There is less agreement on how to
At the start of the new millennium, global define and measure poverty (yen 1996).
health problems are still dominated by high Two different definitions of poverty are cur-
mortality among the poor in low-income rently used. The first is the conventional
countries. In low-income countries, most economic understanding, which is known
premature deaths, diseases and disabilities as income poverty. The second is a wider
are caused by varying combinations of the concept of poverty that includes income, ig-
seven types of determinants described in norance, ill health, disempowerment, gen-
this chapter. We fully recognise that individ- der issues and vulnerability1. There is even
ual genetic factors also are important in all greater disagreement about the relative im-
human populations, but the genetic disease portance of each of these components. In
determinants are not dealt with in this the past, the debate has related to the rela-
book. Many behavioural and social health tive importance of pure economic factors
determinants that are not mentioned in this such as household income in relation to so-
book are also of great importance for health cial factors such as literacy. Some have ar-
in high-income countries and in some mid- gued that, if a country had strong economic
dle-income countries. Many contemporary growth, this would almost automatically
health issues of populations in the most af- lead to all of the changes that result in im-
fluent countries are not related to survival. A proved health status. Others have stated
very low or non-existent pregnancy-related that health is marginally or even negatively
mortality is now taken for granted in Swe- associated with economic growth, and that
den. The health impact of birth delivery improvements in health result from im-
services in contemporary Sweden is very proved education, human rights, gender eq-
much a question of the direct psychosocial uity and general access to health services,
outcome of the experiences of the delivery. rather than from any economic change. To-
Most psychosocial health determinants in day, social and economic changes are re-
high-income countries are not covered in garded as intensely interlinked. The under-
this text. The chapter focuses on determi- standing of the complex interactions be-
nants of worldwide importance for survival. tween different socio-economic factors has
The main determinant of disease in the been advanced by the Bengali Nobel Prize
world is poverty. Gender is another health Laureate in Economics in 1998, Amartya
determinant that transcends all societies Sen (1999), as described in chapter 1.
and modifies the effect of other determi- Amartya Sen simultaneously emphasises
nants mentioned in this chapter. Ethnicity the close relationship between economic
and other cultural dimensions are also over- progress and health improvement, and the
arching factors that modify other health de- fact that health improvements also are
terminants. strongly related to non-economic develop-
C ment dimensions, such as education. There
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are two influences in particular that weaken
the relationship between the economic level
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1
www.worldbank.org/poverty/voices

of a country and the health status of its pop- times greater than that of Cuba. This enor-
ulation. mous difference in child health was mainly
The first influence is how the economic explained by differences in domestic health
resources are distributed between communi- policies between the two governments. The
ties, households and individuals. One strik- extensive development of the Cuban social
ing example of this is that the child mortal- and health systems secured the good health
ity of countries with a very uneven distribu- of the population through long periods of
tion of economic wealth, such as South economic hardship, while the Saddam Hus-
Africa, Brazil and Turkey, is several times sein regime failed to make optimal priorities
higher than in countries with the same in- during the period of economic hardship.
come per capita but with a more even distri- Economic growth will have little health im-
bution of economic wealth, such as the pact if money is wrongly or unfairly spent.
Czech Republic, Costa Rica and Malaysia What has been said about economic
(See the World Health Chart on the back progress and health at national levels can
cover). also be applied to this relationship at the
The second influence is how public and household and individual level. Increased
household resources are spent with regard income within a family may be spent exclu-
to their effect on health. Diseases induced sively on the alcohol consumption of a ciga-
by severe poverty can be largely prevented rette-smoking father. Such an application of
or alleviated at a relatively low cost. The past economic progress will obviously only result
50 years provide many examples of coun- in a deterioration in the health status of the
tries that, despite limited economic re- family. In contrast, a family that spends an
sources, have managed to provide primary increase in income well will be able to gain
education for all children and a general pri- daily access to safe water, improved hygienic
mary health care service that greatly re- sanitation, a more nutritious diet, and better
duced the burden of disease. Prominent access to health information through me-
examples are China, Vietnam, Costa Rica dia.
and Sri Lanka. Other countries with well- The World Health Organization has re-
developed social services and general access cently taken the discussion about the rela-
to health services have had periods of severe tionship between economic growth and
economic decline without a deterioration of health development one further step for-
the general health status. The reason was ward. The Director-General of WHO in 1998
that the social and health services were to 2003, Gro Harlem Brundtland, argued
maintained and that prior investment in that improved health is a necessary prereq-
human capabilities helped the population uisite for economic growth. The basis for
during the economic crisis. this argument is that recent decades of rapid
An interesting comparison can be made economic growth in many Asian tiger econ-
between Cuba and Iraq (See the World omies was preceded by extensive public in-
Health Chart on the back cover). These two vestments in improved health. These invest-
countries are estimated to have had about ments in South Korea, mainland China and
the same per capita income during the last Taiwan concerned both preventive pro-
decade. During this period both countries grammes and the equitable provision of
experienced international trade boycotts, basic curative health services. These coun-
and political isolation that contributed to tries provide good examples of economic
C an economic decline. In spite of the eco- growth being preceded by improved health.
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nomic and political similarities between the There is in fact no good example of a coun-
two countries, the health status varied try that has had a rapid, stable and diversi-
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widely. Iraqs child mortality rate before the fied economic progress over several decades
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2003 war was estimated to have been 15 without preceding or simultaneous im-

provements in the health status of its popu- verting GDP per capita to US dollars as an
lation occurring. The exceptions are so- estimate of the economic development of a
called mineral countries. However, these country (Box 2.2). This conversion factor for
countries did not have a diversified eco- GDP takes into account the number of units
nomic growth. In Saudi Arabia and Bot- of a countrys currency required to buy the
swana the sudden economic progress was same quantities of goods and services in the
due to the onset of the exploitation of oil domestic market as one dollar would buy in
and diamonds, respectively. In the mineral the United States. In other words, how
countries health improvements only fol- many US dollars worth of goods and serv-
lowed after more than a decade of economic ices can be bought for a unit of the countrys
growth. currency? This has also been called the in-
The World Health Organizations Commis- ternational dollar. If we use the value of the
sion for Macroeconomics and Health delivered purchasing power of the national currency,
its report in December 2001 (Sachs 2001). the difference in GNP per capita or GDP per
This research programme led by Jeffery capita decreases a little, but a 100-fold differ-
Sachs commissioned 87 studies, which re- ence remains between the economic level in
viewed aspects of the relationship between the richest and the poorest country.
economic growth and health investments. Counted as purchasing power, the average
The conclusion is that increased invest- income per capita in the poorest countries
ments in health in the worlds poorest coun- increases from USD 100 to USD 300500 per
tries will save millions of human lives and person. The Indian rupee, for instance, is
also contribute to economic growth in these worth about five times more if used for pur-
countries (see chapter 11). chases in India than if it is changed into US
dollars at existing exchange rate and used to
make purchases in the United States. In con-
2.1.1 Income, poverty and equity trast, the Japanese yen is worth less if used
The level and distribution of economic re- in Japan than if it is exchanged into dollars
sources is today the main determinant of and used in the United States. The differ-
health throughout the world. One reason ence between the exchange-rate dollar and
for income poverty emerging as the most the purchasing-power dollar is more impor-
important determinant of the health of na- tant when comparing economic level in the
tions is that the disparity in average income countries of the world than if the level is
within and between the nations of the measured by GNP per capita or GDP per cap-
world is so very wide. Calculated as the in- ita. As a rule of thumb, the poorest countries
come per capita in US dollars using the ex- have a purchasing power that is 35 times
change rate between national currency and stronger than the exchange rate of their cur-
dollar, the differences range from a little rency, and for most countries GNP is almost
more than USD 100 to USD 40 000 per in- the same as GDP.
habitant, i.e. more than a 100-fold differ- However, it is not mainly the relative dif-
ence. ferences in income per capita in the world
There are several problems related to the that makes money such an important deter-
comparison of economic indicators between minant of global health. What makes money
countries. The main problem is that the cost so important is that daily incomes are so
of living varies between countries in a way very low among the poorest two billion peo-
C that is not expressed when using the ex- ple. They live on the purchasing power of
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change rate to convert national currencies less than USD 2 per day. This implies that
into US dollars. This has been partly over- they spend the major part of their economic
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come by using the Purchasing Power Parity resources on buying the staple food needed
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(PPP) of the national currency when con- to survive. There is today almost unanimous

Box 2.2
The two main measurements of economic level of nations
GDP (Gross Domestic Product)/capita The value of all goods and services produced
in a country by nationals and foreign residents
during one year divided by the mid year resi-
dent population of that year.
GNP (Gross National Product)/capita The value of all goods and services produced
= GNI (Gross National Income)/capita during one year by the nationals in a country
plus the income of nationals earned abroad
divided by the mid-year national population
of that year.
GDP and GNP can be expressed in US dollars in two ways:

Current U.S. dollars by Atlas method
The domestic currency is converted to US dollar by a factor that averages the exchange
rate for a given year and the two preceding years, adjusted for differences in rates of infla-
tion between the country and the rate of inflation of France, Germany, Japan, UK and USA.
If the official exchange rate does not reflect the rate effectively applied to actual foreign ex-
change transactions or if the exchange rate fluctuates considerably alternative conversion
factors may be used.
Purchasing Power Parity (PPP) (= International Dollars)
The domestic currency is converted to US dollar by an exchange rate at which all the goods
and services that comprise the gross domestic product will cost the same to buy in the coun-
try as in United States. As PPP conversion reflects the services and goods that inhabitants can
buy in their own country, the GDP/capita expressed in international dollars (= PPP) is the
best estimates of the economic differences between the countries in the world.
agreement among international organisa- The total income of a country can be

tions, national governments and researchers measured in different ways (Todaro 1997).
that poverty is the main obstacle to human The average income measurements listed in
development. The majority of the two bil- Box 2.2 do not tell us anything about how
lion poor people in the world live in the the income is distributed within each na-
western part of China, India, Bangladesh, tional population. To understand the health
Pakistan and Sub Saharan Africa. impact of national economics, it is therefore
There is agreement that the world has im- crucial to simultaneously measure both the
proved in social development areas such as average income level and the distribution of
schooling, health, lowering of fertility rates income within a country. This can be done
and improvement of human rights in recent in several ways, but each method has a
decades. The improvements in these softer number of limitations.
dimensions of development have, however, One way to measure income inequality is
C only partly been matched by economic by calculation of the Gini-coefficient. This
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growth in the less affluent countries. The measure is named after the Italian statisti-
proportion of people living in poverty has cian who formulated it in 1912. The Gini-
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started to decrease, but the total number has coefficient is based on the much-used
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not decreased. Lorenz curve. This curve shows the relative

100% 48 % of the total income and the poorest

10 % only earned 0.7 % of the total income
A
in 2002.
Cumulative % of Wealth
Gini Coefficient=
A+B
A third way to measure income distribu-
tion is to calculate the proportion of the
A population living in absolute poverty, de-
fined as being unable to satisfy basic needs.
A household is classified as living in abso-
B
lute poverty when found to have a daily
income of less than the purchasing power of
one US dollar per person. This line is defined
0% Cumulative % of Households 100%
as purchasing power in dollars and is
Figure 2.1 How the Gini-coefficient is calculated intended to be the same cut-off point
based on the Lorenz curve. throughout the world. Some countries may
define poverty in relative terms, but relative
income poverty just means that someone
distribution of income in a population, with has low income in relation to the majority
the percentage of population on the x-axis in the country. The most widely used defini-
and the percentage of income on the y-axis. tion of absolute poverty is an average in-
A perfectly equal distribution of income come of a purchasing power parity of less
yields a straight line, and the more unequal than USD 1 per day. For a nation, poverty is
the distribution, the more bent the curve expressed as the proportion of households
will be. The Gini-coefficient is the propor- that live either in poverty, with less than
tion obtained by dividing the area between USD 2 in PPP/day, or in absolute poverty,
the straight line and the curve by the area of with less than USD 1 in PPP/ day. Brazil has
the half square under the straight line (Fig- about 12 % of its population living on less
ure 2.1). A small Gini-coefficient means an than 1 USD/day and 26 % living on less than
equal distribution, while a large value of the 2 USD/day. Mozambique is estimated to
coefficient means more inequality. A value have 38 % of its population living on less
of 0.0 means perfect equality, while a value than 1 USD/day and 78 % living on less than
of 1.0 means that one person earns the en- 2 USD/ day (World Bank 2003).
tire national income. Recently, the Gini-co- Almost all data from low and middle-in-
efficient of Brazil and South Africa was esti- come countries are based on surveys of
mated at 0.57; of United States and Thailand household income that are being carried out
0.39; and of Sweden and Japan 0.27. several years apart. It must be emphasised
Another way to express income distribu- that this data will not show the distribution
tion is to calculate the percentage of na- of the economic resources within the house-
tional income earned by the richest 20 %, hold. Gender differences further exacerbate
the next 20 %, the middle 20 %, the second a very unequal distribution of income in
lowest 20 % and finally the poorest 20 % of countries with a low general economic level.
the population. This calculation may also In practice, this means that, even if the gross
be used to express the income ratio of the national product of Guatemala is measured
20 % richest (the upper income quintile) to together with the proportion of income be-
the 20 % poorest (the lower income quin- tween the richest 20 % and the poorest 20 %
C tile). The World Bank used the indicator of households, this does not tell us how
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percentage share of income or consump- much of the countrys resources are availa-
tion by the richest and poorest 10 % in ble for women and children in the poorest
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their World Development Report 2003. In households. Unfortunately, gender differ-
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Brazil, for example, the richest 10 % earned ences often disfavour women most in the

poorest households in the poorest countries emerges when an unequal distribution of re-
(Sen 2002). sources, responsibilities and rights of access
Unequal distribution of health exists in to health exists between the sexes. As men-
every country in the world. Health inequal- tioned before, gender is a socio-economic
ities constitute unfair and avoidable gaps in health determinant that modifies all the
health status within populations. These ine- other determinants, as do poverty and eth-
qualities are due to differences in socio-eco- nicity. Gender determines access to and use
nomic status, effects of gender roles and eth- of resources, be they financial or educa-
nicity, and effects from combinations of tional; it determines the type and quality of
these factors and other contextual factors social support a person receives; it deter-
determined by the geographical location. mines access to food and water, as well as in-
The inequity in health is partly explained by dividual behaviour such as alcohol and to-
differences in access, utilisation and quality bacco use. Finally, gender determines acces-
of health care. This has been summarised by sibility and use of health services.
the Indian scholar, K. Park (1997), in his One biological reason for health differ-
textbook on public health: ences between the sexes relates, for exam-
ple, to the biological difference of the repro-
Health is not mainly a matter of doctors,
ductive organs e.g. pregnancy complica-
social services and hospitals, but an issue of
social justice. tions and breast cancer in women, or
prostate cancer in men. However, besides
A surprising finding has been that many in- the biological differences there may be a low
equalities in health remain very pro- and unfair coverage and quality of health
nounced even in high-income countries services for pregnant women. There may
with a well-developed social security system also, due to cultural norms, be a greater ten-
and general access to health services. It has dency by men to drink more alcohol. The
been shown that cardiovascular disease in consequence will be inequity in health due
Northern Europe is much more common to gender differences, not due to biological
among less educated people with low in- differences. Striking examples are that ma-
come than among people with more educa- ternal mortality is exceedingly high in
tion and a greater income. This difference countries such as Yemen. The performance
remains after controlling for differences in of harmful traditional practices such as fe-
tobacco smoking, diet, degree of physical ac- male genital mutilation is another striking
tivity and all other known individual risk example of gender differences in health. The
factors. In high-income countries, the une- higher rate of death in men due to sub-
qual distribution of major diseases is much stance abuse is yet another gender differ-
more pronounced among adults, while ence.
child morbidity and mortality do not differ Inequity in disease occurrence between
as much between income groups (Evans men and women may thus depend on vary-
2001). ing underlying and interacting biological,
social and political causes. The fact that
women and men work in different jobs or
2.1.2 Gender have different tasks in agriculture is one ex-
Gender is the social construct and interpre- ample. The gender role may vary between
tation of the biological sex difference be- different regions and ethnic groups within a
C tween men and women. Gender differences country. In parts of many African countries,
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are determined by how female and male women are the main farmers, and this
roles are perceived on the basis of social val- places a very heavy physical burden on
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ues, on cultural norms and on how societies them and decreases their opportunities to
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are organised. Gender inequity in health offer optimal care to young children. Back

pain in nursing employment has a high in- between men and women. This is probably
cidence in women in high-income coun- due to interrelated biological and social fac-
tries. Women in low-income countries are tors, but it is noteworthy that the precise
more prone to infection from water-borne causes are unknown. The male lifestyle con-
parasites, because they are exposed to infec- tributes to a higher injury frequency in men
tion when they fetch water for the family. and partially explains the life expectancy
Studies in high-income countries show that, differences (see chapter 8). The increased
even if women work and earn money, which risk of injury for men outside the home
increases their economic independence, relates to the higher exposure of males to
they still have a higher burden of household dangerous professions and to their different
work. On the other hand, in societies where social roles. It has also been explained par-
men are responsible for the greater part of tially by biological differences. The higher
the family economy, the psychological bur- incidence of male victims of road traffic ac-
den on men may be harder in times of eco- cidents, as opposed to women victims, prob-
nomic recession and unemployment. One ably reflects both a higher male presence
example is Russia where, during the last dec- and more risky behaviour in the traffic envi-
ade, the suicide rates and high-risk behav- ronment.
iour such as drinking alcohol and taking More male than female babies are born in
narcotic drugs increased much more in men societies where either sex is equally socially
than in women. Today the Russian female acceptable. The proportion of 105 boys to
life expectancy is 23 % longer than the male 100 girls is believed to be a biologically de-
whereas in Sweden women only live 6 % termined relationship. Where this ratio is
longer than men. A study in Central Amer- not observed, as in China, this most proba-
ica revealed an interesting relation between bly reflects the application of selective abor-
parental gender differences and child sur- tion, or underreporting of female births. It
vival. Children with two illiterate parents may even occasionally be due to female in-
had a better chance of survival than the fanticide, due to a social preference for boys
child of the family where only the father and the national policy of the one-child
could read (Aleman 1997). family. After birth males have higher death
The high degree of domestic abuse of rates than women at all age intervals, but so-
women relates to the powerlessness of the cial class modifies this trend. It is wrong to
woman in relation to the man she lives attribute this difference entirely to biologi-
with. In South Africa domestic violence cal factors, and it may even be wrong to at-
against women has recently been recognised tribute it mostly to biological factors.
as a major health problem. The background In contrast to the mortality statistics, in
to this violence is the social norm that ac- most countries women report a higher de-
cepts male dominance in society and at gree of morbidity than men. This tendency
home. The weaker social and economic po- is more pronounced in mental rather than
sition of young women makes it difficult for physical illness. The reason may be that
them to refuse to have sex with a dominant men have greater difficulty in accepting that
man; they are therefore at greater risk of ac- they are sick, or that the burden of disease
quiring HIV infection than men in the same affecting women causes greater morbidity,
age group. while that affecting men causes greater mor-
Knowing the level of discrimination tality. Excess female reporting of illness can
C against women in the world, it is surprising also be related to more frequent illnesses in
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that women live longer than men in almost their reproductive organs i.e. a biological ex-
all societies, except for those societies unu- planation. Higher female acceptance of re-
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sually oppressive towards women. There is a porting morbidity may be a social effect
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considerable difference in life expectancy among women. Men may instead under-re-

port morbidity due to their social roles and India. Although there are public hospital
norms. It should be noted that most of the services available to all, there is no function-
gender research on morbidity has to date ing public ambulance service. If a woman
been carried out on the populations of high- has a life-threatening haemorrhage in the
income countries and results should not be last month of pregnancy, the family has to
extrapolated to other contexts. find money for emergency transport to the
hospital. Among poor people, it is common
that the husband or the relatives have to
2.1.3 Social support borrow money from neighbours to pay for a
An individuals social support network con- taxi to the hospital. They become indebted
sists of family, friends, neighbours, teams at to their neighbours and will eventually
work and relatives or members of the same repay the loan. If they can borrow from
clan or ethnic group. It can be defined as re- friends at a low interest rate, they will not be
sources provided by other persons (Cohen as severely impoverished as if they have to
1985). A good social support network has borrow at an exploitative interest rate from
been found to be important for sustaining the local commercial moneylender.
good mental and physical health. It is fur- The very special social bond between
ther essential for a persons ability to deal mother and child is essential for child sur-
with periods of illness. This means that a vival in every society. This is most needed in
person may not have the financial resources societies with high risks for children. In low-
needed for treatment and care, but through income countries if the mother dies at or
the social network money may be borrowed following delivery, up to 95 % of their new-
at a reasonable interest rate. An individual born children will die before the age of five.
with a good network may deal with a period An infant is usually dependent on the
of disease more effectively than one in a bet- mother for both breastmilk and care. Of
ter financial situation but with a weaker net- course the father or another responsible
work. adult may replace the mother, but they can
It has been shown in numerous studies not fulfil all aspects of childcare, breastfeed-
that married people have a lower mortality ing being the most important one. Breast-
rate after myocardial infarction than single, feeding is one of the most important deter-
widowed or divorced people. This is particu- minants of survival from infectious diseases
larly true for men. Part of this differential and of prevention from malnutrition in the
death rate is explained by a selection effect, young child. The mothers basic care, along
in that unhealthy people may remain un- with her knowledge of how to treat com-
married, or that people are divorced because mon diseases and when to take the child for
of unhealthy behaviour such as alcoholism. health care are also necessary for survival. If
People with large social support networks the mother is continuously able to stay close
have lower death rates than people with few to the child, she can prevent accidents. A
contacts with family and friends. The size womans status in society and social support
and quality of the social support depends on network largely determines what care she
many factors, such as size of family, the in- can offer her child. This also depends on her
dividuals social abilities, occupation and education, workload and decision-making
skills. These factors in turn may all affect the power.
ability to stay healthy. A social network thus
C provides a range of support from psycholog-
ical counselling to fast loans of cash when 2.1.4 Education
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most needed. After income education is one of the most
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An example can be taken from Kerala, the important determinants of health. Female
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state that has the best health status in all of education in particular has proved to be of

Table 2.2 Adult literacy rate* by region in 2000 for male and female.
Region Male Female

East Asia and Pacific 93 81
CEE/CIS and the Baltic states 99 96
Latin America and Caribbean 90 88
Middle East and North Africa 74 52
South Asia 66 42
Sub-Saharan Africa 69 53
High income countries 99 97
* Adult literacy = % of persons >15 years old who can read and write.
Source: State of the worlds children 2004. UNICEF.
Table 2.3 Percent* of relevant age group (male and female) attending primary,** secondary and tertiary
education in different regions in 19972000*.
Region Primary Primary Secondary Secondary University

school school school school
male female male female total
East Asia & Pacific 106 106 65 61 17
CEE/CIS and the Baltic states 99 95 81 78 47
Latin America & Caribbean 126 123 82 87 26
Middle East & North Africa 95 86 68 62 23
South Asia 107 87 53 39 10
Sub-Saharan Africa 89 78 29 23 5
High income countries 102 102 105 108 67
* Ratio of total enrolment regardless of age to the population of the age group that officially corresponds to the level
of education, which is why it may be >100 %.
** Primary = elementary or primary school, Secondary = high school, Tertiary = university.
Source: State of the worlds children 2004, UNICEF and World development indicators 2004, The World Bank.
great significance for child survival. It is live in the four big Asian nations. Gender
therefore most promising that the world- disparities in primary education have not
wide adult literacy rate has increased from changed much in the last 20 years; 400 mil-
70 % in 1980 to 80 % in 2000. The adult lit- lion of the illiterate are women. In South
eracy rate is expected to continue to rise to Asia a total of 66 % of adult males are liter-
83 % by the year 2010 (UNESCO 2002). ate, but only 42 % of adult females are liter-
However, due to population growth, the ab- ate (Table 2.2).
solute number of illiterate adults remains al- Large gender disparities in literacy rates
most the same as 20 years ago. There are be- also appear in Sub-Saharan Africa, the Mid-
tween 600 and 700 million adults in the dle East and North Africa. Within each re-
world who cannot read or write. Of these gion, the disparities in national literacy rates
C one-third live in India and another one- are wide. In the year 2000, Ethiopia had a
M third in China, Pakistan and Bangladesh. male adult literacy rate of 47 % and a female
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Despite the fact that Africa has the greatest rate of 31 %, while the rates in Botswana
proportion of illiterate adults, more than were 75 % and 80 %, respectively. In Bangla-
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half of the illiterate population of the world desh, the male literacy was 49 % and the fe-

male 30 %, while in Sri Lanka the rates were even after controlling for socio-economic
94 % and 89 %, respectively (UNICEF 2004). situation, maternal education remains an
School enrolment at the primary school important health determinant. The advan-
level is depicted in table 2.3. The disparities tages of higher income, clean water, safer
between geographical regions increase at sanitation and better housing account for
higher levels of education. Sub-Saharan Af- only about half of the association between
rica is lagging particularly far behind when education and child survival (Cleland
it comes to university education. 1988). Education itself is thus associated
The state of Kerala in South India is with better health. Educated mothers can,
known for its high literacy rates, 94 % in of course, be expected to have more knowl-
men and 86 % in women. This is high com- edge and therefore adopt new health inter-
pared to India as a whole, where male liter- ventions, such as immunisation, to a greater
acy is 68 % and female 45 %. The high liter- extent than illiterate women. An under-
acy is regarded as the main reason why Ker- standing of the causation of disease, nutri-
ala has achieved an under-five mortality rate tion, preventive and curative home care
of less than 20 per 1 000 live births, while may be enhanced in the educated mother,
India as a whole had an under five mortality leading to improved hygiene and a healthier
rate of 96 per 1 000 births in 2002. If all of diet. The educated mother may sense a
India had the same literacy rate and social larger personal responsibility for the childs
development as the state of Kerala, in the survival than someone who has a more tra-
tropical southern tip of this vast nation, the ditional and fatalistic view of health and
lives of more than one million children disease. She may be less prone to practising
would be saved each year. dangerous forms of traditional medicine.
Kerala is the rule, not the exception. High She may be more vocal, with greater social
parental, particularly maternal, literacy is confidence, and more persistent in demand-
linked to low child mortality rates almost ing care for her children from health care
everywhere in the world where this relation- personnel. In fact, higher education in
ship has been studied. Using data from the women may also be an indicator of a
41 countries covered by the World Fertility stronger social position for women in the
Survey (ISI 1984) it was shown that the asso- family and the community. The association
ciation between mothers education and between a mothers education and her
survival of children is stronger for children childs survival may thus largely represent
aged 14 years than in infants. This study an association between greater empower-
also showed that more maternal years in ment of women and child survival. The ed-
school were associated with better child sur- ucated mother may have both greater moti-
vival. Latin American mothers with 46 vation and greater ability to travel promptly
years in school had a 35 % lower infant mor- to seek health care for her child, and also
tality compared with mothers without any better compliance with prescribed treat-
schooling. If the mother had 7 or more years ment. She may also have a greater decision-
in school, the infant mortality was half of making role in health-related matters, if she
that for children of uneducated mothers. is educated because of her higher status in
The positive effect of female literacy on the society (Caldwell 1996).
health has been shown in many studies but There are some exceptional examples of
this finding has been notably difficult to low-income societies, such as Kerala and Sri
C translate into political actions. Lanka, which have achieved a very good
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Several factors may explain the disparity health status for their populations. These
in child survival between educated and un- countries success stories have come from a
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educated mothers. Education may be a conscious choice of public policy to achieve
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proxy variable for higher family income, but high female educational levels, coupled

with a high degree of female autonomy, a In all parts of the world, the strongest cul-
radical tradition and a deep-rooted respect tural traditions and rituals surround the
for education. It should also be noted that a main stages in life, such as conception,
high literacy rate in women may be associ- birth, and passage from adolescence into
ated with improved health and decreased adulthood, marriage, reproduction and
fertility despite many limitations in death. Circumcision of boys is a widespread
womens rights. Iran, where literacy rates cultural practice, representing an initiation
have improved considerably during recent rite in several ethnic groups and countries.
decades, provides a prominent example. Circumcised men have a lower risk of devel-
In conclusion, children of educated par- oping cancer of the penis and a lower risk of
ents, especially educated mothers, have transmitting sexually transmitted diseases,
lower death rates, because education is asso- including HIV. In contrast, there are consid-
ciated with other positive health determi- erable health risks following the female gen-
nants, because parents increased knowl- ital mutilation practised mainly in Egypt,
edge helps them to make more rational deci- Somalia and Sudan. This is complicated by
sions and because education is accompanied an increased risk of infections, impaired uri-
by higher status and more power. Access to nation and complications at delivery, not to
primary school education is crucially de- mention the psychological distress of the
pendent on public policy and public finan- circumcision itself and the loss of the sexual
cial allocations. The amount and type of pleasure (WHO 1996).
public spending on education is thus a cen- When a child becomes ill its survival
tral issue for health policy in low and mid- largely depends on the familys cultural atti-
dle-income countries. tudes towards treatment. In some cultures,
childrens health is believed to be under the
control of God, fate or luck (Caldwell 1989).
Infanticide or differential care of female in-
2.1.5 Culture and ethnicity fants when boys are more valued in society
Culture is a concept that designates the ac- is another tragic consequence of cultural be-
quired behavioural pattern and conceptual liefs. Some generations ago, some African
views on life of a group of people. Culture is ethnic groups had strong cultural beliefs di-
intertwined with language, the arts, social rected against twins, who were believed to
structure, laws, religion, ethics and morals. represent evil spirits. As a consequence of
Culture profoundly affects peoples atti- this belief, one of the twins used to be killed
tudes, beliefs and actions. However, no cul- directly after birth. This is a traditional cul-
ture is static. All cultures are in constant tural practice that has disappeared due to se-
change at a faster or slower rate, depending vere legal actions taken during colonial
on the pace of other changes in society. New times, as well as bold interventions by reli-
cultural trends emerge, and some aspects of gious leaders. The number of children a
culture disappear over time. Concepts of family has is influenced by the preference of
health and disease, diet and the choice of sex, but also by the customary age at mar-
modern evidence-based health care or tradi- riage, socio-cultural preferences of number
tional and complementary health practi- of children, concerns for security in old age,
tioners are all aspects of human cultural be- customs surrounding sexuality and family
haviour that affect health. Cultural factors planning practices.
C may thus affect health in both negative and Dietary practices are closely related to cul-
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positive directions, while many cultural ture. In the cultures of the Middle East, pork
phenomena are quite neutral in relation to is not included in the diet. This naturally
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their effect on the health status of popula- protects against parasites transmitted by the
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tions. pork tapeworm. This tapeworm is a great

health problem in other parts of the world. engaging in the cannibalistic practices of
Breastfeeding customs also vary across cul- eating the deceased persons brain and vis-
tures and over time. In Europe there has cera during the mourning ritual. When the
been a resurgence of breastfeeding, particu- practice was discontinued, the disease disap-
larly in the Nordic countries, since the peared. Cholera is a very contagious bacte-
1970s. In Islamic countries breastfeeding is rial disease that causes vomiting and diar-
practised widely, partly due to promotion rhoea, leading to dehydration and possibly
on religious grounds. Presently there is a death within 24 hours if untreated. Burial
sub-cultural trend among the youth popula- ceremonies in northern Mozambique in-
tion of Northern Europe to eat vegan food, clude a practice by which family members
on the ethical basis of respecting the rights jointly and carefully clean the dead body be-
of animals. The influence of culture upon fore the funeral, and thereafter eat a shared
diet may both remain stable over thousands meal. As the body of an individual who has
of years and change over short time periods. died from cholera remains highly conta-
Elderly people are regarded with different gious, this respectful practice places the
levels of respect in different cultures. In whole family at risk of contracting cholera.
many countries in Asia and Africa, old peo- Cholera control in such communities de-
ple stay with the family and still enjoy an pends to a high degree on the early modifi-
important role, based on the life-experience cation of this cultural ritual.
they possess. In Japan elderly women, who Ethnicity is a term that is used with differ-
enjoy a high status, have the greatest life ex- ent meanings. It is sometimes used as a syn-
pectancy in the world. In Europe and North onym for race, or to refer to a specific cul-
America most of the elderly stay by them- ture, and sometimes to both at the same
selves or in homes for the elderly that may time. In the health context, this changing
lead to isolation and a feeling of lowered terminology relates to the old question of
self-esteem. These cultural changes with re- whether genetics or the environment is the
spect to the elderly are largely explained by main determinant of human behaviour and
changes in population composition and health. The most common use of the term
longevity. The matter may be summarised ethnicity in social science is that it refers to
crudely as follows. Where old people are rare a subjective understanding of common ori-
and do not survive so long, they are re- gin by a group of people. It may refer to ei-
spected, but when the old are common in ther a national identity or the identity of a
the population and live longer, they become minority within a nation (Allen 2000).
less respected. This change has great impli- The formerly common view that behav-
cations for the occurrence of depression ioural and health differences in the world
among the elderly. Japan is facing a dra- were related to genetic differences between
matic situation because the proportion of races is rarely advanced today. However,
old people has rapidly increased in the last some people still think of ethnicity as par-
decade. The cultural norms still state that tially a matter of genetics. They claim that
younger women in the family must take population groups in the course of evolu-
care of the old at home, but this cultural ob- tion have developed certain genetic differ-
ligation will most probably change. ences in response to the environment in
Different cultural rituals of burial sur- which they live. Few would argue that this is
round death. Such practices may have con- completely wrong. Pigmentation of the skin
C siderable health implications. One of the is one factor that has undoubtedly changed
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most drastic examples induced the neuro- genetically with differing environmental ex-
logical disease, kuru, until fairly recently posure. When genetic factors determine
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practised in New Guinea. This disease was prejudices against and social oppression of a
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caused by prions infecting family members population group, it is obvious that,

through social mechanisms, these genetic develop with the arrival of new technologies
factors may be health determinants for the and knowledge. For health services to func-
whole group. However, the view that the tion, the cultural context must be under-
health risks conveyed by ethnic identity are stood and respected. But culture should not
mainly genetic is not evidence-based. There be confused with other social and economic
is no reason to assume any significant ge- health determinants. Cultural factors such
netic explanation for the wide disparity in as a cast system, may be an obstacle to
health status between black, Hispanic and poverty alleviation, but income poverty and
white people in the US. illiteracy should be separated from the mar-
As a health determinant, ethnicity is ginalisation induced by cultural concepts
mostly used to refer to cultural and social when making a social analysis of contempo-
heritage alone, as distinct from any genetic rary India. This is especially important for
factors that may be associated to a certain the understanding of what poverty means
ethnicity. The high prevalence of the hae- for health. Medical sociologists and anthro-
moglobin mutation causing sickle cell anae- pologists help greatly with their research to
mia in people of African origin is not con- unravel the relationships between social
sidered to be due to the ethnicity of those change and culture in the complex causa-
African population groups. The differences tional web of disease.
between ethnicity and genetics resemble the
difference between the social concept gen-
der and the biological concept sex. The 2.1.6 Security
former refers to a social construction, the The nature of armed conflicts has changed
latter to differences due to molecular genet- since the Second World War. In the last dec-
ics. An illustration of the terminological ades, most wars in the world were internal
issue is provided by the question of whether conflicts. The armed conflicts involved
Swedish citizens who were adopted from different ethnic groups in the same low-
other countries as young infants have a income countries. Such were the wars in
Swedish ethnicity or the ethnicity of their Sierra-Leone, Rwanda, Bosnia and parts of
country of birth e.g. Korean or Bengali. the former Soviet Union. Due to the charac-
These persons share Swedish norms of be- ter of these conflicts the number of civilian
haviour and are thus ethnic Swedes, but victims has increased considerably. Civilians
they may also be regarded as a special ethnic now far outnumber the deaths of soldiers
sub-group in Sweden that shares a collec- directly involved in the fighting. It is esti-
tive sense of common origin. mated that about 85 % of casualties of war
We conclude that genetic factors are very are civilians and only 15 % military person-
strong health determinants at an individual nel. During the First World War, these pro-
level, but of minute significance as determi- portions were reversed. Targeted violations
nants of the considerable differences in of human rights, such as rape, forced dis-
health status between different parts of the placement and ethnic cleansing, are used
world population. That ethnicity is regarded as part of war strategies.
as a significant factor in the web of factors Refugees and internally displaced people
that explain the health status of a popula- are victims of armed conflicts who cannot
tion is mainly because ethnicity conveys be- stay within their countrys borders or in
haviour and socio-cultural patterns that are their home community. The health deterio-
C linked to direct causes of diseases or injuries. ration caused by armed conflict is often se-
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In conclusion, culture influences health verely aggravated by drought and other nat-
status and health care utilisation in all ural disasters. The United Nations High
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stages of life. Culture is not static, but is Commissioner for Refugees (UNHCR) esti-
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constantly changing, and new practices mates that there are currently about 4050

Table 2.4 Countries with most refugees in 2002.
Country of origin Main counties of asylum Refugees

Afghanistan Pakistan, Iran 2 480 000
Burundi Tanzania 574 000
Sudan Uganda, Democratic Republic of Congo, Ethiopia, Kenya, 505 000
Central African Republic, Chad
Angola Democratic Republic of Congo, Zambia, Namibia 432 000
Somalia Kenya, Ethiopia, Yemen, Djibouti 429 000
Gaza Saudi Arabia, Iraq 428 000
Democratic Republic of Congo Tanzania, Zambia, Rwanda, Congo Brazzaville 415 000
Iraq Iran 400 000
Bosnia-Herzegovina Yugoslavia, Croatia, USA, Sweden, Netherlands, Denmark 371 000
Source: UNHCR 2003 (http://www.unhcr.org).
million people who have been forced to flee due to armed conflict in the last decade.
their homes. This means that about one per- Today an estimated 300 000 children serve
cent of the world population have fled their as soldiers (Human Rights Watch 2001).
homes! Half of these people are what is War affects health in many ways apart
known as internally displaced persons, i.e. from direct physical or psychological war in-
they have left their homes but not their juries. The breakdown of infrastructure e.g.
country of origin. water, sanitation, education and the health
The countries of origin of most refugees service systems, as well as deteriorating
in 2002 are listed in table 2.4. As shown the socio-economic and nutritional situations,
vast majority of the worlds refugees end up all affect the health of populations. In times
in a neighbouring country whose economy of war governments may be weak or absent
was strained even before the refugees ar-
rived. The health care of refugees in the
emergency stage usually depends on inter-
national aid organisations access to the Box 2.3
refugees and the resources of the host coun- Top ten priorities at the beginning of
try. Swift provision of basic needs and ac- a humanitarian crisis
tions against malnutrition and epidemic
diseases such as cholera and measles can 1 Initial assessment
dramatically reduce the mortality in these 2 Measles vaccination
3 Water and sanitation
populations. The ten most significant ac-
4 Food and nutrition
tions at the beginning of a refugee crisis are
5 Shelter and site planning
listed in Box 2.3. The future life of the refu- 6 Basic health care in the emergency
gees will depend on the political situation phase
in their country of origin and on how they 7 Control of communicable diseases
are accepted and integrated into the society and epidemics
of the country that provides asylum. It is 8 Public health surveillance
C estimated that more than 170 000 people 9 Human resource mobilisation and
M were killed in 2002 as a consequence of war training
and armed conflict. An estimated 2 million 10 Co-ordination
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children and young people have been killed Source: Refugee Health, MSF 1997
K
and 6 million have been seriously injured

2.2 Food
in parts of the country, and unable to pri- broke out they were thrown into suffering of
oritise the health of their population. The biblical proportions. The resulting infant
economies of countries and families are mortality was estimated to be one of the
severely damaged by war. highest in the world. Contrary to many as-
Antipersonnel mines cause thousands of sumptions, highly developed, technological
deaths and mutilations every year. Land- societies seem to have better resources to
mines also affect the social and economic re- maintain health during war than poorer so-
covery for decades after a conflict. An esti- cieties with less modern technology in use.
mated 100 million mines remain to be re-
moved in 64 countries of the world. A major
achievement in global health was reached
by the International Campaign to Ban Land-
2.2 Food
mines1. This organisation promoted the Food is required both as fuel and as building
treaty, which has been signed by 146 coun- blocks for the body. The most basic require-
tries, banning the use, production, stockpil- ment for food is to satisfy daily energy
ing, and transfer of antipersonnel land- needs. The minimum dietary energy need
mines. However, landmines are still being for an adult is around 1500 kcal per day.
produced and many mines remain to be re- This corresponds to a daily consumption of
moved. The worst affected countries are Af- half a kilogram of rice, maize or wheat. The
ghanistan, Angola, Cambodia, Laos, Iraq, daily energy need may also be satisfied by
Mozambique, Somalia and the former Yugo- the corresponding amounts of carbohy-
slavia. Mine clearing is exceedingly expen- drates from root crops like potato or cassava,
sive, risky and time-consuming. Clear but due to their high water content, the
health priorities for the populations in the daily minimum need corresponds to 1.5 kg
worst affected countries, are firstly to reduce fresh weight of these starchy root crops.
the incidence of injury and, even more im- Physical activity increases energy needs and
portantly, to restore access to land for agri- heavy work may double the energy require-
cultural activities to recommence. ments. A cold climate also increases energy
The level of socio-economic development needs. Children need more energy per kilo-
of a country at war clearly affects the way gram of bodyweight because they are grow-
people cope with the crisis situation. This ing. Energy is not enough for normal
can be seen in the greater increase in mortal- growth and body function; a supply of pro-
ity in Sierra Leone compared with the Bal- teins, vitamins and minerals is also essen-
kans during the recent periods of war. In the tial, but as a basic rule of thumb humans
war-affected societies in the Balkan coun- need half a kilo of cereals per day to survive
tries, people were able to apply innovative in the short term.
technological solutions to maintain a mini-
mum of basic hygiene, safe water supply
and life-saving energy supply for warming 2.2.1 Food supply
and cooking. This resilience to external cri- A family needs to have enough food for all
sis shows that, once people have acquired its members every day of the year. The fulfil-
the necessary technological knowledge and ment of this need used to be called food se-
skills of how to maintain health, their ac- curity. It is important to realise that when a
quired health status is amazingly resistant to family is food insecure, i.e. it does not have
C severe military conflict. In Sierra Leone the enough to eat; this may not necessarily
M
population in peace time lived very close to mean that there is not enough for the small
or under the poverty line, and when the war children. The reason is that small children
Y
need relatively small amounts, compared to
K
1
www.icbl.org adults. Still, food insecurity will damage the

mand to feed animals for meat production.

Box 2.4
Perhaps future generations will become veg-
Definition of food security etarians for economic reasons.
Sustainable access to safe food of suffi-
cient quality and quantity, including en- 2.2.2 Breastfeeding
ergy, protein and micronutrients, to en-
sure adequate dietary intake and a Children place special demands on their en-
healthy life for all members of the vironment if they are to thrive. An addi-
household. tional set of health determinants comes into
play concerning young children. At delivery
the child leaves a highly protected life in the
mothers womb. The human child is help-
less when exposed to the outer world.
small childs health, because the parents Natures way of supporting the child in this
cannot fully care for them if they have to new environment is through the mothers
spend much of the day in search of food. In- breastmilk and intensive parental care dur-
sufficient quantities of food and the resulting years to come. It is possible to replace
ing hunger will affect all aspects of family natures food supply artificially, but it re-
life. In the mass media malnutrition in chil- quires time, money and special efforts and
dren is often portrayed as a direct effect of skills. For mothers living under difficult con-
food shortages. However, pure food shortage ditions, breastmilk substitutes are inferior to
will have a greater direct impact on the nu- natures supply by any criterion. For chil-
tritional status of the adult population. dren born into poverty breastfeeding is a
Small children will suffer to a greater degree matter of life or death.
from the combined effects of food shortage, Bottle-feeding is costly and implies severe
reduced care and increased susceptibility to risk of contamination if optimal hygienic
infectious diseases, when food insecurity conditions are not maintained in the
strikes a family. mothers environment. The commercial pro-
World food production can sustain the motion of feeding bottles and breastmilk
present population, even at a population substitutes in low-income countries in the
growth rate of 1.5 %, but a more equitable 1970s and 1980s killed many small children.
distribution is necessary. Food production The risk of infections and diarrhoea is partic-
has increased to match population growth, ularly high when the feeding bottle is han-
and it is estimated that, with the technolog- dled in a home with poor, unsanitary condi-
ical advancements of increased yield and in- tions, using un-boiled water and, as often oc-
creased arable land, world food production curs due to poverty and illiteracy, an under-
will support the estimated 7 billion or more dosage of milk powder.
people who will live on earth by the year Breastmilk provides the childs first immu-
2010, and also the billions more to be added nisation; the colostrums (first breastmilk) in
in the decades to come (Cohan 1995). particular contains lymphocytes, antibodies
Diet changes as a country develops so- and vitamin A. It is tailor-made to the spe-
cially and economically. In low-income cific environment into which the child is
countries most people eat mainly starchy born, because the mother has met most of
cereals and root crops. During development the microbes in this environment and pro-
C this changes to a diet with a higher content vides ready-made antibodies against the
M of sugar, fat and animal products. This is microbes for the child through the breast-
presently taking place in most middle-in- milk.
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come countries. Access to food in the world Breastmilk is also the optimal food for
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depends on how we solve the increased de- the child. It is composed of all the nutrients

2.2 Food
first 6 months of life. The risk of non-breast-

fed babies in a low-income country dying
from diarrhoea during the first months of
life may be 25 times greater than that of ex-
clusively breastfed babies. Exclusiveness of
breastfeeding during the first 6 months is
therefore an important determinant of child
health in many parts of the world.
In many cultures breastmilk is tradition-
ally given together with water, cows milk or
other food. This is considered a harmful tra-
ditional practice. Not until the age of six
months should the infant begin to consume
food products other than breastmilk. The
practice of exclusive breastfeeding for the
first three months varies from 1 to 90 %
among mothers in different countries,
mainly due to different cultural traditions
(Table 2.5). Breastfeeding creates a psycho-
logical bonding between mother and child
that protects the child from neglect. It also
protects the child from getting siblings too
soon as it releases hormones in the mother
UGANDA, Masaka. Woman breastfeeding her child. that reduces fertility through what is known
as lactation amenorrhoea. Breastfeeding
Sean Sprague/PHOENIX.
also stimulates a hormone release that helps
the uterus to contract, which is helpful to
stop bleeding after birth.
the child needs in adequate amounts for In almost all countries around the world
optimal growth and development. It is the modernisation in the last 50 years was
probably even better than we understand. associated with a decrease in breastfeeding.
For instance over the last decade it has been In the 1970s the use of a feeding bottle also
established that the fatty acid composition
of breastmilk is optimal for the develop- Table 2.5 Percent of babies exclusively breastfed for
ment of the central nervous system. In fact, the first six months 19952002.
anything else given to the child will be in-
ferior in composition. Adults have the abil- Country % exclusively breastfed
children < 6 months
ity to cope with foods of varying quality,
but the infants capacity to do this is very Bangladesh 46
limited. Pakistan 16
Breastfeeding reduces exposure to mi- Egypt 57
crobes. While suckling from the breast, the Gabon 6
child avoids being contaminated with bac- Kenya 5
teria and viruses from water and unsafe
Madagascar 41
C food. Exclusive breastfeeding for the first six
Rwanda 84
M months prevents unnecessary exposure to
Sierra Leone 4
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potentially infectious foods. Infant mortal-
ity from diarrhoea decreases considerably if Vietnam 31
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the child is exclusively breastfed during the Source: State of the worlds children 2004. UNICEF.

spread to poor population groups in low

Box 2.5
and middle-income countries with disas-
trous effects on child health. Since then United Nations advice on breastfeed-
there has been a considerable change. In the ing and HIV
last decades, WHO and UNICEF successfully Exclusive breastfeeding should be pro-
promoted national regulation concerning tected, promoted and supported for 6
the commercial promotion of breastmilk months. This applies to women who
substitutes. The success was partly due to are known not to be infected with HIV
the advocacy campaigns carried out by the and for women whose infection status
International Baby Food Action Network1. is unknown. When replacement feeding
The health regulation concerning artificial is acceptable, feasible, affordable, sus-
feeding was made possible through the In- tainable and safe, avoidance of all
breastfeeding by HIV-infected mothers
ternational Code of Marketing of Breastmilk
is recommended; otherwise, exclusive
Substitutes which was adopted by UN in
breastfeeding is recommended during
1981 as a minimum requirement to protect the first six months of life.
infant health. The extensive scientific docu-
mentation of the benefits of breastfeeding
was the basis for the almost unanimous ac-
ceptance of this code by all member coun-
tries of WHO. The promotion and protec- trend as smoking in the high-income coun-
tion of exclusive breastfeeding has in fact tries: it started out as a sign of status, but
been one of the most successful actions for has now become a habit mainly of unprivi-
improved child health in the world over the leged groups. The interesting question is
last 20 years. This has shown that the pro- whether this is bound to happen in all
motion of better nutrition may be more countries as societies modernise and trans-
beneficial than medical interventions such form.
as vaccines and drugs. HIV constitutes a new challenge to the
Child feeding is determined by a complex promotion of breastfeeding as up to one
set of socio-economic factors, such as the third of children born to HIV infected
status of young mothers in society and in mothers may acquire the infection during
the family, the availability of time for care pregnancy, delivery or through breastmilk.
and food for preparation, but most of all by If resources are available the transmission
how well breastfeeding is protected and can be reduced to 12 % if the mother is on
promoted. The practice of bottlefeeding has antiretroviral treatment during the preg-
had an interesting boom and decline in the nancy, if the delivery is carried out by cae-
Scandinavian countries. In the 1950s it sarean section and if breastfeeding is
became popular, initially among the well to avoided. However, the risk for HIV transmis-
do, as a sign of wealth and modernisation, sion is reduced by exclusive breastfeeding as
and with time it trickled down through all reflected in the present international policy
the social strata. At 1970 less than 10 % of shown in Box 2.5 (WH0 2001).
Swedish mothers breastfed for 6 months. In spite of acknowledging the risk of
The decrease in breastfeeding changed due bottlefeeding in poor settings the applica-
to actions of female action-groups outside tion in practice of these guidelines poses
the health system. Today breastfeeding considerable problems, especially in rural
C rates in Sweden are lowest among less edu- parts of African low-income countries. The
M
cated, young and unprivileged groups. reason is that choice of infant feeding is
Bottlefeeding has thus followed a similar virtually unknown because breastfeeding is
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the cultural norm and bottlefeeding is too
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1
www.ibfan.org costly. Advice from the health service is

2.2 Food
Stage 3
Stage 2
Stage 1
Proportion of nutrients provided
Family foods
Weaning
foods
Breastfeeding
Exclusive Partial Token
Birth About About From 1 to 3 years Age of child

6 month 7 month
Figure 2.2 Complementary feeding.

Source: Savage King F, Burgess A. 1993.
often perceived as advice against breastfeed- been referred to as weaning (Greiner 1996).
ing and the UN Guidelines may in fact just At this time the maternal antibodies from
become a vague promotion of feeding birth are diminishing. The child is begin-
bottles. Furthermore, if a mother does not ning to move on its own and, being exposed
breastfeed questions about her HIV status to more pathogens, is increasingly suscepti-
will be asked with resulting severe stigmati- ble to infections. With time the specially
sation. Many HIV-infected mothers may prepared educational foods or complemen-
compromise by artificially feeding their ba- tary foods become a more important part of
bies at home and breastfeeding in public as the diet and are progressively replaced by
a denial that they are HIV-infected. Thereby family foods (see figure 2.2).
the advice to avoid breastfeeding may in- The complementary foods need to be nu-
crease the risk of transmission of HIV trient-dense, which means that they must
through mixed feeding and increase the risk provide a great mass of nutrients per gram.
of diarrhoea through non-exclusive breast- In addition the child needs frequent but
feeding. small feeds. The stomach of a child is small
A vulnerable time in a childs life is when and can only be filled to a certain volume.
other foods are introduced into the childs This volume does not correspond to its en-
diet. At about 6 months of age, the childs ergy requirements if the child is only given
nutritional needs start to exceed the breast- three meals a day, like the rest of the family.
milk production, which thus needs to be A child under five years old needs at least
complemented with other food. This does five meals a day, plus extra snacks. The nu-
C not mean that the child should reduce the trient-density is particularly a problem in
M amount of breastmilk consumed per day. low and middle-income countries, where
Y
Typically, specially prepared educational the diet consists mainly of bulky, energy-
foods are given as token meals for the child poor porridges and vegetables. The energy
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to adapt to other foods. This process has density can be improved by adding fat or

sugar to the food, or by changing the con-

Box 2.6
sistency of the food by germination or fer-
mentation. Minimum daily survival requirements
UNICEF has pointed out that, in order to per person
provide adequate nutrition for a child, a
5 litres of safe water & 0.5 kg cereal equiv-
number of prerequisites must be met at dif- alents of food
ferent levels. At the basic level, the society
needs sufficient human, organisational and
economic resources and control of these re-
sources along with adequate knowledge. for flushing toilets into the public sewage
This in turn could promote household food system.
security, adequate maternal and childcare, Water is a prerequisite for health, but can
sufficient health services and a healthy envi- also be a vehicle of disease. Communicable
ronment. These are the underlying determi- diseases associated with water can be divided
nants of an adequate dietary intake and into water-borne, water-washed and water-
good health, which will prevent the child related vector diseases. Water may transmit
from developing malnutrition or even save virus, bacteria, parasites and worms. Con-
it from death. taminated water can cause water-borne dis-
eases such as dysentery, cholera and other
diarrhoeal diseases (WHO 1992).
Water-washed diseases result from water
2.3 Water scarcity, which impairs personal hygiene.
The supply of sufficient amounts of safe The inability to wash can result in the
water is a fundamental health determinant spread of lice and mites, and eye diseases
for human populations. The reason is not like trachoma and bacterial skin infections.
only that water is essential for the life proc- Water-related vector diseases are caused
esses within the human body; water is also by microbes that are transmitted by water
essential for daily personal and domestic hy- dependent vectors (i.e. insects that transmit
giene. It is also a requirement for food prep- the disease). The most prominent of these
aration. Production in agriculture and in- diseases is malaria, which is transmitted by
dustry requires large amounts of water. In mosquitoes that need water for replication.
emergency situations, such as in refugee Another prominent water-related vector dis-
camps, a minimum supply of five litres of safe ease is schistosomiasis. This disease is caused
water is needed for each person per day to stop by a parasite that is excreted in human urine
excess mortality. Two to three litres of water and reproduces in a snail that lives on the
are needed for drinking and cooking, and shores of freshwater lakes and rivers. The
the remaining two litres for washing and transmission of schistosomiasis can be re-
cleaning. Within weeks, in the post-emer- duced if the population refrain from urinat-
gency phase, a daily ration of 20 litres per ing in the water. It can also be controlled if
person per day has proven necessary to the number of snails is reduced and if in-
avoid the transmission of major water- fected humans are treated with available
borne diseases. In contrast to these mini- drugs.
mum requirements, the average Swedish cit- Water may also be the vehicle of toxic
izen uses 200300 litres of drinking water substances that cause disease. Substances
C per day for their personal use, which in- such as arsenic naturally occur in the soil in
M
cludes frequent use of flush toilets (Yassi certain areas, and humans will be exposed
2001). It is interesting to note that a country when drinking water from wells containing
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like Sweden has such an unlimited supply of natural arsenic. This has been the unfortu-
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high quality drinking water that it is used nate side effect of drilling for microbiologi-

2.3 Water
ZAMBIA. Water is taken from the broken water pipes.

Trygve Blstad/PHOENIX.
cally safe drinking water in Bangladesh and countries are, despite intensive industriali-
in a number of other Asian countries. Sub- sation, very rarely exposed to any toxicolog-
stances such as nitrates may enter the water ical contamination in their drinking water.
from industrial waste, and agricultural activ- These countries have sufficient resources to
ity may result in water being contaminated avoid the introduction of toxic substances
by toxic pesticides. Toxicological contami- into their drinking water supply.
nation is a severe local health problem in As a country develops socio-economically,
many areas. However, on a global scale, the the use of freshwater increases dramatically.
communicable water-borne diseases give This is due to the increased use of water in
rise to a much higher burden of disease than mechanised agriculture, industry and do-
the toxicological ones. It seems that toxico- mestic consumption. The modern agricul-
logical contamination from naturally occur- tural sector is by far the largest consumer of
ring substances occurs mainly in low-in- freshwater, followed by the industrial sector.
come countries and in deprived populations The total freshwater reserves of the earth ex-
who cannot afford to make arrangements ceed the requirements for both the present
for a safe water supply. Toxicological con- and the foreseeable future. However, the
tamination from agriculture and industry geographical distribution of the human pop-
C tends to increase gradually when the coun- ulation and the availability of freshwater are
M try develops economically and gains the extremely uneven. The Middle East and
economic resources to buy and produce North Africa have the lowest availability of
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such toxic substances, but not enough to water, but paradoxically their economies
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control them. Populations in high-income have one of the highest dependencies on ag-

riculture. With further population growth set down on the ground but only used to
and economic development these regions pour the water into other buckets, is an im-
will need to import real or virtual water in portant improvement of water safety. A
the future. Virtual water import means im- completely covered well with a hand pump
porting food products that require a lot of pouring safe, clean water directly into the
water for their production. In such areas vessel of each household is the next step in
there is an urgent need to improve water improvement. Thereafter, the community
management. Efficiency in the use of water may strive for a motorised pump and pip-
must be increased by targeted irrigation and ing, so that each household can have a tap
industrial water conservation, as well as re- at the house, and ultimately a tap inside the
cycling water for domestic needs. The pre- house.
vention of leakage in water systems in urban Such improvements in water supply also
areas is another effective measure. The qual- have indirect effects on health, besides
ity of the water supply needs to be main- keeping the microbes away. Fetching water
tained by the control of sewage and waste- is a very time and energy consuming task,
water. Wastewater from industrial, agricul- carried out mainly by women. The provi-
tural and urban areas poses direct health sion of piped and tap water relieves women
risks. It may also indirectly impair health by from a lot of hard work, giving them time to
polluting fishing waters. care for their children and themselves. The
The organisation of the water supply is as provision of an improved water supply is
important for health as the volume of water also linked to better facilities for washing
available in a community. Many poor peo- clothes. There are several steps of gradual
ple in the world still draw their drinking improvement on the path from washing in
water from rivers, streams and open, unpro- rivers to the use of modern electrical wash-
tected wells. The safety of a drinking water ing machines that reduce working time and
supply can be greatly improved by protect- effort, mainly for women, and increase the
ing the wells. This means building a rim and availability of clean clothes.
a cover so that rainwater does not transmit Though difficult to quantify, it seems that
dust and dirt into the well. Animals also the main environmental health problem in
have to be stopped from using the same well the world is still unsafe, microbial contami-
as humans use. The way water is withdrawn nated water for drinking and household use,
from the well is also important. The intro- combined with a lack of adequate sanitation
duction of a special well bucket that is never for the disposal of waste, faeces and urine.
Table 2.6 Percent of population using safe water and sanitation in different regions in 2000.
Region % with improved % with adequate sanitation

drinking water
urban rural urban rural
East Asia and Pacific 93 67 73 35

CEE/CIS and the Baltic states 95 82 97 81
Latin America and Caribbean 94 66 86 52
Middle East and North Africa 95 77 93 70
C South Asia 94 80 67 22
M
Sub-Saharan Africa 83 44 73 43
High income countries 100 100 100 100
Y
K Source: State of the worlds children 2004. UNICEF.

2.4 Sanitation
Water safety can be secured by relatively

Box 2.7
simple technologies, such as protective
wells and hand pumps as mentioned above. Requirements for quality sanitation
In drier areas the drilling of deep-water wells
1 Protect against disease transmission.
and the installation of mechanised pumps
2 Eliminate the bad smell of faeces and
and piping may be necessary to supply safe urine.
water. 3 Stop insects from breeding on the
In the last decades of the 20th century, an excreta.
estimated 2 billion people in low and mid- 4 Provide the privacy needed for the
dle-income countries have gained access to comfort of the user.
safe water, and 400 million have gained ac- 5 Return the nitrogen and nutrients in
cess to basic sanitation. The 1980s was the excreta to the field where food is
International Drinking Water Supply and grown.
Sanitation Decade (UNDP 1998). During 6 Use limited amounts of water and
energy.
this decade many international organisa-
tions put great efforts into research and into
building latrines and safe wells even in re-
mote villages. The percentage of popula-
tions with access to safe water and adequate community has varying degrees of hygienic
sanitation in different regions of the world rules and practices for defecation and urina-
is shown in table 2.6. In Sub-Saharan Africa tion.
about half of the population has access to The practice of defecating or urinating in
safe water, while access to adequate sanita- the bush or in the fields may not pose any
tion is least frequent in South Asia, where significant health or environmental prob-
these needs are met for only a third of the lem in scarcely populated areas or among
population. However, 1.3 billion people, nomadic populations living in an environ-
corresponding to one-fifth of the worlds ment that is conducive to this practice. How-
population, still lack access to safe water, ever, as the population density increases, all
and 2.5 billion (40 % of the worlds popula- human societies have had to develop techni-
tion) lack access to adequate sanitation. cal solutions and special practices for excreta
These will remain the main environmental disposal.
problems in the world for many years to Unfortunately, even seemingly simple la-
come. trine construction remains relatively expen-
sive for the poorer part of the population in
low and middle-income countries. This ex-
plains why more than 40 % of the worlds
2.4 Sanitation population still live without access to proper
Faeces constitutes a major route of transmis- sanitation. The estimated percentage living
sion of communicable diseases in human without improved sanitation facilities is
populations. Urine transmits only a few, but 20 % in Latin America and 4050 % in Africa
nevertheless important parasitic diseases. and Asia. Latrines can solve a number of
The ways in which the excretathe joint problems (Box 2.7).
term for faeces and urineare disposed of is There is no best latrine or toilet solution
therefore a most important health determi- for the whole world. The modern flush toilet
C nant. The disposal of excreta and other is probably not the best option for providing
M
wastes is referred to as sanitation. In all soci- most households in the world with im-
eties there are in fact a number of culturally proved sanitation facilities. The flush toilet
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determined taboos linked to defecation offers the perfect solutions to issues 1 to 4,
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practices and excreta disposal and each but fails completely on 5 and 6. There are a

number of different latrine constructions, wind blowing across the top of the latrine
adapted to various environments, income and the sun heating the pipe will make the
levels and cultures (Esrey 1998). Two exam- air flow travel down through the central
ples are worth mentioning. hole into the pit and hence up and out of
In rural Vietnam, the population density the pipe. A net covering the top of the pipe
is high, and due to the irrigation of rice stops flies from getting out, but the light
fields, the water level in the ground is high. shining down through the pipe into the la-
Faced with these realities and very limited trine pit attracts the flies to fly up into the
economic resources, Vietnams public pipe. The flies reach the net, where they are
health professionals still managed to de- trapped and die. This latrine is thus free of
velop an appropriate latrine solution, both smell and flies. The disadvantage is
known as the Vietnamese double septic tank. that this latrine is rather expensive.
The latrine is built in brick and has two con- With such smart solutions, as exemplified
tainers for faeces. It enables the urine to be above, it is hoped that almost all house-
separated through a half-pipe of bamboo or holds in the world will gain access to im-
metal, to be collected in a vessel outside the proved sanitation within one or two dec-
latrine. When one septic tank has been filled ades. This would break the transmission of
with faeces, it is sealed for several months many infectious diseases and provide a
and left to ferment while the other tank is major contribution towards better world
used. When the time has come to seal the health.
second tank, the first one is opened. The
now fermented faeces can be used as ferti-
liser in the fields. The urine is also used for
targeted fertilisation, putting nitrogen back
to the cultivated land. The success of this la-
2.5 Other environmental
trine in Vietnam is not only that it protects determinants
against infectious diseases but also that it Unsafe water and sanitation remain the
helps maintain soil fertility and agricultural main environmental health determinants in
production. Whether a latrine is appropriate the world. In the following section, we will
and accepted in a community depends describe additional environmental determi-
jointly on technical, environmental, cul- nants of human health: housing, occupa-
tural and economic factors. tion, traffic, air, climate and natural disas-
In Zimbabwe, the Blair Institute devel- ters.
oped the ventilated improved pit latrine,
which is appropriate for many settings in
Africa, although still too expensive to afford
for most rural families. It is a covered pit la- 2.5.1 Housing
trine that has the disadvantage that the ex- Housing is a basic health determinant, as it
creta are not returned to agricultural pro- contributes to the physical, mental and so-
duction, but many other advantages. A ce- cial well being of individuals. The house
ment floor covers the latrine pit. The floor also protects families and their assets from
has a central hole for defecation and a violence and theft. At least 600 million
smaller hole at the side for ventilation. A urban dwellers and more than 1 000 million
pipe is placed in the smaller hole, like a rural inhabitants in Africa, Asia and Latin
C chimney. The pipe leads the airflow from America live in shelters or under precarious
M
the latrine pit up above the roof of the la- housing conditions in neighbourhoods that
trine, thus removing the bad smell. The la- pose severe threats to life and health (WHO
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trine house is built in a spiral, so that light 1998). In addition tens of millions of people
K
never enters through the central hole. The are homeless. In high-income countries, the

2.5 Other environmental determinants
Box 2.8
Summary of WHOs definition of a Healthy House
structurally sound and free from acciden- free from excessive noise from both inte-
tal injury hazards, rior and exterior sources of the structure,
sufficient space for all normal household natural and artificial means of illumination
activities for all members of the family, that are adequate for all household activi-
adequate supply of potable and palatable ties,
water, free from toxic and/or noxious odours,
sanitary means of collection, storage and chemicals and other air contaminants or
disposal of all liquid and solid wastes, pollutants,
appropriate installed facilities for personal adequate but not excessive solar radia-
and household hygiene, tion,
weatherproof and watertight with proper adequate protection from insects and
protection from the elements, rodents,
indoor environment which is healthful health, welfare, social, educational, cul-

and comfortable, tural and protective community services.
problem of housing largely concerns consid- come countries today. Disease vectors in the
erations of light, insulation, ventilation and surrounding of human settlements can be
the psychosocial environment in the sur- restricted by locating houses away from
roundings, since the basic needs of water, mosquito breeding places, restricting the ac-
cooking, washing, food storage and waste cess of mosquitoes and flies with screens
disposal are solved. The World Health Or- over windows and doors, preventing access
ganization has identified the requirements to food, disposing of waste and repairing
for healthy housing (Box 2.8). cracks in walls and floors. Actions from
Most housing in low-income countries many sectors of society are needed to solve
and a considerable part in middle-income the problem of unhealthy living conditions.
countries fall outside the basic standards of Both public and private services are needed
safety or protection against ill health. The to construct healthy living conditions in
combination of overcrowding with high lev- safe neighbourhoods.
els of virus, bacteria and disease vectors in Today about 48 % of all people in the
particular increase the risk of severe respira- world live in urban areas. An estimated in-
tory infection and measles, as well as many crease from 2.6 billion to 4 billion urban set-
other diseases. Historical data from Sweden tlers is expected between 1995 and 2015. Ur-
in the 19th century show that overcrowding banisation has both positive and negative
was associated with a three times greater risk effects on human health. In low- and mid-
of measles mortality, after controlling for dle-income countries, it appears as if the
young age, low social class and being born positive effects are the greatest. Even if poor
out of wedlock (Burstrm 1996). Tuberculo- segments of the population live in miserable
C sis is another airborne disease that is spread conditions in the big cities, the majority of
M easily in conditions of overcrowding in them would have been in a worse situation
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combination with poor ventilation and if they had remained in rural areas. In most
malnutritiona combination affecting mil- countries, industrialisation and economic
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lions of people living in low and middle-in- growth lead to urbanisation. Unfortunately

UGANDA, Kampala. Skyline of the city with children living in a slum area in the foreground.
the development of water and sanitation the continents with the best health status
systems and safe housing is not paralleled have the highest proportion living in urban
by the increasing number of people that areas, while in Africa and South Asia, having
move to the rapidly growing cities in low the worst health status, less than one-third
and middle income countries. of the population live in urban areas. Less
Today urbanisation in the world is occur- than half of the worlds population earn
ring mainly in low and middle-income their living from agriculture, and the
countries (Table 2.7). It should be noted that number of people who produce food is
fewer than the number who only consume
(Figure 2.3).
Table 2.7 Urban population as % of total popula-
tion by region in 1975 and 2002. Poverty, population growth, war and nat-
ural disasters, and shortages of land are
Regions 1975 2002 some of the main reasons why people move
East Asia and Pacific 19 40 to urban settlements. Changes in social and
Europe and Central Asia 56 64 cultural values are also contributory factors.
The people who move to urban areas need
Latin America and Caribbean 61 76
employment, housing, education, fuel, as
well as social, sanitary and medical facilities.
South Asia 20 28
C Few of the low and middle-income countries
M can keep up with the supply of these serv-
High income countries 72 78 ices. It is the poorest population that suffers
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Source: World Development Indicators 2002, The World most from living in growing shantytowns
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Bank and State of the worlds children 2004, UNICEF. without basic services. In many parts of the

of work offer little possibility to escape pov-

Urban population
erty. In fact, it has recently been recognised
Rural population
that the informal sector in cities in low- and
4000 middle-income countries is much larger
3500 than formerly realised. It has been suggested
3000 that the lack of the right to property among
2500 the entrepreneurs in the informal sector is
2000 the main obstacle to economic develop-
1500 ment in most low and middle-income coun-
1000 tries (de Soto 2000).
500 In high-income countries, unemploy-
0 ment rates vary from less than 5 % in Japan
1955 1975 1995 2015 and Luxembourg to more than 20 % in
Spain. In low-income countries, unemploy-
Figure 2.3 The worlds urban and rural population ment rates may be as high as 45 %. It is ob-
in millions 19552015. vious that these high unemployment rates
Source: World Health Report, 1999. WHO. do not imply that this half of the labour
force is not involved in economic activities.
The mechanisms and obstacles of the infor-
mal economic sector have emerged as a
world, urban settlement is followed by se- major research area in development studies
vere social problems such as increased alco- in recent years. In all countries unemploy-
hol and drug use, increased crime rates and ment among urban youth breeds severe psy-
prostitution, fuelled by the lack of social chosocial problems, with delinquent behav-
control and the anonymity of large cities. iour, violence and social disintegration
(WH0 1998).
Almost all occupations and income-gener-
2.5.2 Occupation ating activities are linked to health risks.
The right to employment is part of the Uni- Most risks are known to occupational medi-
versal Declaration of Human Rights, but far cine and can be prevented if the workplace
from all people are guaranteed this right. is designed for safety. However, this is not
About 120 million people in the world are often the case in low-income countries. De-
registered as unemployed, but this is a gross ficient occupational safety is also common
underestimate. Unemployment in urban in middle-income countries, but not in
areas is as high as 50 % or more in some low- high-income countries. The use of pesticides
income countries. The urban poor make in agricultural plantations is a drastic exam-
their livelihood in the so-called informal ple. Their toxicity is well known, and in
sector, as street vendors or car attendants, as high-income countries their use is carefully
casual labour, in personal services such as regulated, and adequate protection is of-
shoe-shining, etc. The informal sector refers fered to all workers handling these toxins.
to economic activity beyond government In plantations in Latin America, Asia and Af-
regulation and taxation. Many or most of rica, however, acute toxicity and chronic ef-
the underemployed in the informal sector fects of pesticides constitute a growing
suffer from poverty, inequality, loss of self- health problem. The same pattern can be
C esteem and reduced psychosocial well-be- seen in almost all occupations. While risks
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ing, due to a lack of proper employment. are controlled and accidents and exposures
The majority of the worlds population work are kept to a minimum in high-income
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in the agricultural sector and the informal countries, exposure to occupational hazards
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sector. In low-income countries, these types are greater in middle-income, and even

more so in low-income countries. In poor caused by outdoor air pollution occur in low
countries the threat posed by industrialisa- and middle-income countries. Forest fires
tion is not limited to workers. Through the are another reason for air pollution. In 1997
leaking of toxic substances to food, water, a large forest fire in Indonesia caused the
air and the environment at large, the rapid deaths of more than 1 000 people and respi-
ongoing industrialisation in Asia in particu- ratory problems among more than 20 mil-
lar is bound to increase toxicological and lion people in large areas of South East Asia.
other environmental problems in the near Acid rain has been presented as another
future (Yassi 2001). Environmental lead, ar- threat to human health and livelihood. Fos-
senic, mercury and other heavy metals re- sil fuel burning power stations with high
leased from industrial activities enter the chimneys, to avoid air pollution among the
food chain and can cause serious toxic ef- local population, spread sulphur and nitro-
fects. They may also deplete body stores of gen oxides, which are converted to sulphu-
iron, vitamin C and other essential nutri- ric and nitric acid, giving rise to acidic pre-
ents, leading to decreased immune defences cipitation far away from the point of emis-
and other disabilities associated with mal- sion. However, the consequence of this
nutrition. acidification is unclear. The death of areas of
forest experienced in Central Europe have
been attributed to acid rains, but a combina-
2.5.3 Air and Energy tion of cold winters and the planting of in-
Air pollution is estimated to kill about three appropriate eco-types of pine trees in high-
million people each year through lung and altitude forests may have caused the deaths.
heart diseases. A common misconception is Acidification mobilises metals such as lead,
that most of these deaths are due to out- mercury, cadmium copper and aluminium
door air pollution in cities in rich indus- in the soil, and these may eventually enter
trialised countries. On the contrary, 90 % of freshwater and the food chain.
deaths are estimated to occur in low and Fossil fuels such as oil, coal and natural
middle-income countries, and more than gas are used as raw materials for 90 % of the
half of them are estimated to occur as a re- worlds commercial energy production. Oil
sult of indoor air pollution, due to poor remains the dominant source of energy sup-
housing in rural areas (WHO 1998). Accord- plying about 40 % of global energy needs.
ingly the burden of disease from air pollu- The high-income countries use over 70 % of
tion mainly affects poor women and chil- the worlds fossil-fuel consumption. Adverse
dren in rural areas, and particularly girls in- health effects of fossil fuel include air pollu-
volved in cooking food indoors. Poorer tion due to burning oil and coal, as de-
populations burn biomass such as dung, scribed above, and most probably the green-
wood and coal for cooking and indoor heat- house effect. If the coal is impure when
ing in large areas of Sub-Saharan Africa and burning, residual metals including lead, cad-
Asia. Open fires without appropriate stoves mium, mercury and arsenic may spread.
or chimneys to conserve heat and reduce air Eastern Europe and China use coal to a large
pollution are used by poor households extent, and in combination with inadequate
rather because they cannot afford them control of emissions this poses a serious en-
than due to lack of knowledge. vironmental problem (WHO 1992).
Outdoor air pollution is also increasing in Hydroelectric power stations cause ad-
C the world, and mostly in low and middle-inverse health effects through indirect effects
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come countries, because of rapid industriali- on the environment and by displacing peo-
sation and the spread of motorised vehicles ple to make room for building the large
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without proper control mechanisms for dams. The dams may provide water for
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emissions. More than 70 % of all deaths drinking and irrigation, but in tropical re-

gions dams may enhance the transmission 2.5.4 Climate

of vector-borne parasitic diseases. Is climate in itself a determinant of health?
Nuclear power can cause severe health ef- For certain diseases, such as the severest type
fects if accidents occur; otherwise this is, in of malaria, falciparum malaria, there is a
environmental terms, a fairly safe energy strong link to tropical climate (See Chapter
supply, as regards human health. The detri- 1.3). Whereas a warm climate increases the
mental health effects following the Cherno- transmission of certain vector-borne dis-
byl accident in 1986 were of different kinds. eases, a cold climate may also have negative
A total of 31 emergency workers died from health effects. In poorer populations, cold
acute radiation injuries, 300 others became climate leads to very crowded living condi-
severely ill from high levels of radiation, tions during winter, and this greatly in-
and some ultimately died from these effects. creases the transmission of poverty-related
Increased rates of thyroid cancer in children diseases such as leprosy and tuberculosis,
were noted in southern Belarus in the fol- which do not require any insect vector. In
lowing years. More than 100 000 people fact a better term for the so-called tropical
were permanently evacuated from the con- diseases is diseases of poverty, but the in-
taminated area in Ukraine. The resulting fectious diseases affecting poor people are
psychosocial distress probably caused more partly determined by the climate they live
ill health than the direct effects of radiation. in. Parasitic diseases are not exclusive to
Several distant areas of Europe became con- tropical countries but also affect popula-
taminated with radioactivity. The long-term tions in cold climates (Britton 2003).
effects of these lower degrees of contamina- Human activities affect climate in a long-
tion in remote countries have not yet been term perspective. Destruction of the strat-
clearly linked to any substantial adverse ospheric ozone layer will increase exposure
health effect. Low doses of radiation have to ultraviolet radiation, which is a contrib-
been detected in the environment around uting factor to skin cancer and cataracts.
nuclear power plants, but no clear correla- Ozone is continuously being produced and
tion to increased disease frequency has been destroyed in the stratosphere, but human
proven. consumption of certain types of gases causes
The final disposal of high-level radioactive a thinning of the ozone layer. The detrimen-
waste may pose a problem for future genera- tal gases are chlorofluorocarbons (CFCs),
tions if safe storage cannot be achieved. It is used in refrigerators, aerosol propellants and
a delicate task to assess these obvious long- fire extinguishers, and methyl bromide, a
term risks in relation to the likely positive chemical used in pesticides. Emissions from
short-term benefit to health that a cheaper high-flying aeroplanes add further gases. In-
energy supply without carbon dioxide emis- ternational efforts are being made to reduce
sion may offer in many countries. or ban the use of these compounds. Prevent-
Better-quality energy sources with fewer ative measures involving cautious exposure
negative health effects and new technolo- to the sun, through the use of protective
gies for increased production efficiency and clothing, sunscreen and sunglasses, are rec-
energy consumption are continuously un- ommended.
der trial. Even with new energy-saving tech- Global warming is caused by the green-
niques, alternative energy sources and lower house effect, meaning the increased con-
the per capita energy consumption in the centration of carbon dioxide (CO2), meth-
C future, the projected global population ane and certain nitrogen-containing gases
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growth will demand more energy than is in the atmosphere. These gases create an en-
currently produced in the world. ergy trap around the earth, because they ab-
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sorb the re-emitted energy from the earths
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surface, but admit incoming heat from solar

radiation like a greenhousehence the ment and the capacity and willingness of
name. Because of the rising concentration of their social and political structures to cope
these gases, a global warming effect in the with crises. Bangladesh suffers from being
atmosphere has been confirmed, but the fu- flooded during monsoon periods, some
ture magnitude and impact is still uncertain. years (as in 2004) more severely than others.
Therefore the potential effects of global This densely populated low-income country
warming on health are poorly understood. repeatedly battles against floods. However,
It may act through effects on agricultural disaster preparedness has gradually im-
production, freshwater shortages and a ris- proved during recent decades. Another pos-
ing sea level. Harvests may be reduced in itive development is the sharp drop in fertil-
some areas and increased in others, as the ef- ity rates that have slowed the population
fects most probably will be very unequally growth rate so that Bangladesh may rela-
distributed. Africa, South Asia and Latin tively soon achieve a two child family level
America will have less rainfall and lower and eventually a stable population. Without
crop yields, while Europe and Canada will this there will always be very poor people
benefit from increased rainfall and better that have to cultivate and live on land suf-
harvests. Deserts are expected to spread in fering from frequent flooding.
Sub-Saharan Africa, South Asia and the Arab Tornadoes, typhoons, hurricanes, vol-
States. canic eruptions and earthquakes are familiar
The high-income countries account for natural disasters, which are obviously not
most of the emissions of greenhouse gases preventable. Prevention of the health effects
produced by burning fossil fuels, but it of these natural disasters depends on the
seems as if the least developed regions of the emergency preparedness for humanitarian
world suffer the most from the environmen- assistance in the affected countries. In Cen-
tal changes. International organisations tral America in 1998, Hurricane Mitch killed
have agreed on treaties to deal with this over 10 000 people and destroyed extensive
threat to environmental change by phasing parts of the infrastructure, causing damage
out the use of chlorofluorocarbons, and corresponding to decades of development.
many governments support research into Natural disasters may contribute substan-
and the introduction of alternative energy tially to local mortality and human suffer-
sources. It is annoying to have to conclude ing, but their joint health effects remain sur-
that the expected health effects of global prisingly small on a global scale compared
warming range from close to none to very to how much time is allocated to natural
severe (Yassi 2001). disasters in TV news. The earth is a relatively
safe place for humans, were it not for the
health risks related to poverty.
2.5.5 Natural disasters
Drought and floods occur repeatedly in
many parts of the world, causing displace-
ment and hunger due to damaged harvests.
Ethiopia, Sudan and Bangladesh are just
2.6 Behaviour
three of the countries that have been af- The effect on health of the determinants de-
flicted many times by droughts and floods scribed so far is modified by a persons indi-
leading to starvation and epidemics of dis- vidual behaviour. An example is provided
C eases such as cholera. In Sudan in 1998 a by the way a person handles food and water
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combination of war and natural disasters before eating. Apart from hygienic practices,
caused widespread starvation. The extent of there are a few factors that strongly and di-
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the impact of natural disasters on health is rectly influence health status. These are to-
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dependent on countries levels of develop- bacco, alcohol, sex, and traffic; they are re-

2.6 Behaviour
viewed in the following sections. Another sumption should support and inform the in-
important behavioural determinant is the dividual, but simultaneously, public policies
degree of physical activity, which is re- such as an age limit for buying cigarettes,
viewed in chapter 6. taxation on cigarettes and laws to control
the tobacco industrys marketing practices
are helpful in limiting the use of tobacco.
2.6.1 Tobacco Following determined efforts by the former
The health hazards of tobacco smoking are Director General, Gro Harlem Brundtland,
well established. About one billion people in WHO Member States concluded a ground-
the world today are regular tobacco-smok- breaking public health agreement in 2003.
ers. Each year three million people are esti- This Framework Convention on Tobacco
mated to die from lung cancer and cardio- Control sets out new rules for curbing to-
vascular diseases caused by tobacco smok- bacco advertising and promotion, and illicit
ing. Tobacco use was estimated to cause 4 % trade in tobacco products.
of the total burden of disease in the world in A sad and paradoxical fact is that many of
the year 2000 (WHO 2002), when measured the poorest low-income countries depend
as disability-adjusted life years lost (DALYs) heavily on the export of tobacco for their
(Chapter 3.6). In the high-income countries economic viability. A reduction in the price
and former socialist countries of Europe, as of tobacco and lower export volumes will
many as 15 % of deaths are mainly due to have an indirect adverse health effect in
tobacco use. But in many high-income these countries.
countries, there has been a decrease in to-
bacco use during recent decades, which con-
tributes to the decreased mortality from cor- 2.6.2 Alcohol and illicit drugs
onary heart disease in these countries. In Alcohol has been consumed in human pop-
the 1990s, smoking increased among young ulations for millennia. It has negative
females, and smoking is becoming increas- health and social consequences via intoxica-
ingly common in the lower socio-economic tion, dependence and long-term biochemi-
strata of high-income countries. In parallel cal effects. Intoxication is a powerful media-
with the habit of bottle-feeding babies, the tor for acute outcomes, such as road traffic
habit of smoking has trickled down through accidents or domestic violence. Alcohol de-
the socio-economic strata, from the well pendence is a disorder in itself. It is esti-
paid, highly educated to becoming an indi- mated that 120 million persons worldwide
cator of psychosocial deprivation. In high- suffer from alcohol dependency, which is
income countries smoking is also changing strongly associated with higher rates of vio-
from being a male to being a female habit. lence, accidents, cirrhosis of the liver, some
Unfortunately, a rapid increase of tobacco types of cancer and mental disorders. Alco-
use has taken place in low and middle-in- hol abuse caused 4 % of all DALYs lost in the
come countries over the last 30 years. The world in 2000. In contrast to tobacco, alco-
tobacco-related mortality in the world is hol consumed in moderation is believed to
predicted to rise to 8 million yearly by the slightly reduce the risk of cardiovascular dis-
year 2020. This is largely the direct effect of ease. The abuse of alcohol and narcotics is
the determined marketing policy of the to- already a very severe and growing health
bacco industry, which is seeking new mar- problem around the world. The religious
C kets as those in Europe and North America ban on alcohol in Islamic countries consid-
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are shrinking. Interventions are urgently erably reduces the adverse health effects
needed to counteract this catastrophic effect from alcohol, but this is partly replaced by a
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on global health status. Public health pro- frequent use of narcotic drugs in some of
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grammes for the prevention of tobacco con- these countries. Iran is estimated to have a

RUSSIA, Vazhini. Man buying liquor in the kiosk.

relatively limited alcohol problem, but the health and social effects that could not be
country has several hundred thousand in- quantified include other blood-borne dis-
travenous drug users. See further chapter eases such as hepatitis B and C, and criminal
7.1.6. activity associated with the drug habit. Glo-
Global alcohol consumption has in- bally, 0.2 per cent of deaths (86 000/year) are
creased in recent decades, with most of this attributed to illicit drug use. Illicit drugs ac-
increase occurring in low and middle-in- count for a high proportions of the disease
come countries, where alcohol is being mar- burden in men among countries in the
keted increasingly. Both average volume of Americas, Eastern Mediterranean and Euro-
alcohol consumption and patterns of drink- pean regions.
ing vary dramatically between different
parts of the world.1
The estimated prevalence of illicit drug 2.6.3 Sex
use varies considerably across WHO regions. Unsafe sex accounted for 6 % of DALYs lost
The most hazardous use patterns are found in the world in 2000 (WHO 2002). Before
among dependent users who typically inject the appearance of the HIV virus, the preven-
drugs daily or nearly daily over periods of tion of sexually transmitted infections (STIs)
C years. Injecting opioids is associated with in- was given low priority in most national
M creased overall mortality from HIV/AIDS, health policies. The HIV epidemic has
overdose, suicide and trauma. Other adverse forced governments to act, and in some
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countries, where governments have been
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1
www.ias.org.uk/theglobe open about the problem, such as Brazil,

2.6 Behaviour
Thailand and Uganda, it appears as if ac- income countries, the relative impact of
tions by the public sector and the civil soci- traffic on the general mortality and morbid-
ety have curbed the epidemic. In Africa unity is less. Hence, traffic is a health determi-
safe sex is currently estimated to cause about nant that in relative terms causes most suf-
20 % of DALYs lost, mainly due to HIV/ fering in middle-income countries. It also
AIDS. This means that unsafe sex is now as seems that making traffic safe is a lengthy
important a cause of disease as is under-nu- process. The rebuilding of roads to make
trition, the other major cause of preventable them safe and the establishment of the
morbidity and mortality. In the most se- monitoring and regulation that is needed to
verely affected countries, such as Botswana, ensure car safety and careful driving habits
unsafe sex is the absolute dominant cause of take decades. Hence, newly rich countries
human suffering from disease and prema- such as the United Arab Emirates and other
ture death. See further chapters 5 and 9. Gulf States are today high-income countries
with extremely high mortality and morbid-
ity from traffic.
2.6.4 Traffic Similarly, Sweden had its highest number
Injuries from traffic follow a pattern similar of deaths due to traffic 50 years ago in the
to that of occupational hazards. Although first decade of a long period of strong eco-
the populations of high-income countries nomic growth. This is in spite of a much
have more vehicles and travel more kilome- greater number of cars on the roads today.
tres per person per year, their risk of being Five decades ago, Sweden already had good
injured or dying as a result of traffic is economic resources, but it took careful re-
smaller than in both middle- and low-in- search, advocacy, legislation and mass com-
come countries. In fact, the risk of dying as a munication to make the traffic environment
result of traffic is highest in densely popu- as safe as it is today. Still, traffic is a major
lated middle-income countries. It is in these cause of death and disability among the
countries that the economy is good enough young and middle-aged in Sweden and
to allow quite intense traffic, while resources other high-income countries. The reduction
are not sufficient to make this traffic safe of mortality due to road traffic accidents in
(see further chapter 8). Although the risk per high-income countries has not come about
car or transport kilometre is greater in low- automatically. It is a combined effect of safer
Box 2.9
Successful actions for traffic safety in Sweden
In 1948 the National Society for Road Safety, a non-governmental organisation, commis-
sioned Swedish authors to write short stories that promoted traffic safety. Stig Dagerman
wrote, To kill a child (http://hem.passagen.se/iblis/dagerman.html). This short story has
become one of the most read texts in the Swedish language. Few of the millions of readers
realised that this powerful story about the unnecessary death of child in a traffic accident was
commissioned in the cause of health education.
The reduction from more than 1 300 annual traffic deaths in Sweden 40 years ago to 535
deaths in 2002 came about in spite of a steep increase in the number of cars. This successful
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health promotion was achieved through a number of actions that ranged from cultural high-
lights to technological innovations and various legislations. It serves as a good example of
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how public health actions should be directed at many points and levels in the causational
Y web of a specific disease or injury.
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cars, better roads, more monitoring of traffic of acute diarrhoea. It has even been sug-
and strict legal regulation of the traffic envi- gested that the unregulated and unofficial
ronment. It also required a major shift in at- sale of antibiotics at village markets by med-
titudes regarding safety and preventive ically untrained persons is largely responsi-
measures in the general population. In fact ble for the improved child survival in the
traffic safety may also be regarded as a cul- poorest parts of the world. We are conse-
tural issue e.g. how acceptable it is to drink quently unable to provide the reader with
and drive (Box 2.9). an estimate of the relative importance of
medical services for the present global
health situation. We strongly encourage fur-
ther readings and studies of this issue (Mer-
2.7 Health services son 2001, Beaglehole 2003).
Health service is not the most important The term medical services mostly refers to
prerequisite for good health. The other six curative services for sick patients, whereas
determinants mentioned in this chapter are health care includes preventive, curative,
more fundamental to human health than and rehabilitation services. The terms health
health services. However, it is difficult to es- service and health care are more or less syn-
timate the relative importance of health onymously used. Health system is a wider
services for the health status of a specific concept and includes health actions outside
population based on scientific evidence. the health care sector. The types of health
One of the main reasons is that the access care provided in a country may be classified
and utilisation of health care jointly vary as public, private, traditional or informal.
with the other determinants in most parts of The first two are supposed to be evidence-
the world. There are in fact very few in- based activities supported by scientific stud-
stances in which it is possible to isolate the ies, often referred to as modern medicine.
effect of health services from the other Traditional care is sometimes easily classified
health determinants in an intelligent way. A based on long standing cultural tradition but
classical study by Thomas McKeown (1979) today this is often no longer the case. It in-
compared the decline in mortality from includes completely new forms of alternative
fectious diseases in Western Europe with the treatment and also merges with activities re-
availability of antibiotics and anti-tubercu- ferred to as informal care. In many countries
losis drugs. In a time series analysis, he ar- the conventional dichotomy between mod-
gues that, since most of the decline in mor- ern and traditional medicine is no longer a
tality occurred before the introduction of reality. The informal sale of drugs on local
these drugs, general social factors played a markets or in small clinics by untrained per-
more important role than drugs for the de- sons merges with traditional medicine in
cline in mortality. However, it was not the many low-income countries. Untrained per-
same combination of factors as one century sons that provide similar services as those
earlier in Europe, that caused the impressive selling drugs on local markets staff many
decline in child mortality in middle and small private clinics in low-income coun-
low-income countries over recent decades. tries. Officially these clinics should provide
The recent decrease in child mortality has evidence based medical care by qualified
occurred following modest improvement in professionals. Careful health system analysis
socio-economic and nutritional determi- is needed to understand the health care in a
C nants. It is therefore assumed that the im- country, especially in a low-income country
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proved child survival in the world in the last where the situation today is far more com-
few decades is largely due to the improved plex than the old concepts of modern and
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access to vaccines and antibiotics, and to traditional medicine (see chapter 11).
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oral rehydration therapy for the treatment

2.7 Health services
2.7.1 Modern medicine The disparity in access to and quality of the

Access to health care is measured as the per- health care and the level of health care ex-
centage of the population that can expect penditure in different populations, vary
evidence-based treatment for common dis- greatly throughout the world (World Bank
eases and injuries, including treatment with 2003).
essential drugs within one hours walk or The access to health care for an individual
travel. In almost all high-income countries patient depends on three factors. The eco-
and in many middle-income countries, such nomic level of the country, the financing
as Poland, Cuba and Costa Rica, access to system for the health service in the country
health care is nearly 100 %. In other middle- and the economic resources of the patient.
income countries, such as Thailand, it is es- Almost all countries have a mixture of pub-
timated to be about 60 %, while in most lic and private health care provision, as will
low-income countries, less than half of the be reviewed in chapter 11. Cuba and North
population is estimated to have access to Korea only have a public health system, as
health care. In many low and middle-in- private practice is not allowed and the infor-
come countries, the percentage with access mal medical practices are relatively limited.
to health care is not known or difficult to es- The organisation of the health care sys-
timate. Even when a community has access tem in most countries is based on a chain of
to modern medical services, the utilisation referral (table 2.8). Preventive work and
of available services depends on price and basic care are performed by the primary
quality of services, on peoples faith in and health care as close to the family and com-
perception of modern health care as such, in munity as possible. The most common dis-
the way they have had to pay and how they eases should be treated at primary level, and
have been treated in the past. major preventive interventions such as im-
Modern medicine can now provide a wide munisation are also performed at that level.
range of treatments for most diseases but ac- The primary level should be served with
cess to these treatments depends mainly on training and supervision from higher levels
affordability. The most drastic example is of the health care system, and they should
the antiretroviral treatment that can pro- be able to refer patients suffering from more
long life for many years for those infected complicated disease conditions efficiently to
by HIV. The care and drugs needed are avail- either the secondary or tertiary level of care.
able for all infected in high-income coun- The secondary level is the basic hospital
tries, for many of the infected in middle in- service and the tertiary level deals with the
come countries but only for about 1 % of advanced treatment of special conditions.
those infected in low-income countries. Remember that outlined above is a model
The ways health care is financed in each system, and that reality in most countries is
country is documented in National Health different. The demand for secondary and
Accounts (WHO 2002). Per capita spending tertiary care is often great, leading directly
on health care in current USD is 100 times to an over-burdening of emergency rooms
higher in the high-income countries than in in the hospitals with patients that could
the low-income countries in South Asia and have been treated at the primary level. Eco-
Sub-Saharan Africa. The United States is nomic limitations lead to shortage of staff
now the country with the highest percent- and lack of drugs at the primary level in low-
age of GDP spent on health care (13 %); a income countries. This also leads to people
C total of USD 4 500 per capita is spent annu- directly seeking care at hospitalsor per-
M ally on health care. In Sub-Saharan Africa haps more often going directly to the local
the annual spending on health services var- market to buy their drugs from informal
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ies between 4 to 30 USD per capita. Cuba drug sellers. The information flow back and
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and Russia spend about USD 100 per capita. forth along the chain of referral concerning

Table 2.8 Health care and staff according to economic level.
Level of Health care Activities Low-income Middle-income High-income

and population per countries countries countries
facility
Home care Family actions like child Family and social Family and social Family and home
care, breastfeeding, network network, some visit of health care
home care of disease, places home visits staff when needed
water and sanitation by health care staff
Primary health care Immunisation, maternal Nurses with few Nurses with many Specialised physi-
2 0005 000 and child clinic, family years training years training cians and nurses
planning, health educa-
tion and treatment of
common diseases
First referral level District hospital for cura- 1 or 2 physicians Team of special- Team of many spe-
100 000200 000 tive care and emergency and limited ised physicians cialised physicians
services resources and nurses and nurses
Second referral level Teaching hospital with Specialised physi- Care for all but Very advanced
0.51 million sub-specialities for cians for those advanced care care for almost all
advanced treatment affording transport only for fee in need
the patients condition is deficient in many abetes and hypertension are even less acces-
low-income countries; for most patients the sible in low-income countries. However,
referral chain is a fiction. In middle-income successful management of these life long dis-
countries the access to referral depends on eases requires regular clinical and laboratory
the economic resources of the patients fam- check-ups that are almost as costly as the
ily. The public hospitals in low and middle- drugs. Beside the problems of financing, the
income countries can often offer most pa- production and distribution of the drugs
tients basic treatment for delivery and acci- needed by poor patients, there are three
dent care, but most advanced examinations major obstacles regarding the supply of es-
and treatments require extra payment from sential drugs to those who need them.
the patient. The first obstacle occurs when the drug
Private health care can be provided for has been developed during the last 20 years
profit or by non-profit organisations such as and the producing company has a valid pat-
churches or charities. The care offered may ent and sells the drug at a high price. The
be in the form of private hospitals offering price should cover the cost of synthesis of
tertiary specialised care, smaller hospitals the active molecule, the production of the
with basic care, or outpatient clinics, all de- tablet, the cost of the research for the drug
pending on the demands and economic re- in question and for other drug projects that
sources of the local community. failed, and finally the profit for the inves-
The access to cost-effective life-saving tors. The lack of access is determined by
drugs to cure major infectious diseases such high prices, which simply excludes most of
as malaria, acute respiratory infections and the population of the world. Patents encour-
tuberculosis is exceedingly unequal in the age the pharmaceutical industries to invest
world. An estimated one-third of the worlds in the development of new drugs, but it
C population lack access to essential life-sav- makes new drugs very expensive during
M ing medicines for diseases that can be cost- their first 20 years of production, when their
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effectively cured following a short examina- patents are valid. Many new drugs are useful
tion for diagnosis. Drugs for life-saving treat- against the major infectious diseases but
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ment of chronic conditions such as HIV, di- cannot be used by those affected because

2.7 Health services
the price is too high. A two level price sys- and tuberculosis, we still use drugs devel-
tem whereby the high income countries oped 50 years ago. Increasing resistance
would pay for the research and middle and makes these drugs increasingly ineffective.
low-income countries would only pay for Research and development of drugs for ma-
the synthesis of the substance and making laria and tuberculosis is virtually non-exist-
of the tablet would solve the situation. ent. During the last 25 years, only 13 out of
There are presently intense discussions in 1,233 newly developed drugs were for dis-
the World Trade Organisation (WTO) to eases affecting mainly the poorer popula-
reach a solution to this most unethical situ- tions of the world (Pecoul 1999). This lack of
ation (see chapter 12). research investment in drugs for the diseases
A second obstacle may occur with drugs of the poor constitutes a clear market fail-
that were developed more than 20 years ago ure that is partly being addressed by the for-
for which no patent exists. Most drugs used mation of the Global Fund to Fight AIDS, tu-
in middle and low-income countries are of berculosis and malaria (see chapter 12.3). Of
this type, the reason being that the prices are course, access to drugs cannot in itself solve
markedly lower because consumers do not the problem of ill health in poorer coun-
have to pay for the research. The main cost is tries, but it is one important factor for the
the synthesis of the active substance which reduction of morbidity and mortality.
is today mainly carried out in middle-in- The main sources of financing in health
come countries, while the final production care are shown in table 2.9. The World Bank
of the tablets may be carried out in low-in- changed its policy during the 1990s to also
come countries, which greatly reduces the include financing the social sector. In most
price. However, drugs that are only needed countries in Africa and South Asia, public
for diseases affecting poor communities, health care has traditionally been free for
such as the parasitic disease sleeping sick- the consumer. Revised financial systems are
ness, may still be too expensive to produce now on trial in most middle and low-in-
with the available funds. Such drugs may come countries, including user fees for both
even go out of production because the mar- health care services and drugs. Studies show
ket is not large enough to generate profit. that in most communities there is a great
This was the case for eflornithine, a drug for willingness to pay for good health care
the treatment of sleeping sickness, until the within their economic potential. User fees
drug was recently found to be effective in the have the advantage of discouraging unnec-
treatment of female facial hair. This market essary consumption of health care, which is
is enormous in the rich countries and pro- the motive for their use in the public health
duction of eflornithine was resumed. care system in high-income countries. The
The third obstacle is that the drugs do not serious disadvantage of user fees in low- and
exist due to a lack of research. For malaria middle-income countries is that the poor-
Table 2.9 Main sources for financing of health care*.
Public health care financing Private health care financing
Taxation User fees

Custom duties and other revenues of the national Revolving drug funds
and local government
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Compulsory social insurance Private insurance
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* Health expenditure per capita = the sum of private and public health expenditure as a ratio of total population in
Y current USD. Public health care expenditure includes government spending, borrowings and donations from inter-
national organisations and health insurance funds. Private health care expenditure includes household spending, pri-
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vate insurance, charitable donations, and direct service payments by private corporations.

Table 2.10 Public, private and total health expenditure in current USD in 2000.
Region Public as % of GDP Private as % of GDP per capita in current USD
East Asia and Pacific 2 3 44

Europe and Central Asia 4 2 108
Latin America and Caribbean 3 4 262
Middle East and North Africa 3 2 170
South Asia 1 4 21
Sub-Saharan Africa 2 3 29
High income countries 6 4 2,735
Source: World Development Report 2004, The World Bank.
est, most sick and most vulnerable popula- 2.7.2 Traditional and complementary
tions may become excluded from receiving medicine
assistance, even when fees are minimal. Sys- The majority of the people in Africa and
tems that exempt the poorest populations other low-income countries use traditional
from user fees represent an attempt to de- and complementary forms of medicine.
crease inequalities. A sustainable solution to These are also popular in middle and high-
the financing problem of a public health income countries, in the latter, especially
care system can only be found within the among highly educated women. However,
contexts of sound economic growth and the utilisation of traditional and comple-
public policies that include a willingness to mentary forms of health care varies greatly
finance health care. between countries. In France, for example,
As shown in table 2.10, there is an almost an estimated 75 % of the population has
even balance between private and public used traditional or complementary medi-
health expenditure in Latin America and the cine at least once (WHO 2002).
Caribbean, in the Middle East and North Af- The concept of traditional medicine
rica. In East Asia and the Pacific, Sub-Saha- merges with that of alternative or comple-
ran Africa and South Asia, private health ex- mentary medicine. These are more or less
penditure is higher, while in Central Asia well-defined systems of curative and preven-
and in the high-income countries, public tive care that are propagated beside the sci-
spending dominates. This will be further entific medicine that is developed and
discussed in chapter 12. taught in medical schools. Medical practi-
tioners of different types have existed in all
societies. In the ancient Chinese civilisa-
Box 2.10
WHO definition of traditional medicine
Diverse health practices, approaches, knowledge and beliefs incorporating plant, animal,
C
and/or mineral based medicines, spiritual therapies, manual techniques and exercises ap-
plied singularly or in combination to maintain well-being, as well as to treat, diagnose and
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prevent illness.
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Source: WHO traditional medicine strategy 2002
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2.7 Health services
homeopathy successfully compete with tra-

ditional Ayurvedic practitioners in India. It
is interesting to see that, in the era of globali-
sation, alternative systems of medicine are
very successful in crossing wide geographical
and cultural gaps. It even seems as if an ex-
otic factor makes other countries traditional
systems of medicine especially popular
where they are not part of the local tradition,
as is the case with homeopathy in India and
Chinese traditional medicine in Europe.
Traditional Chinese medicine, like acu-
puncture, is today widely practised and ac-
cepted in Europe, and herbalists of all kinds
practise widely across the globe using both
traditional herbal drugs and exotic imports
from remote countries. In the discussion
about the effects of traditional herbal drugs,
the malaria drug quinine is an interesting
example. Those who think that traditional
drugs are not effective should note that qui-
nine remains the best drug against one of
the main diseases of the world. However,
the active substance has been purified over
CAMBODIA, Siem-Reap. Man is being treated with many years, tested and integrated into sci-
cupping glasses. entific medicine. Those who think that
Jean-Lo Dugast / PHOENIX. herbal drugs are safer than synthetic should
note that quinine is responsible for many se-
vere side effects and deaths. This is why few
if any use it in the herbal form, in which
tion, a variety of written traditional systems there may be considerable variations in con-
of medicine exist, some as much as 5 000 centration of the active substance. A drug
years old. In India, the Ayurvedic system is that can interfere in a disease process in the
used by large parts of the population, either body can also cause side effects, whereas
for conditions where evidence-based treat- drugs without any type of side effect rarely
ment is not available or because such treat- have beneficial effects on the pathological
ment is not affordable or acceptable to the processes of a disease.
family or community. Both these systems In many countries, traditional and mod-
from the ancient Asian civilisations repre- ern types of medicine and also surgical pro-
sented the best evidence-based knowledge cedures are utilised for different kinds of dis-
up to a point in time when they gradually ease conditions, or they may be used simul-
became stagnant schools to which no fur- taneously for the same condition. They can
ther advances were added. also be harmful, as when homeopathy is
Homeopathy is a separate system of com- used to treat children with life-threatening
C plementary medicine that originated in Ger- pneumonia, instead of life-saving antibiot-
M
many only a century ago and has spread to ics. Herbal drugs can be lethal, due to hepa-
many other countries. It prescribes a wide totoxicity. The traditional practice of
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variety of extremely dilute solutions to treat uvulectomy involves cutting the tip of the
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a variety of illnesses. Today, practitioners of soft palate of an infant in the belief that this

will reduce the incidence of diarrhoea. This poor. Access to health service also depends
is a very strongly established practice in Eri- on cultural, gender and social factors as well
trea, and has no known benefits but implies as if the mix of public, private, traditional
considerable risk for the child and expense and informal health service is rational or
for a poor family. Female genital mutilation not. The access to drug treatment is heavily
is a very harmful practice that like many influence by global trade policy. Globalisa-
other traditional practices has more than tion may be beneficial for the poor if WTO
health motivations in the local culture. will make it possible for poor countries to
However, in general, alternative and tradi- access patent drugs for treatment of life-
tional practices are biologically neutral but threatening conditions (Smith 2003).
can still be quite costly for poor families; for
example, the practice to tie a thread with an
amulet around the arm or foot of a child in References and suggested further reading
India or Africa in order to protect against Aleman J, Liljestrand J, Pena R, Wall S, Pers-
diseases. Although they are biologically neu- son LA. Which babies die during the first
tral, such actions may have great psycholog- week? A case control study in a Nicara-
ical advantages for the worried mother. In guan hospital. Gynecol Obstet Invest.
many African nations, pure herbalists may 1997;43:1125.
offer their services at very modest costs or Allen T, Thomas A (eds.). Poverty and devel-
free of charge, whereas diviners may charge opment into the 21st century. Oxford
high prices for their services, sometimes University Press; 2000.
even more expensive than biomedical treat- Antonsson-Ogle B, Gustavsson O, Hambreus
ments. Traditional treatments will therefore L, Holmgren G, Tylleskar T. Nutrition,
contribute to poverty in many households. agriculture and health when resources are
It should be remembered that poor families scarce. 2nd revised edition. Uppsala: Upp-
spend almost all of their small economic re- sala University; 2000.
sources on food, education and health care. Basch P. Textbook of International Health.
During recent decades attempts have been Second edition. Oxford University Press;
made in low-income countries, especially in 1999.
Africa, to promote co-operation between the Beaglehole R. (ed) Global Public Health: A
traditional practitioners and the modern new era. Oxford University Press; 2003.
health care system. One example involved Britton S. Linneus, Armauer Hansen, and
measures to educate traditional birth at- Nordic research on some neglected dis-
tendants to use clean practices and tools. eases. In: Akuffo H, Linder E, Ljungstrm
Other challenges, according to the newly I and Wahlgren M (eds). Parasites of the
adopted WHO traditional medicine strategy, colder climates. Taylor & Francis; 2003.
are to produce national policies and a regu- Burstrom B. In: Risk factors for measles mor-
latory framework, guaranteeing safety, effi- tality. Ph D thesis. Stockholm: Karolinska
cacy and quality as well as access and ra- Institutet; 1996.
tional use of traditional medicine. Caldwell P. Child survival: Physical vulnera-
In conclusion, access to cost-effective evi- bility and resilience in adversity in the
dence based health care is an important de- European past and contemporary Third
terminant for health. The access depends on World. Soc. Sci. and Med. 1996;43:609
the economic level of the country and of the 619.
C family. It is also dependant on whether the Caldwell P, Santow G. Selected Readings in
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country has a fair policy for financing the Cultural, Social and Behavioural
health service. That means the healthy help Determinants of Health. Health Transi-
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to pay for the treatment of the sick and the tion Series; 1989. (http://htc.anu.edu.au/
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rich help to pay for the treatment of the html/htsl.htm)

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De Soto H. The Mystery of Capital: Why McMichael T. Human Frontiers, environ-

Capitalism Triumphs in the West and ments and disease. Cambridge University
Fails Everywhere Else. Times Books; 2000. Press; 2001.
Chaloner EJ, Mannion SJ. Antipersonnel Merson MH, Black RE, Mills A. International
mines: the global epidemic Ann R Coll Public Health. Aspen; 2001.
Surg Engl 1996;78:14. Park K. Textbook of Preventive and Social
Cleland JG, van Ginneken JK. Maternal edu- Medicine. 15th edition. M/s Banarsidas
cation and child survival in developing Bhanot Publishers: Jabalpur, India; 1997.
countries: the search for pathways to Pecoul B, Chirac P, Trouiller P, Pinel J. Access
influence. Soc. Sci. and Med. 1988;27: to Essential Drugs in Poor Countries. A
13571368. lost battle? JAMA 1999;281:36167.
Cohen S, Syme SL. Social support and Ramalingaswani V, Jonsson U, Rohde J. The
health. London: Academic press; 1985. Asian Enigma. Progress of Nations,
Cohan JE. How many people can the world UNICEF; 1996
support? Norton; 1995. Sachs JD. Report of the Commission on
Evans T, Whitehead M, Diderichsen F, Bhu- Macroeconomics and Health. Macroeco-
iya A, Wirth M (eds). Challenging Inequi- nomics and Health: Investing in Health
ties in Health From Ethics to Action. for Economic Development. Geneva:
Oxford University Press; 2001. World Health Organisation; 2001.
Esrey S, Gough J, Rapaport D, Sawyer R, Savage King F, Burgess A. Nutrition in devel-
Simpson-Hebert M, Vargas J, Winblad U. opment countries. 2nd edition. Oxford:
Ecological Sanitation. Swedish Interna- Oxford University Press; 1993.
tional Development Co-operation Agency Sen A. Development as Freedom. Oxford
(Sida); 1998. University Press; 1999.
Greiner T. The concept of weaning: defini- Sen G, Georg A, Ostlin P. Engendering Inter-
tions and their implications. Hum Lact. national Health: The Challenge of Equity.
1996;12:1238. MIT Press; 2002.
Helman CG. Culture, Health and Illness. 3rd Smith RD, Beaglehole R, Woodward D,
edition. Butterworth Heinemann, Oxford; Drager N. Global Public Goods for Health.
1996. Health economics and public health per-
Human Rights Watch. Global Report on spectives. Oxford University Press; 2003.
Child Soldiers, 2001. Todaro MP. Economic Development. 6th edi-
ISI (International statistical institute) World tion. Longman; 1997.
fertility survey: major findings and impli- UNESCO 2002, Education for all monitor-
cations. 1984. ing report; 2002.
Last JM. Public health and human ecology. UNDP, Annual Report, 1998.
Prentice-Hall International Editions, UNICEF, State of the Worlds Children,
Appleton & Lange, USA; 1987. 2003, 2004.
Lomborg B. The sceptical environmentalist. Wamala SP, Lynch J. Eds. Gender and Social
Measuring the real state of the world. Inequalities in Health A Public Health
Cambridge University Press; 2001. Issue. Lund, Sweden: Studentlitteratur;
Marmot M, Wilkinsson RG. Social Determi- 2002.
nants of Health. Oxford University Press; Whaley RF. A textbook of World Health. A
1999. practical guide to global health care. Par-
C McKeown T. The Role of Medicine, (2nd edi- thenon Publishing Group; New York:
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tion). Oxford University Press for the 1995.
Nuffield Provincial Hospitals; 1979. World Bank, World Development Indica-
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tors. 2001 and 2002.
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World Bank, World Development Report WHO, New data on the prevention of
2003, Sustainable development in a mother-to-child transmission of HIV and
dynamic world. Oxford University Press; their policy implications: conclusions
2002. and recommendations. WHO Technical
World Bank, World Development Report Consultation on behalf of the UNFPA/
2004, Making Services Work for Poor Peo- UNICEF/WHO/UNAIDS Inter-Agency
ple. Oxford University Press; 2003. Task Team on Mother-to-Child Trans-
WHO, Our planet, our earth: report of the mission of HIV. Geneva: World Health
Commission on Health and Environ- Organisation, 2001. Report No. WHO/
ment. Geneva; 1992. RHR/01.28.
WHO, Female Genital Mutilation: Report WHO, Traditional Medicine Strategy 2002
of a WHO Technical Working Group: 2005. WHO/EDMrTRM/2002.1
Geneva: 1719 July 1995. Geneva: World Yassi A, Kjellstrom T, de Kok T, Guidotti TL.
Health Organisation; 1996. Basic Environmental Health. Oxford Uni-
WHO, World Health Report (WHR). 1998 versity Press; 2001.
2004. yen E, Miller SM, Samad SA. Poverty, a
WHO, Climate Change and Human Health: global review. Scandinavian University
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001. May 2000.

2.7 Health services

3 Health indicators
3 Health indicators
For me a good life is to be healthy.
An old man, Ethiopia
The basic health indicators, such as child They turned global public health into an
mortality and life expectance, are as crucial area of innovative and debated research
for understanding the health situation in a from having been dominated by doubtful
country as are the pulse rate and body tem- diplomatic compromises about numbers to
perature for the diagnosis of an individual be used in mass-media-oriented advocacy.
patient. A health indicator is a variable that But how well do the internationally pub-
provides a single numeric measurement of lished numbers from different countries re-
an aspect of health within a population for a flect the health reality in each country? It is
special period of time, normally a year. often asked if we can trust the numbers. This
Many of the United Nation organisations is the wrong question. The provided number
such as WHO, UNICEF, UNDP, UN Statistical for child mortality in a given country is not
Division, UN Population Division and the right or wrong, it is more or less correct.
World Bank annually publish health indica- Therefore the question that always should
tors for all countries of the world. be asked is: What is the degree of uncer-
Health indicators are of two types. The tainty of each number for a certain indicator,
first type is summary measures of survival/ country and year? Murray and Lopez also
mortality, such as child mortality and life ex- started to provide such a systematic assess-
pectancy. The second type is measures of the ment of uncertainty intervals for some of the
burden of specific diseases or risk factors. health indicators (WHO 2002).
The analyses of global variations in disease The quality of the data for a certain indi-
occurrence have been greatly influenced by cator from a certain country depends both
the pioneering work of Christopher Murray on the method used for its collection and on
and Allan Lopez. They started the global bur- how well this method was applied that year
den of disease study at The Harvard School in the country. The authority and the meth-
of Public Health. Between 1996 and 2003 ods used to collect and compile national
they published five major books (Murray health and demographic statistics differ be-
1996, 1998, 2003) with the first coherent es- tween countries, as does the quality of the
timates of the occurrence and impact of all primary data collection. The Ministry of
major diseases in all countries of the world. Health or the National Statistical Bureau
When Murray was head of health statistics at supplies the international organisations
the World Health Organization (WHO) he with national statistics on demographic and
further developed new measures for health health indicators. It is very important to
system performance. These measures in- note that countries can use different ways to
duced an intensive debate (Murray 2002). obtain data for the same health indicator
The critique focused on the quality of the and international organisations use differ-
C data used and was partly correct, as the new ent methods to edit and compile the infor-
M concepts were used before sufficient data mation into numerical values for each year.
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had been made available. However, Murray Civil registration, i.e. routine registration of
and Lopez have left a lasting intellectual im- all births, deaths and migrations, are clearly
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print in the field of global public health. incomplete for more than 80 % of the

3 Health indicators
worlds population, including China, India Demographic surveillance sites constitute a

and large parts of Africa (Murray 1997). The methodology that is similar to the sentinel
absence of routine civil registration of births system. The difference is that the area in
and deaths in a given country does not mean which detailed information on demogra-
that nothing is known about health and phy, health and deaths is collected does not
mortality in that country. Child mortality represent the country as a whole. Such sites
can be used as an example. The data is obvi- are still useful for following the time trends
ously compiled from routine vital registra- and especially for doing community based
tions of all births and deaths where that research on different health interventions.
exist, but in the majority of countries child INDEPTH is the name of a growing interna-
mortality is estimated through the use of tional organisation for the improvement of
other data collection methods. the quality of such surveillance sites, espe-
National census of the whole population cially in Africa. More than a million people
enables estimation of child mortality by the across Africa live in areas with complete reg-
use of indirect demographical methods. A istration of births and deaths and the qual-
national census is only performed about ity on health indicators in Africa are steadily
every tenth year. The reason is the high improving. INDEPTH is led by African
costs of tracing and registering everyone in a scholars and is co-ordinated from Ghana.1
country. The information about children A national household sample survey is the
that have died is often not obtained in the most cost-effective method to estimate the
rapid interviews of a census. national child mortality. Information is ob-
Hospital and health facility registers provide tained from careful interviews of women in
data on deaths of children. However, health a group of households in a representative
facility registers are of very varied quality. number of local communities. The women
Their reliability depends both on the moti- are interviewed regarding births and deaths
vation and time available for the local of children during past years and a number
health worker to fill in the forms, as well as of additional issues concerning the health of
on the proportion of the population in the the family and their utilisation of health
area that are effectively covered by the serv- services. Such surveys are done at three to
ice provided. In many countries most of the four year intervals in most low-income
child deaths occur at home and are neither countries. Most receive technical and finan-
registered in hospitals nor reported to the cial support from USAID and a company in
authorities; the ceremonies around death the US that has developed impressive skills
are entirely a responsibility of the family. In in conducting such surveys. These surveys
countries like Sweden the authorities carry are known as Demographic and Health Sur-
out almost all actions around a death and veys (DHS). The actual surveys are under-
therefore have almost perfect statistics on taken by national agencies in each country
the deaths and their causes. but all data is provided free to the world.2
Sentinel systems provide good estimates of The data quality is not the only problem
the child mortality in some major countries when using data from periodic household
such as China and India. The data on popu- surveys to assess the general health status of
lation changes and health are obtained low and middle-income countries. Another
through regular careful registration in a rep- problem is that health and demographic in-
resentative selection of small areas in the dicators such as child mortality may vary
C country. The complete civil registration in considerably from one year to the next or
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the small areas enables an extrapolation to from season to season. In low-income coun-
the whole country as the small areas have
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been selected as representative of the coun- 1
www.indepth-network.net
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try. 2
www.measuredhs.com

3 Health indicators
tries the harvests largely depend on suffi- and middle-income countries results in var-
cient rainfall. During a drought year the ying degree of uncertainty. For many coun-
child mortality will increase considerably tries the uncertainty is relatively small and
and following a year with good rains the the available data are therefore most useful.
child mortality decreases. The seasonal vari- For a few countries, especially very poor and
ations of mortality also mainly depend on war-torn countries, the uncertainty is very
weather. Malaria is just one of the diseases wide and the data is only available for a few
that increase in incidence during the rainy indicators. For some health indicators, such
season, thus affecting the seasonal variation as maternal mortality rate, the numbers for
of child mortality. Natural or man-made dis- most countries have an uncertainty of up to
asters can quickly affect the health and de- plus/minus 50 % (Hill 2001).
mographic situation in a country. In the year 2000 WHO began to publish
Internationally published time series, the uncertainty interval for some health in-
with child mortality from low-income coun- dicators. Most country health indicators are
tries, show data for each year. However, unfortunately still published without any
these numbers are averages for the last three information about the uncertainty and usu-
to five years. The data given for a specific ally without stating the method of data col-
year is often just an interpolation between lection used in each country. It is therefore
estimations for different time periods. Un- difficult to judge the level of uncertainty of
fortunately the way these interpolations the data and when making comparisons it is
have been made and the values used for the not fruitful to look at exact figures but rather
interpolations are not regularly provided. in what range the indicators lie for each
The data internationally published also lags country. Whether the life expectancy is 45 or
a few years behind because of the retrospec- 65 years is interesting, but not whether it is
tive character of the data collection and exactly 64 or 66 years. One could say that
compilation. The health status also varies most of the available data on major health
geographically within a country, between indicators is useful for almost all countries in
urban and rural areas and between different spite of varying degree of uncertainty. Cau-
regions, depending on variations in socio- tious conclusions can be made about the
economic status and access to health care. general trend of the state of health in the
The conclusion is that when health indica- countries of the world, but we should refrain
tors are used to assess the development of from making detailed comparisons and
countries precautions must be taken because ranking between countries that have almost
the method of collection used in most low the same value for an indicator.
Table 3.1 World Health progress over the last 40 years.
World Indicators 1960 2002

Infant mortality rate 126 56
Under 5 Mortality Rate 197 82
Life Expectancy 48 63
Total Fertility Rate 5.0 2.8
Maternal mortality ratio 400
C
Crude death rate 17 9
M
Crude birth rate 36 22
Y
Population Growth Rate 2.0 (19651980) 1.5 (19902002)
K
Source: State of the Worlds Children; UNICEF 1997 and 2004.

3.1 Infant mortality rate
This chapter explains the most useful birth to the 28th day of life. Survival is in
health and demographic indicators that are this period highly dependent on the care of
needed for judgement of the health profile the mother during pregnancy, delivery and
of a country. Most of the selected indicators the postpartum period. After the 28th day,
are shown in Table 3.1. To these have re- the main factors that determine survival are
cently been added disability-adjusted life safe environment, good feeding practices
years (DALYs), which measure the combined and the quality of care. As the infant mortal-
effect of mortality and disability of specific ity rate in a country decreases, a greater and
diseases. We also explain the measures of greater proportion of the infant mortality
disease occurrence as well as anthropometri- occurs in the neonatal period. The most
cal indicators used to assess nutritional sta- common global causes of infant deaths in
tus. These numeric indicators constitute the the neonatal period are pre-term delivery,
basis for any understanding of the national birth asphyxia, infections and congenital
health and demographic development of malformations. These neonatal conditions
any country. By studying table 3.1, you will cause most of the infant deaths in high-in-
see the extraordinary positive gain the come countries. In the richest countries pre-
world has made in improved health status term babies down to 23 weeks of gestation
over the last 40 years! today survive with high technology careof
course at very high costs.
The causes of post-neonatal mortality are
mainly dependent on socio-economic, envi-
3.1 Infant mortality rate ronmental, nutritional and care issues. As a
country develops, living standards and nu-
The annual number of children less than
one year of age who die per 1 000 live tritional status in the population improve
births. and the infant mortality rate decreases.
With enough political will to adhere to an
appropriate evidence-based health policy,
There has been an impressive decrease in in- all middle-income countries could reduce
fant mortality rates worldwide over the last the infant mortality rate to 50 per 1 000 live
half century. The infant mortality rate in the births. The policy should include literacy
world in 2002 was estimated at 56 per 1 000 campaigns, primary education, safe water
live births, less than half of the estimated and sanitation, immunisation programmes,
rate of 126 per 1 000 live births in 1960. The basic primary health care, health education,
reported infant mortality rates for countries including promotion of breastfeeding and
today vary between 3 and 165 per 1 000 live- good weaning practices.
born babies. In 2002, the average infant About 4 million stillbirths (deaths of the
mortality rate was 106 per 1 000 live births foetus before birth) occur worldwide every
for Sub-Saharan Africa, 70 for South Asia, 46 year. Of these, half are caused by complica-
for the Middle East and North Africa, 33 for tions during labour and delivery. These
East Asia and the Pacific, 27 in Latin Amer- deaths are not included in the infant mor-
ica and the Caribbean, 33 in the former so- tality rate, but they are included in the peri-
cialist countries of Europe and only 5 per natal mortality. Perinatal mortality is defined
1 000 live births in the high-income coun- as the total number of deaths of the foetus
tries (UNICEF 2004). from a gestational age of 22 weeks to the
C Each year an estimated 7.5 million chil- seventh day of life of the newborn (figure
M
dren die during their first year of life in the 3.1). Perinatal disorders include preterm de-
world. Infant mortality can be divided into livery, asphyxia, congenital anomalies, ob-
Y
neonatal and post neonatal mortality (figure stetric trauma and severe bacterial infection,
K
3.1). The neonatal period stretches from including sepsis and meningitis. Chapter 9

3 Health indicators
22 weeks
pregnancy Birth 1 week 1 month 1 year 5 years
Perinatal
Neonatal Postneonatal
Infant
Under 5 years
Figure 3.1 Definitions of childhood mortality.
discusses the causes of perinatal morbidity 3.2). It is currently estimated at 82 per 1 000
and mortality further. To care for newborn live births, a decline from 197 in 1960. In
children after birth, a few basic factors are 1960, about 21 million children throughout
more vital than others: warmth, cleanliness, the world died each year before their fifth
early and exclusive breastfeeding, eye care, birthday. In 2001, it is estimated that 10.4
and immunisation. It is also important to million children died before their fifth
establish the early recognition and prompt birthday. It is estimated that national under-
treatment of infections (WHO 1998). With five mortality rates varied from 20 to 375 per
these few simple measures and with basic 1 000 live births in 1960, and in 2002 it var-
obstetric care, the majority of the perinatal ied from 3 to 284 between the countries of
and neonatal mortality in the world could the world (UNICEF 1998 and 2004).
be prevented. Sub-Saharan Africa had the highest mean
The infant mortality rate is not only the under-five mortality rate, amounting to 174
most used health indicator but it is also per 1 000 live births in 2002, followed by
widely used as a general indicator of the South Asia 97, the Middle East and North
socio-economic development of a country. Africa 58, East Asia and the Pacific 43, Latin
The reason being that rapidly growing in- America and the Caribbean 34, and the for-
fants are in the most vulnerable stage of life merly socialist countries of Europe 41. The
and their survival depends on a range of high-income countries have a mean under-
socio-economic factors (see chapter 2). five mortality rate as low as 7 per 1 000 live
births. There are great disparities between
countries on the same continent. In 2021
the under-five mortality rate was 11 in Costa
3.2 Under-five mortality rate Rica and 41 in Nicaragua, 19 in Sri Lanka
and 93 in neighbouring India, 67 in Na-
The annual number of children dying
mibia and 260 in Angola. Within countries,
between birth and exactly five years of
C age, expressed per 1 000 live births. the under-five mortality rate differs between
M social groups in almost every society of the
world.
Y
The world under-five mortality rate, like the As mentioned before, 10.4 million chil-
K
infant mortality rate, is improving (Figure dren die before reaching their fifth birth-

3.2 Under-five mortality rate
300 Others
13% ARI
19 %
250
Su Deaths
b- associated with Diarrhoea
Sa
ha malnutriton 17 %
Under-five mortality per 1000 live births
ra 50 %
n
id
Af
d
ric
le
200 a
E
Perinatal
as
ta
37% Malaria
So
nd
8%
ut
No
h
As
r th
Measles
Eas
ia
HIV
Af
150 4%
tA
ric
La 3%
a
ti
sia
an n Am
and
d
th eria
Figure 3.3 Major causes of death among children
e C ca under five, worldwide, 2003.
Pac
ar
100 ib
be
ific
Source: Bryce, 2005.

Fo an
rm
er
So
cia
list age are mainly accidents and late effects of
c ou
50 ntr congenital disorders.
ies
High of
-inco Eu Under-five mortality rate is more and
me c rop
ount e more frequently used as an aggregate meas-
ries
ure of overall socio-economic development
0 of a country or a population group. The rea-
1960 1970 1980 1990 2004 son is that under-five mortality, even more
Year than infant mortality, depends on socio-
economic factors such as female education,
Figure 3.2 Trends in under-five mortality by region
access to preventive and curative health
19602002.
services, quality of water supply and sanita-
Source: State of the Worlds Children. UNICEF. 2006.
tion, food security and diet. When living
conditions improve, the incidence of death
between one and four years decreases faster
day. The main direct causes are acute respi-
ratory infection, diarrhoea, malaria, mea- Table 3.2 The most common disease conditions
sles, malnutrition and perinatal disorders causing Under-Five-Mortality* in 2001.
(Figure 3.3, Table 3.2). Malnutrition is also
Acute respiratory infection 2.0 million
an important underlying cause of almost all
Diarrhoea 1.4 million
other conditions causing child mortality.
Of the global under-five mortality rate, Measles 0.5 million
about 70 % is constituted by the infant Malaria 0.9 million
mortality rate, which is to say that the ma- Perinatal disorders 2.4 million
jority of all deaths in children less than 5 HIV 0.3 million
years old occur during the first year. When Other 2.9 million)
C child survival improves, the infant mortal-
TOTAL: 10.4 million
M ity rate gradually increases to constitute a
Y
greater part of the under-five mortality rate. * Annual number of children dying between birth and
In high-income countries the remaining exactly 5 years of age expressed per 1 000 live births.
K
causes of deaths in the period 14 years of Source: Unicef, State of Worlds children 2004.

3 Health indicators
than the infant mortality rate. In Sweden, 100

for example, the number of deaths between 2025
1 and 4 years has been reduced almost to 90
1995
zero, while there are still 3 per 1 000 live 80
births who die in the first year mostly due to 1975
pre-term delivery or malformation. 70
1955
% of survivors
60
50
40
3.3 Life expectancy at birth
30
The number of years a newborn baby
20
would live if subjected to the present mor-
tality risks prevailing for each age group 10
in the population.
0
0 10 20 30 40 50 60 70 80
The worldwide life expectancy at birth is es- Year
timated to be 63 years. It was estimated to
Figure 3.4 Survival curves for the world 1955
be 48 years in 1960 and is calculated to rise
2025.
to 73 years by the year 2025. Regional differ-
Source: World Health Report, WHO. 1999.
ences in life expectancy at birth are great.
Sub-Saharan Africa has the lowest life ex-
pectancy, 46 years. The high-income coun-
tries had an average of 78 years in 2002. linked to each other. The survival curves in
Japan has the longest life expectancy, at an figure 3.4 show that much of the remarkable
average of 81 years, partly explained by the improvement in life expectancy is caused by
healthy Japanese diet. Zambia and Sierra the improved child survival in the world.
Leone are today countries with the lowest The definition of life expectancy at birth
life expectancy at birth, around 35 years. mentioned above is a complex calculation.
The main reasons are poverty, together with Another, more simple way of explaining life
AIDS and consequences of war, respectively. expectancy at birth is: the average number
As for child and infant mortality rates, life of years that would be lived by those born
expectancy is an indicator of socio-eco- today if the current risk of dying at each age
nomic development, and indeed they are were to persist throughout their whole life.
Table 3.3 Life Expectancy by region in 1970 and 2002.
Region Life expectancy in 1970 Life expectancy in 2002
South Asia 48 63
East Africa and Pacific 58 69
C
Latin America and the Caribbean 60 70
M
CEE/CIS and Baltic States 66 69
Y High income countries 72 78
K
Source: State of the Worlds Children, UNICEF 2004.

3.3 Life expectancy at birth
DENMARK, the island Fur. Elderly couple in their home.

Jrn Stjerneklar/PHOENIX.
Life expectancy can also be calculated at The size of the elderly population is in-
other ages than at birth. Life expectancy at creasing all over the world. With socio-eco-
age 15 can be used to understand adult mor- nomic and medical advancements, people
tality. Life expectancy at 65 measures the not only live a longer life, but a healthier life
changing conditions among the elderly in a as well. In the high-income countries, 13 %
country. Life expectancy is sensitive to so- of the population, representing 135 million
cial change, since the death rates in all age people, are over the age of 65 years, and 35
groups are included. Often, but not always, million are over the age of 80 (UNDP 1998).
life expectancy co-varies with child survival This success challenges the capacity of the
rates. health and social service system to provide
Male and female life expectancy figures good care for the elderly. However, with an
differ globally. In most countries in the increased life expectancy in most parts of
world, women live longer than men (see the world, not only the rich nations of the
also chapter 2 on gender). Russia has seen a world are experiencing an ageing of their
drastic decrease in the life expectancy at population. In 2025, it is estimated that
birth for males over the last fifteen years. more than 800 million people in the world
This has been due mainly to an increased will be older than 65 years, and of these
C use of alcohol and tobacco, and reflects the 65 % will be living in low and middle-in-
M changing life conditions in Russia that re- come countries (WHO 1998).
sults in increased rates of cardiovascular dis-
Y
ease, suicide and accidents involving alco-
K
hol.

3 Health indicators
3.4 Disease occurrence In high-income countries the prevalence of

HIV is now increasing because the anti-ret-
Prevalence: The proportion of a popula- roviral treatment is so effective that few of
tion affected by a disease at a given point those infected die of AIDS. As treatment in-
in time creases the duration of the disease it will re-
Incidence: Number of new cases of a dis- sult in higher prevalence even in the ab-
ease in a population during a specified sence of increase in incidence.
time period
So far this chapter has described the most 3.5 Maternal mortality ratio
useful summary health indicators. Before we
go on to the demographic indicators, we Number of deaths of women from preg-
will describe the most basic measures of oc- nancy-related causes per 100 000 live
births
currences of specific diseases; prevalence
and incidence. Prevalence is the proportion
of a certain disease in a given population,
Around 500 000 women die of pregnancy-
usually at a specific date or another given
related causes throughout the world each
point in time. One example is the preva-
year. These deaths occur almost exclusively
lence of tuberculosis in a village which is the
in the low- and middle-income countries, as
number of cases of tuberculosis in the vil-
modern gynaecological and obstetric serv-
lage at a certain point in time divided by the
ices have brought mortality to almost zero
total number of persons in that village at the
in high-income countries. The Maternal mor-
same point in time.
tality ratio expresses the number of maternal
Incidence is the number of new cases of a
deaths per 100 000 live births. This ratio
disease occurring during a set time interval
(MMR) measures the risk of death among
in a certain population. The incidence of tu-
pregnant and recently delivered women.
berculosis in a village is the number of new
The strength of this measure is that it ex-
cases of tuberculosis in the village during
presses the quality of pregnancy care and
one year divided by the total number of per-
delivery care, safe motherhood. MMR is
sons in the village in the middle of that
not sensitive to fluctuations in fertility.
year. These two basic measures are related to
Though very important for health policy
each other and to the duration of the dis-
this is an indicator that is presently meas-
ease. A disease with very short duration can
ured with considerable uncertainty in most
have high incidence and yet low prevalence.
countries. The worldwide maternal mortal-
In contrast a disease with life long duration
ity ratio is estimated to be 397 with a lower
may have high prevalence but a low inci-
and upper uncertainty interval of 234 and
dence. The relationship between incidence,
635, respectively, deaths per 100 000 live
duration and prevalence is as follows:
births.
Incidence duration = prevalence Another measure used is the maternal mor-
tality rate, which expresses the number of
By way of example, diarrhoeal episodes may maternal deaths per year per 100 000 women
have a high incidence in Uganda, i.e. many aged 1549. This expression, which is rarely
people fall ill during a year. However, most used, reflects both the risk of death among
C will have recovered in about one week, and pregnant and recently delivered women and
M
the prevalence of diarrhoea will never be the proportion of all women to become
high. In contrast, the incidence of HIV is rel- pregnant in a given year. It can consequently
Y
atively low in Uganda, but the prevalence of be reduced either by making pregnancies
K
HIV is high since HIV is a lifelong infection. safer (like the maternal mortality ratio) or by

3.5 Maternal mortality ratio
lowering fertility. It measures the contribu- dicator does not reflect the outcome of the
tion of maternal mortality to the overall care they are still preferred for monitoring
mortality among women of reproductive because much better data is available for the
age. process indicators. The most used process in-
Observe the difference between rate and dicators are the assistance of a skilled attend-
ratio. Ratio is the value obtained by dividing ant at delivery, trends in coverage of antena-
one quantity by another: a general term of tal or delivery care, percentage of all deliver-
which is proportion. Rate is the value ob- ies in which caesarean section is carried out,
tained by division when time is an element and the percentage of women dying from a
of the denominator. In this context ratio predefined disease affecting a pregnant
tells the proportion of 100 000 pregnant woman. In a given setting, hospital or health
women that will die and the rate is how unit, process indicators are more reliable as
many pregnant women that will die during an expression of improvement of maternity
a year per 100 000 women in the reproduc- care. Still, there is a need to make careful
tive age group. studies at the community level of the mater-
Maternal mortality is difficult to estimate, nal mortality ratio. They should be carried
especially in the countries with the highest out at long intervals, since they are costly
mortality. Firstly, it is a comparatively rare and yet yield results with wide uncertainties.
event, since it typically occurs in only 0.5 In most low and middle-income countries it
1.5 % of deliveries even in low-income coun- is only meaningful to measure maternal
tries. Secondly, deaths related to sexuality mortality at five to ten year intervals.
and reproduction tend to be stigmatising Lifetime risk of maternal death measures the
events (e.g., clandestine abortions). There- risk of maternal death over a womans entire
fore, reporting is often incomplete, and reproductive life span and is related to the
under-registration a common problem. total number of pregnancies. As a conse-
Thirdly, the denominator when maternal quence of high infant and child mortality,
mortality is estimated would ideally be the total fertility rate tends to be high for
number of pregnant women, but this is im- two principal reasons. Firstly, there is a psy-
possible to calculate with any certainty. The chological replacement effect aiming at sub-
convention is therefore to define a proxy stituting the loss of a child with a new preg-
denominator, which implies that the ma- nancy. Secondly, there is an endocrine ef-
ternal mortality ratio is the quotient (ratio) fect: when a breastfed infant/child dies, the
between number of maternal deaths in the sucking stimulus on the nipple stops, with
numerator and 100 000 live-born babies in an ensuing reduction in circulating prolac-
the denominator. The desire to assess tin. Such a reduction implies return of ovu-
changes in maternal mortality is hampered lation, enhanced fertility and a probable
by the above-mentioned uncertainties. It new pregnancy. The final result is that the
has recently been estimated by Hill (2001) lifetime number of pregnancies tends to in-
that the uncertainty of maternal mortality crease in societies with high infant and
ratios for most low and middle-income child mortality. The lifetime risk of mater-
countries are so wide that this indicator is nal death is then increased, and the number
useless for monitoring improvements in ma- of pregnancies per lifetime should multiply
ternal health in periods less than a decade. the individual risk associated with each
Instead of using an outcome indicator, such pregnancy. In the least developed countries,
C as maternal mortality ratio, to evaluate the lifetime risk may be as high as one in
M
health programmes, a number of process inten, whereas in Northern Europe it is in the
dicators have been defined. The process indi- order of one in 10 000.
Y
cators reflect access to and quality of care of The global variation of national maternal
K
pregnant women. Although the process in- mortality ratio (MMR) is even greater than

3 Health indicators
that of infant and under-five mortality. The

2002 maternal mortality ratio was estimated 1
at 2 000 /100 000 live births in Sierra Leone,
Level of health
meaning that one woman died per 50
births. The regional differences are great,
from Sub-Saharan Africa 940/100 000 live
births and 560 in South Asia, to 110 in East
Asia and Pacific and 13 in high-income
countries (UNICEF 2004). 0
Maternal mortality ratios have decreased 0 40 80
enormously in Western European countries Age in years
in the last 200 years. In Sweden, the decline
started around 1750, with the ratio falling Figure 3.5 Presentation of a life in full health until
from 1 000 to 500 per 100 000 live births by sudden death at the age of 80 years.
1850, and now being less than 5 per 100 000 Source: Stefan Peterson, Karolinska Institutet, Stockholm.
live births. The major determinants for this
decline were better obstetric practices, im-
proved hygiene and nutrition, and declin- in a standardised and comparable way. This
ing fertility rates. Pregnancy-related mortal- increased the validity of comparisons of the
ity constitutes an important part of adult fe- burden of different diseases between world
male mortality in low-income countries, but regions and countries over time. In fact, the
not the major part. In a typical Sub-Saharan World Bank and the World Health Organiza-
population of 100 000 persons, around tion were the first to use the DALY measures
4 000 children will be born each year. to compare the burden of disease in differ-
Around 500 of these children will die, as ent regions of the world and thereby the
compared to around 40 women that will die value of different health interventions
of a pregnancy-related cause. The causes of (World Bank 1993). It became possible to es-
maternal mortality are further elaborated in timate and compare the cost of avoiding the
chapter 9. loss of a DALY for each intervention.
The method uses 107 diagnoses, covering
all conceivable causes of death and 95 % of
all possible causes of disability. As a basis for
3.6 Disability-adjusted life the DALY measure, a gold standard, or
most desirable life, is defined as living in a
years (DALY) completely healthy state until death at age
around 80 years. Perfect health is 1 and
A comprehensive indicator including both
losses of healthy years due to disability death is 0 on the DALY diagram shown in
and premature death figure 3.5.
As we all know, life is not usually like that.
For each premature death, the number of
Disability-adjusted life years (DALY) is an in- years lost is counted up to 82.5 years for fe-
dicator that measures the disease burden in males and 80 years for males, which is the
a population, taking into account not only highest national life expectancy at birth in
premature mortality but also disability the world, i.e. Japan. For example, if a man
C caused by disease or injury. Murray and dies in a car accident at 20 years of age (80
M Lopez (1994) developed the measure for 20 years); 60 years are lost due to this prema-
Y
their study on the Global Burden of Dis- ture death. Such a measure of premature
eases. The DALY measure is used to present deaths in number of years lost is known as
K
the health impact of all diseases and injuries years of life lost (YLL).

3.6 Disability-adjusted life years (DALY)
hatched area in figure 3.6 represents his life

years lost due to disability and early death.
0,9 Another component of the DALY measure
is that years lost due to premature death or
Level of health
disability are given different values at differ-

ent ages. These differences in values are in-
troduced in DALY calculations by what is
called age weights. The age weight used in
0 the DALY calculations is obtained from a
0 20 60 80
scale where the value of a year lost rises
steeply from zero at birth to a maximum at
Age in years
25 years of age, and then decreases progres-
Figure 3.6 Illustration of a person who gets a knee sively in older ages (Figure 3.7). This means
injury at the age of 20, recovers and later gets dis- that if a newborn girl dies, 32.5 DALYs are
abled from cancer and dies at the age of 60. lost, if she dies at age 30 years, 29 DALYs are
Source: Stefan Peterson; Karolinska Institutet, Stockholm. lost, and at age 60 years, 12 DALYs are lost.
For males, the above figures will be slightly
lower, because their shorter life expectancy
is taken into consideration. Finally, the years
Injury and disease cause not only deaths lost in the future are discounted, so that
but also varying time periods with morbid- years lost now are worth more than years
ity and disability. The time period in years lost in the future. This is a standard proce-
that is lived with a disability due to each dis- dure in economics and in the DALY calcula-
ease is also added to the DALY measure. The tions a discount rate of 3 % per year is used.
disability is measured in length in years and The innovative Global Burden of Disease
in severity. Severity weights have been ap- study calculated the total sum of the com-
pointed for each disabling condition on a bined loss of all premature deaths that oc-
scale from one to zero. Schizophrenia was curred in the world in 1990 and the loss of
given a weighted severity loss of 0.8, healthy life from disability in future years
whereas the common cold only causes a loss from specific diseases arising in that year
of 0.007. The disability severity weight for (Murray 1994). The study used all possible
each disease reflects the average degree of data sources of recorded causes of death and
disability a person suffers with each condi-
tion. Panels of healthy experts with knowl-
edge about disease conditions have deter- 1,6
mined the weights. The severity weight is
then multiplied by the average time a per-
1,2
son is suffering from the disability from
each disease.
Let us look at an example from a persons 0,8
life, in figure 3.6. This man gets a knee injury
at the age of 20 with a weighted severity of 0,4
0.1. During the years he suffers from the
knee injury his health is only 0.9 of the max- 0
C imum of 1.0. After a few years of knee disa- 0 10 20 30 40 50 60 70 80 90
M bility he is successfully operated on and re- Age x
Y
covers completely. At the age of 45 he gets
cancer, which disables him more and more Figure 3.7 Age weights in the DALY calculations.
K
until he finally dies at the age of 60 years. The Source: World Bank; World Development Report, 1993.

3 Health indicators
But bearing all these inherent weaknesses

1000 in mind, DALY is still an interesting meas-
ure, because it is the first comprehensive at-
Number at persons
tempt made to summarise the worlds bur-

den of injury, disease and premature death.
Years lost to:
Premature death
It has initiated a debate and new research to
Disability find even better complex indicators for glo-
bal comparisons (Murray 2002). The DALY
0 measure is useful to describe the disease bur-
0 80 den across the world and to make projec-
Age in years tions for the future. At present, many coun-
tries are exploring the possibility of using
Figure 3.8 Illustrations of DALYs lost due to prema-
DALYs as a measure of trends in disease bur-
ture death and disability by a large population.
den and as a tool for cost-effectiveness stud-
Source: Stefan Peterson; Karolinska Institutet, Stockholm.
ies and priority setting. The main results
from the Global Burden of Disease study are
prevalence and incidence of disease, as well presented in chapter 4.
as expert judgement when data were not Since Murray and Lopez moved to work at
available. By adding all the DALYs lost for a the WHO in 1999, WHO has started to in-
certain disease in a defined population, the clude the DALY measure in their annual re-
DALY curve looks like the example in figure port. This allows for refinement of the results
3.8. from the initial study because of new health
The DALY measure has been criticised be- data. From the year 2000, they also included
cause of the four built-in social preferences. a DALE, disability-adjusted life expectancy,
These are (1) different weights for sexes, (2) which was renamed as the more cheery
different age weights, (3) discounting future HALE, health-adjusted life expectancy, in
years lost and (4) severity weighting of disa- 2002. This measure is based on life expect-
bilities. Many argue that life years for men ancy at birth, but includes an adjustment for
and women should be given the same the time spent in poor health. It is the equiv-
weight. However, as has been described alent of the number of years a newborn can
above the difference is small and only gives expect to live in full health, based on current
a slightly greater value for diseases that af- statistics of mortality and morbidity. In Ja-
fects females. Some people argue that all pan, for instance, the HALE is 72 years, while
years lost should be given the same value in- in Afghanistan only 35 years. Many find this
dependently of the age at which the years are a measure that is instinctively easier to un-
lost. Others argue that discounting years is derstand compared to DALY.
wrong, because they value years now and in
the future equally. In a complex measure like
DALY, the built-in social preferences may 3.7 Total fertility rate
conceal issues of inequity. However, sensitiv-
ity analysis has shown that the results of the The number of children that would be
Global Burden of Disease study are not born per woman if she were to live to the
end of her childbearing years and bear
greatly affected by these social preferences.
children at each age in accordance with
Another problem is that the Global Burden the prevailing age-specific fertility rates
C of Disease study calculates DALY on data,
M which on some continents are of poor qual-
Y
ity. Especially for the disability calculations, The fertility rate measures how many chil-
the data is of varied quality in different re- dren an average woman would give birth to
K
gions and for different disease conditions. if all through her own reproductive age pe-

3.7 Total fertility rate
1964 2003
Developing Pakistan Iran Nigeria
7 7
countries Mexico Congo
Philippines Bangladesh
Thailand India
China Congo
6 6 Nigeria
Vietnam
Number of children per women

Number of children per women
Brazil Turkey Ethiopia Ethiopia
Indonesia
5 5 Pakistan
4 Industrilized 4
USA countries Philippines
Bangladesh
3France Italy 3 India
India
UK
Germany
Size of bubble = Size of bubble =
2 Japan
Russia
size of population
2 size of population
China
1 1
0 100 200 300 0 100 200 300
Child deaths before age 5 per 1 000 born Child deaths before age 5 per 1 000 born
Figure 3.9 Changes in fertility rate and child in 22 countries with > 50 million people.
(See in moving graphics with all countries at www.gapminder.org)
riod she was to give birth each year at the woman, as against 3.5 in the Middle East
rate of women in her country for a particu- and North Africa, 3.4 in South Asia, 2.6 in
lar year. Latin America and the Caribbean, 2.0 in East
If the total fertility rate is 2.1, the popula- Asia and the Pacific, 1.7 in the former social-
tion is replacing itself, meaning that one ist countries of Europe and 1.7 in high-in-
man and one woman replace themselves come countries. In all of these regions the
with the same number of individuals in the fertility rates continue to decrease.
course of their reproductive career. If all It is remarkable to see that all over the
women on earth had a total fertility rate of world the decreasing trend in under-five
2.1, there would be no population growth. mortality rates occurs along with a decreas-
Unlike the crude birth rate, the total fertility ing trend in total fertility rates. This trend is
rate is not affected by the age structure of created not in a straight causation chain but
the population. This makes total fertility as a web of factors that affect both child sur-
rate more relevant for comparison of fertil- vival and fertility. However, most scientists
ity across countries and times, whereas agree that a decline in child mortality pre-
crude birth rate is needed for calculation of cedes a decline in fertility, because mothers
population growth rate. must be confident that their children will
The total fertility rate in the world has de- survive before they will go for two child
C creased dramatically from 5.0 in 1955 to 4.2 families (Figure 3.9).
M in 1975 and 2.8 in 2002. It is estimated to
Y
decrease further to 2.3 in 2025 (WHO 98,
UNICEF 2004). Today, Sub-Saharan Africa is
K
at the top of the list, with 5.5 children per

3 Health indicators
3.8 Crude birth rate with a large proportion in the childbearing

age naturally has a higher crude birth rate
Number of births per 1 000 population than a population with predominance of ei-
during one year. ther children or people beyond fertile age.
So the high crude birth rate in Africa arises
from the combination of high fertility and a
The total number of births in the world in young age structure.
2002 was about 130 million. The crude birth
rate in the world is 22 births per 1 000 people
per year, a decrease from 33 in 1970. The
crude birth rate varies between the countries 3.9 Crude death rate
of the world from 8 children born per 1 000
population to 53 per 1 000 population. The Number of deaths per 1 000 population
sub-Saharan region has the highest figure, 41 during one year.
births per 1 000 population. Middle East and
North Africa has 27 per 1 000 population,
South Asia 26, Latin America and the Carib- On a global scale, crude death rate varies
bean 22, East Asia and the Pacific 17, the from 2 to around 20 per 1 000 population.
former socialist countries of Europe 13 and The total number of deaths in the world in
the high-income countries 12 (Table 3.4). 2002 was about 57 million (WHO 2004).
Crude birth rates have declined in all re- Sub-Saharan Africa has the highest crude
gions of the world over the last 30 years. In death rate in the world, with 18 deaths per
Sub-Saharan Africa, that decline has been 1 000 population per year, but this still rep-
the slowest, only from 48 to 41, while in resents a decline from 21 in 1970. Crude
East Asia and the Pacific region, the decline death rates in the Middle East and North Af-
was from 35 to 17 in the same time interval. rica regions were 17 in 1970 and 6 in 2002.
In 2002, many of the former Socialist coun- During the same time period, crude death
tries of Eastern Europe and central Asia, rate declined from 18 to 9 in South Asia,
Sweden, Switzerland, Austria, Greece, Italy from 11 to 7 in East Asia and the Pacific, from
and Germany had a crude death rate higher 10 to 6 in Latin America and the Caribbean,
than crude birth rate, causing a negative and from 10 to 9 in the high-income coun-
population growth if immigration is insuffi- tries, but increased from 9 to 11 in the former
cient to compensate. All other countries had socialist countries of Europe (UNICEF 2003).
higher birth than death rates. In refugee camps, the crude death rate is a
Crude birth rate is dependent on the age useful indicator of the adequacy of emer-
structure of the population. A population gency interventions. It is easy to calculate,
Table 3.4 Crude birth rate, crude death rate by region in 2002.
Region Crude birth rate Crude death rate

South Asia 26 9
C
Latin America and the Caribbean 22 6
M
CEE/CIS and Baltic States 13 11
Y High Income countries 12 9
K
Source: State of the Worlds Children, UNICEF, 2004.

3.9 Crude death rate
RWANDA, Gikongoro district. Refugee camp. November 1994.

the total number of deaths during one year found in 1994 following the genocide in
divided by the total population times 1 000, Rwanda among the population in the refu-
to get number of deaths per 1 000 popula- gee camps of Goma in the present Demo-
tion. Crude death rate is also sensitive to cratic Republic of Congo. The reason was a
changing conditions in the life of the refu- cholera epidemic on top of the other suffer-
gees, for example if a cholera epidemic has ings of the refugees. The crude death rate
started. Since the health situation may was as high as 43 per 10 000 population per
change very rapidly in a refugee camp, day (Paquet 1994). The regular death rate in
death rates are mostly measured as the Rwanda of 20 per 1 000 population per year
number of deaths per 10 000 populations per corresponds to 200 deaths per 10 000 popu-
day. A decrease in crude death rate is always lation per 365 days, about 0.5 deaths per
good in a high-mortality population. 10 000 population per day. This means that
Cause-specific death rates may also be use- the death rates had increased 80-fold among
ful for planning interventions. If, for exam- the refugees.
ple, there is an increase in death rate from The risk of death varies with age. The
diarrhoeal disease, one has to find out highest age-specific death rates in life are
whether the deaths are caused by cholera, seen in the first week of life, and especially
shigellosis or ordinary diarrhoea, and then the first 24 hours, and then above the age of
C plan to isolate and treat the patients cor- 65 years, increasing progressively in older
M rectly and try to discover and eliminate the age (Figure 3.4). Because of this the crude
Y
source of contamination. death rate is very dependent on the age
The highest crude death rate ever meas- composition of the population. This is why
K
ured and published in modern times was crude death rate is a useless health indicator

3 Health indicators
Table 3.5 Crude death rate and Crude birth rate in United Arab Emirate and Sweden in 2002.
Crude death rate Crude birth rate Life expectancy

United Arab Emirate 2 17 75
Sweden 11 10 80
Source: State of the Worlds Children, UNICEF 2004.
for international comparisons, as illustrated efforts into developing the education sys-
by the example of Sweden and the United tem and the health services. With social and
Arab Emirates, in Table 3.5. medical advancements, the health has im-
The United Arab Emirates have a crude proved but the risk of dying is not lower in
death rate of 2 per 1 000 population, a de- any age group in UAE than it is in Sweden.
crease from 12 per 1 000 in 1970. Sweden The reason for the low crude death rate is
has had an increase in crude death rate from only a different population composition
10 to 11 per 1 000 population since 1970. with very few old people. In Sweden, where
Does this mean that the risk of dying is a large proportion of the population is over
lower in the United Arab Emirates than in 65 years of age, the crude death rate is
Sweden? If the two population pyramids in higher; because of a large proportion of the
the two countries are compared, one can see population belong to age groups where the
that the United Arab Emirates have a more risk of death is higher (Figure 3.10).
broad-based population pyramid, meaning In conclusion, as a country experiences a
that the population is younger than in Swe- positive socio-economic development, with
den. In the United Arab Emirates the health increasing life expectancy and falling fertil-
has improved immensely because of a good ity rates, crude death rate will gradually fall
economy and because the country has put from 30 per 1 000 to less than 5 death per
Y
Figure 3.10 The population pyramides of Sweden and United Arab Emirate 2000.
K
Source: UN statistics 1996.

3.10 Population growth rate
1 000 population. When the population Population annual growht rate 197090
pyramid changes to a less broad based distri- Population annual growht rate 19902001
bution, the crude death rate will increase to
3,5
around 10 per 1 000 population, despite
continued improved life expectancy. There- 3,0
fore, the crude death rate is useless as a
health indicator for international compari- 2,5
sons.
2,0
1,5
3.10 Population growth rate
1,0
Growth of the population size in one year
expressed in percent. 0,5
0
The annual population growth rate in per- Africa
Sub-Saharan
and North Africa
Middle East
South Asia
and Pacific
East Asia
and the Caribbean
Latin America
Baltic States
CEE/CIS and
countries
High Income
cent between 1990 and 2002 varied globally
from 1.4 % in Estonia to +4.2 % in Afghan-
istan. In shorter time periods, the variation
in growth rate can be even greater. The
world population growth rate was estimated
at 1.5 % between 19902002, a decline from
Figure 3.11 Population annual growth rate by
1.8 % for the period 19701990. The re- region between 19701990 and 19902000.
gional differences in annual population
Source: State of the Worlds Children. UNICEF, 2003.
growth rate are large (Figure 3.11).
The annual population growth rate in a
country depends on three factors: death therefore useful to understand the force in
rates, birth rates and migration. Underlying population growth but it does not consti-
these factors is a complex web of cultural, tute an exact prognosis (see chapter 10).
environmental and socio-economic factors One way of depicting foreseeable popula-
like child survival, access to family plan- tion growth is to plot the population pyra-
ning, literacy rate, the status of women in mids of a country or region. When the pyra-
society, etc. The speed of growth is better ap- mid has a large base, there is a high fertility.
preciated by calculating the doubling time In contrast, high-income countries have a
at present growth rate. The doubling time of small base, and since survival is larger at all
a population can be rapidly estimated from ages, the pyramid only slowly diminishes
the equation with higher ages.
69
------------------------------------------------------------------------------------------------------
Annual population growth rate in %
3.11 Anthropometrical
For example, Zimbabwe had an annual
growth rate of 3.0 % between 1980 and
indicators
C 1996. 69/3 = 23, meaning that the popula- The most used method for the assessment of
M
tion in Zimbabwe is doubling from 11 mil- under or over nutrition in a population is to
lion to 22 million in about 23 years, if noth- measure the size of the body of a represent-
Y
ing happens to birth rate, death rate or mi- ative sample of individuals from a specific
K
gration. The doubling time concept is age and gender group (Gibson 1990). The

3 Health indicators
measurement of body size is called anthro- whether the objective is to assess shape or
pometry. The word means to measure man, growth or perhaps both of these characteris-
from Greek anthropos = man and metrein = to tics. With the basic measurements of a child,
measure. In its simplest form it includes the weight, height, age and sex, three major an-
measurement of the body weight and the thropometric indices can be calculated using
body height. In adults over 18 years of age, for example free software called Epi Info
the aim is to assess if the subject is thin, or- 2002.1
dinary or overweight by comparing the
weight with the height of the subject. This is
done by combining these two measure- 3.11.1 Body mass index (BMI)
ments in the indicator called Body Mass In-
Proportion of overweight adults:
dex (BMI), which is a measurement of the
% with BMI (kg/height in m2) > 25
shape of the body. The proportion of the
Proportion of underweight adults:
population with a BMI below and above the % with BMI (kg/height in m2) < 18.5
normal range becomes the indicator of
under and over nutrition.
Anthropometry in children is more de- BMI is the most used anthropometric indi-
manding than in adults, because two as- cator of nutritional status in adults. It is cal-
pects must be evaluated. First, just as with culated as the weight in kilograms divided
the adults the proportion of children with a by the height in metres squared. The BMI
body shape that is thin, ordinary or over- value reflects the balance between dietary
weight. Second, the proportion of children energy intake and physical activity during
that have normal and abnormal growth per- the last few months or several years. Dis-
formance, respectively. Growth is specific to eases that affect digestion and metabolism
children. The difficulty with measurement as well as infectious diseases that put extra
of growth is that the child must be com- energy demand on the body also influence
pared with a group of healthy children of BMI. Therefore BMI cannot distinguish be-
the same age and sex. A thin child is said to tween a person that is thin due to lack of
be wasted and the phenomenon is generally food, due to AIDS or due to both.
called wasting. If a child has impaired Adults with a BMI between 18.5 and 25
growth, she/he is said to be stunted and the tend to have fewer diseases and to live
phenomenon is known as stunting. The joint longer than persons with a lower or higher
effect of stunting and wasting is that the BMI. A person who is unhealthily thin is
child weighs less than normal for its sex and said to be wasted, and the phenomenon is
age and this is referred to as underweight. generally known as wasting. In contrast, a
Whenever anthropometric surveys of chil-
dren are done, it should be made clear 1
www.cdc.gov
Acceptable range
Thinness Obesity
Optimum
C 16 17 18,5 20 22,5 25 30 40
M
Figure 3.12 A schematic diagram outlining the optimum range of BMI and the cut-offs for warning grades
Y
of thinness and obesity.
K
Source: TALC, Teaching aids at Low Cost.

3.11 Anthropometrical indicators
person who is unhealthily fat is said to be meaning that the child has been frequently
overweight or obese. A BMI >25 indicates sick in the last weeks and months. In order
overweight, but this is not necessarily equiv- to know whether a child has an acceptable
alent to obesity, as athletes with great mus- weight-for-height, the index of a child must
cle mass will also have a high BMI. Over- be compared with a population of ordinary
weight is usually classified as grade 1: 2530; and healthy children of the same age and
grade II: 3040; or grade III: >40. If BMI is sex as described below in section 3.11.3.
below 18.5, the risk of death increases. It has Mid-upper arm circumference (MUAC) is
also been suggested to classify adult wasting commonly used as a proxy for body shape,
into three grades: grade I: 1718.5; grade II: substituting for BMI in adults and weight-
1617; and grade III: <16, the last bearing for-height in children. MUAC usually re-
the highest death risk. If the number of indi- mains almost unchanged from the age of 1
viduals with low BMI in a population is in- to 5 years. The normal circumference at this
creasing, it is likely that there is a food age is around 16.5 cm. Below the cut-off
shortage. point of 13.5 cm, the child is moderately
One shortcut to assessing the shape of the wasted. A child with a MUAC below 12.5 cm
body is to measure the mid-upper arm cir- is classified as being severely wasted.
cumference (MUAC), assuming that a thin
arm accompanies a thin body. This is
quicker, but may still be good enough in 3.11.3 Height-for-age (HFA), stunting in
emergency settings. It is useful for pregnant children
women, as the thickness of the arm is not af-
The proportion of stunting in children is
fected by the pregnancy. It should be noted
the % of children in a specific age group
that BMI does not tell if a person or a popu- with height-for-age below 2 standard
lation is tall or short. The attained height of deviations of a reference group.
adults is the best summary measure of life
conditions during childhood and adoles-
cence, as it is not further affected by what If the height is related to age, the index is
happens in adult life. called height-for-age (HFA). This index as-
sesses the childs growth performance and
answers the question: How short is the
3.11.2 Weight-for-height (WFH), wasting in child for his age? or How stunted is the
children child? If the childs HFA is low, he/she is
classified as stunted. Stunting is a condi-
The proportion of wasting in children is
tion in which the child is short for his/her
the % of children in a specific age group
with weight-for-height below 2 standard age. This condition seems to reflect overall
deviations of a reference group. socio-economic conditions and has no im-
mediate connection with the diet, because
too many other factors also influence
By relating the weight to the height of a growth performance. It is often erroneously
child, an index called weight-for-height is said to be a sign of hunger and lack of food,
derived. This index is often abbreviated as but stunting is mostly not caused and can-
WFH. It is similar to body mass index and not be treated by better diet alone.
answers the question: How thin is the In order to know whether a child has an
C child? or How wasted is the child? Wast- acceptable height-for-age, the height of the
M ing is a condition in which a child has a low child must be compared with a population
weight for its height and has lost muscle of healthy children of the same age and
Y
mass and fat stores. It is a sign of current and sex. But how should one select ordinary,
K
recent malnutrition or of over-diseasing, healthy children? For a long time, it was

3 Health indicators
thought that each ethnic group needed its centage of median the childs height is: 87/
own reference or standard. However, it has 100 = 87 %. So the child is 87 % of median in
been found that children from different eth- WFH. The lower cut-off used for height
nic and genetic groups grow at the same rate (HFA) is 90 % and the child is thus stunted
if they are living in well-to-do circum- according to this definition. The cut-off
stances. In contrast, wide differences are used for weight (WFH and WFA) is 80 %.
found within countries between the well-to- A third method sometimes used is the cal-
do children and the poorest children in the culation of percentiles of the reference pop-
same ethnic and genetic group. In India the ulation. The cut-off for the percentile of any
mean height in 7 year-old boys differ by of the indices is usually below the 3rd centile.
more than 10cm between the upper and A child who is below 2 SD score in WFH
lower income groups. In Sweden, this socio- is wasted, and if the child is below 3 SD
economic gap in height between poor and score or has symmetrical oedema (i.e. swell-
rich closed some decades ago, when chil- ing) of the feet and legs he/she is severely
dren from families with low income reached wasted and in immediate danger. Such a
the same growth performance as children in child should be admitted to hospital where
the upper income groups. he/she can be observed, treated and fed day
The nutrition unit at WHO co-ordinates a and night. A child that has a very low height-
multi-centre study on how children grow in for-age but a normal weight-for- height has a
well-to-do groups around the globe. WHO chronic problem that must be alleviated but
recommend the use of an American refer- the child is not in urgent need for care.
ence database until the new data will be-
come available as a worldwide reference.
The recommended database was collected 3.11.4 Weight-for-age (WFA), underweight
and compiled by the National Centre for in children
Health Statistics in the United States. It is re-
The proportion of underweight in children
ferred to as the WHO/NCHS database and is
is the % of children in a specific age group
used as a reference in anthropometric stud- with weight-for-age below 2 standard
ies of children around the world. When deviations of a reference group.
comparing a childs weight-for-height with
the weight-for-height of the children of the
same age and sex in the reference popula- A third common index is derived by com-
tion, there are three mathematical ways to bining weight and age to weight-for-age,
express any deviation: (1) Standard devia- WFA. This index summarises in a way the
tion (SD) scores are also called z-scores, (2) two previous indices, the body shape and
percent of median and (3) centiles. the growth performance. This index an-
Standard deviation scores (SD scores), are swers the question: How underweight is
the best to use but a little complicated to ex- the child for his/her age? This index is eas-
plain. A normal value is defined as a value ily perceived as the most straightforward as
of any of the three child anthropometric in- it is what is frequently done in clinical ex-
dices falling within 2 and +2 standard devi- amination of sick children. However, this
ations from the median. Any value outside index is not very useful as an indicator of
2 and +2 standard deviations is considered the health and nutritional status of a child
abnormal. population because it is a messy mix of
C The percent of median is simpler to un- wasting that is mainly linked to nutrition
M
derstand. For example, a child has a height and stunting that is only partly linked to
of 87cm and the median for his age is nutrition. In spite of this the weight for age
Y
100cm. By considering the median to be index is unfortunately frequently used as an
K
100 %, it is possible to calculate what per- indicator of malnutrition. This is probably

because malnutrition indexes are mainly Normal Wasted Stunted

used to advocate for action rather than to
analyse which action is needed. In popula-
tions where stunting rates are high, such as
in India, the weight for age indicator will
identify a lot of children as malnourished. A
project to improve the diet in such an area is
highly unlikely to influence the stunting
rate and might easily be said to have failed
when it is found that the stunting rate re-
mains almost the same. In contrast an in-
creased rate of underweight young children
that have suffered the effects of a war can be
almost exclusively due to increased wasting
due to prevalent diarrhoea and lack of food Figure 3.13 llustration of the difference between a
during the previous weeks. It is usually bet- normal child, a wasted child and a stunted child of
the same age. A child could also be simultaneously
ter to separate the assessment of body stores
stunted and wasted. The priority for nutrition inter-
of energy and growth performance by the
vention is on wasted children.
two other indices: weight-for-height (WFH)
for wasting and height-for-age (HFA) for
stunting. down to 12 % in South America. On a global
The World Health Organization has estab- basis, 10 % of children in low-income coun-
lished a Global Database on Child Growth tries are wasted, which means the situation is
where all major surveys on child anthro- poor. Different kinds of disasters may raise
pometry are gathered.1 the figures dramatically in affected areas.
The percentage of wasted children (weight- This is a disturbing picture of under-nutri-
for-height below 2 SD of WHO/NCHS refer- tion among children under five in underpriv-
ence value) in low-income countries ranges ileged populations. These children should be
from 25 % in Afghanistan and 16 % in India an important target group for any kind of nu-
trition intervention undertaken in these
1
www.who.int/nutgrowthdb countries.
Table 3.6 Classification of under nutrition.
Moderate undernutrition Severe undernutrition

Symmetrical oedema No Yes (oedematous undernutrition)*
Weight-for-height
Z-score Between 2 and 3 Z-score Below 3 Z-score
% of median Between 70 to 79 % Below 70 %
(moderate wasting) (severe wasting)**
Height-for-age
Z-score Between 2 and 3 Z-score Below 3 Z-score
% of median Between 85 to 89 % Below 85 %
C
(moderate stunting) (severe stunting)
M
* This includes kwashiorkor and marasmic kwashiorkor in older classifications. However, to avoid confusion with the
Y clinical syndrome of kwashiorkor, which includes other features, the term oedematous malnutrition is preferred.
** This corresponds to marasmus (without oedema) in older classifications. However, to avoid confusion, the term
K
severe wasting is preferred.

3 Health indicators
Table 3.7 Global estimates for the prevalence* of wasted, stunted and underweight children in different
regions 19952004.
Region % wasted % stunted % underweight

Sub-Saharan Africa 9 38 29
Middle East and North Africa 6 21 14
South Asia 14 44 46
Latin America and the Caribbean 2 16 7
CEE/CIS and Baltic States 3 14 5
High Income countries
* % below 2 SD of WHO/NCHS reference value.

Source: State of the Worlds children, UNICEF 2006.
Stunting (height-for-age below 2 SD of has suffered from physical violence. Other

WHO/NCHS reference value) is widespread reasons are smoking and placental insuffi-
among children in low-income countries. It ciency. At the population level, low birth
ranges from 52 % in Afghanistan and 46 % weight is mainly a reflection of the health,
in India to 16 % in South America. The glo- social, nutritional, and cultural status of the
bal average prevalence of stunting among pregnant women. Poverty and low social
children in low-income countries is 32 %. status cause malnutrition in women. A
Increasing evidence shows that stunting is woman may be working hard in the fields
associated with poor developmental attain- and have too many children, too close to-
ment in young children and poor school gether, without access to fertility regulation
achievement or intelligence levels in older methods. Recurrent episodes of malaria de-
children. The underlying causes of this plete her stores of iron, and her general nu-
growth retardation are poverty and lack of tritional status may be poor even before a
education. new pregnancy. The prevalence of low birth
weight varies between regions, from 30 % in
South Asia, 15 % in Africa, 8 to 10 in middle-
3.11.5 Low birth weight income countries and 7 % in the high-in-
come countries. (UNICEF 2004). The strong
The proportion of newborns with low
association between poverty and low birth
birth weight is the % of children born
with a weight less than 2,500 grams. weight is confirmed by the fact that 95 % of
all low-birth-weight babies (20 out of 21
million per year) are born in low-income
Low birth weight is defined as a weight less countries. The fact that the proportion of
than 2,500 grams at birth, regardless of low birth weight and underweight in chil-
whether the child is born pre-term (i.e. be- dren in South Asia is so much higher than in
fore the end of the pregnancy) or not. The Africa, where infant mortality is higher, has
birth weight is strongly correlated to the not been well explained.
chances of survival of a newborn baby. Low
C birth weight may be caused by low food in-
M
take and hard work by the mother during
the pregnancy. It may also be caused by dis-
Y
eases such as malaria that have affected the
K
mother during pregnancy or because she

References and suggested further reading Murray CJL, Lopez AD. Global Health Statis-
Antonsson-Ogle B, Gustavsson O, Hambreus tics: A Compendium of Incidence, Preva-
L, Holmgren G, Tylleskar T. Nutrition, lence and Mortality Estimates for over
agriculture and health when resources are 200 Conditions. (Global Burden of Dis-
scarce. 2nd revised edition. Uppsala: Upp- ease and Injury, No 2) Harvard School of
sala University; 2000. Public Health, World Health Organisa-
Bryce J et al, Can the world afford to save tion, World Bank 1996.
the lives of 6 million children each year? Murray CJL, Lopez AD. Health Dimensions
Lancet, Vol 365, 2005; pp. 21932200. of Sex and Reproduction: The Global Bur-
Gibson RS. Principles of Nutritional Assess- den of Sexually Transmitted Diseases,
ment. Oxford University Press; 1990. HIV, Maternal Conditions, Perinatal Dis-
Hill K, AbouZahr C, Wardlaw T. Estimates of orders, and Congenital Anomalies. (Glo-
maternal mortality for 1995. Bulletin of bal Burden of Disease and Injury, No 3)
the World Health Organization 2001;79: Harvard School of Public Health, World
18298. Health Organisation, World Bank 1998.
Jamison DT, Breman JG, Measham AR, Murray CJL, Salomon JA, Mathers CD, Lopez
Alleyne G, Claeson M, Evans DB, Jha P, AD (eds). Summary measures of popula-
Mills A, Musgrove P. Disease Control Pri- tion health. WHO 2002.
orities in Developing Countires. Oxford Murray CJL, Lopez AD. The Global Epidemi-
University Press, 2006. ology of Infectious Diseases (Global Bur-
Last JM. A Dictionary of Epidemiology. den of Disease and Injury, No 4) Harvard
Oxford University Press; 1983. School of Public Health, World Health
Lopez A, Mathers CD, Ezzati M, Jamison DT, Organisation, World Bank 2003.
Murray CJL (eds) Global Burden of Dis- Murray CJL, Lopez AD. The Global Epidemi-
ease and Risk Factors, Oxford University ology of Non-communicable Diseases:
Press, 2006. The Epidemiology and Burdens of Can-
Murray CJL Quantifying the burden of dis- cers, Cardiovascular Diseases, Diabetes
ease: the technical basis for disability- Mellitus, Respiratory Disorders, and Other
adjusted life years. Bulletin of the World Major Conditions (Global Burden of Dis-
Health Organization 1994;72:429445. ease and Injury, No 5) Harvard School of
Murray CJL, Lopez AD, Jamison DT. The Public Health, World Health Organisa-
Global Burden of Disease 1990: summary tion, World Bank 2003.
results, sensitivity analysis and future Paquet C, van Soest M. Mortality and malnu-
directions. Bulletin of the World Health trition among Rwandan refugees in Zaire.
Organization 1994;72:495509. Lancet 1994:823.
Murray CJL, Lopez AD. The Global Burden State of the Worlds Children. UNICEF
of Disease: A comprehensive assessment 19972004.
of mortality and disability from diseases, World Bank, World Development Report
injuries, and risk factors in 1990 and pro- 1993. Investing in Health. 1993.
jected to 2020. (Global Burden of Disease WHO, World Health Report, 19982004
and Injury, No 1) Harvard School of Pub- (www.who.int/whr.en).
lic Health, World Health Organization,
World Bank 1996.

4 Health transition
4 Health transition
Health transition is a concept that describes socio-economic factors as the most impor-
the change in disease patterns that occur tant for the early health transition in West
during socio-economic development (Om- Europe (McKeown 1983). However the spec-
ran 1971). Health transition is composed by tacular improvement of health in the world
two interlinked components: demographic during the last 50 years is to a large part, per-
transition and disease transition. The disease haps up to 50 %, attributed to new health
transition is sometimes called the epidemio- technologies.
logical transition. The socio-economic development of a
The health transition is caused by the country may reverse during war, political
changes in life conditions and environment conflicts and long-standing economic de-
that occur during development. These clines. Recent analysis has noted that
changes decrease the occurrence of some achieved health improvements are surpris-
diseases and increase the occurrence of oth- ingly resistant to economic backlashes and
ers, but the occurrence of diseases also deteriorations of access to medical technol-
change as a result of the new composition of ogy. This made Murray and Chen (1993)
the population. During socio-economic de- suggest that the joint effect of socio-eco-
velopment the proportion of children and nomic improvements, behavioural changes
adolescents will fall and the proportion of that favour hygiene and use and provision
old people will increase as a result of the de- of health service even in difficult periods are
mographic transition. The health transition due to accumulated health assets in the
starts from a disease pattern dominated by society. These assets are the professional and
malnutrition and infectious diseases in a so- personal knowledge, skills and traditions in
ciety with high fertility where half the pop- society that promote health and favour the
ulation is less than 15 years of age. It pro- needs of the vulnerable in times of scarcity.
ceeds gradually to a society with low fertil- This view parallels the interpretation of
ity, where a quarter of the population is multidimensional development presented
more than 65 years of age and where non- in chapter 1.9.3. An example of this is when
communicable diseases prevail. Cuba suffered a severe and prolonged eco-
The driving forces behind the health tran- nomic decline during the 1990s. The back-
sition are socio-economic changes, welfare ground was the sudden loss of favourable
policies, public health actions, and cultural trade conditions with The Soviet Union
and behavioural changes that jointly lead to when the latter nation dissolved. The result-
a new age distribution and a new pattern of ing economic crises resulted in some nega-
disease in the population (Figure 4.1). In- tive health effects but the child mortality
creased use of health technology may also and life expectancy continued to improve in
C be added but it should be noted that the ac- Cuba throughout the decade. Another ex-
M cess to vaccines and antibiotics occur at dif- ample is Sweden during the same decade
Y
ferent stages of socio-economic develop- when economic recession resulted in in-
ment in different countries. The analysis of creased unemployment and budget cuts in
K
the different driving forces has favoured the the public health service system. In spite of

4.1 Disease transition
Health transition
Demographic Disease transition

transition
Socioeconomic Infectious Fertility Non- Decreased

development brings disease, declines communic- mortality in
better nutrition, maternal, and the able some non-
better housing, perinatal population diseases communicable
increased literacy, and ages. and diseases, but
safe water and nutritional injuries new diseases
sanitation. mortality increase. arrive...
declines.
Modern health
technology Cultural and behaviour factors affecting
hygiene, use of health service, tobacco,
alcohol, safe sex etc.
Figure 4.1 The health transition, showing the relationship between the demographic and the disease tran-
sition.
Source: Adapted from Mosely et al., 1997.
these economic difficulties the child mortal- The countries of the world are at very
ity fell during the entire decade and life ex- many different stages of health transition.
pectancy increased for both men and To understand the different stages of health
women. A third example is Sri Lanka that transition it no longer makes sense to clas-
had suffered a prolonged civil war during sify countries into the two groups; industri-
the last two decades and in the same time alized and developing (see chapter 1.10).
period the formerly low child mortality has This chapter explains the reciprocal effects
continued to fall in the country. between general development, disease oc-
The health transition occurs at different currence and demographic changes. We
times and speeds, depending on the pattern focus first on the disease transition and then
and rate of social and economic develop- the demographic transition even though
ment in the country. Even within a given they are closely interlinked. We will thereaf-
country, the transition often occurs at differ- ter review the disease pattern in the world of
ent time periods in different population today and point to future projections as well
groups. High-income countries, which today as discuss the future implications for the
are post-industrial societies, are still under- health sector in countries at different stages
going a health transition due to changes of socio-economic development.
within the group of non-communicable dis-
eases. The earlier dominance of cardiovascu-
lar diseases and cancer is being replaced by
an increasing burden of Alzheimers disease
4.1 Disease transition
C and osteoporosis. This is both due to a Little is known about disease patterns in
M decrease in the age specific incidence of the pre-agricultural societies. It is assumed that
Y
first two types of diseases and to a continued when human societies passed from living on
increase of the proportion of very old in the hunting and gathering to practising agricul-
K
population. ture as the main means of subsistence, the

4 Health transition
mortality decreased and the fertility in- This stage persisted in Europe until around
creased. However, agriculture had its peri- the second half of the 18th century. Large
odic failures and it made people live close parts of the populations in some of the least
together in daily contact with domestic ani- developed countries suffering from complex
mals. Infections and periodic hunger domi- emergencies are still in this stage. These are
nated the disease pattern. The denser popu- collapsed countries (or parts of countries)
lation settlements in agricultural societies such as Sierra Leone, Somalia and Afghani-
led to severe hygienic problems, especially stan, and they may still be regarded as being
when urban settlements emerged. Trade and in this stage of the health transition.
travel over long distances formed the basis
for countrywide, continental and later pan-
demic (the whole world) diseases. One of 4.1.2 Stage of receding pandemics
these epidemic diseases was plague, and (todays low-income countries)
wide spread epidemics are known as pesti- In this stage of health transition, mortality
lence. declines but fertility remains high, with a re-
Based on the main causes of mortality in sulting exponential population growth. The
each historical period the disease transition life expectancy at birth is between 30 and 50
is arbitrarily divided into four stages (Omran years of age. Larger epidemics become less
1977; Olshansky 1986). frequent, but infectious diseases, maternal
disorders and malnutrition are still the main
1 pestilence and famine
causes of mortality.
2 receding pandemics
Most of the low and middle-income coun-
3 non-communicable diseases
tries entered this stage in the end of the
4 delayed degenerative diseases
1940s. Many of the low-income countries
Broadly speaking, these four historical stages are still at this stage today, especially those
are in the modern world represented by the in Sub-Saharan Africa. Following the severe
dominant disease patterns in (1) collapsed impact of the HIV/AIDS epidemic some
countries, (2) low, (3) middle and (4) high- countries in Africa may be considered to
income countries, respectively. However, have reversed to the pestilence stage of
this is a didactic simplification. Many coun- health transition. Europe and North Amer-
tries today have population groups that rep- ica entered the stage of receding pandemics
resent two, three or even all four of these towards the end of the 18th century and
stages at the same time. emerged from it about 100200 years later.
It is during this stage that the major de-
mographic changes known as the demo-
4.1.1 Stage of pestilence and famine graphic transition occur. Above all, women
(todays collapsed countries) and children benefit from the decline in
At this stage in development, mortality is mortality and fertility, since they previously
high and mainly determined by infectious suffered the greatest burden of infectious
diseases, malnutrition and pregnancy & diseases and maternal complications, in
birth related disorders. Some of the infec- combination with malnutrition.
tions, such as the Plague and smallpox were
spread in epidemics. Fertility rates are high,
and pregnancy-related mortality is also sig- 4.1.3 Stage of non-communicable diseases
C nificant. Population growth is slow or non- (todays middle-income countries)
M
existent because the high fertility is counter- This stage is entered through socio-eco-
balanced by high mortality. During this pe- nomic development, improved living con-
Y
riod, life expectancy at birth fluctuates be- ditions and targeted health interventions.
K
tween 20 and 40 years of age. With declining mortality due to infectious

4.2 Demographic transition
diseases, life expectancy at birth increases to public health actions resulting in an aware-
70 years of age and beyond. With an ageing ness of the importance of physical activity
population, the disease panorama changes and the risks of smoking. Also, the curative
from a high prevalence of infectious diseases aspect of medical science has become more
to a greater degree of chronic and non-com- successful in keeping people with chronic
municable diseases. When people survive diseases alive longer, at least when the soci-
communicable diseases, they may live long ety can afford these treatments. Many high-
enough to contract the non-communicable income societies have also experienced an
diseases. As a result, the ageing population increased occurrence of allergy, eating disor-
dies mainly from heart attacks and strokes, ders and several emerging psychosocial dis-
resulting from arteriosclerosis, and from orders of unclear aetiology, such as electro-
other non-communicable diseases, such as magnetic allergy, sick house syndrome
diabetes, cancer and obstructive pulmonary and chronic fatigue syndrome. These new
disease. In this stage, injuries become a great emerging disorders in the post-industrial
public health problem. society have tentatively been summarised
Most middle-income countries in the as confidence insufficiency disorders as they
world have entered this stage of the health are believed to mainly have psychosocial
transition now. In some middle-income causes.
countries a growing part of the population Many high-income countries have low
are already in the fourth stage. At the same fertility, often far less than 2 children per
time the more affluent parts of the popula- women. This result in an increased propor-
tion in todays low-income countries have tion of very old in the population and to-
entered into the stage dominated by non- gether with the disease transition the stage
communicable diseases. of delayed degenerative diseases puts a
heavy economic burden of care for the eld-
erly on the post-industrial societies. Only
4.1.4 Stage of delayed degenerative high-income countries with substantial im-
diseases (todays high-income migration such as the United States main-
countries) tain a high fertility rate in the post-indus-
This stage designates a new pattern of trial period and thereby the economic bur-
chronic diseases. This pattern gradually den of care for the elderly is relatively less in
emerges when the mortality due to ischae- the USA than in Western Europe.
mic heart disease and certain common types
of cancer start to decrease. When tobacco
smoking decreases and the dietary fat intake
is reduced people will die from Alzheimers
disease instead of a heart attack and instead The transition of a society from equally high
of suffering from chronic obstructive pul- birth and death rates with a stable size of the
monary disease they will live 10 years longer population to equally low birth and death
and then suffer from osteoporosis. Mortality rates, and once more a stable size of the pop-
from injuries also tends to decrease due to ulation, almost always involves a stage of
preventive measures, better trauma care and rapid population growth. The reason is that
improved rehabilitation. This results in a birth rates tend to fall later than death rates.
greater relative importance of chronic dis- This sequence, stable population, falling
C eases such as Alzheimers disease and oste- death rates, population growth, falling birth
M
oporosis, and other conditions, which are rates, and once more stable population, is
common in old age. known as the demographic transition. It oc-
Y
The increased burden of delayed degener- curs at different rates and in different time
K
ative diseases is partly a result of successful periods in the countries of the world. It is

4 Health transition
Table 4.1 Simplistic overview of the present stage of the demographic transition in different types of
countries.
Type of country Number born Number dead Surviving Size of the next
Generation
Collapsed countries 6 4 2 Equal

Low income countries 6 2 4 +200 %
Middle income countries* 4 1 3 +150 %
High income countries 2 0 2 Equal
* Some former communist countries have a low birth rate and therefore a decreasing size of next generation.
differently related to the socio-economic de-

Western Model England
velopment in different countries. Table 4.1 & Wales
shows an overview of the average number of 60
Crude birth rate & death rate per 1.000 population
Population in millions
60
children that are born and that die from 50
every women at each economic level in de- Population 50
40 Birth rate
velopment; collapsed countries, low, middle 40
30
and high-income countries, respectively. 30
20
Three different patterns of demographic
20
transition have been described as (1) classi- 10 Death rate
cal, (2) accelerated and (3) delayed, respec- 10
0
tively (Omran 1971). The classical transition
in Western Europe occurred over a period of Accelerated Model Japan
almost 200 years. In contrast the accelerated 60
140
transition in Japan lasted less than one cen- 50
120
tury and several middle-income countries 40
now appear to be making an even faster de- Birth rate 100
30
mographic transition. 80
20 Death rate
The transition in low-income countries, 60
especially in Sub-Saharan Africa, is desig- 10 Population
40
nated as delayed. This means both that the 0
onset of the decline in mortality occurs at a
late stage in history and that the decline in Delayed Model Sir Lanka
fertility is further delayed in relation to a rel- 60 12
atively rapid decline in mortality, assumed 50 10
to be due to the provision of new technolo- 40 Birth rate 8
gies through the health service. This has re- 30 Death rate 6
sulted in very fast population growth in Population
20 4
many African countries of the last 20 years.
However, the HIV epidemic is changing this 10 2
in several, but not all Sub-Saharan African 0 0
countries. To the three earlier categories of 1810 1850 1890 1930 1970
demographic transitions must now be Years
C added a new category resulting from the se-
Figure 4.2 Demographic transition in three differ-
M vere impact of the AIDS epidemic in popula-
ent patterns, 18101970.
tions where HIV have infected 2550 % of
Y Source: Omran AR. The epidemiological transition. Mid-
the adult population. This new model, land Memorial Fund, 1971.
K
which may be called reversed demographic

transition, i.e. a reverse to death rates almost eases. Literacy, as described in chapter 2, is
as high as the birth rates and thereby a de- one of the important determinants of the
crease and almost stop of the population decline in mortality. The age at marriage,
growth (Figure 4.2). trends in breastfeeding practices and ulti-
mately the changing roles of women are so-
cial and cultural changes that took place
4.2.1 Classical transitionsocio- over long time periods, but they are impor-
economically driven tant parts of the social changes affecting the
The classical (or Western) type of transition disease transition (Murray 1993).
took place in Europe over a period of 200 In Europe and North America, mortality
years. It mainly depended on socio-eco- began to decline during the age of receding
nomic changes in the society. The crude pandemics at the end of the 18th century,
death rate gradually decreased from about and the decline in fertility followed some
30 per 1 000 population to 10 or less per 5075 years later. But fertility initially in-
1 000 population, and the crude birth rate creased to some extent, because of better
decreased from about 35 to less than 20 per health and survival, and therefore young
1 000 population. This decline in mortality people survived and had a longer fertile age
started at the time when Edward Jenner interval. A small family norm gradually
made the smallpox vaccine available, but emerged and it improved child survival, ed-
more than a century before medical science ucation and the emancipation of women.
provided antibiotics. This reduced the population growth in Eu-
Up to the 18th century in Europe, crowded rope, in combination with the emigration to
living conditions with small, poorly venti- other continents. Almost 25 % of the popu-
lated apartments increased the likelihood of lation of Europe left for North America,
spread of diseases such as typhus, tuberculo- Latin America, South Africa, Australia and
sis and measles. Sweden and Finland have New Zealand in the 19th and the early 20th
maintained a thorough registration of vital centuries.
events since the mid 18th century. From this Industrialisation and the mechanisation
data, a decrease in mortality is seen as early of agriculture brought economic growth,
as the 1750s. Improved nutritional status but also adverse health effects, due to pesti-
and living standards, with better sanitation cides and occupational hazards. Urbanisa-
and access to clean water due to economic tion disrupted much of the social context,
growth and social policy, were responsible was associated to high unemployment rates,
for much of the decrease in the panorama of increased risk of accidents, and resulted in
infectious diseases in Europe and North what has been termed social pathology.
America. The elucidation of the transmis- Examples of social pathology are alcohol-
sion of cholera by John Snow in 1855, the ism, increased drug use and antisocial be-
discovery of the tuberculosis bacterium by haviour, with violence and rising crime
Robert Koch in 1882 and the development rates. Behavioural change following urbani-
of vaccine against rabies by Louis Pasteur in sation has also increased the prevalence of
1885 exemplifies the rapid increase in un- risk factors such as unsafe sex, smoking, and
derstanding of the infectious diseases. Diag- eventually a diet with a high content of
nosis and treatment gained a solid scientific sugar and saturated fats. These behavioural
basis, and the preventive measures were im- changes have increased the risks of develop-
C plemented. These preventive measures, to- ing some of the non-communicable dis-
M
gether with a gradually decreasing family eases, such as the neuropsychiatric and car-
size and improved economy yielded better diovascular diseases.
Y
housing that promoted a decline in the inci-
K
dence of tuberculosis and other airborne dis-

4 Health transition
4.2.2 The accelerated modelmedicine- 4.2.3 The delayed modelpopulation

and technology-driven growth and medical advances
The accelerated type of transition occurred The delayed model refers to the transition
in Japan, Eastern Europe and the former So- that is taking place in low and some middle-
viet Union. It started later than the classical income countries. This is characterised by a
model, on the basis of the late start of social decline in mortality over the last 50 years,
changes. However, the accelerated model probably largely driven by medical advances
was also catalysed by the worldwide im- and public health programmes, but where
provements in medical science and technol- social change and fertility decline lag be-
ogy, not the least in the introduction of con- hind, due to poverty. The decline in fertility
traceptive methods and safe induced abor- occurs but has not been rapid, and there is
tion, which rapidly lowered birth rates. very little possibility of emigration. There-
Mortality decline commenced at the begin- fore the population growth remains high.
ning of the 20th century in Japan, well be- The transcontinental emigration in historic
fore some of the major inventions of excel- Europe is urbanisation in contemporary
lent medical technology such as immunisa- Sub-Saharan Africa. In the classical and ac-
tion, antibiotics and oral rehydration celerated models, the population growth was
solution, but the introduction of these inno- seldom higher than 0.71 %, but in the de-
vations caused the mortality curve to delayed model, in some low-income countries,
cline more steeply. What took the high-in- it is still as high as 2.53.5 %.
come countries more than 100 years to Demographic transition is further de-
achieve has taken many of the accelerated scribed in Chapter 10. It describes the
countries less than 50 years. change in mortality and fertility that a coun-
Smallpox vaccination made a significant try experiences when undergoing socio-eco-
contribution to the decline in mortality nomic development. In summary, the tran-
since Jenner invented it in 1796. In Europe, sition is from high fertility and high mortal-
the last epidemic of smallpox was in 1870 ity in less industrialised societies, to low
72, and thereafter, with the introduction of fertility and low mortality in highly industr-
vaccination, disease surveillance and the ialised societies. If the decline in mortality
isolation of infected cases, the disease disap- exceeds the decline in fertility, for example
peared. In Sri Lanka, mortality in the post- due to access to medical interventions, pop-
war period declined rapidly, largely due to a ulation growth will increase rapidly. Many
malaria control programme using the new of the countries undergoing the delayed type
chemical technologies, DDT against the of transition were at this stage of rapid pop-
mosquito and chloroquine as a drug against ulation growth when they were stricken by
the malaria parasite. With other medical in- the HIV/AIDS epidemic.
novations, such as the manufacture of insu-
lin, not only mortality rates but also survival
rates of chronic diseases have improved. De- 4.2.4 The reversed modelHIV induced
mographic change can be very fast when Many but not all low-income countries have
people find that their children survive and been severely affected by HIV/AIDS, espe-
when acceptable family planning methods cially in Eastern and Southern Africa, in-
are available. Modern family planning cluding the middle-income countries South
methods, in use since the 1960s, represent Africa and Botswana. The HIV epidemic has
C
an important advancement in medical tech- in these countries slowed down the popula-
M nology, which has affected both the demo- tion growth due to a considerable increase
Y graphic trend in those areas with access to in mortality from AIDS. In 1960 the life ex-
K
the technology and the role of women pectancy at birth in Botswana is estimated
when planned pregnancies became a reality. to have been 47 years. Due to successful

4.3 Global Burden of Disease
Table 4.2 Birth, death and growth rate of the ates a new pattern in most countries se-
population in Botswana. verely affected by HIV. They have a very
slow population growth due to the com-
Rate per 1 000 population 1960 1987 2002
bined effects of high mortality and a simul-
Crude Birth Rate 52 40 31 taneously slight fertility decline that results
Crude Death Rate 19 8 20 in birth rates that are only slightly higher
Growth Rate in % 3.2 3.2 1.1 than the death rates, and hence there is a
Source: State of the Worlds Children, UNICEF, 2004. very slow population growth. (See also
Chapter 5.2).
socio-economic development and develop-

ment of preventive and curative health serv- 4.3 Global Burden of Disease
ices life expectancy increased to 61 years by
1987. All of this improvement and more has As a consequence of the different speed of
now been lost due to HIV/AIDS. Today the the health transition, the contemporary dis-
life expectancy in Botswana is estimated to ease patterns vary considerably between the
be around 40 years. Botswana is probably regions of the world. The Global Burden of
the country that has been most severely af- Disease study by Murray and Lopez (1997)
fected by HIV in the whole world. Presently was the first extensive study of the world-
39 % (sic!) of pregnant women are found to wide occurrence of all major diseases and of
be HIV infected. The corresponding demo- their impact on disability and mortality in
graphic rates for Botswana are shown in the human population. The study was done
Table 4.2. The table shows that the birth rate in collaboration between the Harvard
continues to decrease in spite of the in- School of Public Health, the World Bank
creased number of AIDS deaths. This gener- and the World Health Organization. Murray
600
DALY
Disability part of DALY
500
400
300
200
100
0
Sub- India Middle Other Latin China Formerly Established
Saharan Eastern Asia and America Socialist market
C
Africa Crescent islands and the countries economies
Carribean of Europe
M
Figure 4.3 Burden of disease measured as DALYs lost per 1 000 population for total DALYs and for only the
Y
disability part of the DALY indicator by region in 1990.
K
Source: World Development Report; World Bank 1993.

4 Health transition
I. Communicable, nutritional, perinatal and maternal disorders

II. Noncommunicable disorders
III. Injury
Africa
India
Eastern Mediterranean region
Western Pacific region middle and

low income countries
South East Asian region middle and
The Americas middle and
China
Europe middle and low

income countries
Western Pacific region high
income countries
The Americas high
income countries
Europe high income countries
0% 20 % 40 % 60 % 80 % 100 %
Figure 4.4 The burden of disease by broad cause group as percentage of total for the region in 1998. Rela-
tive importance of group I, II and III disorders.
Source: World Health Report; WHO 1999.
and Lopez developed the DALY measure to and the low- and middle-income countries
be able to compare the disease burden in dif- of Central and Eastern Europe, the non-
ferent regions of the world (defined in chap- communicable diseases dominate as the
ter 3.6). Figure 4.3 describes the total burden causes of mortality and DALYs lost. These
of DALYs lost in 1990 in the eight world re- countries have advanced furthest in the dis-
gions. This graph shows that already in ease transition and switched from a high
1990 the health transition had decreased prevalence in the communicable disease
the total disease burden in many regions of group to a disease pattern where non-com-
the world. The region of Sub-Saharan Africa municable diseases prevail (Figure 4.4). In
had the largest burden of disease per popula- India, Sub-Saharan Africa and the Eastern
tion, followed by India. The other regions Mediterranean region, in contrast, commu-
had a decreasing disease burden in parallel nicable, perinatal, maternal and nutri-
to their socio-economic development. Fig- tional disorders dominate. In the low and
ure 4.3 also shows that the mortality part of middle-income countries of the Western
the DALY measure declines more rapidly in Pacific and Southeast Asian regions, the
the beginning of the transition. burdens of communicable and non-com-
The Global Burden of Disease study clas- municable diseases are nearly equal. The
sified diseases into a first group, including proportion of injury as a cause of mortality
C communicable diseases, maternal, perinatal and DALYs lost varies the least between
M and nutritional disorders, a second group, in- regions. Between 710 % of the deaths in
cluding non-communicable diseases, and fi- the world are caused by injury, and be-
Y
nally a third group, including injury. In all tween 1114 % of the DALYs lost are due to
K
high-income countries, as well as in China injury.

4.4 Future projections
In conclusion, there is a great variation in change in the rank order of the most com-
disease patterns according to region, and be- mon causes of death from the year 1990 to
cause of different socio-economic develop- the year 2020 (table 4.3 modified to include
ments and differential application of public the DALY data from the update for 2002).
health measures, the countries of the world Ischaemic heart disease and cerebrovascular
show a great variation in their paths disease are projected to continue as the two
through the health transition. Many of the main causes of deaths in the world. The
low and middle-income countries will not communicable diseases (diarrhoeal disease,
have the privilege of dealing with one major respiratory infection, measles and malaria)
disease group at a time, but have to fight the and the perinatal disorders are projected to
communicable and non-communicable dis- decrease considerably.
ease groups simultaneously. This, of course, HIV was projected to rise from 30th place
has a profound influence on the health sec- in 1990 to 9th place in 2020, but HIV has al-
tor. ready, in 2002, reached number four as most
important cause of death (Table 4.3). With
an estimated 3 million deaths and 5 million
newly infected by HIV in 2003 it is most
4.4 Future projections probable that even before 2020 HIV will
The Global Burden of Disease study (Murray turn out to be the worst disease in the world.
1997) calculated the total number of deaths Tuberculosis will probably remain the same
and DALYs lost in 1990 and produced lists of or increase as a consequence of the increas-
rank order for the diseases and disorders ing prevalence following the HIV epidemic.
causing most deaths and DALYs lost. Murray The injury group is also projected to rise in
and Lopez also calculated the projected the list of causes of death.
Table 4.3 Ranking for the most important causes of death in 2002 and expected change in ranking to
2020.
Disorder % of deaths Estimated Ranking

in 2002 in 2020
1. Ischemic heart disease 13 % 1
2. Cerebrovascular disease 10 % 2
3. Lower respiratory infections 7% 4
4. HIV/AIDS 5% 9
5. Chronic obstructive pulmonary disease 5% 3
6. Perinatal disorders 4% 16
7. Diarrhoeal diseases 3% 11
8. Tuberculosis 3% 7
9. Malaria 2% 29
10. Lung cancer 2% 5
11. Road traffic accidents 2% 6
12. Diabetes mellitus 2% 19
13. Hypertensive heart disease 2%
C
14. Self-inflicted injuries 2% 10
M
15. Stomach cancer 2% 8
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Source: Murray 1997 & World Health Report, WHO, 2004, and
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www3.who.int/whosis/menu.cfm?path=whosis,burden&language=english

4 Health transition
Table 4.4 The diseases estimated to cause most loss of healthy life years (DALYs) in the world in 2002.
Diseases or disease groups % of total Millions of Millions of

DALYs lost healthy life years deaths
lost (DALY)
1. Perinatal disorders 6% 97 2.5
2. Lower respiratory infection 6% 91 3.9
3. HIV/AIDS 6% 84 2.8
4. Unipolar major depression 4% 67 0.0
5. Diarrhoeal diseases 4% 62 1.8
6. Ischemic heart disease 4% 59 7.2
7. Cerebro-vascular diseases 3% 49 5.5
8. Malaria 3% 46 1.3
9. Road-traffic accident 3% 39 1.2
10. Tuberculosis 3% 36 1.6
11. Maternal disorders 2% 34 0.5
12. Chronic obstructive pulmonary diseases 2% 28 2.7
13. Congenital anomalies 2% 27 0.5
14. Measles 1% 21 0.6
15. Violence 1% 21 0.5
16. Self inflicted injuries 1% 21 0.9
17. Alcohol use disorders 1% 20 0.1
18. Protein energy malnutrition 1% 17 0.3
19. Falls 1% 16 0.4
20. Diabetes mellitus 1% 16 1.0
21. Schizophrenia 1% 16 0.0
22. Osteoarthritis 1% 15 0.0
23. Asthma 1% 15 0.2
24. Cirrhosis of the liver 1% 14 0.8
25. Bipolar disorders 1% 14 0.0
26. Pertussis 1% 13 0.3
27. Anaemias 1% 12 0.1
28. Sexually transmitted diseases except HIV 1% 11 0.2
29. Trachea/Bronchus/ lung cancer 1% 11 1.2
30. Drowning 1% 11 0.4
31. Alzheimer and other dementia 1% 10 0.4
Major disease groups

Communicable, maternal, perinatal & 41 % 610 18.3
nutritional
Non-communicable 47 % 697 33.5
Injuries 12 % 182 5.2
Total in the world 100 % 1490 57.0
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Source: World Health Report, WHO 2004 and

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www3.who.int/whosis/menu.cfm?path=whosis,burden&language=english
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4.5 Impact of the health transition on health services
If we look instead at the DALYs projected 4.5 Impact of the health tran-
lost to different disease groups, an interest-
ing pattern arises. In its World Health Re-
sition on health services
port 2004, the World Health Organisation The change in disease pattern that is trig-
published a list of DALYs lost in 2002 gered by the health transition has a funda-
(ranked in table 4.4). On the basis of health mental impact on the demands on the
data from 1990, Murray and Lopez also pro- health care sector. In many low and middle-
jected the relative significance of each dis- income countries, this change is occurring
ease group for the year 2020. Ischaemic rapidly, and the already strained human and
heart disease is projected to advance to first financial resources of the health sector are
place for most DALYs lost in the high-in- insufficient to keep up with the demands for
come countries, as well as middle and low- health care. Cost-effective choices and prior-
income countries. Unipolar major depres- ity setting of the past must be revised when
sion will take second place. In 2020, 14 % of the non-communicable disease burden rises
DALYs lost are projected to be caused by (Mosley 1997).
neuropsychiatric disorders in low and mid- The total burden of disease measured by
dle-income countries, and 22 % in high-in- DALY will decrease per 1 000 population as
come countries. Of the DALYs lost, 13 % are shown in figure 4.3. However, it should be
expected to be due to all types of injury in noticed that the burden from disability as a
high-income countries, and 21 % in low and percent of total burden increases as a coun-
middle-income countries, by the year 2020. try undergoes socio-economic development.
Only 4 % of the DALYs lost will be due to Non-communicable diseases and disabili-
communicable, perinatal, maternal or nutri- ties caused by injury increase the complex-
tional disorders in high-income countries ity of the demand for healthcare services.
and 22 % in low and middle-income coun- The diversity of services needs to increase,
tries. and the staffs need new qualifications and
Some have criticised the Global Burden of probably more diverse levels of specialisa-
Disease study precisely because it projects so tion. Childhood diseases will continue, de-
clearly the rise in the burden of non-com- manding their share of primary health care
municable diseases and injury in the world. as before in low and middle-income coun-
Many believe that the study may lead to an tries. However, the rehabilitation of victims
excessive focus on non-communicable dis- of injury, counselling of AIDS patients and
orders and injuries, and that the group of good surveillance of diabetes patients are all
communicable, perinatal, maternal and nu- complex and demanding health interven-
tritional disorders that mainly affect the tions that also need consideration in the fu-
poorest may be forgotten in the planning ture. When it comes to demand on curative
and management of health-care services. As services HIV infection is similar to diabetes.
we will show in the next four chapters of The new anti-retroviral drugs must be taken
this book, many of the most common dis- for life and require careful check-ups with
eases in all three disease-groups can be pre- laboratory testing. In this sense the HIV epi-
vented, and many can be treated and poten- demic just increases the demand for chronic
tially cured. The future will tell to what treatment in the same way as most non-
extent Murray and Lopez have been right in communicable diseases do.
their projections. Even if the world will be The paradox is that a greater demand for
C able to alleviate poverty and reduce the bur- health services can be predicted at the later
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den of the communicable diseases, the now stages of the health transition. This is trig-
low-income countries will still face a steep gered by increased health care needs for
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increase in non-communicable diseases chronic non-communicable diseases, which
K
(Laxminarayan, 2006). are not as easily preventable or curable as

4 Health transition
communicable diseases. It is also triggered by References and suggested further reading:

the increased awareness of a better educated Caldwell JC. Health Transition: The cultural,
population, in which people know the causes social and behavioural determinants of
and possible treatments for different diseases, health in the Third World. Soc. Sci. Med.
and can thus demand their rights to health 1993;36:25135.
care. As the mass media become more perva- Chen L, Kleinman A, Ware N. Health and
sive, health notices will reach a greater pop- social change in International Perspec-
ulation. Urbanisation will decrease the phys- tive. Harvard University Press; 1994.
ical distance from health care facilities and Cleland J. Population Growth in the 21st
further increase the demand for health care. Century: Cause for Crisis or Celebration?
For the reasons listed above, all the Journal of Tropical Medicine and Interna-
changes throughout the health transition tional Health 1996;1:1526.
will result in increased costs for health care. Laxminaraya R. et al, Advancement of glo-
The higher costs will be mostly in the de- bal healh: Key messages from the Disease
mand for secondary and tertiary level care. Control Priorities Project. Lancet Vol.
Hospitals in many of the low-income coun- 367, 2006; pp. 11931208.
tries are already filled with patients with McKeown T. Looking at diseases from the
non-communicable diseases. light of human development. BMJ 1983;
The solution for the rising cost of health 283:594596.
care as a consequence of the health transi- Mosley, Bobadilla, Jamison. Disease Control
tion may actually lie partially outside the Priorities in Developing Countries: An
health care sector. As has been discussed in Overview and The Health Transition:
chapter 2, the causes of mortality, morbidity Implications for Health Policy in Devel-
and disability can be found and prevented oping Countries. Oxford Textbook of
at different levels, from the structure of the Public Health; 1997.
society via the individual behaviour to bio- Murray CJL, Chen LC. In search of a contem-
logical mechanisms. The debate in public porary theory for understanding mortal-
health on the best level of action for pre- ity change. Social Science and Medicine
venting disease and promoting health will 1993;36:143155.
continue forever. For example, to prevent Murray CJL, Lopez A. Mortality by cause for
lungcancer and other tobacco-related dis- eight regions of the world: Global Burden
eases individuals may benefit from health of Disease Study. Lancet 1997;349:1269
education on the adverse effects of smoking. 76.
At the societal level, restrictive laws on to- Murray CJL, Lopez A. Regional patterns of
bacco marketing and taxation may be effi- disability-free life expectancy and disabil-
cient. The low and middle-income countries ity-adjusted life expectancy: Global Bur-
can probably not afford to abstain from den of Disease Study. Lancet 1997;
using all possible measures to lower the im- 349:134752.
pact of tobacco smoking on the burden of Murray CJL, Lopez A. Global mortality, disa-
non-communicable diseases. But tobacco bility, and the contribution of risk fac-
use prevention is just one example of how tors: Global Burden of Disease Study. Lan-
public policy must tap in to modify the ef- cet 1997;349:143642.
fects of the health transition. Public policy Murray CJL, Lopez A. Alternative projec-
must accept an increase in government tions of mortality and disability by cause
C health expenditures, and other sectors in- 19902020: Global Burden of Disease
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volved in promoting health and preventing Study. Lancet 1997;349:14981504.
disease must meet the increased costs and Omran AR. The Epidemiologic Transition: A
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demands on the health care services follow- Theory of the Epidemiology of Popula-
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ing the health transition.

4.5 Impact of the health transition on health services
tion Change. Milbank Memorial Fund delayed degenerative diseases. Milbank

Quarterly 1971;49:50938. Quarterly 1986;41:155178.
Omran AR. The Epidemiologic Transition in Rogers RG. Hackenberg R. Extending Epide-
the US: The Health Factor in Population miologic Transition Theory: A New Stage.
Change. Population Bulletin 1977;32:3 Social Biology 1987;(34):23443.
42. (Population Reference Bureau, Inc., World Bank. World Development Report
Washington, D.C. 1977). 1993.
Olshansky SJ. and Ault AB. The fourth stage WHO, World Health Report, 19982004
of epidemiologic transition: The age of (www.who.int/whr.en).

5 Communicable diseases (30 %)
5 Communicable diseases (30%)*

Take the death of this small boy this morning, for
example. The boy died of measles. We all know
he could have been cured at the hospital. But the
parents had no money and so the boy died a slow
and painful death not of measles but of poverty.
A man, Ghana 1995
Most of the global burden of human com- and HIV. Communicable diseases therefore
municable diseases is caused by a relatively continue to be the main part of the disease
small number of microorganisms. These few burden in the poorest countries (WHO
are microorganisms of all different types. 2004).
Some are viruses, some are bacteria, others Some of the major infectious diseases,
fungi, protozoa or worms. These major in- such as lower respiratory tract infection and
fectious diseases of different types cause a diarrhoea, remain common all over the
wide variety of signs and symptoms, but world, but due to general access to effective
with the exception of HIV/AIDS they all treatment at the primary health care level
have one thing in common: the fact that these two diseases cause limited suffering
scientific advances have made it relatively and almost no deaths in high-income coun-
easy and cheap to reduce mortality by pre- tries. Other major infectious diseases, such
ventive and curative actions. as tuberculosis, measles and many of the
This reduction of mortality from commu- sexually transmitted diseases, are today also
nicable diseases has already taken place in rare in high-income countries. This is due to
high-income countries. It is currently taking improved living conditions, as well as effec-
place in most middle-income countries. The tive control, treatment and vaccination that
reduction in mortality has been achieved have jointly reduced their transmission. The
both through improved life conditions and major parasitic diseases, of which malaria is
better nutritional status of the population, the most prominent, occur almost exclu-
as well as through vaccination, correct diag- sively in low-income countries. These para-
nosis and effective treatment with anti-mi- sitic diseases are often referred to as tropi-
crobial drugs at an early stage of the illness. cal diseases. One of the reasons for this
The remaining high morbidity and mortal- label is that the transmission of some of the
ity from infectious diseases in low-income most important parasites requires the pas-
countries is closely related to poverty and sage through an insect, known as a vector,
malnutrition. However, as a result of suc- which only survives in tropical climates.
cessful implementation of immunisation This is the case for sleeping sickness, or
the burden of the vaccine-preventable dis- trypanosomiasis, which is transmitted by a
eases, such as measles and polio, has also tropical insect known as the tsetse fly.
been decreased in low-income countries. A large part of the severe poverty among
Even in war-torn southern Sudan it has been humans today is found in tropical regions.
possible to eradicate polio. Unfortunately, In these countries poverty is partly due to
C the decreased occurrence of the vaccine-pre- the occurrence of the parasitic diseases and
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ventable diseases in low-income countries is the occurrence of these diseases is also
replaced by increased occurrence of malaria caused by poverty. This vicious circle of pov-
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* % in parentheses is the share of the global burden of disease estimates by WHO in 2002.

5.1 Acute lower respiratory tract infection (6 %)
erty and parasitic diseases has been broken into these diseases. It should be noted that
in several tropical countries. Parasitic dis- several nutritional diseases, such as under-
eases have been successfully eliminated by nutrition and deficiencies of vitamin A and
economic and social development in combi- iodine, have a similar global distribution as
nation with special disease control pro- the tropical diseases, i.e. today they mainly
grammes in tropical countries such as Singa- occur in tropical low-income countries.
pore, Malaysia, Mauritius, Sri Lanka and When considering the classification of
Cuba. Some types of malaria parasites were a diseases, it should also be noted that the line
century ago a public health problem in sub- dividing communicable and non-communi-
Arctic countries such as Sweden, when cable diseases is becoming less clear-cut. The
housing conditions did not protect the pop- reason being that several diseases, which
ulation from frequent bites of the Anophe- used to be classified as non-communicable,
les mosquito. During summer the malaria- have been found to be caused by microor-
transmitting mosquito is still common in ganisms. It has been shown that cancer and
Sweden, but the malaria parasite was eradi- cirrhosis of the liver are induced mainly by
cated one century ago through drainage of chronic infection with hepatitis virus type B
mosquito breeding sites, improved housing or C. Cancer of the cervix of the uterus, one
and access to treatment. Socio-economic ad- of the most prevalent types of cancer in
vances can counteract the burden of para- women, is induced by the human papilloma
sitic diseases. But the poverty related para- virus. Chronic infection with Helicobacter
sitic diseases constitute an extra cost for de- pylori bacteria has been found to cause pep-
velopment in low-income countries. tic ulcer and some related disorders of the
The World Health Organization has a spe- stomach.
cial research programme for tropical dis- In this chapter we review the communica-
eases.1 The reason being that the absence of ble diseases that cause most suffering, i.e.
these parasitic diseases in high-income most DALYs lost in the world. For each type
countries makes the research oriented phar- of disease we review its occurrence, causa-
maceutical companies reluctant to invest in tion, clinical features, requirement for diag-
research about human parasitic diseases. nosis, and possible treatment and preven-
The term tropical diseases thus refers to tion. The small world maps show how many
parasitic diseases that, for reasons of both bi- millions of DALYs are lost due to each dis-
ological and socio-economic circumstances, ease. A similar review is performed in the
occur exclusively in tropical countries. How- following four chapters, concerning nutri-
ever, these tropical diseases do not consti- tional disorders, non-communicable dis-
tute the main burden of disease in these eases, injuries and reproductive health, re-
countries. They do not even constitute the spectively. The percentage in parentheses in
main burden of communicable diseases in each subtitle shows the proportion of the
tropical low-income countries. In these global burden of disease in DALY caused by
countries the burden of each of the four each condition.
main communicable disease groups (lower
respiratory tract infections, diarrhoea, HIV
and tuberculosis) is bigger or in the same
range as that of malaria. However, these four 5.1 Acute lower respiratory
main communicable diseases also occur in
C middle- and high-income countries. There-
tract infection (6 %)
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fore the high-income countries allocate con- Acute lower respiratory tract infections may
siderable amounts of money for research be regarded as the second worst disease in
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the world in DALYs lost, preceded only by
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1
www.who.int/tdr perinatal disorders (see chapter 9). Acute

= 1 million DALYs
Map 5:1 Lower respiratory tract infections cause 90 million disability adjusted life years (DALY) lost per year.
Source: WHO, 2002.
lower respiratory tract infection was esti- from impairment of the immune system
mated to cause 6 % of the total loss of due to concomitant malnutrition (see chap-
healthy years of life in the world (see Table ter 6).
4.4) (WHO 2004). More than half of this loss Children all over the world are estimated
of healthy years of life occurred in India and to suffer from about five episodes of acute
Sub-Saharan Africa, in spite of acute lower respiratory tract infection per year. These
respiratory tract infection being common in episodes of cough, fever and runny noses
all countries of the world. Most infections of put an enormous strain on their families
the lower airways and lungs are also called and on the health services in all countries.
pneumonia. In 2002, pneumonia ranked as The acute respiratory tract infections are di-
number one cause of death in children vided into three groups. Upper respiratory
under the age of five years in the world. This tract infections include the common cold,
is in spite of life-saving treatment with pen- ear and throat infections, tonsillitis and si-
icillin and other antibiotics having been nusitis. These diseases are very common,
available for more than 50 years. Pneumo- but rarely lethal. Many of the mid-respira-
nia still causes the death of two million chil- tory tract infections, which are restricted to
dren each year due to lack of access of a the trachea and larynx, may be life threaten-
treatment discovered half a century ago! Of ing, but do not occur as frequently as the
these 5 000 child deaths per day, almost all upper and lower infections. The acute lower
occur in low and middle-income countries. respiratory tract infections, which in strict
The main reason why lower respiratory tract medical terminology may be divided into
C infection remains one of the worst killers in pneumonia, bronchiolitis and alveolitis, are
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the world, is that lifesaving antibiotic drugs both common and serious.
are not available to those in greatest need of Microorganisms that are spread by air or
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these medicines. Pneumonia is a deadly dis- by direct contact commonly colonise the
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ease in poor children because they suffer upper respiratory tract. The disease often

starts as a viral infection of the mucosa of studies that primary health care staff can
the nose and throat and then proceeds to learn to diagnose pneumonia with high ac-
become a lower respiratory infection, lead- curacy without using a stethoscope, x-ray or
ing to a secondary bacterial pneumonia. any fancy laboratory tests, the medical ex-
About half of all patients with bacterial aminer only needs to count the number of
pneumonia show evidence of a previous breaths per minute. Between 1 and 5 years
viral infection. The types of bacteria that of age a breathing rate above 40 per minute
cause pneumonia are surprisingly similar is considered a sign of pneumonia and the
throughout the world and their occurrence child should be given antibiotics. The obser-
is independent of climate. The main bacte- vation of subcostal and intercostal chest in-
ria are Streptococcus pneumoniae, Haemo- drawings and five other danger signs help
philus influenzae and Staphylococcus au- to determine the severity of the pneumonia.
reus. The viruses that cause most acute respi- If subcostal or intercostal chest indrawing is
ratory tract infections are also quite similar observed, the pneumonia is considered to
throughout the world. The most common be severe. The infection is classified as very
are the measles virus, respiratory syncytial severe if the child shows any of the five dan-
virus, influenza virus, parainfluenza virus ger signs: unconsciousness; convulsions;
and adenovirus. While viral infections of lethargy; inability to drink or breastfeed; or
the respiratory tract are frequent through- vomiting everything eaten (Box 5.1).
out the world, the incidence of pneumonia Good case management of lower respira-
is higher in children in low- and middle-in- tory tract infection is being promoted
come countries than in children in high-in- throughout the world by a WHO pro-
come countries. gramme called Integrated Management of
Acute lower respiratory tract infection no Childhood Illnesses1. Good case manage-
longer needs to constitute a serious threat to ment consists of prompt identification of
life, since we have the necessary antibiotics. children who need antibiotic treatment
However, it is vital that a correct diagnosis is through proper diagnosis and severity classi-
made, that adequate treatment is prescribed, fication of children with pneumonia, and
that the drug prescribed is available to the correct administration of the antibiotics.
sick person and that the drug is correctly The recommended management also in-
taken. It is thus the weakness in the health cludes treatment to reduce fever and meas-
service system that mainly explains why ures to secure adequate breastfeeding, as
two million children still die each year from well as adequate intake of fluid and food
this disease. during the illness (Lambrechts 1999).
The first difficulty in reducing the inci- WHOs guidelines for treatment are thus
dence of child death due to lower respira- based on the severity of the pneumonia. If
tory tract infection is thus to enable caregiv- the child only shows signs of increased
ers and primary health care workers to diag- breathing frequency without chest recession
nose the life-threatening lower respiratory or danger signs, the child can be treated at
tract infections among the vast number of home. WHO recommends the use of cotri-
children presenting with cough, fever or moxazole, an antibiotic with few side effects
breathing difficulty. A major advance in the that is effective against most bacteria caus-
management of acute lower respiratory in- ing pneumonia. An equally important rea-
fection was the demonstration that the di- son is that this drug has become very cheap
C agnosis of pneumonia in a child is possible since the expiry of the patent. If it is pur-
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without a medical doctor or x-ray, but by chased in large quantities by the National
observing the breathing rate and counting Health Service and distributed rationally to
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the number of breaths per minute. It has
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been convincingly shown in controlled 1
http://www.who.int/child-adolescent-health

Box 5.1
Integrated management of childhood illnesses
Integrated management of childhood ill- have two or all three of these diseases at the
nesses (IMCI) is a world-wide WHO pro- same time. It is thus very relevant of WHO to
gramme. The main objective is to lower the combine these programmes into one for in-
mortality due to the five major childhood tegrated management of the main child-
diseases. hood illnesses. This has lead to more rational
guidelines for the peripheral health worker
lower respiratory infection in low and middle-income countries and
diarrhoeal disease hopefully to more relevant courses and in-
malaria struction material for the primary health care
staff in those countries.
measles
The main activities of the IMCI programme
malnutrition.
are to assist Ministries of Health to formulate
national guidelines and to arrange short
Formerly WHO had separate programmes
courses for health staff on how to implement
for lower respiratory infection, diarrhoeal
the national guidelines in their daily work
diseases and malaria. However, the main
with sick children. The home page of WHOs
problems for peripheral health staff in low
department of child and adolescent health
and middle-income countries in diagnosing
contains extensive information about IMCI
these diseases have been that many of the
(www.who.int/child-adolescent-health).
sick children only present with general
symptoms like fever and weakness. These The model chapter for textbooks and the in-
symptoms may be compatible with all these formation package for IMCI are especially
major diseases. Sometimes sick children may recommended for reading.
peripheral units of the health service sys- As many as 25 % of patients under two years
tem, the necessary one week treatment for of age with malnutrition develop a pneu-
one child costs less than 0.5 USD. However, mococcal sepsis, i.e. the bacteria spread
if purchased in a non-rational way, it can be from the lungs to the blood. This condition
several times more costly for the health serv- has a high mortality. WHO recommends
ice, or for the paying family in countries that these children should be treated with
where patients have to cover the costs of the form of ordinary penicillin that can be
drugs. The challenge to reduce child deaths injected intramuscularly, known as pro-
from pneumonia is thus very much the caine penicillin, or with some form of
challenge of improving the access to and broad-spectrum penicillin, such as ampicil-
correct use of antibiotics. It is a tragic para- lin or amoxycillin. Chloramphenicol is an
dox that the current over-use of antibiotics alternative, cheaper type of broad-spectrum
promotes the development of resistance to antibiotic for very severe pneumonia with
these life-saving drugs. Unfortunately, re- good absorption when taken orally. It is
sistance to cotrimoxazole is now rather today rarely used in high-income countries,
common among pneumococci, one of the because it can cause a rare but serious dys-
C most important bacteria that kills children function of the bone marrow.
M by causing pneumonia. Based on WHO recommendations each
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Children with severe or very severe pneu- Ministry of Health decides which antibiotics
monia should, whenever possible, be re- should be recommended for treatment of
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ferred urgently to a hospital for treatment. acute lower respiratory infections in its own

C
Figure 5.1 Integrated management of childhood illnesses. Assessment, classification and treatment of pneu-
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monia.
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Source: IMCI programme at WHO.
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country. In addition to general information monia in low and middle-income countries.

about efficacy and side effects, these na- Regular distribution of vitamin A to chil-
tional antibiotic policies are based on infor- dren in low-income countries has been
mation about the pattern of bacterial resist- shown to considerably decrease mortality in
ance, treatment tradition, and availability acute lower respiratory tract infections
and prices of different drugs as well as on (chapter 6.4.2).
the funds available to buy the drugs. This is Immunisation with existing vaccines
a difficult choice for low-income countries. against measles, diphtheria and pertussis
Should a cheaper antibiotic with a slightly prevents a proportion of deaths due to lower
greater incidence of side effects be recom- respiratory tract infections. A new vaccine
mended because it is the only drug that the against Haemophilus influenzae type B bac-
country and the families can afford? In teria has shown a 100 % protection rate
other words, should a few deaths from side against lower respiratory tract infection due
effects be accepted in order to save many to this type of bacteria. This is of great sig-
more lives from life-threatening lower respi- nificance, as this type of bacteria is the sec-
ratory tract infections? With good reason, ond most common cause of acute respira-
many Ministries of Health find that the an- tory disease in the world. It is sad that the
swer is Yes. It should be realised that tech- high price of this new vaccine, USD 2.70 per
nical decision-making on drug policy in dose, with three doses needed for full pro-
countries with very limited resources actu- tection, still restricts its use to the richer part
ally requires more skill and consideration of the world. If the financial issues could be
than in countries that can afford the more solved, this vaccine could be included in on-
simplistic approach that only the best is going immunisation programmes in low
good enough for us. and middle-income countries, thus saving
The number of deaths due to lower respi- many thousands of children around the
ratory tract infections can also be reduced world from dying of pneumonia. The same
through improved housing, better nutri- is the case for a new and expensive vaccine
tion, and partly through vaccination. In- against the very common Streptococcus
door air pollution and crowding in small pneumonia.
houses are well-known risk factors for pneu- The efforts needed to reduce the burden
monia in children. This air pollution comes of acute lower respiratory tract infections
from cooking food and heating the house thus span from politics, economics, nutri-
without having the benefit of a chimney, tion and health education to health service
probably for economic reasons. In fact this organisation, immunology and microbiol-
air pollution from poverty seems to kill ogy.
more persons each year than the more
talked about air pollution from industry and
traffic in major cities. This explains why eco-
nomic development and increased equity in 5.2 HIV infection and AIDS
countries and in the world will indirectly re-
duce the incidence of severe pneumonia in
(6 %)
children. By the year 2002 HIV/AIDS was the disease
Health education can contribute by pro- that caused the third greatest number of
moting breastfeeding and good nutrition. healthy life years (DALYs) lost in the world
C Malnutrition during foetal life, as reflected (table 4.4). This new disease of the human
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by a low birth weight, is a risk factor for se- immune system was named Acquired Im-
vere pneumonia. A low intake of vitamin A muno Deficiency Syndrome (AIDS), when
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has been identified as another major nutri- first described in United States in August
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tional reason for high mortality from pneu- 1981. The causal human immunodeficiency

5.2 HIV infection and AIDS (6 %)
= 1 million DALYs
Map 5:2 HIV/AIDS cause 88 million disability adjusted life years (DALY) lost per year.
Source: WHO, 2002.
virus type 1 (HIV-1) was identified in 1983 million were children. About 12 million Af-
and in 1985 it became possible to test rican children are today orphans because of
whether a person was infected. This was first the AIDS epidemic.1 Worst of all, while the
done by the identification of antibodies to HIV epidemic seems to have been curbed in
the virus in the blood. A second type of the most high-income countries and in many
virus, HIV-2, was identified in 1986 and by middle-income countries, the situation con-
then the main ways of transmission were tinues to deteriorate in many low-income
elucidated. There is evidence that HIV trans- countries as shown in Table 5.1.
mission had already started in 1958 (Zhu The highest identified HIV prevalence is
1998), and clinical cases of AIDS have in ret- found in some parts of African countries.
rospect been identified in the 1970s (Bygb- Around 60 % of the adult population (1549
jerg 1983). It is assumed that the virus as all years old) are infected in the most affected
other major human epidemics passed from areas. In the demographic situation of most
animals to humans. This may have occurred countries in Sub-Saharan Africa the popula-
as early as 1940, but how it occurred is not tion growth will stop at an adult HIV preva-
confirmed. In spite of the rapid research lence of about 50 %. This is now happening
achievements following the rapid spread in in parts of some countries, such as Bot-
the beginning of the 1980s, AIDS has today swana. In parts of Zimbabwe, it has been
become one of the main diseases of the found that 58 % of women between 19 and
world. At the end of 2003 an estimated 38 40 years are HIV-positive. This constitutes a
million people were infected with HIV, cor- hitherto unprecedented effect of disease in
responding to about 1 % of the adult popu- contemporary world history. In South Africa
C lation of the world. More than two-thirds of around 50 000 newly infected individuals
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those infected were living in Africa south of are registered every month, and in Swazi-
the Sahara. In 2005 it was estimated that 3.2 land about 25 % of the adults of fertile age
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million became infected with HIV and that
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2.4 million died of AIDS, of whom half a 1
www.unaids.org

Table 5.1 Estimated occurrence of HIV and deaths in AIDS in 2005.
Region People living Newly infected % HIV Number of

with HIV in by HIV in 2002 prevalence rate deaths in AIDS
millions in millions in 1549 year during 2003
olds in the end in millions
of 2003
Sub-Saharan Africa 25.8 3.2 7.2 2.40

North Africa & Middle East 0.5 0.07 0.2 0.06
South and South-East Asia 7.4 1 0.7 0.48
East Asia 0.8 0.1 0.1 0.04
Latin America 1.8 0.2 0.6 0.06
Caribbean 0.3 0.03 2.4 0.025
Eastern Europe & Central Asia 1.6 0.3 0.9 0.06
Western Europe 0.7 0.02 0.3 0.01
North America 1.2 0.04 0.7 0.02
Oceania 0.07 0.00 0.5 0.00
TOTAL 40.3 4.9 1.1 3.10
Source: UNAIDS www.unaids.org, AIDS Epidemic Update, 2005.
are now estimated to be HIV-positive. To of infection, followed by homosexual trans-

date the greatest impact of the pandemic of mission and intravenous drug use. The lat-
HIV/AIDS has been in Central, Eastern and est estimates from UNAIDS are shown in
Southern Africa. The burden of HIV/AIDS in table 5.1 (UNAIDS 2005), but readers are ad-
some West African countries is only one vised to look for updates.1
tenth of that in the most affected countries The scenario is also alarming in Eastern
in southern Africa. The good news is that Europe and Central Asia. This is considered
careful studies show a falling HIV incidence to be the area with the most rapidly growing
in some formerly heavily affected areas HIV epidemic. The rapid growth is thought
(Kwesigabo 2000). to be due to both the high prevalence of
In Asia and the Pacific region the progres- other sexually transmitted infections and
sion of the epidemic has been rapid since concomitant high rates of infection through
the late 1980s (table 5.1). In India alone widespread intravenous drug use. In high-
there are 5 million infected persons, proba- income countries, the epidemic has also
bly the highest number in any one nation, reached ominous proportions; more than
and in China, about half a million people 75 000 people acquired HIV infection in
are infected. HIV is now spreading in the 2002, bringing the total number of infected
worlds two biggest countries. In China the people in high-income countries to 1.6 mil-
transmission is largely through commercial lion.
sex and intravenous drug use, but with a sig- At present, vertical (mother-to-infant)
nificant contribution from the transfusion transmission accounts for approximately
of blood derived from unregulated profes- one-fifth of all cases of AIDS seen in Sub-
sional blood donors. In the Americas there Sahara Africa, and it is anticipated that a
C are more than two million infected persons similar scenario will prevail in Asia. The out-
M but the number of newly infected is no come for the infected newborn is poor with-
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longer increasing, neither in North America out modern advanced treatment. In Africa
nor in Latin America. Heterosexual trans-
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1
mission remains the most important means www.unaids.org

TANZANIA, Dar-Es-Salaam. Social worker visiting mother and child with aids.
up to 40 % of infected newborns die in the while HIV-negative individuals have a life-

first year of life, and up to 75 % die before the time risk of 10 %. At present most of the pa-
age of 5 years. Only a few will survive into tients diagnosed with pulmonary tuberculo-
adolescence. A study in 39 countries in Sub- sis in Central, Eastern and Southern Africa
Saharan Africa indicates that about 8 % of are HIV-positive.
the deaths in children below 5 years of age HIV infection and its spread are no longer
are directly caused by HIV/AIDS. However, seen through the medical lens alone, but
the proportion of child deaths directly also through the social and economic
caused by HIV varies from 1 % to 42 % lenses. It is becoming a disease of the mar-
between the African countries. The relative ginalised and impoverished of the world.
impact of HIV is greatest in Botswana and The vulnerable groups are commercial sex
other countries in Southern Africa that have workers, intravenous drug users, women liv-
a better economy and that have successfully ing in oppressive relationships, where sex-
reduced child death from other causes. ual contact is not negotiable, and the poor-
The incidence of tuberculosis is increasing est, which are deprived of access to health
throughout the world, and the main factor education. HIV/AIDS remains a severe social
responsible for this is immunosuppression stigma in many societies. This influences
C due to HIV infection. About 7 million indi- how and if people avoid transmission and
M viduals are simultaneously infected with HIV seek help from health services. A significant
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and Mycobacterium tuberculosis. Through- effort remains to be done to fight prejudice.
out the world HIV-infected subjects run a 30 A political commitment and will to stop the
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50 % lifetime risk of acquiring tuberculosis, epidemic is crucial. In spite of the general

increase in HIV infection in low-income much higher challenge to provide antiretro-

countries, several studies show a positive ef- viral treatment in Zambia compared to Bra-
fect of prevention, especially when both po- zil. Highly affected middle-income coun-
litical actions and economic resources are tries like Botswana and South Africa are
present. A clear reduction of transmission presently trying to make the anti-retroviral
has been shown in many community-based drugs available but the impact of these at-
projects run by NGOs. Examples are pro- tempts has not yet been studied.
grammes to supply condoms to commercial The tragic widespread incidence of HIV in
sex workers in Thailand, Tanzania and the Southern and Eastern Africa especially has
United States, which have decreased the ex- lead to a heated debate on what to do about
pected spread of the infection. For preven- it. It seems as if too many arguments in this
tion to be effective, it is necessary to influ- debate lack an evidence base. This is the case
ence sexual behaviour and reinforce the in- with claims that AIDS may not be due to
dividuals opportunity to make healthy HIV as well as suggestions that all those in-
decisions. It is necessary that the health and fected should get access to anti-retroviral
social services provide education, care and treatment. Evaluation of the impact of dif-
social support to the most vulnerable groups ferent actions against the spread of HIV as
if the epidemic is to be stopped. As it is prob- well as cost effectiveness analyses is impor-
able that pre-existing sexually transmitted tant for the decisions on global, national
illnesses (STIs) increase the risk of acquiring and local policy for HIV control. Policy also
HIV infection, an important aspect of the depends on many factors other than evi-
prevention strategy is to reduce the occur- dence and cost, but the ten to hundred fold
rence of STIs. differences in cost per life saved (Creese
Vaccine research efforts are being con- 2002) between different HIV interventions
ducted, but no vaccine has yet been shown makes it important to always include some
to be clinically effective. The present judge- cost assessments when choosing interven-
ment among specialists is that for the fore- tions (Table 5.2).
seeable future no vaccine will be available to The widely different costs per healthy year
stop the HIV epidemic. However, effective of life saved with the different interventions
antiretroviral drugs are now available but (Table 5.2) are due to the differences in HIV
only as a life long complicated and costly prevalence and the health system coverage
treatment. When available this treatment as well as all the other differences between
has dramatically reduced mortality from the affected societies. Standard solutions
HIV infection in high-income countries and against the epidemic should be doubted.
large efforts are being made to make these Adoption to local context appears to be cru-
drugs available for the more than 38 million cial for successful curbing of the epidemic.
that are infected. The drugs have also been Facing the real sexual behaviours behind the
successfully made available in some middle- epidemic in each country, as well as the
income countries where HIV prevalence is clandestine use of intravenous drugs is the
around 1 % and a relatively well functioning main challenge to tailor the right preventive
health system exists, e.g. Brazil. The high interventions. All interested in the control
cost of the drugs, the laboratory tests and of the global HIV epidemic must have basic
medical consultations needed still make it knowledge about both the biological and
impossible to treat the majority of the HIV clinical aspect of the disease as well as of the
C infected in the low-income countries with socio-economic, political and cultural con-
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prevalence above 20 % in adults. It should texts in which the epidemic occurs. Section
be noted that Brazil has a 10 times better 5.2.1 provides the basic facts about the
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economy than Zambia whereas Zambia has human immune system and the HIV virus
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20 times higher HIV prevalence. It is thus a infection.

Table 5.2 Estimated cost effectiveness of different interventions against HIV/AIDS in Africa.
Intervention Reduce the main Cost in US dollar per healthy life year
HIV transmission saved (DALY*)
Condom distribution yes 199

Blood safety yes 143
Peer education of sex-workers yes 47
Stop mother to child transmission no 1731
Control of STIs yes 12
Voluntary counselling and testing yes? 1822
Short course TB therapy no 268
Co-trimoxazol prophylaxis no 6
Home care of AIDS patients no 771230
TB preventive therapy no 169288
Anti retroviral therapy no? 1,1001,800
* Varies depending on the HIV prevalence and whether a well functioning health service exists or not.
Source: Creese 2002.
5.2.1 The HIV infection it to get under the skin. Blood transfusion
The human immune system consists of an is such a mechanism, and sexual relations is
antibody-mediated defence and a cell-medi- another. Outside the human body HIV is
ated defence by the type of blood cells called rapidly killed by soap, sun or some other
lymphocytes. Simplistically it can be said desinfectant.
that the antibodies kill bacteria whereas the If the HIV virus gets into the human body,
lymphocytes are more important to over- it will infect many of the bodys cells. How-
come viral infections, tuberculosis, fungal ever, the gp120 buds on the virus envelope
infections and parasites. As viruses infect fit especially well onto a receptor on the
cells, the cell-mediated defence attacks by CD4 T-lymphocytes, and the CD4 cells
killing the infected cells to clear the infec- therefore become the prime target of HIV in-
tion. The white blood cell called CD4 T- fection. The presence of so-called chemok-
lymphocyte has a central role in the im- ine-receptors is also needed for HIV to at-
mune system. It is the co-ordinator of the tach to the lymphocyte and to fuse with the
system, like an officer directing soldiers. The cell membrane. Thereafter HIV will enter to
cell-mediated defence depends on the good the inside of the cell where the contents of
functioning of the CD4 cells and it is this the virus are released. The reverse tran-
leading cell in the immune system the HIV scriptase will now start to make a DNA copy
viruses infect and destroy. of the virus RNA. This is the reverse of the
The HIV virus consists of an outer envelope usual procedure, which is to make RNA
with buds made of a glycoprotein that is working copies of the DNA original stored
called gp120. Inside the envelope there is a in the cell nucleus. This is why this group of
core with the genetic code in the form of RNA viruses are called retroviruses. Once the
as well as three enzymes called 1) reverse virus has produced DNA copies of its genetic
C transcriptase, 2) integrase and 3) protease. code, the integrase enzyme will introduce
M It is important to remember that the HIV this DNA code into the genes of the cell, in
virus has a very low infectivity. It can only other words into the chromosomes of the
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transmit from one human to another lymphocyte. When the genetic code of the
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through some special mechanism that helps virus is included in the chromosomes, the

body can no longer eliminate the infection, weeks), the virus replicates rapidly and the
because the genetic code of HIV can no viral load is high. During this first period
longer be identified as an infection. Instead, blood and body fluids from the infected per-
the genetic code of the virus resembles a son are highly infective. In the second,
part of the genes of the infected individual. asymptomatic phase, the immune system
When the virus gene is activated, it takes gains control over viral replication and
command of the CD4 cell and converts the keeps the viral load low. This also means
cell into a virus production unit. When it that infectivity is lower than during the ini-
does so, it will be targeted by the cell-medi- tial phase. The CD4 count is almost normal
ated immune defence system, and the in- and the infected person has no symptoms.
fected CD4 cell will rapidly be killed. The However, the CD4 count gradually declines,
body will compensate for the loss of CD4 and after some years the number of CD4
cells by increasing production of this type of lymphocytes has become so low that the
lymphocytes, but with time the capacity to person will start to get more infections and
do this will be exhausted and the number of other symptoms of AIDS. In this third phase
CD4 cells /ml of blood will decrease. When viral replication will also escape the hosts
the number of CD4 cells decreases from the immune defences, the viral load increases
normal 8001,500 cells/ml of blood to and the person becomes more infective
below 200 cells/ml, the bodys cell-mediated again. If HIV infection is not counteracted
defence system becomes weakened and the with anti-HIV drugs, a number of disease
body is easily infected with viruses such as symptoms will emerge as the patient devel-
Herpes zoster, with funguses such as Cand- ops AIDS. The most common clinical pres-
ida causing thrush in the mouth and by bac- entations of AIDS in adults in sub-Saharan
teria such as tuberculosis. The control of Africa are as follows:
transformed cells is also affected, and can-
cers appear more readily. The number of Severe weight loss (slim disease)
CD4 cells /ml of blood is thus an important Enlarged lymph nodes known as lym-
measurement in the assessment of an HIV phadenopathy
infected person. The CD4 count can predict Chronic diarrhoea
when a HIV infected person begins to suffer Persistent cough
from the immune deficiency, in other words
when the HIV infected individual develops The human immunodeficiency virus (HIV)
the disease AIDS (acquired immuno defi- is genetically closely related to the simian
ciency syndrome). At this point in time the immunodeficiency viruses (SIV) that are
weakened immune defence can no longer found among monkeys in Africa. Scientifi-
stop the HIV virus from multiplying, and cally, there is little doubt that HIV and SIV
disease progression speeds up. Without anti- have a common origin. HIV probably origi-
retroviral treatment AIDS is a deadly disease, nated as a zoonosis, an infection that passed
even if treatment is available for the oppor- from animal to man (Zhu 1998). This is the
tunistic infections. However, cost-effective same as happened with the human influ-
treatment of opportunistic infections can enza virus, which is closely related to similar
prolong life for many years. viruses found in domestic birds in China.
But how did this cross-infection happen?
There is evidence that HIV has existed for
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5.2.2 The AIDS disease several decades before it was discovered. Be-
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The HIV infection has three phases: the pri- cause monkeys are hunted for meat in Cen-
mary HIV infection, an asymptomatic phase tral Africa, it is not improbable that the virus
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and the symptomatic phase called AIDS. spread through blood contact during
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During the primary infection (first 412 slaughter. Just as with the influenza virus, a

mutation of the foreign virus is needed for the infection is under control and that the
it to be able to survive in humans. Two person is not so infective. A high viral load
other proposed hypotheses should be con- of several million of particles/ml blood indi-
sidered. The first one suggests that the virus cates that the person is either newly infected
originated from polio vaccine obtained or is starting to get AIDS. Such persons are
from cultures on monkey kidney cells. This usually highly infective.
vaccine was used in campaigns in Central There are many indirect, rapid tests,
Africa in the 1950s. The main argument which involve different so called ELISA or
against this hypothesis is that neither SIV Western Blot techniques. The rapid tests are
nor HIV viruses grow in kidney cells; they relatively cheap (USD 4 per test) and they
both need lymphocytes to grow. A third hy- are easy to perform. The major problem
pothesis suggests that the virus was pro- with the indirect tests is that they do not be-
duced in laboratories as part of biological come positive until the body has started
warfare research. The plausibility of the last producing antibodies against the virus. This
hypothesis should be considered in the light usually takes 13 months from the time of
of the difficulties present-day virologists infection. In this first period after infection,
have in incorporating new genes into vi- an indirect test may be negative in spite of
ruses for gene therapy. The knowledge the person being infected. Somebody who is
needed to make a new virus was not there testing negative should therefore come back
3040 years ago. As with the other major vi- after 3 months for re-testing. An alternative
ruses that have passed from animals to hu- is a direct test, which will give the correct re-
mans we do not yet understand the mecha- sult to those that can afford it.
nisms by which this occurred. Another disadvantage with indirect tests
is that they cannot be used in children born
to HIV-positive mothers. The reason is that
5.2.3 The HIV tests most mothers transfer their antibodies to
There are two main types of tests for HIV. the child, but often not the virus. Many of
Both tests are made on blood. The direct these children will be positive in an indirect
tests detect the RNA or DNA of the virus. test without being infected. Indirect tests in
The indirect tests detect the bodys antibod- children cannot be used reliably until the
ies against the virus. The best known of the age of 15 months. To know if a child is in-
direct tests is called PCR (polymerase chain fected before this age, a direct test must be
reaction). This test method can detect small performed.
amounts of the virus in the blood and it can
establish for sure whether the person is in-
fected or not. The disadvantage with the 5.2.4 The HIV transmission
PCR method is that it is expensive. It costs The four modes of transmission of the HIV
50100 USD per test which is ten times virus are through (1) sexual intercourse, (2)
more than the total amount of money that blood transfusion, (3) intravenous drug use,
is annually available per person for health or (4) from mother to baby during preg-
services in the majority of HIV affected low- nancy, delivery or breastfeeding. The risk of
income countries in Africa. The PCR transmission between sexual partners is
method is costly because it requires sophisti- considerably increased when there is a si-
cated laboratory facilities and well-trained multaneous infection with gonorrhoea or
C staff. The advantage with the PCR test is the other sexually transmitted infections (STIs).
M
estimate of how many virus particles there In general, susceptibility to HIV is enhanced
are per unit of blood. This is referred to as when the genital mucosa is damaged or in-
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the viral load. A viral load of less than fected, presumably both by facilitating the
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10 000 particles/ml is low, indicating that entry of the virus into the bloodstream and

through the recruitment to mucosal surfaces The fact that transmission of HIV through
of the cells of the immune system that are breastfeeding has been confirmed in several
targets for HIV invasion. epidemiological studies constitutes a big di-
A number of infections can be transmitted lemma for health authorities and infected
from mother to foetus or infant during preg- women in low-income countries. If the Min-
nancy, delivery or infancy. This is called ver- istries of Health advice HIV infected women
tical transmission, with one generation in- against breastfeeding and if they follow
fecting the next, as opposed to horizontal such an advice, more children would most
transmission, where persons of the same probably die from diarrhoea and malnutri-
generation infect each other. HIV is only tion than are saved from reduced HIV trans-
one of the infections that can be transmit- mission. The reason is that most mothers
ted vertically. It may be transmitted to the cannot afford to buy enough breastmilk
foetus during pregnancy, during delivery or substitutes, and even if these were distrib-
through breastfeeding after birth. If no spe- uted free the women are not in a position to
cial measures are taken about 3040 % of prepare them hygienically enough. There-
HIV positive mothers in Sub-Saharan Africa, fore, the poorest countries and the poorest
will transmit HIV to their babies. Although HIV infected women must accept the risk of
this is a high proportion it means that al- transmission through breastfeeding, as the
most two-thirds of these babies born to HIV alternative is even more risky for the health
positive mothers in Sub-Saharan Africa will of the child. Needless to say, the will to
not be infected! Up to 10 % of the babies are breastfeed is enormously strong among
infected before birth. Most of this transmis- many of these mothers. At the same time,
sion takes place in the last month of preg- high and middle-income countries are
nancy, when the placenta may leak blood strongly advising against breastfeeding, and
from mother to child. Most of the children a few countries, such as Sweden, are even
that get infected, about 1020 % of all chil- forbidding HIV infected mothers to breast-
dren born to HIV infected women, get the feed. This ethical dilemma has become even
infection during labour. This is thought to more dramatic now that drugs are available
take place through exposure to maternal to reduce the risk of transmission, as this
blood in the birth canal. It is noteworthy treatment is not affordable to those popula-
that the first twin is infected twice as often tions that have the highest prevalence.
as the second twin, indicating that much of The risk of postnatal transmission rises if
the transmission occurs in the birth canal, the mother is sick or if she has breast prob-
where the first twin spends more time. Mu- lems such as cracked nipples or mastitis. Re-
cosal damage due to other sexually trans- cent studies also indicate that mixed feed-
mitted infections (STIs) or vitamin A defi- ing, with a combination of breastmilk and
ciency is associated with higher rates of other feeds, may increase transmission. So,
transmission to the child during birth. at present, it is advised that the mother
Transmission after birth almost exclusively should either exclusively breastfeed or re-
occurs through breastmilk. Up to 10 % of place the breastmilk completely with other
newborns may be infected through this forms of feeding. Exclusive replacement
route. Newly infected women have a very feeding should only be used if it is AFASS:
high level of virus in their blood, and the acceptable, feasible, affordable, sustainable
risk of transmission through breastmilk to and safe. It is judged that this is not the case
C their foetuses is therefore higher. A peculiar in many African settings, and exclusive
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feature of HIV-2 is that it is transmitted from breastfeeding therefore remains the wisest
mother to offspring at a much lower rate, recommendation in these areas today.
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around 5 % or less.
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5.2.5 Antiretroviral therapy 300 000 infected persons in the country. The
Antiretroviral (ARV) drugs have dramati- treatments were given to those that had
cally changed the future for HIV infected probably been infected during their work in
persons in high-income countries. With a the health service. ARV is also slowly being
combination of several drugs it is now possi- made available to some of the infected per-
ble to give a highly active antiretroviral sons in low-income countries, both to those
therapy (HAART). HAART has increased the that can afford to pay, and in some projects
expected lifespan of HIV infected persons also free of charge to those that cannot af-
from one to several decades. But the drugs ford. The cost of the drugs has dropped
have many side effects, and experience sharply but a three-drug combination still
shows that it is not easy to comply with costs 300 USD per year in the capital of
such extensive life long medication. To re- Uganda. Leaving drug cost aside, many other
duce compliance problems, the tendency costs must be covered such as medical con-
has therefore been to delay the introduction sultations for patient follow-up and manage-
of ARVs to a point where the CD4 count has ment of side effects, and laboratory analysis
fallen to 200 cells/ml of blood. as well as for treatment of other infections.
There are currently four groups of ARV: As a welcome and rational new response
to the challenge to finance basic health serv-
Nucleoside reverse transcriptase inhibi- ices in low and middle-income countries
tors (NRTI). The Global Fund to Fight AIDS, Tuberculosis
Non-nucleoside reverse transcriptase and Malaria was created in 2002 on the ini-
inhibitors (NNRTI) tiative of the Secretary General of the UN.1
Protease inhibitors (PI) The aim of the fund is To attract and dis-
Fusion inhibitors (FI) burse additional resources to prevent and
treat AIDS, tuberculosis and malaria. As a
Several others are in the pipeline but are not partnership between governments, civil so-
yet in routine clinical use. A minimum of ciety, the private sector and affected com-
three drugs are needed for HAART. For a munities, the Global Fund represents a new
long time, one PI was combined with two approach to international health financing.
NRTI. Today there are several combinations The Fund works in close collaboration with
used without any PI, as the protease inhibi- other bilateral and multilateral organisa-
tors cause most side effects. During treat- tions, supporting their work through sub-
ment with HAART the patients are followed stantially increased funding.
up with CD4 counts and viral load assess- In spite of the low cost effectiveness of the
ments four times a year. Ideally, the CD4 provision of ARV in low-income countries
count should return virtually to normal, the fund is contributing a part of the grants
and the viral load should be less than 50 to purchase such drugs (Table 5.2). Of the
particles/ml. Adherence to the prescribed commissioned 3.5 billion USD for the first
drugs seems to be the single most important four rounds of applications the fund uses
factor for sustainable effect of the therapy. 56 % for HIV/AIDS and a part of that for
Antiretroviral therapy is already in wide drugs. The outcome of the provision of free
use in some middle-income countries. It has anti retroviral drugs in low-income coun-
been very successfully supplied through the tries will only be judged after some years. It
public system in Brazil. The authorities in may prove to be a way to achive more open-
C Thailand have started to supply treatment ness about HIV and thereby more effective
M for some thousands of the more than one prevention. It may also prove to have a low
million infected persons in the country. In direct effect due to low compliance and the
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2002, the Vietnamese government provided
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treatment for only 50 of the more than www.globalfundatm.org

effect on prevention may be doubtful as the alarmingly in several low and middle-in-
political focus may remain on the medical come countries during the years to come.
aspects of the epidemic. Readers are strongly Endurance is the main character needed for
suggested to look for recent studies on the those that want to contribute to stop the
impact of provision of free anti-retro viral HIV pandemic.
drugs in the most affected low-income
countries.
5.3 Diarrhoea (4 %)
5.2.6 ARVs to prevent mother-to-child Diarrhoea is usually a harmless condition of
transmission short duration, but severe acute diarrhoea
It has been shown that short-course, single- can lead to the loss of large amounts of flu-
drug or two-drug regimens can reduce HIV ids, dehydration and death. Diarrhoeal dis-
transmission from mother to infant at rela- eases caused the fifth largest number of
tively low cost. Cheapest, at only USD 4 per DALYs lost in the world in 2002 (Table 4.4).
pregnancy, is a single oral dose (200mg) of Although the vast majority of the estimated
the non-nucleoside reverse transcriptase in- 1.8 million deaths due to diarrhoea occurred
hibitor, Nevirapine, to the mother at onset in low and middle-income countries, diar-
of labour and a follow-up dose to the infant rhoea remains a common disease all over
(2mg/kg) within the first 72 hours of life. the world. In health statistics, diarrhoea is
Such treatment cuts intrapartal transmis- often listed as one disease entity, but it is in
sion by more than 50 %. Functionally, this is reality just a symptom that can be caused by
a prophylaxis to the infant at the time when a number of different viruses (of which Ro-
risk of transmission is greatest per time unit. tavirus is the most common), bacteria or
Alternatives where the mother is treated in protozoa. These microorganisms are gener-
the last trimester to cut down the viral load ally spread from the faeces of one person to
(= infectivity) before delivery has also been the mouth of another via food, water or un-
attempted, but these treatment regimes are washed hands. Improved hygiene decreases
more expensive. Most programmes to cut the occurrence of diarrhoea due to all types
vertical transmission have built on antena- of microorganisms. It is also justified to re-
tal voluntary counselling and testing (VCT), gard diarrhoea as a single clinical entity be-
followed by treatment of positive mothers. cause the treatment is relatively similar, in-
The total cost of transmission avoidance de- dependently of the cause. Diarrhoea is clini-
pends very much on the acceptability of the cally defined as having loose stools at least
screening component; with low acceptance four times per day. Depending on duration
rates and low coverage, the cost is high. The of illness, character of the stools and
introduction of ARVs for the prevention of whether other symptoms occur simultane-
vertical transmission raises several ethical ously, diarrhoeal diseases are divided into
questions. For instance: is it right to focus three major types: acute watery diarrhoea;
on identifying women as HIV-positive and dysentery and persistent diarrhoea, respec-
letting them be the messengers of bad news tively (Table 5.3).
in the family? And will subsequent treat- One of the most important medical ad-
ment with ARVs be less effective, due to vances in the second half of the 20th century
brief exposure to ARVs at delivery? was the introduction of oral rehydration
C However, despite measures to prevent the therapy (ORT) for the treatment of life-
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spread of HIV and advances in the treat- threatening dehydration from diarrhoea.
ment of AIDS, the incidence of HIV infec- Following the introduction of ORT in 1972,
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tion and the number of AIDS deaths and there has been a worldwide decrease in the
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AIDS orphans will continue to increase mortality due to diarrhoea, and much of

5.3 Diarrhoea (4 %)
= 1 million DALYs
Map 5:3 Diarrhoeal disease cause 63 million disability adjusted life years (DALY) lost per year.
Source: WHO, 2002.
this decrease can be attributed to ORT. This bicarbonate and glucose to drink was almost
treatment is given by mouth instead of in- as effective as intravenous infusions. The
travenous drip directly into the blood treatment with ORT was also found to be ef-
stream. It is based on the finding that a solu- fective in children with dehydration from
tion containing the right mixture of water, other types of diarrhoea. Hence, ORT was
salt and sugar allows for a very effective ab- soon widely promoted for better treatment
sorption of water through the mucous of dehydration in children with all types of
membrane of the gut. This absorption takes diarrhoea, through extensive international
place through transport of glucose accom- programmes led by UNICEF and WHO.
panied by sodium and water. It was first These programmes have been relatively suc-
used in practice to treat large numbers of cessful in recent decades, because they have
refugees from Bangladesh who suffered ex- included a willingness to reformulate policy
tensive epidemics of cholera while living in and adapt it to conditions in different coun-
camps in India in 1972. It was shown that tries on the basis of the results of evalua-
giving patients water mixed with salt, some tions and operational research.
Table 5.3 The three main types of diarrhoea.
Type of diarrhoea % of all childhood % of all childhood deaths % of deaths preventable by

diarrhoea due to diarrhoea standard case management
Acute watery 80 50 100

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Dysentery 10 15 80
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Persistent 10 35 80
Y Total 100 100 90
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Source: IMCI: the integrated approach. WHO/CHD/97.12 rev 1.

The initial exclusive emphasis on ORT ORT remains the basic treatment for dehy-
was found to have no effect or even to ag- dration from acute watery diarrhoea, and in-
gravate the malnutrition that follows in travenous fluids are only recommended for
children after frequent, prolonged diar- the most severe cases. Box 5.2 illustrates the
rhoeal episodes. Hence, the importance of recommended treatment according to the
feeding children and of continued breast- degree of dehydration.
feeding during diarrhoeal episodes was in- It was also realised that persistent diar-
cluded in the WHO guidelines. Further- rhoea contributes to proportionally more
more, it was found very difficult to make the deaths than diarrhoeal episodes, and that
ready-made package in aluminium foil, con- concomitant malnutrition is a very signifi-
taining the right proportion of salt, bicarbo- cant contributing factor in many child
nate and glucose to prepare one litre of ORT, deaths from diarrhoea. The incidence of per-
available at all times to the mothers in low- sistent diarrhoea is also increasing because
income countries who needed to prevent of the HIV epidemic. For persistent diar-
dehydration in their children. This was due rhoea, which is the most difficult of all the
to both the cost of such packages and the different types of diarrhoea to treat, the
poor functioning or unavailability of health focus is therefore on combating malnutri-
facilities in many parts of low-income coun- tion. A combination of dietary therapy, zinc
tries. Hence, it was found that the promo- and vitamin supplementation, and treat-
tion of home-based ORT could be included ment of co-existing infections is the basis
in the treatment recommendations for less for the management of this type of diar-
severe forms of dehydration, to comple- rhoea.
ment the use of industrially produced ORT Dysentery is a type of diarrhoea that is
packages for more severe forms. The last combined with other signs of infection such
change in the policy for reducing deaths in as fever and/or bloody stools. Bacteria such
diarrhoea has been to include this activity as Shigella and Campylobacter, or protozoa
into a programme for Integrated Manage- such as Entamoeba histolytica and Giardia
ment of Childhood Illnesses. This is mainly lamblia are the main causes. This type of di-
because the focus has changed from simply arrhoea is treated with antimicrobial drugs.
providing the treatment to increasing the As with antibiotics for lower respiratory
skills of peripheral health workers in assess- tract infections, national guidelines may dif-
ing the level of dehydration of sick children. fer, and the rapid development of resistance
Box 5.2
Treatment of diarrhoeal disease
A. If the child is not dehydrated:

Oral rehydration therapy (ORT) at home
ORT = 4 table spoons of sugar (20g) + 1/2 table spoon of salt (3.5g) + 1 litre of water
Food + BREASTFEED
B. If the child is dehydrated but can drink:
ORT at the health facility until he child is rehydrated and the mother understands the mes-
sage.
C BREASTFEED
M C. If the child has severe dehydration and can not drink:
Y Hospitalisation for treatment with intravenous fluids
BREASTFEED
K

5.3 Diarrhoea (4 %)
M
Figure 5.2 Integrated management of childhood illnesses. Assessment of level of dehydration in a child with
Y
diarrhoea.
K
Source: IMCI programme at WHO.

YEMEN, Taiz. Nurse at the childrens hospital is showing a mother how to spoonfeed her dehydrated child
with oral rehydration salts.
Heldur Netocny/PHOENIX.
against many of the cheaper antibiotics is a The prevention of diarrhoea includes the
major global problem. Ciprofloxacin or nor- promotion of safe drinking water supplies
floxacin for five days is an effective choice and latrines that interrupt faecal-oral trans-
against Shigella, and cotrimoxazole, ampi- mission. It also includes improvements in
cillin or chloramphenicol may be a cheaper personal hygiene and clean cooking prac-
alternative if the resistance pattern permits. tices, which depend on knowledge, atti-
Campylobacter does not always require an- tudes and cultural practices, but above all
tibiotics, but if necessary ciprofloxacin can on economic factors. Good nutrition starts
be used. Metronidazole is used to treat dys- with exclusive breastfeeding during the first
entery caused by protozoa. This type of diar- six months of life, which reduces the risk of
rhoea thus requires quite advanced diagnos- infection for the young child. Continued
tic resources to choose effective treatment, breastfeeding during the first two years and
and thus it is difficult to cure all cases in intensive feeding during and after an epi-
countries with scarce resources. A central sode of diarrhoea prevent it from develop-
part of the global policy for treatment of di- ing into persistent diarrhoea and malnutri-
arrhoea is that non-dysenteric diarrhoeas tion. Breastfeeding has been shown to lower
should not be treated with antibiotics, since the mortality rate and severity of cholera
C this does not help. The main way to reduce and Shigella infection by a factor of 2.5 to
M the global burden of diarrhoeal diseases re- 4.0 (WHO 1998).
mains prevention through improved hy- Vaccines are still of limited significance in
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giene, reduced malnutrition and treatment reducing the global burden of diarrhoeal
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of acute dehydration with ORT. diseases. A relatively new vaccine provides

5.4 Vaccine-preventable childhood diseases (3 %)
good protection against cholera for three 5.4 Vaccine-preventable

years, and simultaneously relatively good
protection (70 %) against enterotoxic
childhood diseases (3 %)
Escherichia coli diarrhoea (the so-called Edward Jenner took material from a pustular
tourist diarrhoea), but only for three lesion on the hand of the milkmaid Sarah
months. Several new vaccine candidates are Nelmes and inoculated it into the skin of
now being tested and there is a high ex- James Phipps on 14 May 1796. This was the
pectation that a new and safer rotavirus first scientifically developed vaccine (from
vaccine will become available. A vaccine Latin vacca = cow), and the only one to be
against rotavirus would reduce mortality developed in the 18th century. In the 19th
due to diarrhoea in the world, but the ques- century another four vaccines were devel-
tion is whether it can be made available at a oped, starting with rabies in 1885 (Pasteur),
sufficiently low cost to the countries and and in the 20th century around 30 new vac-
families in greatest need. From a conven- cines, including different combinations, fol-
tional public health point of view, it can be lowed.
argued that the best use of resources in The world experienced the last case of
these countries is to permanently improve smallpox in 1977. The last patient was a
water supply, handling of excreta and per- cook at the hospital in the town of Mecca,
sonal hygiene. However, this is so costly south of Mogadishu, in Somalia. The World
that the cheaper treatment offered by ORT Health Organization declared smallpox to
is preferable. Using resources for vaccina- be eradicated in 1979, following decades of
tion against one of the main causes of diar- very determined vaccination campaigns
rhoea can only be justified if this saves against this devastating viral disease. This
more lives than using these resources for success provided a hope of eradicating other
improved hygiene or better treatment. The diseases, such as measles and poliomyelitis,
idea expressed here may seem a bit strange, for which effective vaccines now existed.
as the opposite is usually stated. Most read- A worldwide Expanded Programme on
ers would probably prefer to apply a pre- Immunisation (EPI) was started by WHO
ventive approach rather than first contract- and UNICEF in 1974, with the goal that all
ing a disease and then applying a cure, even countries should start national programmes
if the cure may be cheaper. to immunise all children according to a pro-
posed schedule (Table 5.4). Latterly, hepati-
tis B has been added to the programme in
countries with a high prevalence of infec-
Table 5.4 WHO recommendations for standard routine immunization schedule for infants.
Disease Vaccine Time of Vaccination
Tuberculosis BCG at birth

Poliomyelitis OPV at birth, 6, 10 and 14 weeks
Diphtheria DTP 6, 10 and 14 weeks
Pertussis DTP 6, 10 and 14 weeks
Tetanus DTP 6, 10 and 14 weeks
C
Measles 9 months
M
Yellow Fever 9 months if relevant
Y
Hepatitis A+B at birth if relevant
K Tetanus in pregnancy 2 injections during pregnancy to avoid neonatal tetanus

tion with this virus. Haemophilus Influen- Expanded Programme on Immunisation

sae and other immunisations are recom- (EPI).
mended. In a 15-year period up to 1990, immunisa-
Immunisation is one of the most cost- tion rates rose to around 80 %, under the
effective interventions to lower the under- slogan of Universal Childhood Immunisa-
five mortality rate. The cost of DTP (diphthe- tion. This was largely a result of the success-
ria-tetanus-pertussis), measles, polio, and ful guidance provided by the organisations
BCG (Bacille Calmette-Gurin) vaccines for a of the United Nations, especially the practi-
fully immunised child (FIC) is now no more cal approach of UNICEF. They developed
than USD 1.5. This is due to a very effective new material for transporting and storing
international purchase system initiated by vaccines at the lowest cost possible. Special
UNICEF and WHO. However, the total cost credits should go to the dynamic leader of
of these immunisations, including labour, UNICEF, James Grant.
transport and logistics, health facilities, Unfortunately, these achievements are
planning and the training of staff and man- difficult to sustain. Under the impact of eco-
agement, as well as provision of refrigerators nomic crises, and with global support de-
and other cold chain equipments can be es- creasing, coverage rates stagnated or even
timated at around USD 17 per child. In other began to decline. By 1999, the coverage rate
words, the cost of the vaccines is only 10 % (as measured by DTP3) stood at 76 %. Many
of the cost of the vaccination. This is an av- countries today, particularly in Africa, have
erage across different countries. In individ- coverage levels below 50 %. Among coun-
ual countries this cost may vary from USD 6 tries in crisis or at war, rates are less than
to over USD 20. The cost increases for exam- 30 %. An exception has been polio, where
ple in nomadic populations. When coverage eradication efforts have been focused on Na-
rises above 80 % the marginal cost for reach- tional Immunisation Days, on which all
ing additional children also tends to rise children are expected to receive Oral Polio
steeply in most countries. With the newer Vaccine (OPV). As this oral vaccine does not
and more expensive vaccines, the costs of require an injection, the advantage is that
the vaccines will inevitably rise. However, a health service staff is not required to give
vaccine tends to become less and less costly the immunisation. This has frequently led
over time. The first recombinant hepatitis B to OPV coverage levels above 90 or 95 %.
vaccine in the mid-1980s, for example, cost Unfortunately, all other vaccines in the EPI
USD 50 a dose, while the latest price is now programme need to be injected.
down to USD 0.3 per dose. In contrast the A particular problem is that all injections
cost of delivering the vaccine remains more are not given in a safe manner. Unsterilised
or less the same. It is important to realise needles may be used. One problem may be
that the cost of the vaccine is a minor part of that disposable syringes are not successfully
the cost of vaccination. destroyed after use. Informal health practi-
A multitude of immunisation strategies tioners may reuse such needles again with-
has been tried over the years. The basic out proper sterilisation. This could result in
strategy, however, remains to provide the the spread of blood-borne infections, partic-
basic routine immunisations in fixed health ularly hepatitis B, hepatitis C and HIV. Up to
facilities, supplemented by outreach strate- one-third of the estimated 12 billion injec-
gies of various kinds, especially in low-den- tions given every year are not safe. Of these
C sity populated areas. Although many of the 12 billion, an estimated one billion are im-
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present vaccines were developed, overall munisation injections, while the rest are in-
global immunisation coverage of children jections for curative purposes. Great efforts
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in the early 1970s was less than 5 %. This have been made to develop systems that di-
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was the time when the WHO established its minish the risk of unsafe injections in the

Box 5.3
Combination vaccines, with several antigens Manufacturers do not feel that there is suffi-
in the same injection, are especially impor- cient incentive to spend around USD 200
tant for low-income countries. The most million to develop such a vaccine without
common of these is the DTP (diphtheria-tet- the assurance of a market that will make it
anus-pertussis) vaccine. MMR (measles- possible to recover the research invest-
mumps-rubella) and MR vaccines are mainly ments. It must be realised that the objective
used in high-income countries. Industry has of commercial pharmaceutical companies is
now developed a tetravalent vaccine includ- to make profit on invested capital. The mar-
ing hepatitis B (DTP-HBV) and even a pen- ket mechanisms will not provide the vac-
tavalent DTP-HBV-Haemophilus type B. Ob- cines that the world needs. Therefore there
viously combination vaccines have a great has been little research into vaccines for ma-
potential in countries with fragile health sys- laria and tuberculosis. A pull mechanism in
tems, even if the cost of the actual vaccines the form of an artificial market has been
becomes higher. These new combination suggested to encourage the pharmaceutical
vaccines are still costly and in short supply industry to step up research efforts for or-
but may become much more used in a few phan vaccines (Sachs 2001). This requires a
years. system whereby the public sector, through
The development of new vaccines is donor agencies or multilateral organisa-
costly, and somebody has to pay. If this cost tions, guarantees the purchase of a specified
is to be covered by the market, through quantity of malaria vaccine at an agreed
high prices, most children in low and mid- price, e.g. USD 10 per dose. If manufactur-
dle-income countries will not benefit from ers succeed in producing such a vaccine,
these scientific achievements. Put more they will know what the return will be, and if
bluntly, the new vaccines will not be used to they do not, they take on the risk of losing
save millions of lives, but only to reduce the their investment themselves. Traditional
incidence of illness among children who al- push mechanisms are also possible; but
ready have access to adequate treatment if this implies that the public sector or philan-
they get pneumonia. The development of thropic billionaires pays for research to be
rational and adequate financing mecha- conducted and take the risk of loosing the
nisms for the development, purchase and money if the research fails. The currently
provision of new vaccines to all the children promising vaccine candidates to meet the
in the world is obviously as great a chal- needs of low-income countries are those
lenge. against rotavirus and the common bacteria
Vaccines that are not in sufficient demand causing pneumonia and meningitis (NIH
on the market are called orphan vaccines. 2000).
vaccination programmes. Disposable (one- duce the practice of throwing things away
time) syringes were once thought to do so, in poor countries. The most promising de-
although it has been found that they actu- velopment is the invention of the auto-de-
ally entail increased risk, as they are in prac- struct (AD) syringe, which cannot be reused
tice often reused without sterilisation. The once the plunger has been depressed. WHO-
simplistic idea that disposable needles could UNICEF and UNFPA have adopted a policy
solve the problem of unsafe injections in by which only these AD syringes are pro-
C poor countries is but one of many strange vided, and countries are to make a sched-
M suggestions originating from high income uled switch to them within a few years.
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countries that are contra-productive because Pending the switch, sterilisable syringes
they completely fail to understand the char- should be used in preference to disposable
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acter of poverty. It is very difficult to intro- ones in many settings.

One of the most important and contro- ease has become rare, due to high immuni-
versial recommendations by WHO was that sation rates.
the primary health care services in low and Measles is always a severe disease, but it
middle-income countries should also use has an extremely low mortality among well-
the opportunities to vaccinate sick children. nourished children. In contrast, measles is a
These children are in fact a special priority devastating disease for a malnourished child
group for immunisation. The success of this without access to health care. It has a 3 to
policy has also undoubtedly contributed to 5 % case fatality rate in low-income coun-
the falling under-five mortality rate in the tries. In refugee camps and other high risk
world. populations the percentage of children
Estimates indicate that 3 million children dying from measles is commonly 10 to 30 %.
are saved annually by vaccinations. Another The disease starts with a cough and fever.
4 million lives could be saved by immunisa- After a few days, the fever reaches a peak
tion utilising all existing vaccines and ex- and a skin rash appears. The measles virus
tending coverage (WH0 1998). In the fol- infects all of the mucous membranes of the
lowing sections we will describe one by one body. The body needs vitamin A to repair
the diseases, that can be prevented by im- mucous membranes, and thus measles eas-
munisation. ily depletes stores of vitamin A, especially if
they are already low. The disease increases
the risk of the most severe complications of
5.4.1 Measles (1.4 %) vitamin A deficiency: blindness due to de-
Measles is a very contagious viral infection struction of the cornea and death from sec-
that spreads by direct contact or by droplets ondary infections due to a compromised im-
in the air. It is a severe febrile disease, affect- mune system. In children that survive the
ing mainly children. The peak incidence is measles infection severe malnutrition is a
at 23 years of age in an unimmunised pop- common complication that may take
ulation. An estimated 40 million children months to recover from. The child is prone
contract measles each year. This corre- to get complicating infections in the eyes,
sponds to about 30 % of all children born; mouth or ears, as well as diarrhoea and res-
the remaining 70 % do not get the disease piratory tract infections, including reactiva-
because they are protected by vaccination. tion of primary tuberculosis. Following an
About 600 000 children still die of this dis- episode of measles, the immune system be-
ease each year, and measles remains one of comes weakened, both during the acute ill-
the five most common causes of death in ness and for months afterwards. A higher
children on a global scale. It is noteworthy energy intake than usual is necessary to
that this is the case even though an effective fight the infection, but the child with mea-
and safe vaccine has been available for al- sles has difficulty eating enough to secure
most 30 years. The fact that measles still even basic energy needs due to fever, diar-
ranks as number 14 among diseases causing rhoea and infection in the mouth. It is very
most loss of healthy years of life in the demanding and resource consuming to care
world indicates that the provision of vacci- for a child with measles.
nation for those who need it seems to be There exists no treatment for the viral dis-
more difficult than many would think. The ease itself, but malnutrition and secondary
vast majority of DALYs lost due to measles bacterial infections can be successfully
C are in Sub-Saharan Africa, where the combi- treated. Vitamin A supplementation is cru-
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nation of low immunisation coverage and cial for survival. Since measles appears in as-
widespread malnutrition render children sociation with pneumonia, diarrhoea and
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susceptible to severe forms of measles. In malnutrition, the Integrated Management
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middle and high-income countries, the dis- of Childhood Illnesses approach is particu-

= 1 million DALYs
Map 5:4 Measles cause 26 million disability adjusted life years (DALY) lost per year.
Source: WHO, 2002.
larly appropriate for this disease. Good nu- distribution to the final child health clinic,
trition, including continued breastfeeding where the vaccine is finally to be injected
during and after the disease, is essential for under the skin of the child. This may seem
the survival of children with measles. easy, but in practice it is an enormous obsta-
It is sad that so many resources must be cle in countries with scarce and irregular en-
used to treat measles, since it is a very easily ergy supplies. The need to maintain sterility
preventable disease. A live attenuated vac- at immunisation also places high technical
cine, which provides good protection, is safe demands on both equipment and the
and today also cheap. It is estimated that knowledge and skills of the staff. The cost of
more than 70 % of all children in the world the vaccine itself is only about 10 cents per
currently are vaccinated, and this has al- dose. In fact the cost of the vaccine is a neg-
ready saved many lives. But hopes of eradi- ligible part of the cost of vaccination. The
cating measles through vaccination have success entirely depends on the coverage
been tuned down, since immunisation cov- and quality of the health service in each
erage of more than 95 % is required to stop country.
the transmission and thus eradicate the vi- The coverage of immunisation against
rus. WHO recommends one dose of vaccine measles and DTP (diphtheria-tetanus-per-
at the age of 9 months, although in special tussis), is a good indicator of how well the
situations two doses may be needed. health service system functions in a coun-
Although new stabilisers have made the try. National immunisation rates vary from
freeze-dried vaccine less heat-sensitive, the 90100 % in high or middle-income coun-
C present vaccine still requires a well-func- tries to only 3035 % in a few low-income
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tioning cold chain. This expression refers countries, or even lower in some of the
to the need to store and transport the vac- most war-torn countries. In all of Sub-Saha-
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cine at a temperature below 4oC from its site ran Africa, it is estimated that about 50 % of
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of production, through storage and during the children are immunised. Further im-

provement of the coverage of measles im- 5.4.3 Tetanus (0.5 %)

munisation thus remains one of the most Although the bacteria that cause tetanus are
cost-effective health interventions in the present worldwide, this disease causes
world. DALYs to be lost almost exclusively in low
and middle-income countries. The main
reason is that the populations of high-in-
5.4.2 Pertussis (0.8 %)
come countries are protected from tetanus
Whooping cough is the lay term for pertus- through a very effective immunisation. The
sis. This disease caused an estimated 300 000 few cases occurring in high-income coun-
child deaths in 2002, almost all in low and tries occur in elderly people or immigrants
middle-income countries. Pertussis was, with inadequate or absent immunisation.
after measles, the vaccine-preventable child- An estimated 210 000 deaths due to tetanus
hood disease that caused the most DALYs occur in the world every year, which repre-
lost globally in 2002. sents a decrease from about 1 000 000 in the
It is an infection of the airways by bacteria early 1980s. This decrease is mainly due to
of the Bordetella pertussis species. The dis- more or less successful national immunisa-
ease starts with a nasal discharge, cough and tion programmes in most countries.
fever. After ten to fifteen days, the cough The bacteria causing tetanus, Clostridium
gradually worsens and each coughing attack tetani, is abundantly present in soil and
is followed by a peculiar airway spasm re- may be introduced into the body through
sulting in the whooping that has given the wounds. The use of unclean instruments to
disease its name in many languages. In Chi- cut the umbilical cord after delivery can also
nese, the disease is called 100-day cough cause tetanus in the newborn, known as ne-
because the cough generally lasts more than onatal tetanus.
three months, but the disease is eventually After an incubation period of 12 weeks,
self-limiting. The child often vomits at the the bacteria produce a neurotoxin that
end of the coughing attacks, and is therefore causes generalised muscular spasms. The
prone to becoming malnourished during muscle rigidity and spasm start in the face,
the period of illness. The disease can be es- spread within days to involve the whole
pecially life threatening if the affected child body, and continue for two to four weeks.
is less than one year of age and if the child is These generalised spasms cause the death of
already malnourished at the start of the dis- 10 to 90 % of the patients affected by tetanus.
ease. The death rate is highest in newborns and the
Pertussis is special in that, although bacte- elderly, but the prognosis largely depends on
ria cause it, it cannot be cured with antibiot- whether ventilator care is available. Modern
ics. Antibiotics only have effect if given be- high-technological intensive care can save
fore the convulsive cough starts, but at that almost all cases of tetanus, but there is no
early stage the disease is very difficult to di- low-cost treatment that can achieve this.
agnose. In small children, pertussis may be However, a very cheap, safe and effective
complicated by a bacterial pneumonia that vaccine is available against tetanus. The dis-
can be treated with antibiotics. Otherwise, ease can be prevented in the newborn baby
treatment is symptomatic. Above all, par- if the pregnant woman is given at least two
ents need great patience to wait for the doses of tetanus vaccine during pregnancy,
disease to pass and frequent small feeds as if she has not already been immunised. The
C long as the cough lasts. The only prevention antibodies formed in the mother following
M
is immunisation with the low cost vaccine vaccination are transferred to the child and
(Table 5.4). protect it during the first months of life. Pre-
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K
vention also includes clean care of the um-
bilical cord after birth. Vaccination with the

diphtheria-pertussis-tetanus (DTP) vaccine affects only one arm or leg. Before WHO and
should be carried out three times during the UNICEF launched the worldwide vaccina-
first year of life, starting from the age of six tion programme, polio caused about half of
weeks (Table 5.4). Health education is im- the walking disabilities in the world. Most of
portant to prevent tetanus. People must the healthy life years lost from polio are due
come early for treatment of severe wounds to permanent paralysis. Only if the respira-
by cleaning and booster-vaccination, and tory muscles are affected may the disease be
must understand the importance of vaccina- fatal.
tion and clean birth practices. As late as the 1950s, epidemics of polio oc-
curred in all high-income countries, but in
the 1960s the vaccine ended polio as a pub-
5.4.4 Poliomyelitis (< 0.5 %) lic health problem in high-income coun-
Before the development of the vaccines tries. In the last epidemic in Sweden in 1953
against polio in the 1950s, it was a world- a total of 5 000 victims suffered from various
wide disease. In the year 1988, when the de- degrees of paralysis. The last case in the
cision to eradicate polio was taken, there Americas was reported in Peru in 1991. This
were 350 000 cases per year around the was after six years of joint international
world. Polio has been eradicated in Europe, work towards eradication, using routine vac-
the Western Pacific region and the entire cinations, national vaccination days and
American hemisphere. Following the suc- mop-up operations to control outbreaks, as
cessful eradication of smallpox 20 years ago, well as building up a surveillance network.
the poliovirus may be the second major mi- The success in the American hemisphere in-
croorganism to be eradicated from the dicates that it should be possible to eradicate
world. Due to high coverage of vaccination, polio throughout the world and WHO has
polio is also on the verge of eradication in formed a special organisation for this eradi-
North Africa, Middle East and East Asia. The cation. In the year 2002 less than 2 000 cases
majority of cases now occur in India, and occurred in the 7 countries where polio is
Pakistan, and to a lesser extent in western yet to be eradicated. These countries are In-
and central Africa. Particularly vulnerable dia, Pakistan, Afghanistan, Somalia, Egypt,
populations are: refugees, victims of war and Niger and Nigeria. It is interesting that eco-
the urban poor in countries whose infra- nomic calculations show that the cost of the
structure and preventive health services extra effort needed is less than the cost of
have been destroyed. To finally eradicate po- the ongoing vaccinations in the world. But
lio, these pockets of populations at high risk with very few cases in some areas, there is a
need to be reached with vaccination. false sense of security and the motivation to
Poliomyelitis is a diarrhoeal disease caused keep up massive national campaigns may
by a very contagious virus, which spreads decline. It is feasible but by no mean clear
from faeces to the mouth, like other diar- that polio eradication will succeed in the
rhoeas do. More than 90 % of all subjects in- near future. The readers are suggested to fol-
fected by the virus show no sign of disease or low the outcome of this important effort
only a slight fever, headache or diarrhoea for through the web site.1
a few days, and yet they gain immunity for
the rest of their lives. However, in about 1 %
of persons infected with the poliovirus, the 5.4.5 Diphtheria (< 0.5 %)
C disease progresses to destroy the anterior Around 100 000 new cases of diphtheria
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horn cells in the spinal cord, transmitting occur every year, leading to around 5 000
signals to the muscles. Various forms of flac- annual deaths worldwide at the turn of the
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cid paralysis may result, often permanent.
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The paralysis is usually asymmetrical, i.e. it 1
www.polioeradication.org

21st century. Diphtheria was one of the lead- healthy life years lost in the world. In high
ing causes of childhood mortality in the transmission areas malaria affects mainly
world until the introduction of the vaccine children and pregnant women. The cost of
and antibiotics 50 years ago. The reason for malaria is enormous, both in lost productiv-
including it in this review of global health ity through death and disease and in treat-
problems is that vaccination against diph- ment costs. In Africa alone the direct costs
theria is part of the EPI programme. It is also are estimated to be more than USD 2 billion
interesting to note that the socio-economic per year (Sachs 2001).
decline in the former Soviet Union after Four types of malaria parasites can infect
1990, resulted in an epidemic of diphtheria humans. These four types are known as Plas-
that spread to 15 countries and caused as modium falciparum, P. ovale, P. vivax and P.
many as 25 000 (WHO 1996). Thus the im- malariae. These parasites are all transmitted
portance to keep up the vaccination efforts. from one person to another via the Anophe-
Diphtheria is a bacterial infection that les mosquito. When a mosquito sucks
causes a severe respiratory tract infection blood, it infects the person with parasites
with fever and severe damage to the mucous that are present in the saliva that the mos-
membranes of the nose, throat and larynx. quito injects before sucking. Plasmodium
The bacteria also produce a toxin that falciparum is the most dangerous type of
spreads through the blood and can affect malaria, since it causes the severe and po-
the heart and nerves. Death may occur due tentially fatal form of cerebral malaria. This
to obstruction of the larynx or to effects on species of the parasite multiplies most rap-
the heart. The case fatality rate is 5 to 10 %. idly in the blood, but cannot remain dor-
Penicillin and erythromycin are both effec- mant in the liver like the other types.
tive against the diphtheria bacteria. How- An attack of malaria typically has a sud-
ever, diphtheria can be fully prevented by den onset, with fever, muscle stiffness and
immunisation with the diphtheria-pertus- headache. Other general symptoms, such as
sis-tetanus (DTP) vaccine three times from diarrhoea and vomiting, are also common.
the age of six weeks. To avoid epidemics, it is When an attack of falciparum malaria in-
essential to maintain immunisation cover- volves the brain, the disease may suddenly
age in all countries. Surveillance and rapid be aggravated with convulsions, uncon-
management of cases of diphtheria, as well sciousness and death. The most terrifying
as the detection and prevention of close aspect of the falciparum type of malaria is
contacts, are necessary to further hinder the the speed with which the disease can de-
spread of epidemics. velop. Respiratory distress and acidosis are
severe symptoms. Particularly in children
the disease can progress from chills and
fever to death in the course of one to two
5.5 Malaria (3 %) days, if treatment is not commenced in
Worldwide the malaria parasite is estimated time. A single episode of malaria lasts 114
to be the direct cause of about 1.3 million days. Anaemia is a common complication of
deaths and an estimated 300 to 500 million malaria attacks, especially in populations
clinical cases annually. More than 90 % of with co-existent malnutrition.
all parasite carriers live in Africa (WHO Malaria attacks are more frequent in preg-
2001), and currently 5 % of all children born nant women than in other adults. The rea-
C in Africa are expected to die of malaria. Two- son is that pregnancy decreases the immu-
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fifths of the worlds population live in areas nity they have earlier acquired against the
of risk for malaria infection in Sub-Saharan disease. Malaria is a major cause of maternal
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Africa, Asia and Central and South America. mortality, abortion and low birth weight.
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The disease is among the top ten causes of Mothers transmit a passive immunity via

5.5 Malaria (3 %)
= 1 million DALYs
Map 5:5 Malaria causes 41 million disability adjusted life years (DALY) lost per year.
Source: WHO, 2002.
the placenta, and these antibodies protect ment, as well as due to increasing drug re-
the infant for the first four to six months in sistance that so many children in Africa die
life. In areas with intensive malaria trans- of malaria.
mission, young children are the main vic- During recent decades, the drug most
tims. Children who survive the attacks of commonly used to treat malaria was chloro-
the disease gradually develop immunity. quine. This drug was developed in the
However, immunity against malaria is tran- 1940s. It replaced quinine, because it was as
sient. If a previously immune individual effective and much safer. For this reason
spends a year outside areas with malaria- chloroquine became very widely used. The
transmitting mosquitoes, she again becomes malaria parasites began to become resistant
susceptible to the parasite and may suffer a to chloroquine in South-East Asia and Latin
fatal attack of the disease on return. America in the 1960s, and this resistance
Treatment of simple malaria is fairly easy spread to Africa in the 1970s. In large parts
if it is diagnosed early and the parasites are of Sub-Saharan Africa, the resistance levels
not resistant to the anti-malarial drugs used are now as high as 60 % or higher. In the
in the area. Most attacks of malaria can be areas in East and Central Africa with the
cured through home treatment prescribed highest percentage of resistance to chloro-
by briefly trained staff at primary health quine, this drug is no longer an efficient
care facilities or by the parents of the sick treatment. Despite this chloroquine is still
child. In contrast, successful treatment of the drug of choice for uncomplicated ma-
very severe forms of cerebral malaria re- laria in many countries. This is due to its low
C quires the most sophisticated form of inten- cost, lack of political will and slow proce-
M sive care. Children in heavily affected areas dures to change national treatment policy.
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often die from anaemia, resulting from re- A major alternative to chloroquine has
peated malaria infections. It is in the ab- been sulfadoxine-pyrimethamine (Fan-
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sence of early diagnosis and proper treat- sidar), but this drug produces more side ef-

fects. Resistance to it is also spreading in Multinational pharmaceutical companies

South-East Asia, Latin America and East Af- have the scientific expertise and capacity
rica. Mefloquine is used in multi-resistant required, but they have no economical rea-
strains, but resistance is also developing rap- son to invest in a project that will not pro-
idly against this drug in South-East Asia. Ar- vide sufficient profit. The world is waiting
temisin has been developed and used in for the innovative financial solution that
China for hundreds of years. It is obtained can enable medical research to solve this
from plant extracts and is now being tried major global health need.
with success in the treatment of severe, Global strategies to prevent malaria have
multi-resistant malaria. The malaria treat- changed several times during the last half-
ment of the future in which most research- century. Given the spread of resistance and
ers believe today is a combination of artem- the occurrence of toxic side effects, chemo-
isin with one or two other drugs. The prophylaxis for populations in endemic
combination therapy is due to a rapidly de- areas is today out of the question. After the
veloping resistance to the first and second- Second World War, the aim was to eradicate
line drugs, chloroquine as well as sulfadox- malaria by a two-pronged attack. The new
ine-pyrimethamine, and to avoid future re- pesticide DDT, was sprayed in large cam-
sistance to artemisin. These combinations paigns to reduce the number of mosquitoes,
are currently being used in Asia and are and chloroquine was given widely to eradi-
under trial in Africa. The problem is the in- cate the parasite from humans. It was gradu-
creasing costs of these combination drugs, ally realised that DDT itself might be dan-
which is why many Ministries of Health still gerous to humans and that it caused side ef-
recommend outdated malaria treatment. fects in the environment. The mosquitoes
The fact that quinine after 300 years of soon developed resistance to the pesticide,
wide use still remains the most important just as the malaria parasite developed resist-
treatment for severe malaria reflects the ap- ance to chloroquine. The large-scale eradica-
pallingly limited investment in research tion campaigns were stopped, because posi-
into new drugs for this disease. Quinine is a tive results were not sustainable with this
naturally occurring compound, initially approach. In India malaria was almost erad-
found in a traditional herbal drug in South icated in the 1970s, but the disease has been
America that has been used against malaria recurring during the last decades of the 20th
for centuries. It has a very good effect century. India is now estimated to have 11
against severe forms of falciparum malaria. to 15 million cases of malaria per year. WHO
Resistance to quinine has only been docu- had to adopt the more modest goal of con-
mented in some parts of Latin America, and trolling mortality by providing treatment
in South-East Asia, but not yet in Africa. The for those contracting malaria rather than to
disadvantage with quinine is that it is very try to eradicate the disease.
toxic and an overdose may cause lethal car- The latest preventive option is to pro-
diac effects. mote insecticide-impregnated bed nets.
It is very easy to foresee a great need for These have been widely tested as an ecolog-
more drugs against malaria in the near ically sound, large-scale intervention. The
future. The advances in molecular biology distribution of impregnated bed nets in
and pharmacology make it scientifically rural villages in Gambia has achieved a 70 %
highly possible that such drugs can be devel- reduction in mortality among children
C oped. The obstacle is on the financing side. (Alonso 1991). Unfortunately, the cost of
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Since the disease affects almost exclusively bed nets is still too high in relation to the
the poorest populations of the world, the resources available to the Ministries of
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research required is not a high priority for Health and the average families in the most
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the multinational pharmaceutical industry. affected African countries. The cost per

5.6 Tuberculosis (3 %)
healthy life year saved is about USD 25. The search strategy remains unclear. Some prior-
problem of preventing malaria is thus eco- ity issues include allocating more scientific
nomic, organisational and scientific. The resources to developing new drugs, investi-
scientific challenge is not to find effective gating how malaria is treated in affected
methodsthey already exist. The challenge communities, improving the way bed nets
is to find methods cheap enough to be sus- are made available and the development of
tainable among the poor in the low-income a vaccine, which may take years or decades,
countries where malaria mainly occurs, or if at all possible.
to find increased external funding. In No-
vember 2002, the Global Fund against
AIDS, TB and Malaria (GFATM) signed an
agreement with the government of Tanza-
nia to provide millions of impregnated bed Infection with the tubercle bacteria causes
nets for the children of Tanzania. The drain- about 7 million new clinical cases of tuber-
age of mosquito-breeding wetlands is also a culosis annually, and half a century after the
potentially simple and effective measure in discovery of life-saving treatment, it is still
areas where the breeding sites are well de- estimated to kill around 1.6 million people
fined, but it appears to be a feasible interper year (WHO 2004). The majority of cases
vention in only a few areas. occur in South and East Asia and Sub-Saha-
Extensive research efforts to find a vaccine ran Africa. Tuberculosis is, after HIV/AIDS,
against malaria are being made, but so far the leading killer of adults among the com-
the few candidate vaccines tested have not municable diseases. 99 % of all DALYs lost
been sufficiently protective. Only one vac- due to tuberculosis occurred in low and
cine candidate has shown some protective middle-income countries. The economic
effects in adults, which increases the hope burden of the disease is extensive, since it
of finding a vaccine that is sufficiently effec- mainly affects economically productive
tive for children. The progress in molecular young adults.
biology, including the revelation of the At the end of the 19th century and during
whole genome of both the malaria parasite the first half of the 20th century tuberculosis
and the Anopheles mosquito in September was a major public health problem in Eu-
2002, makes vaccine development a more rope and North America. Overcrowded
hopeful goal. However, it remains very diffi- housing and poor sanitary conditions gave
cult to predict how much more research is rise to the spread of the disease. The fact
needed to produce an effective vaccine. Esti- that the incidence of tuberculosis was
mates are that an effective vaccine will not higher in Scandinavia a hundred years ago
be available within the next decade. than it is in Africa today may be because
At present there is no doubt that the bur- transmission is higher under poor living
den of malaria is increasing in the world, al- conditions in a cold climate. The reason
though the disease occurs almost exclu- being that indoor crowding is worse when
sively in low-income countries. WHO has poor people have to stay warm during the
responded with a programme called Roll winter. In the climatic sense of the term, tu-
Back Malaria, which presents a joint strat- berculosis is definitely not a tropical disease,
egy to co-ordinate existing resources in a although the incidence today is highest in
better way.1 In the short term, the focus is to the tropics. The disease incidence decreases
C improve the use of existing drugs and to im- with socio-economic development and was
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prove the use of health services by the af- under control in all high-income countries
fected populations. The best long-term re- by the 1970s or 1980s. The decrease of tu-
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berculosis in the richest countries occurred
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1
http://mosquito.who.int mainly before the discovery of tuberculo-

= 1 million DALYs
Map 5:6 Tuberculosis causes 36 million disability adjusted life years (DALY) lost per year.
Source: WHO, 2002.
static drugs around 1950. The decrease in TB ries. The PPD test involves injecting a pro-
before the drugs has been attributed to bet- tein from the bacterium into the skin,
ter nutrition, better housing, better sympto- which develops a red swelling in people in-
matic care of the sick and early isolation of fected with the bacteria. Unfortunately, the
contagious cases as correct diagnosis be- result is also positive in those vaccinated
came available at the end of the 19th cen- against tuberculosis, and so this test is not of
tury. However, there has been a resurgence much use in the fight against tuberculosis.
of tuberculosis in the world, including Only in countries where immunisation
many of the high-income countries, since against TB is rare does this test have good di-
the mid-1980s. This is because HIV infection agnostic value.
increases the risk of contracting tuberculosis A special feature of Mycobacterium tuber-
and, more importantly, of reactivating dor- culosis is that only 10 % of newly infected
mant TB. Other reasons are that many tu- persons have any signs of disease. Although
berculosis strains have developed resistance the primary infection passes unnoticed in
to the drugs used against the disease, and most persons, the bacteria spreads via the
that control programmes have missed many blood and may remain dormant in many
socially deprived cases even in some high- body organs. The dormant bacteria may
income countries. wake up and cause disease many decades
The bacteria causing tuberculosis, Myco- later in life. In fact most forms of tuberculo-
bacterium tuberculosis, is transmitted via sis, especially pulmonary tuberculosis is a re-
droplets from coughing persons with pul- sult of reactivation of an infection that was
C monary tuberculosis. The bacteria can be di- acquired many years or decades earlier. Mal-
M rectly diagnosed by microscopy after stain- nutrition, diabetes, alcoholism and HIV in-
ing of sputum. This is a low-cost test, while fection are predisposing factors for reactiva-
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diagnosis through cultivation of the bacte- tion. Most reactivations occur in the lungs.
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ria requires advanced and costly laborato- We will restrict the discussion about tuber-

velopment of resistance. Second, the drugs

must be taken regularly for a period of 6 to 8
months, although most symptoms will dis-
appear after a few months. The drugs used
are combinations of isoniazid, rifampicin,
streptomycin, pyrazinamide, and ethambu-
tol. Because of the long treatment and un-
pleasant side effects of some drugs, the risk
of interruption of treatment is high. Drug
resistance is worse in Asia, but is now be-
coming a problem all over the world. For
many decades WHO has promoted non-
hospitalised treatment for TB patients.
Compliance to treatment has remained low
in most countries. WHOs strategy is known
as directly observed treatment short-course
(DOTS). This strategy implies that patients
must swallow their tablets daily in front of a
trained health worker or specially desig-
nated controller in their local community.
There should be a good, regular supply of
anti-tuberculosis drugs to health facilities.
The case detection is based on self-reporting
at health centres and on the use of sputum-
CAMBODIA, Tonle Sap. A doctor examining a man smear microscopy. The collection of a repre-
suffering from tuberculosis. sentative sputum sample is quite demand-
Sean Sprague/PHOENIX. ing. So is the correct staining and examina-
tion in the microscope. It thus requires well-
trained laboratory staff. In special interven-
tion studies, the DOTS strategy has been
culosis to this form that should be called found to produce about 95 % cure rate
post-primary pulmonary tuberculosis, but it among TB patients. However, when imple-
is often only called lung TB. Pulmonary tu- mented countrywide the cure rate has been
berculosis is especially important as it both found to be lower.
constitutes the majority of cases and is re- Besides improved treatment of pulmonary
sponsible for almost all transmission. The tuberculosis, the main options to prevent
most common symptoms are prolonged the disease are of general character, i.e. im-
cough, shortness of breath, fever, weight proved housing and nutrition. The BCG
loss and fatigue. A particular feature of tu- (Bacille Calmette-Gurin) vaccine against
berculosis is that treatment of patients is the tuberculosis is given at birth. Unfortunately
best way to prevent the spread of the infec- the vaccine provides protection mainly
tion. against severe forms of primary tuberculosis
Effective drugs against tuberculosis have infection in young children. The vaccine
been available for the last 50 years. There are does not protect well against the secondary
C many reasons why the control of tuberculo- pulmonary forms of TB. Health education
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sis has failed in many middle and low-in- programmes dealing with the mode of
come countries in spite of the existence of transmission, methods of control and the
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effective drugs. First, it is necessary to treat importance of early detection and treatment
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with a combination of drugs to avoid the de- are important. Delayed diagnosis or ineffec-

tive treatment of tuberculosis often cause tries formally belonging to the Soviet Un-
long-term dysfunction of the lungs, loss of ion. Other middle-income countries, such
job, economic hardship for families and im- as Cuba, China and Costa Rica, are known
paired national economic development. to have implemented successful strategies to
counteract the spread of STIs. Chlamydia
trachomatis infection remains a widespread
problem in middle and high-income coun-
5.7 Sexually transmitted tries alike, but the contribution of Chlamy-
infections (excluding HIV) dia infection to the panorama of STIs in
low-income countries is largely unknown.
(1 %) During pregnancy the STIs may cause foe-
It is estimated that 330 million cases of cur- tal diseases and low birth weight. They may
able sexually transmitted infections (STIs) also cause pre-term birth and postpartum
occur in the world every year, most of them infections in the mother and newborn, in-
in low-income countries. Excluding HIV including eye infections in the newborn. It is
fection, the STIs jointly caused 0.8 % of the estimated that up to 80 million women in
worlds DALYs lost in 2002. Syphilis infec- the world are infertile. The vast majority
tion caused most of those DALYs lost, fol- having lost their fertility due to pelvic in-
lowed by chlamydial infections and gonor- flammatory disease resulting from various
rhoea. For many decades STIs have ranked STIs. The pelvic inflammatory diseases also
among the top five conditions for which increase the incidence of ectopic pregnancy,
adults in many low and middle-income leading to severe maternal morbidity and
countries seek health care services. Signs of even mortality. The burden of disease from
genital infection are common in several STIs is aggravated not only by the high rate
Sub-Saharan African countries. STIs are of complications but also by an increasing
often the third most frequent diagnosis, problem of antimicrobial resistance.
after malaria and diarrhoea, in primary Conventionally, the three most important
health care facilities. After tuberculosis and aims of STI control are: (1) interrupting
pregnancy-related disorders, STIs are re- transmission by promoting safer sexual prac-
ported to represent the third greatest burden tices; (2) rapidly curing those infected; and
of disease in women between 15 and 45 (3) preventing the development of compli-
years of age. cations and sequelae by screening for the
The occurrence of STIs does not seem to diseases in high-risk groups. However, only a
be diminishing in the world. However, few few countries have national health pro-
domains of ill health show such a programmes dealing specifically with STI con-
nounced global variation in occurrence as trol. Where they exist, such programmes are
STIs. This is obviously related to cultural and often fragmented, with a focus either on a
social norms related to sexuality and repro- particular disease, such as HIV/AIDS, or on a
duction. Syphilis and gonorrhoea are two il- general aspect, such as fertility control or
lustrative examples. In various parts of Sub- maternal and child health. Different disease-
Saharan Africa, the prevalence of seroposi- oriented programmes often overlap and may
tive syphilis is 15 %, and prevalence rates for be interrelated in terms of the problems each
gonorrhoea may reach up to 10 % in the programme attempts to address. An inte-
sexually active part of the population. Dur- grated approach has many advantages. STI
C ing recent decades, prevalence figures for programmes generally need to improve ac-
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these two classic STIs have fallen to very low cess to and quality of services, be more re-
levels in high-income countries, while si- sponsive to clients needs, more cost-effec-
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multaneously rising rapidly in some middle- tive and more likely to reach groups cur-
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income countries, especially in the coun- rently poorly served, such as women and

5.8 Other parasite infections and intestinal worms (1 %)
young people. In low-income countries, an insect, and mostly also occurrence of a

with budgetary constraints, the need for in- low level of socio-economic development
tegrated services is even more urgent. Coun- (Cock 2002). However, it should be noted
tries are presently advised to deliver more that the burden of most of these diseases
broadly based reproductive health care inter- could be greatly reduced by cost-effective
ventions, preferably integrated into basic control programmes making use of the
health care, maternal and child health care knowledge of the life cycle of the parasite.
and family planning services. There is a gen- The interventions are based on breaking this
eral consensus in the world today that most cycle at one or several points. Altogether,
countries need to develop a more compre- these parasitic diseases caused about 1 % of
hensive approach to STI control. In practice, the global burden of DALYs lost and about
however, programme development always 140 000 deaths in 2002, almost all in low
requires selection of activities and interven- and middle-income countries. Leishmania-
tions on the basis of countries current needs sis and trypanosomiasis cause most of these
and available resources. deaths, but lymphatic filariasis alone causes
Primary prevention activities consist of by far the greatest number of DALYs lost in
the promotion of safer sexual behaviour and this group of diseases. One or the other of
the provision of condoms at affordable these diseases may be very important in
prices. Secondary prevention activities con- some local areas.
sist of the promotion of rational health care Lymphatic filariasis (0.4 %) (mainly
seeking behaviour directed particularly to- Wuchereria bancrofti) is caused by parasites
wards those at increased risk of acquiring that are transmitted by mosquitoes. The par-
STI and HIV infections. It also encompasses asite causes inflammation of lymphatic ves-
the provision of accessible, effective and ac- sels and lymph nodes, mainly in the axilla
ceptable services, which offer diagnoses and and groins. This sometimes results in lym-
effective treatment for both symptomatic phatic obstruction, leading to elephantiasis,
and asymptomatic STI patients and their i.e. a monstrous swelling of the scrotum or
partners. the legs. It is treated with diethylcarbamazine
Globally speaking, there is no single strat- citrate, and controlled with treatment and
egy for the control of sexually transmitted insecticide campaigns. Filariasis occurs in
infections. There are, however, guiding prin- countries with hot and humid areas, both
ciples that apply almost everywhere. Strate- urban and rural, in Africa, Asia, the Pacific,
gies for the attainment of reproductive South America and the Caribbean.
health and the prevention and care of repro- Schistosomiasis (0.1 %) (S. japonicum, S.
ductive tract infections including STIs must mansoni) also known as bilharzia, is caused
be based on the underlying principles of by a parasite with a very special life cycle.
human rights. The improvement of preven- The parasite is passed through human urine
tion and care for STI requires a careful adap- into fresh water in lakes and rivers. There it
tation to local realities. infects special types of snails and transforms
into a form that returns to the water and can
penetrate the skin of other humans when
they take a bath or expose their skin to the
5.8 Other parasite infections water for other reasons. Having passed the
skin the parasite travels through the blood
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and intestinal worms (1 %) stream to the blood vessels of the guts and
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This group of diseases consists of parasitic urinary bladder. There the male and female
diseases that all have a particular geographic parasites mate and produce eggs that are re-
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distribution that is determined by the occur- leased into the bladder and gut to be passed
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rence of the transmitting vector, most often into water by urine and faeces. The most

common sign is blood in the urine. The dis- hair in womena potentially huge and
ease is seldom lethal but causes a lot of profitable market in rich populations. Insec-
weakness and discomfort. The resulting ticide-impregnated traps and screens are
chronic inflammations may lead to cancer used to control the tsetse fly. An additional
in the urinary bladder. Drugs can cure the problem is that the tsetse fly also uses cattle
parasite infection and the disease can be as a host, and therefore large areas must be
controlled if people, especially children, use free of cattle, which reduce access to animal
latrines and if the amount of snails can be protein.
reduced. This has been achieved in large Roundworm (0.1 %) (mainly Ascaria lum-
parts of China, but still 700 000 are infected bricoides) is transmitted by ingestion of eggs
in that country. on vegetables. The adult worm causes diges-
Leishmaniasis (0.1 %) is a parasite trans- tive disorders and malnutrition, and a large
mitted by sandflies. It causes skin ulcers and worm mass can cause death by obstruction
inflammation of liver and spleen that can be of the gut. Children are most affected by
fatal if untreated. Treatment with drugs worms. This is also a health problem that
such as pentavalent antimony is very expen- can be eradicated through the use of la-
sive. In Sudan and Ethiopia leishmaniasis trines. Meanwhile, drugs are effective and
poses a severe health problem. Social unrest cheap enough to be able to reduce the bur-
is a risk factor for its spread. In Afghanistan den of this disease in affected populations.
thousands of cases have been reported River blindness (< 0.1 %), or onchocercosis,
yearly due to war and population displace- occurs in parts of Africa and Central and
ment. Co-infection with HIV and leishma- South America. A fly called Simulium, which
niasis is especially problematic, since the lives beside rivers, transmits the parasite.
immune defence against leishmaniasis is de- The parasite infects the skin and eyes, caus-
pendent on cellular immunity. A vaccine ing severe itching and possibly also blind-
against leishmaniasis would be the best con- ness. In some endemic areas, it is one of the
trol measure and this may become available most common causes of blindness. The
in the near future. drugs ivermectin and diethylcarbamazine
Sleeping sickness (0.1 %), or African kill the microfilariae. Ivermectin is dis-
trypanosomiasis, is a severe public health pensed free by Merck, which has also made
problem in some tropical parts of Sub-Saha- 40 million USD/year available for distribu-
ran Africa. Trypanosoma gambiense and tion. Using these drugs, the disease is being
rhodesiense are transmitted by tsetse flies. subjected to extensive and quite successful
The disease starts with fever, headache, joint eradication campaigns in West Africa. How-
pain, enlarged spleen and lymph nodes. It ever, sustainable eradication requires a func-
may progress to a severe and life threatening tioning health care system.
neurological disorders. The drugs that are Chagas disease (< 0.1 %) is the Central and
available (melarsoprol, pentamidine and South American type of trypanosomiasis,
suramin) often cause severe side effects. which is spread by an insect that lives in the
Production of a very effective drug with few walls of poorly built houses. A WHO-led
side effects, called eflornithine, was discon- campaign against the vector has dramati-
tinued because of the limited market. After cally decreased the incidence of the disease,
massive lobbying from MSF and other but the fear is that the insect will develop re-
NGOs, the drug company has now guaran- sistance against the insecticides used in the
C teed the supply of eflornithine for five years same way as the malaria mosquito did with
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from May 2001, and Bayer has followed with DDT. Infection with the parasite may cause
the same measure for their two drugs. It a severe disease of the heart and brain of
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helped that it was recently discovered that young children. Decades after the initial in-
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eflornithine is useful against excess facial fection, adults may slowly develop a severe

5.9 Other major infections (0.6 %)
chronic disease of the heart, gut and brain. den of disease is in Africa, India, and the
Drugs are available to treat the acute but not Eastern Mediterranean region. Outside the
the chronic form of the disease. neonatal period, the most common bacteria
Hookworm (< 0.1 %) (Anchylostoma duo- causing meningitis are Streptococcus pneu-
denale and Nector americanus) is globally moniae, Haemophilus influenzae and Neis-
the most important of the intestinal worms, seria meningitidis. Epidemics of the latter
also known as nematodes. The microscopic bacteria, also known as the meningococci
larvae of the hookworm live in the soil and bacteria, are common in the so-called men-
can penetrate the skin or be ingested with ingitis belt in Africa. This belt stretches in a
unboiled vegetables. The larvae pass via the semi-arid area from Sudan to Senegal just
blood system to reach the wall and mucous south of the Sahara. The transmission is by
membrane of the small intestine, where droplets or saliva and it is probable that a
they mature and survive by sucking blood. combination of the hot and dry climate and
This causes no pain or discomfort other poor living conditions in this dusty land-
than a gradual development of severe anae- scape explains the distribution of the men-
mia as the host loses blood to the worm. The ingitis belt.
worms eggs are passed with the faeces to Meningitis in the newborn is hard to dis-
hatch in the soil, from where the larvae can tinguish from other severe bacterial infec-
infect other humans. This disease disappears tions, because the typical signs are uncom-
with the use of latrines. Hookworms are mon in very young children. Meningitis
very difficult to control without the use of outside of the neonatal period starts with fe-
latrines, even though effective and cheap ver, proceeding to vomiting, headache and
drugs are available. If children, who are the the characteristic sign of neck stiffness.
most exposed group in the affected commu- Meningitis can, within hours, very rapidly
nities, are successfully treated, they will progress to unconsciousness and death. Di-
soon be reinfected unless the whole com- agnosis can generally be made by clinical
munity begins to use latrines. examination and is verified by a test for a
The global burden of these parasitic dis- turbid cerebrospinal fluid (CSF) in the pa-
eases may appear limited. However all tient. The diagnosis can be confirmed if lab-
mainly affect very poor populations and oratory examination of the CSF is possible
each disease may be a very severe public to do. The normally clear CSF-liquid can be
health problem in a special area. In such obtained through a needle inserted between
areas one of these diseases may be the main the vertebrae of the spinal cord, a demand-
obstacle for poverty alleviation. Cost-effec- ing procedure that may be dangerous to per-
tive interventions are thus needed for all of form at primary health care level. Severe
these diseases if the millennium develop- meningitis can easily be confirmed by just
ment goals are to be achieved. observing if the drops are turbid. Examina-
tion of CSF under a microscope by specially
trained technicians, or preferably by cultiva-
tion in bacteriological laboratories, may
5.9 Other major infections provide information about the specific bac-
teria that caused the meningitis. If advanced
(0.6 %) diagnostic services and treatment are not
Bacterial meningitis (0.4 %) is estimated to available, the mortality rate varies between
C have caused around 170 000 deaths world- 15 and 60 %, and severe life-long neurologi-
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wide in 2002. This severe bacterial infection cal sequelae may occur in half of surviving
affects the membranes that surround the patients. If advanced intensive care is pro-
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brain and spinal cord. It exists all over the vided, the mortality is still 5 % for Haemo-
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world and in all climates. The heaviest bur- philus meningitis and 20 % for pneumococ-

cal meningitis, and again there is a high in- rate of Hepatitis B may be as high as 7 %,
cidence of sequelae among the survivors. and transmission occurs mainly from
Intravenous treatment of bacterial menin- mother to child. In Western Europe, North
gitis with antibiotics needs to be applied America and Latin America with the excep-
rapidly. An infusion of benzylpenicillin, the tion of the Amazon Basin, the carrier rate of
original substance discovered by Alexander hepatitis B is less than 1 %, and sexual trans-
Fleming, can still be used, but more and mission between adults is the most com-
more of the bacteria involved, including mon form of transmission. South- and East
pneumococci, are becoming resistant. Chlo- Europe and South Asia have intermediate
ramphenicol is cheap and effective and is rates of carriers, i.e. 2 to 7 %, and a mixed
therefore often used in low-income coun- adult and child type of transmission. At
tries, but not much in other parts of the present 350 million persons are chronic car-
world because it sometimes causes severe riers of the hepatitis B virus, and 90 % of
side effects. A single dose of intramuscular women who are carriers transmit the virus
chloramphenicol may reduce mortality con- to their children at the time of birth. Chil-
siderably during epidemics. New forms of dren aged 2 to 5 years are at high risk as they
cephalosporin antibiotics are generally used come in contact with small sores and saliva
if they can be afforded. of other children during play. Other risks in-
Several vaccines can now be used to re- clude intravenous drug use and sexual trans-
duce the burden of meningitis. The new mission in adulthood. The hepatitis virus is
vaccine against Haemophilus influenzae, up to 100 times more contagious than HIV.
which offers about 75 % protection against The earlier an individual gets infected, the
this kind of childhood meningitis, is still more likely it is that the individual will be-
used mostly in high-income counties, due come a chronic carrier, with a risk of devel-
to its high cost. A polysaccharide vaccine in- oping complications later in life.
corporating 23 of the 84 types of pneumo- Hepatitis C is transmitted mainly by blood
cocci is used mainly to treat elderly people transfusions and contaminated needles, but
and those who have undergone splenec- it is considerably less infective than hepatitis
tomy in high-income countries. A new con- B. It is therefore not easily transmitted sexu-
jugated vaccine against pneumococci is on ally or from mother to child. Hepatitis C is
the market but is too expensive for low and widespread in the world, with prevalence
middle-income countries. Vaccines against rates of 0.3 to 2 % in most countries.
meningococcus types A and C are effective There is a good vaccine against hepatitis
and useful in the control of meningococcus B, but the vaccine is expensive in compari-
epidemics, even in poor countries. However, son with other vaccines in the Expanded
recent outbreaks in Africa are caused by Programme of Immunisation (EPI). Ninety
meningococcus type W, which requires a countries have integrated the vaccine into
more expensive vaccine. their national immunisation programmes.
Hepatitis viruses (0.2 %) were estimated to Unfortunately, there is no simple cure for
cause only 0.2 % of the global burden of dis- hepatitis B. Nor is there any simple cure, or
ease and about 160 000 deaths in 2002. even a vaccine against hepatitis C. One pre-
Chronic infection with hepatitis virus types ventive measure against the transmission of
B and C causes chronic inflammation and hepatitis virus is blood donor screening.
scarring of the liver, known as cirrhosis. This The long-term effect of hepatitis B and C
C may induce liver cancer. About 70 % of the is the possible development of cancer many
M
cases of liver cancer worldwide are caused by decades after the infection has occurred.
the hepatitis B virus infections in East and Likewise, Helicobacter has been shown to
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South-East Asia, the Pacific Basin and Sub- cause stomach ulcers, with a subsequently
K
Saharan Africa. In these regions, the carrier increased risk of stomach cancer, and the

5.9 Other major infections (0.6 %)
human papilloma virus has been shown to Lambrechts T, Bryce J, Orinda V. Integrated
cause cervical cancer. Thus, recent scientific management of childhood illnesses: a
advances point out the blurred demarcation summary of first experiences. Bulletin of
between communicable and non-communi- the World Health Organisation 1999;
cable diseases (see further chapter 7). 77(7).
NIH, (National Institutes of Health) The Jor-
dan Report 2000.
References and suggested further reading Nuwaha F. The challenge of chloroquine-
Alonso PL et al. The effect of insecticide- resistant malaria in Sub-Saharan Africa.
treated bed nets on mortality in Gambian Health Policy and Planning 2001;16:1
children. Lancet 1991;337:14991502. 12.
Benenson S. (ed.) Control of Communicable Sachs J. Report of the Commission on Macr-
Diseases. Sixteenth edition. APHA; 1995. oeconomics and Health. Macroeconom-
Bygbjerg IC. AIDS in a Danish surgeon (Zaire, ics and Health: Investing in Health for
1976), Lancet 1983;1:925. Economic Development, World Health
Cook GC, Zumla A. (ed.) Mansons Tropical Organisation, Geneva, 2001. page 31 and
Diseases. 21st edition. London: Saunders; 84 ff.
2002. UNAIDS report on the global HIV/AIDS epi-
Creese A, Floyd K, Alban A, Guinness L. demic 2003 and 2004. (www.unaids.org/
Cost-effectiveness of HIV interventions in barcelona/presskit/report.html).
Africa: systematic review of the evidence. Walker
Lancet 2002;359:163543. WHO, Global burden of disease estimates
Kwesigabo G, Killewo JZ, Urassa W, Mbena E, 2001. (www.who.int/whosis).
Mhalu F, Lugalla JL, Godoy C, Biberfeld G, WHO, World Health Reports 19962004.
Emmelin M, Wall S, Sandstrom A. Moni- (www.who.int/whr/en/).
toring of HIV-1 infection prevalence and WHO, State of the Worlds Vaccines and
trends in the general population using Immunisation. 2002.
pregnant women as a sentinel popula- Zhu T, Korber BT, Nahmias AJ, et al. An Afri-
tion: 9 years experience from the Kagera can HIV-1 sequence from 1959 and impli-
region of Tanzania. J Acquir Immune cations for the origin of the epidemic.
Defic Syndr. 2000;23:4107. Nature 1998;391:594.

6 Nutritional disorders (2 %)
6 Nutritional disorders (2%)*

Let hunger be ranked first because if you are hun-
gry you cannot work. No, health is number one
because if you are ill you cannot work.
Discussion group, Zambia
A nutrition transition is taking place along every day, there is no physiological regula-
with the demographic and disease transition to avoid over-consumption. Therefore,
tions (see chapter 4). This is the shift from a all people exposed to permanent abundance
diet dominated by starchy low-fat, high- of food must learn new behaviours to volun-
fibre food items, combined with a labour-in- tary restrict fat and sugar intake, to increase
tensive daily life, to a diet high in fat and fruit and vegetable intake, and also to in-
sugar combined with a sedentary daily life. crease physical activity. In this way the sec-
In other words the nutritional transition is ond nutritional obstacle on the road to a
the change from hunger to obesity. For the long and healthy life can be reduced by new
first time in the history of mankind the dietary practices. This is necessary for suc-
number of overweight people today rivals cessful ageing, that is, postponing infirmity
the number of underweight people. About and increasing the years of healthy life ex-
1.1 billion in each group, is equal to 20 % of pectancy. The WHO response has been first
the worlds population. Both the overweight to ring the alarm bell, then to initiate public
and the underweight suffer from malnutri- awareness campaigns and to develop strate-
tion, a deficiency or excess in a persons in- gies that can make healthy choices easy
take of nutrients needed for healthy living. choices.
The hungry and the overweight both have Whether these new behaviours will con-
high levels of sickness, shortened life ex- stitute a large-scale transition in diet and
pectancies and lowered productivity. Only body shape, with the anticipated health
about 60 % of humans have a healthy benefits, remains to be seen. It seems that
weight. the last generation born in scarcity remains
This escalating global epidemic of over- psychologically more prone to over-con-
weight and obesityglobesityis also af- sumption than later generations. It seems as
fecting part of the population in the low-in- if the second nutritional transition, from
come countries and a substantial part in over-consumption to adequate intake, will
middle-income countries. This creates a not take place in the generation that person-
double burden of disease, from both un- ally benefited from the transition from scar-
der- and over-nutrition. In the urban slums city to over-consumption.
in South Asia and Africa it is not rare that an The number of DALYs lost due to nutri-
obese mother with type-2 diabetes has chil- tional under- or over-consumption is diffi-
dren with malnutrition. cult to estimate. The reason is that under
The human body is biologically prepared and over-nutrition are causes of diseases
for periodic food scarcity, but not for a con- rather than diseases per se. A high body mass
C tinuous abundance of food. This means that index will never appear as the cause of
M when life conditions in a population im- death, not even in extreme cases. A person
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prove and sufficient food becomes available weighing 200kg will always die of something
K
* % of global disease burden is small, but the indirect effects are enormous

6 Nutritional disorders (2%)
= 1 million DALYs
Map 6:1 Nutritional deficiencies cause 32 million disability adjusted life years (DALY) lost per year.
Source: WHO, 2002.
other than obesity, such as a cardiovascular from malnutrition itself. But again the
event, even if the overweight condition con- childs low weight and malnutrition will
tributed to the death. Similarly, a severely have largely contributed to the death from
wasted and malnourished child will more those infectious diseases. Only during fam-
likely die from diarrhoea or pneumonia than ines and starvation will malnutrition appear
as a direct cause of death. Although the dif-
Table 6.1 The contribution in % of different risk ferent aspects of malnutrition cannot easily
factors to the global burden of disease. be quantified as causes of death and diseases,
malnutrition is a major cause of disability
Rank Risk factors % of global
and death in the world. The best available es-
DALY
timate of how nutritional factors contribute
1 Underweight 9 to the burden of disease in the world is sum-
2 Unsafe sex 6 marised in Table 6.1 based on the study pre-
3 High blood pressure 4 sented in World Health Report 2002 (WHO
4 Tobacco 4 2002) and later published in Lancet (Ezzati
5 Alcohol 4 2002). The number of overweight people in
6 Unsafe water and hygiene 4 the world is approaching the number of un-
7 High cholesterol 3 derweight. However, the impact on health
8 Indoor smoke 3 differs as shown in table 6.1. Under-nutri-
9 Iron deficiency 2 tion causes 9 % whereas overweight only
10 High BMI 2 causes 2 % of the global burden of disease.
11 Zinc deficiency 2 The reason being that under-nutrition
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12 Low fruit and vegetable intake 2 mainly affects young children and leads to
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13 Vitamin A deficiency 2 high death risk in infections whereas over-
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14 Physical inactivity 1 nutrition mainly affect an older age group
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Source: Ezzati et al. Lancet 2002. with less immediate death risk.

Malnutrition Manifestations
and Death
Inadequate Immediate
Disease
Dietary Intake Causes
Insufficient Inadequate Insufficient

Household Maternal & Child Health Services & Underlying
Food Security Care Unhealthy Environment Causes
Formal
and
Non-Formal
Institutions
Political and Ideological Superstructure

Basic
Causes
Economic Structure
Potential
Resources
Figure 6.1 Causes of malnutrition.

Source: Urban Johansson, UNICEF 1997.
Under-nutrition is very closely related to tion in children are infectious diseases that
poverty. Note in table 1.5 that the first of the increase the nutritional demand or decrease
United Nations Millennium Development the ability to eat and absorb nutrients from
Goals is Eradicate extreme poverty and hun- the gut. Paradoxically vaccination against
ger. A person living in absolute poverty will measles is one of the best preventions
use most of the resources available to ac- against child malnutrition. Use of hygienic
quire food. Therefore poverty can often be latrines is another way to prevent malnutri-
better measured as lack of food and low tion, as it will reduce the burden of diar-
weight rather than as a daily income below rhoea and hookworm among children. A
a certain cut off limit in US dollar per day. complex web of contributing factors, from
Poverty can thus be measured in the adult socio-economic conditions to more imme-
population as the proportion of persons diate causes such as feeding practices and in-
with a Body Mass Index below 18.5 (Chap- fectious diseases (Figure 6.1), determines the
ter 3.11.1). amount of child malnutrition in a commu-
In contrast to adults, malnutrition among nity. This chapter focuses on the immediate
children is only partly due to a lack of ap- causes, since the underlying causes are dealt
C propriate food. Other causes of child malnu- with in Chapter 2 about health determi-
M
trition are ignorance about optimal feeding nants.
practices or lack of access to specific micro- The burden of nutritional disorders is not
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nutrients, such as iodine or vitamin A. How- visible as direct causes of DALYs lost, but it
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ever, the most important causes of malnutri- has been estimated that under-nutrition

6.1 Nutritionally Acquired Immune Deficiency Syndrome (NAIDS)
Millions of 2 % each. The relative contributions of each

malnourished children of these factors are shown in Table 6.1. Addi-
tionally, almost as much can be attributed to
The Americas risk factors that have substantial dietary
Middle East and determinantshigh blood pressure 4 %,
North Africa
high cholesterol 3 %, high BMI 2 %, low fruit
Sub-Saharan
Africa and vegetable intake 2 % as well as low phys-
East Asia
ical activity 1 %. The patterns are not uni-
form within regions. In some countries the
South Asia nutrition transition has reached a healthier
stage than in others.
0 20 40 60 80 One third (150 million) of the worlds chil-
Figure 6.2 Millions of underweight children by dren are classified as underweight (UNICEF
region, 2001. 2004). The highest proportion of under-
Source: UNICEF, 2002. weight children are found in Southern Asia;
India, Pakistan and Bangladesh (Figure 6.2).
In these three countries almost half of the
contributed to more than half of the child- children weigh less than 2 standard devia-
hood deaths in low-income countries (Black tions below the mean for children with opti-
2003) (Figure 3.3). The World Health Report mal growth as shown in Table 3.7.
2002 identified the following childhood The main effect of poor nutrition is the
and maternal under-nutrition factors as negative impact on the immune system. In
those mostly contributing to childhood this chapter we first describe the interaction
deaths: between nutrition and the immune de-
fences. Secondly, we will describe general
Underweight under-nutrition first in adults and then in
Iron deficiency children. Thereafter the four major micro-
Vitamin A deficiency nutrient deficiencies in the world: iron, vita-
Zinc deficiency min-A, zinc and iodine will be presented. Fi-
Iodine deficiency nally, we review other major nutrition-re-
lated risks. Three UN web-sites are useful
At the other end of the income range the sources for information about nutrition: the
following were the nutrition-related risks, United Nations System Standing Committee
along with high blood pressure and physical on Nutrition1, the nutrition section at
inactivity, that most contributed to the WHO2 and FAOs division of nutrition3.
DALYs lost in the world:
High cholesterol
High body mass index
6.1 Nutritionally Acquired
Low fruit and vegetable intake
Immune Deficiency
The key role of malnutrition for the global Syndrome (NAIDS)
health status is illustrated by the fact that
There is a natural priority among the differ-
about 15 % of the global disease burden can
ent body functions. Some are more vital
be attributed to the joint effects of child-
than others and therefore given highest pri-
C hood and maternal underweight or micro-
ority. Top priority is given to breathing and
M nutrient deficiencies. Underweight is esti-
mated to cause 9 % of the global disease bur- 1
Y www.unsystem.org/scn
den. Iron deficiency, vitamin A deficiency, 2
www.who.int/nut
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and zinc deficiency are estimated to cause 3
www.fao.org

blood circulation. When the dietary intake vided into two systems; one based on cells,
is insufficient to run all the body functions, known as the cellular system, and one based
some functions are given low priority by the on the immuno-globulins, called the hu-
body metabolism and will receive fewer nu- moral (liquid) system (see section 5.2.1 on
trients. The first priority to be lowered is HIV). Nutritionally induced atrophy of lym-
physical activity. If a person does not get phoid tissues predominantly affects the cell-
enough dietary energy, the physical activity mediated immune defence, while the hu-
will be kept to a minimum. But there will moral system tends to be spared. This is sim-
also be a priority inside the body. A starving ilar to what happens in HIV infection, and
woman will lose her menstruation periods therefore malnutrition and HIV are syner-
and her fertility, as survival is more impor- gistic in reducing the capacity of the im-
tant than procreation. A child with malnu- mune system.
trition will stop growing. When the child NAIDS explains why the malnourished
later gets sufficient food and is less at risk child becomes so susceptible to infections.
from infection it can grow faster than nor- In the extreme case of under-nutrition, the
mal to catch up. In periods of scarcity the child may have bacteria in the blood (septi-
immune system will not have top priority to caemia) without developing fever or an in-
nutrients. During hunger the body mass is crease in the white blood cell count, which
being consumed and the body becomes is generally used as a clinical sign of an in-
thin. This will cause cell turnover to be fection.
slowed down and cells with rapid turnover The wonderful thing about NAIDS, com-
like the immune cells will replicate slower pared with AIDS, is that it is curable. If the
and their activity will be decreased. A conse- child is properly treated and fed, all signs of
quence is that the body becomes more sus- immune deficiency disappear.
ceptible to infections. Such adverse conse-
quences of malnutrition have been desig-
nated Nutritionally Acquired Immune
Deficiency Syndrome or NAIDS. This em- 6.2 Underweight
phasises the close relationship between nu- 6.2.1 Adult underweight
tritional status and immune function. Adults with a Body Mass Index (BMI) below
NAIDS impairs both the general host de- 18.5 kg/m2 are by definition underweight.
fences and the more specific immune sys- They are thin in relation to their length.
tem functions. The general defences include This means that their immune system is
the protective anatomic barriers such as the tuned down due to a small energy and mi-
skin, the mucosal surfaces and the products cronutrient budget. Physical activity is com-
these surfaces produce, e.g. gastric acid. promised, which affects working capacity.
Some micronutrients are especially impor-
tant for the immune system, and are called
immuno-micronutrients. These are: vitamin 6.2.2 Hunger
A, zinc (see sections 6.4.23), vitamin E and, Inadequate food intake does not only con-
to some extent, selenium and vitamin C. tribute to diseases and specific nutritional
This means that if these micronutrients are conditions. Hunger has severe direct effects
deficient in addition to a general lack of on the well being of humans, as well as on
food, then the immune deficiency becomes their capacity for physical and intellectual
C even worse. work. The effect of food insecurity, i.e. insuf-
M
The most devastating forms of NAIDS are ficient food to eat, is both loss of weight and
associated with a severe atrophy (shrinking) reduced physical activity. Hunger is so
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of all lymphoid (immuno-competent) tis- closely related to absolute poverty that it is
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sues. Functionally, the immune system is di- almost the same thing. As mentioned when

6.3 Child malnutrition
the United Nations made the eradication of The famines seen in Somalia, Afghanistan
poverty the first Millennium Development and other places in recent years have all
Goal, indicators that measure hunger and been associated with severe civil wars.
malnutrition were chosen as the measure of Persons who have suffered malnutrition
whether poverty is being reduced. The rea- as children or severe hunger during adoles-
son for this is that a person who lives in cence run an increased risk to suffer from
absolute poverty uses most of her or his cardio-vascular disease much later in life as
resources, time or money, to acquire the recently shown in males 50 years after their
basic 1,500 kcal/day a person needs to sur- survival of the siege of Leningrad during the
vive. second world war (Sparn 2004).
6.2.3 Famine
Famine may be defined as hunger that has
become so severe that it has started to kill.
The Nobel Prize laureate in economics, Am- Malnutrition among young children is still
artya Sen, has advanced the understanding a very common disorder of children in
of famines. Firstly, by noting that famine is the world. The usual way to divide child
not primarily a matter of a lack of food, but malnutrition is into three types, namely
rather of a lack of food entitlement, i.e. abil- wasting (weight-for-height below 2 stand-
ity to acquire food. When a rural area is hit ard deviations), stunting (height-for-age
by a drought that destroys all the crops, below 2 standard deviations) and under-
there will be no famine if the farmers have weight (weight-for-age below 2 standard
sufficient cash, savings and assets which deviations). These measures constitute so-
they can use to purchase food. Food will be called anthropometrical measurements, i.e.
transported to the area if they have somebody weight and length (see chapter 3.11).
thing to pay with. When a drought causes In 2002, 10 % of the worlds children were
famine, it is thus not directly because the wasted, 31 % stunted and 27 % under-
crop has been lost but because the value of weight (UNICEF 2004). Wasted children are
an agricultural years work has been lost and to a varying degree affected by NAIDS, and
that the farmers are destitute and lack sav- it is in the group of wasted children that
ings that can be converted to food through many of the child deaths occur. It should
trade or barter. If this happens the whole so- be noted that malnutrition among chil-
ciety will start to break down. This can be dren are largely caused by infectious dis-
stopped if government, as well as voluntary eases, and not only by diet deficiencies.
or international organisations make food
available to those who cannot buy food.
Famine is an extremely severe form of social 6.3.1 Under-nutrition is often over-
collapse due to insufficient political leader- diseasing
ship. An interesting observation is that a Under-nutrition and malnutrition make us
famine has never occurred in a country with think about food. These words do not indi-
a free press in a time of peace. cate any involvement of diseases. But the
The World Food Programme is a special- conceptual framework in Figure 6.1 shows
ised UN organisation that has acquired good that both inadequate dietary intake and
C competence in supporting countries with diseases jointly contribute to under-nutri-
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food if there should be a threat of famine tion. The phrase malnutrition-infection
somewhere in the country. This means that complex has thus been proposed to avoid
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famine today only occurs when rulers do the linguistic problem of using a term that
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not care and suppress freedom of speech. only addresses one of the causes of the

KEY
A = Abscess
Kg BC = Bronchtis
15 BN = Bronchopneumonia e
CONJ = Conjuctivitis curv
gro wth
14 D = Diarrhea
No rmal
I = Impetigo
13 M = Measles
S = Stomatitis
12 T = Oral Thrush
URI = Upper Resp. Tract Illness
11
10 URI BC
BC D
URI
9 S D A
S URI
URI
D D
8 BN URI
CONJ D D
D
D URI URI
7 URI D DURI
A
I URI
6 URI
D M
BN
CONJ CONJ D
5
T
4 D URI
URI
3 URI
0 3 6 9 12 15 18 21 24 27 30 33 36
Age in Months
Figure 6.3 Illnesses and weight curve of a child from birth to 3 years of age. The weight loss during a period
of measles and one of diarrhoea illustrates the close link between malnutrition and infection.
Source: Mata et al. 1977.
abnormal nutritional condition. Another NAIDS, which made him more susceptible
suggested term is under-nutritionoverdis- to new infections. In this vicious circle of in-
easing. Infections thus cause under-nutri- fections and dietary insufficiencies he could
tion and under-nutrition causes infections. not grow in an optimal way.
It is estimated that half the deaths in Diseases cause deterioration of the nutri-
malaria, pneumonia, diarrhoea and neona- tional status through several mechanisms.
tal disorders are due to under nutrition The most important are:
(Black 2003).
Figure 6.3 shows the weight development anorexia (loss of appetite), which de-
during the life of a malnourished boy. This creases the food intake in the child;
child became stunted and was periodically fever, which increases the nutritional
even wasted. He suffered from under nutri- needs of the child;
tion. The cause was partly that his feeding catabolic effects, tissue degradation due
C patterns were sub-optimal. However, an- to tissue damage;
M other cause was the large number of infec- production of immunological proteins,
Y
tions that he was subjected to. The infec- which increases nutritional needs;
tions contributed to his under-nutrition. decreased intestinal function, producing
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The under-nutrition in turn gave him malabsorption;

decreased availability of micronutrients. tries even in non-emergency periods. Al-

For instance measles consumes much of most half of the children in India and Bang-
the vitamin A that is present and diar- ladesh are stunted. The global average for
rhoea increases the loss of zinc. stunting among children in low-income
countries is 32 %. The proportion is less in
The predominant causes of under-nutrition middle-income countries. Increasing evi-
in children vary with their age. During the dence shows that stunting is associated with
first six months the main cause is failure to poor developmental achievement in young
breastfeed. In the period 6 to 12 months the children and poor school achievement or
main cause is infections, but the nature of intelligence levels in older children. The
how complementary foods are given is also causes of this growth retardation are deeply
critical. In the period between 1 to 3 years of rooted in poverty and lack of education.
age malnutrition most commonly manifests Economic development in any significant
itself clinically. This is the time when oede- long-term sense will be faster if optimal
matous under-nutrition is most common. child growth and development are ensured
Inadequate care and poverty in the house- for all children.
hold are the main underlying causes. Above
3 years of age specific diseases such as tuber-
culosis and HIV/AIDS are the main causes of 6.3.3 Long-term effects of malnutrition
malnutrition. However, in times of famine There may be long-term adverse effects on
or disaster, the lack of food may become the the intellectual capacity of previously mal-
main cause at any age. At all ages, and par- nourished children. However, it is difficult
ticularly in marginal groups, heavy intesti- to differentiate the biological effects of mal-
nal worm infestation may tip the balance nutrition and those of the deprived environ-
towards under-nutrition. ment on childrens cognitive abilities. Io-
dine deficiency during pregnancy and iron
deficiency in childhood cause both mental
6.3.2 Occurrence of wasting and stunting and physical impairments. Malnourished
The World Health Organization has estab- children lack energy and become less curi-
lished a Global Database on Child Growth ous and playful, and communicate less with
in which all major surveys of child anthro- the people around them, which impairs
pometry are compiled. This makes it possi- their physical, mental and cognitive devel-
ble to get a global view of the occurrence of opment (UNICEF 1998).
wasting and stunting (Table 3.7). The data- Stunting in childhood has a specific long-
base is accessible online.1 term effect in girls. Because of insufficient
Different kinds of emergencies may rap- growth, the birth canal will also be nar-
idly raise the proportion of wasted children rower, with all the subsequent risks of ob-
in affected areas. Wasting among children is structed labour. The children of a woman
an important measure of the degree of a hu- who has suffered stunting are also going to
manitarian emergency in underprivileged be stunted in the uterus; an adaptation of
populations. Wasted children should be an the child. This means that stunting is partly
important target group for any kind of nu- carried over to the next generation. Malnu-
tritional intervention undertaken in hu- trition in early life also seems to increase the
manitarian assistance. risk of developing coronary heart disease,
C
In contrast to wasting, stunting is wide- diabetes and high blood pressure later in
M spread among children in low-income coun- life.
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1
www.who.int/nutgrowthdb

6.3.4 Treatment of severe under-nutrition tinue care at home, and preparations are
If a child becomes seriously wasted, this in made for the child to be discharged.
itself is a life-threatening condition. Even if Follow-up: Get the car back on the road =
the child is taken to hospital, the risk of after discharge, the child and his family
dying still remains very high unless suffi- are followed to prevent relapse and assure
ciently good care is available. WHO has continued physical, mental and emo-
issued a manual for the management of tional development of the child.
severe under-nutrition (WHO, 1999). It may
be downloaded from the Internet.1 The initial treatment is needed for about one
Imagine a car going downhill at a consid- week. When the compensatory mechanisms
erable speed and the steering wheel is not are lost due to severe under-nutrition, the
working. So when the road makes a small undernourished body is fragile and should
bend the driver cannot follow the road. But be protected from powerful external influ-
not only the steering wheel but also the ences that might put the life of the child at
brakes and the accelerator are not working. risk. The child with wasting, anorexia (loss
So the driver has very little opportunity to of appetite) and infections needs to be
influence the direction or the speed of the treated in a hospital, which the parents can
car. This situation is similar to the one you rarely afford if the hospital care is not pro-
face when you treat a child with severe mal- vided free of charge. Successful initial man-
nutrition. The childs body has lost its nor- agement requires frequent, careful clinical
mal capacity to compensate for external in- evaluations (Figure 6.4). The hospital treat-
fluences. The body of a healthy child is able ment is needed until the childs condition is
to accommodate for a lot of external stable and his or her appetite has returned,
changes; for instance, if it is getting hot out- which usually occurs after 27 days. The
side, the body will start to sweat in order to principal tasks during initial treatment are:
keep the body temperature constant inside.
to treat or prevent low blood sugar with
When food enters the body, insulin is pro-
oral sugar solution via a tube that is passed
duced to keep the blood sugar normal, and
through the nose down into the childs
if there is a prolonged period of fasting, the
stomach;
body will start to produce glucose to keep
to treat or prevent low body temperature
the blood sugar up. So a healthy body is able
with adequate warmth;
to maintain the internal balance; to con-
to treat or prevent dehydration and re-
tinue the metaphor it has a steering wheel,
store electrolyte balance;
brakes and an accelerator. Each of the three
to treat infection routine antibiotics
phases in the treatment of severe under-nu-
should be administered;
trition has a specific aim:
to treat possible shock due to infection;
Initial treatment: Prevent the car from to start to feed the child, usually with a
getting further off the road = Help the milk mixture. While the anorexia is se-
child to survive any life-threatening prob- vere, this may have to be performed by
lems, reverse metabolic abnormalities and tube feeding;
commence feeding. to identify and treat any other complica-
Rehabilitation: Repair the car = intensive tion, including vitamin deficiency, severe
feeding is given to regain lost weight, anaemia and heart failure.
emotional and physical stimulation are
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increased, the mother is trained to con- The rehabilitation starts when the childs ap-
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petite has returned after about one week.
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1
The principal tasks during the rehabilitation
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www.who.int/nut Click on <publications and
documents> and scroll down. phase are:

Activity Initial treatment: Rehabilitation: Follow-up:

days 12 days 37 weeks 26 weeks 726
Treat or prevent
hypoglycemia
hypothermia
dehydration
Correct electrolytic
imbalance
Treat infection
without iron with iron
Correct micronutrient
deficiencies
Begin feeding
Increase feeding to
recover lost weight
(catch-up growth)
Stimulate emotional
and sensorial
development
Prepare for discharge
Figure 6.4 Time frames for treatment of a child with severe malnutrition.
Source: WHO, 1999.
to encourage the child to eat as much as these conditions and preventing the recur-
possible, using food with high energy den- rence of severe malnutrition requires a sus-
sity; tained improvement in the feeding of the
to re-initiate and/or encourage breast- child and in other parenting skills. Planned
feeding; follow-up of the child at regular intervals
to stimulate emotional and physical de- after discharge is essential. Most severely
velopment through comfort, affection malnourished children come from poor
and mental stimulation for the child, families and poverty alleviation is the only
support and sympathy for the family, as- adequate long-term prevention.
sistance with the familys social prob-
lems, counselling for AIDS if necessary;
to prepare the mother or any other care 6.3.5 Marasmus and kwashiorkor
giver to continue to look after the child Two main clinical patterns have been distin-
after discharge, by showing the family guished in severe under-nutrition: maras-
how to feed the child, talking with the mus and kwashiorkor. Marasmus is Greek
family about the childs food needs, and for slim disease, and today it is more often
encouraging mothers to learn from each called wasting. Kwashiorkor is a clinical syn-
other on the ward. drome whose main clinical sign is swelling
C of the legs (oedema), today mostly called
M Follow-up is important even if the child is oedematous under-nutrition.
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much improved at the time of discharge. Marasmus is thus the same as extreme
The child usually remains stunted, and wasting. The affected child is often less than
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mental development is delayed. Managing two years of age, but if the cause is failure to

ZAMBIA. Health centre in the country. The growth monitoring curve is difficult to explain.
breastfeed, the child may be less than one child may develop kwashiorkor after an epi-
year old. The child usually has an extremely sode of acute illness such as measles or diar-
low weight for age, under 60 % of the stand- rhoea.
ard, with evidence of extreme wasting of the Kwashiorkor is the same as oedematous
arms, legs and buttocks. Growth has ceased under-nutrition. The affected child is usu-
and the child consumes subcutaneous fat, ally 1 to 3 years old. There is oedema of the
and ultimately its own muscles, to release face, legs and arms, causing a deceptive in-
energy. The childs body often consists of crease in weight. There is often a moon face,
only skin-and-bone with the typical old and the child usually has a moderately low
mans face because of wasted muscles in the weight for age, at around 60 to 80 % of the
face, but the abdomen is often distended, a standard. There is muscle wasting, especially
so called potbelly. The child may be irritable over the shoulders and upper arms. There is
and fretful, but is often alert and hungry, if often a potbelly, with an enlarged liver and
not infected. The child is often dehydrated diarrhoea is common. The child is often
because of diarrhoea or other infections. It is pale and thin, with peeling skin, where dark
not uncommon that the state of marasmus flaky paint contrasts against pale milk
is explained by underlying infections such chocolate-coloured skin. The hair is often
C as tuberculosis or HIV. Marasmic children sparse and thin, with a lighter colour and
M without incurable infections who receive poor roots, so that it can easily be pulled
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appropriate treatment recover within a few out. Mental disturbance is shown in the
weeks. Marasmus usually starts after a long form of misery and apathy, with poor appe-
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period of underweight, and a marasmic tite. The child is often not crying, but

whines and resists examination and feeding. correctly used in a resource-strong health
Vitamin A deficiency is often so severe that service, the growth chart may be a very sen-
it may cause permanent destruction of the sitive instrument for detection of a number
corneas, resulting in blindness. Associated of diseases that affects the growth of young
infections are almost the rule. Pneumonia children.
may cause sudden death, without previous But several studies indicate that the
signs of cough or fever, since the immune growth chart is not really cost-effective as a
system is not functioning adequately. public health intervention in countries
Children with marasmus and kwashiorkor where more than half of the children have
are intensive-care patients and unless prop- abnormal growth and most mothers know
erly treated they are at high risk of dying. In the reason why, but are unable to do much
the first phase of treatment, the oedema dis- about it. Notably, the state of Kerala in
appears and the weight therefore decreases southern India has had a child health card
during the first week. Blood transfusions are without the growth chart during the period
given according to need. In the second when their child health status became the
phase weight increases first to regain what best of all low-income countries in the
has been lost, and then to gain normal world. The correct use of the growth chart
weight for height. This second phase may requires competent health staff, firstly to
take two to three months. Kwashiorkor and measure the weight, secondly to be able to
marasmus are a reflection of absolute pov- plot the weight correctly on the chart, and
erty or severe social neglect of childrens thirdly to interpret whether the growth pat-
needs. tern is normal or not. Fourthly, they need to
interview the mother to find out the under-
lying causes. Fifthly, they should suggest or
6.3.6 Growth monitoring prescribe possible actions to improve the
The growth chart is a simple instrument for childs situation that are available within
assessing the growth of children. The weight the resources in the home and health serv-
of the child in kilograms to one decimal is ice. On the receiving end the parents of the
plotted against the age in months on a children should also understand the inter-
curve. The plotted weight is compared with pretation of the weight curve, and the fifth
the WHO standard line for average child step is possibly the most difficult, i.e. for the
growth, as well as a line for2 standard de- mother and father to comply with the ad-
viations of the average weight for age (Fig- vice given. Hence, there are many links in
ure 6.3). The growths of all pre-school chil- the chain that may be weak, before the
dren with good nutrition follow the interna- growth chart can be applied in an effective
tional growth standard. Genetic differences way.
between population groups in growth are Equipment consisting of weighing scales
negligible during the childrens first five and a growth chart for each child must also
years. There may be significant genetic vari- be available, affordable and in good condi-
ation within populations, but the differ- tion. This has been a major priority for
ences in averages between countries are not UNICEF for many decades. Growth moni-
big enough to justify differences in growth toring is a typical example of a technology
standards. that has been deemed appropriate and
The growth chart is used all over the widely promoted before any solid commu-
C world at the primary health care level in all nity based research had provided evidence
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types of countries. It was designed to be the for its cost-effectiveness. After being in the
method of screening for dangers of growth top position for UNICEFs strategy in the
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failure so that correct advice about feeding early 1980s, growth monitoring has quietly
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practices and care could be given early. If been tuned down during the last decade.

It is food for thought that the image most are much more significant with regard to
commonly used in rich countries to illus- their global occurrence than are the other
trate development co-operation and aid is a micronutrient deficiencies. We will there-
photograph of a child being weighed during fore leave out descriptions of scurvy (vita-
a growth monitoring session. Yet this inter- min C deficiency), beriberi (vitamin B1 thia-
vention is probably the least effective of the mine), pellagra (vitamin B6 nicotinic acid)
four high priorities that UNICEF launched and rickets (vitamin D deficiency). These
for the children of the world 20 years ago. nutritional diseases still occur in deprived
Oral rehydration, promotion of breastfeed- populations that survive on different types
ing, vaccination against measles and polio of monotonous diets. In humanitarian
have all proven to have much greater im- emergencies these specific dietary deficien-
pact than growth monitoring. This is not to cies may present as epidemic outbreaks that
say that growth monitoring is not a useful are often mistaken to be infectious diseases.
tool in screening for childrens health and In this chapter we only focus on the four mi-
nutritional needs, but it appears that it is a cronutrient deficiencies that are most preva-
better tool for finding a few children in need lent in the world.
in populations where most children are
healthy. As an intervention in low income
countries growth monitoring and growth 6.4.1 Ironnecessary for blood and
promotion for children does not appear to enzymes
have the capacity to break the vicious circle Iron is a necessary component of haemo-
of poverty and disease. globin that carries oxygen in the red blood
cells. Iron is also necessary for many other
body functions. Iron deficiency anaemia
(IDA) affects almost half of the world popu-
6.4 Micronutrient deficiency lation, making it the most frequent micro-
Micronutrients is the term used for those nutrient deficiency. Iron deficiency seems to
essential nutrients that are needed in small be the only micronutrient deficiency that
amounts for human growth and function- occurs across high, middle and low-income
ing. They are used in the body as co-factors countries. Of the total burden of disease in
for enzymes engaged in various biochemical DALY over 2 % is lost due to anaemia. Iron
reactions. They comprise fat and water solu- deficiency causes anaemia because iron is
ble vitamins, as well as trace elements (min- necessary for the production of red blood
erals). Iron, vitamin A, zinc and iodine are cells. Anaemia leads to tiredness, breathless-
estimated to be the most important, but ness, decreased immune function and im-
other important micronutrients are vitamin paired learning in children. The most af-
C and the B-vitamin complex. Diets that fected populations are children in their pre-
supply adequate energy and have an accept- school years and pregnant women in low
able nutrient density will usually also cover and middle-income countries. In these pop-
the needs for micronutrients. However, ulations, deficiencies of dietary iron are ag-
when the diet is otherwise monotonous, it is gravated by loss of iron due to repeated epi-
recommended to supplement it with micro- sodes of parasitic diseases such as malaria,
nutrient-rich foods. Food preservation hookworm infestation or schistosomiasis.
methods, high temperature and exposure to Women also lose iron by menstruation or
C sunlight can reduce the activity of many vi- repeated pregnancies with blood loss at de-
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tamins, particularly vitamins A and C. Most livery. A low dietary intake of iron and the
of the micronutrient deficiencies are influence of factors affecting absorption also
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strongly linked to poverty and human dep- contribute to iron deficiency. About 40 % of
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rivation. However, four of these conditions the women in low and middle-income

6.4 Micronutrient deficiency
countries suffer from anaemia, and up to

15 % in high-income countries.
Better nutrition, iron supplementation or
fortification, child spacing and the preven-
tion and treatment of malaria and hook-
worms can all prevent iron deficiency. Iron
is found naturally in meat, fish, liver and
breastmilk. Vitamin C increases iron absorp-
tion. Correction of iron deficiency anaemia
with iron tablets is very cheap. However, a
functioning health service is needed to pro-
mote the appropriate use of iron tablets
among the most vulnerable groups. Perhaps
one of the worst inadequacies of the health Vitamin A capsules.
service of the world is that so many preg-
nant women still lack sufficient advice and
the cheapest of drugs, iron tablets, to pre-
vent anaemia during pregnancy. Vitamin A deficiency was thought to cause
An international expert group called In- mainly eye problems and blindness. But
ternational Nutritional Anaemia Consulta- over the last decades, the full role of vitamin
tive Group (INACG) organises regular inter- A has been rediscovered and this has had
national meetings to discuss the scientific important implications for promotion of
and programmatic challenges around iron child health and survival (Sommer 1998).
deficiency anaemia.1 Vitamin A is very important for the mu-
cous membranes. These are the linings of
the mouth and gastrointestinal tract, the
6.4.2 Vitamin Aprotecting life and vision lungs and the eye. Here, vitamin A is needed
Vitamin A assumes both important systemic for the proper production of mucopolysac-
functions in the whole body and local func- charides, which keep mucous membranes in
tions in the eye. The systemic functions of good shape to protect against infections. If
vitamin A were identified about 100 years vitamin A is deficient, the wetness of the
ago. At that time, it was found that animals mucous membranes will decrease and the
fed on a diet with vitamin A as the limiting membranes will become more like skin than
nutrient suffered a sharp increase in mortal- mucous membranes. This can be seen in the
ity, a clear increase in the number and sever- eye as xerophthalmia (dry eye in Greek).
ity of infectious episodes, and growth retar- Inside the eye, vitamin A is used in the rods
dation. In the later stages, these animals also (the receptors for low intensities of light). If
developed signs of an eye disease. This illus- there is too little vitamin A, the person will
trates the two types of function of vitamin not be able to see in low light intensity, she
A: systemic and local functions. or he will become night-blind. Vitamin A
For a long time, the knowledge of the sys- deficiency has long been identified as the
temic functions of vitamin A in protecting major cause of nutritional blindness. This is
against death and severe, prolonged infec- still an important problem around the
tious diseases was overlooked in humans. world. It is estimated that 250 000 to
C The reason was possibly the discovery of an- 500 000 children suffer blindness each year
tibiotics, which led to a neglect of the pre- by an eye damage brought about by severe
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ventive role of nutrition in most infections. vitamin A deficiency. The resulting eye dam-
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age, known as xerophthalmia (dry eyes), is
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1
http://inacg.ilsi.org composed of several components. The first

is night blindness, dryness of the conjunc-

tiva (the white parts of the eye), spots on the Severe eye damage/
eyeball called Bitots spots, and dryness of blindness: 0.5 million
the transparent part of the eyeball. The dry
cornea is susceptible to wounds that easily Xerophthalmia:
get infected. This may lead to a rupture of 3 million
the cornea and hence the eyeball may be Night blindness:
emptied through the cornea, creating a 14 million
blind eye.
Vitamin A deficiency does not only cause
eye damage. In 1983, Sommer published a
study in Indonesia, which showed that mild
and moderate vitamin A deficiency in-
creases mortality due to increased vulnera-
bility, especially to diarrhoeal diseases and Inadequate
measles. Vitamin A deficiency can also vitamin A intake:
231 million
develop quite quickly in children with mea- (23% higher risk of death
sles, as this infection makes the body con- from common diseases)
sume its vitamin A stores much quicker.
Vitamin A supplements in severely affected
communities can reduce childhood mortal-
ity by as much as one-third. Data from
Ghana, Sudan and India have indicated
Under-five population,
that vitamin A supplementation in cases of low-income countries:
measles and diarrhoea has a particularly 562 million
dramatic effect.
Children between six months and four
years old are most vulnerable to vitamin A
deficiency.
This finding led to a new intervention
Figure 6.5 Estimated impact of vitamin A deficiency
that has been included in immunisation on children under five in low income countries.
programmes in certain countries. Children
Source: State of the Worlds Childern. UNICEF, 1995.
are given vitamin A capsules every 6 months
when they visit health centres for their im-
munisations. The cost of the capsule is low
(US 5 cents) and through immunisation pro-
grammes it is hoped to reach the majority of 6.4.3 Zinca potent immuno-
those in need (Sommer 1997). micronutrient
An estimated 100 million pre-school chil- The adult human body contains 12 grams
dren globally are estimated to have vitamin of zinc which is distributed to every cell of
A deficiency (Figure 6.5). Vitamin A is the the body. It is crucial for the function of
single most important cause of blindness in over 150 different enzymes in the body.
low and middle-income countries (UNICEF Zinc is therefore important in numerous
1998). Also for vitamin A, there is an inter- metabolic processes, including the synthesis
C national expert group organising regular of DNA, RNA and protein. Zinc is useful in
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meetings about vitamin A. It is called the In- the enzyme because it is like a gentle hand
ternational Vitamin A Consultative Group with which the enzyme can hold, for exam-
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(IVACG), and their informative Web site has
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the following address.1 1
www.ivacg.ilsi.org.

ple, nucleotides for manufacturing DNA It has been demonstrated that zinc sup-
without destroying them by oxidation. The plementation improves the immune status
fact that zinc is important for the synthesis of children in low-income countries, with
of DNA, RNA and protein means that rap- decreased morbidity as a consequence. But
idly growing cells, such as the immune cells, several clinical trials are also inconclusive,
will be affected earlier if the zinc containing possibly indicating that zinc is not the only
enzymes are scarce. Zinc is, together with vi- limiting nutrient in many places. In many
tamin A, one of the important immuno-mi- programmes, multiple micronutrients are
cronutrients. now being administered to eliminate defi-
The other important fact about zinc is that ciencies of these micronutrients as limiting
there is no storage of zinc in the body. Defi- factors for child survival, growth and devel-
ciency develops rapidly in animals on a zinc- opment. The International Zinc Nutrition
free diet. The daily requirement of 10 to Consultative Group (IZINCG) was recently
20mg of zinc has to be taken every day. Meat founded, and hosts regular meetings with a
is the best source of zinc in the diet. A high focus on zinc.1
content of plant material with phytates in
the diet may lower the absorption.
A deficiency of zinc, which occurs in, for 6.4.4 Iodineessential for the main
instance, a congenital zinc malabsorption metabolic hormones
syndrome called acrodermatitis enteropath- At the World Summit for Children in 1990,
ica, causes retarded growth, depressed im- the worlds politicians promised to try to
mune function, skin disorders, delayed sex- end iodine deficiency disorders by the year
ual maturation and lowered fertility. The T- 2000. At that time the scale and severity of
lymphocytes are more affected than other the iodine problem was only just being real-
immune cells, and the cell-mediated im- ised. Since then several surveys have shown
mune response is therefore affected. even more severe damage from this defi-
There is no good laboratory test for the ciency in many regions of the world.
zinc status of the body. The blood concen- Iodine is a very peculiar chemical ele-
tration varies little and does not reflect the ment. At room temperature, it exists as a
situation well. In addition, progressive de- shiny, grey-black substance. When exposed
grees of zinc deficiency probably produce a to the air, it turns into a violet-coloured gas
graded response in the severity of effects. and will have disappeared after some days.
Mild chronic zinc deficiency may be indi- This property of iodine explains why the
cated by impaired immune function and re- distribution of this element is so uneven in
duced growth in children. The lack of obvi- the world. Long ago iodine was more evenly
ous clinical signs and reliable tests of human distributed. But with time the iodine on the
zinc deficiency has delayed the recognition surface of the earth has evaporated into the
of its importance for child survival and child air, and it is also easily dissolved in water.
growth in resource-poor settings. Therefore mountainous areas and areas sub-
It is estimated that zinc deficiency affects ject to flooding are now deficient in iodine.
about one-third of the worlds population, On the other hand, iodine has accumulated
mostly as mild-to-moderate deficiency. The in the oceans, and everything growing in
main consequence of this deficiency is an the ocean or close to the ocean is rich in io-
increase in infections. Zinc deficiency is esti- dine. The atmosphere absorbs iodine from
C mated to be responsible for approximately the sea and brings it back to the soil through
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16 % of lower respiratory tract infections, the rain. In this way, there will be enough
18 % of malaria and 10 % of diarrhoeal dis- iodine in areas close to the sea, while land-
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ease.
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1
www.izincg.org

locked, remote areas will lack iodine. In

these iodine-deficient areas, everything will
lack iodine, the soil, the water, the plants,
the animals and the humans.
The body uses iodine for only one single
function. It is as a part of the thyroid hor-
mones produced in the thyroid gland. The
thyroid gland is a small butterfly-shaped
gland located on the front of the neck, just
below the Adams apple. The thyroid hor-
mones, tri-iodothyronine (T3) and tetra-io-
dothyronine, or thyroxine (T4), both as-
sume a similar role in the body, namely to A package of iodized salt.
regulate the basic metabolic rate in the
body, just as you might regulate the heat of
an electric stove. If there is too much of the This results in an increase in the activity and
hormone, the body will become overheated, size of the thyroid gland. The gland will bet-
and if there is too little, the basic metabolic ter trap the little iodine that passes through
rate will slow down. The thyroid gland will it in the blood. This increase in size can
trap the iodine passing through the blood- reach extreme proportion. The enlarged
stream and incorporate it into the hor- thyroid gland can be seen as a hump in the
mones. The hormones can then be stored in front of the neck, known as goitre. The en-
the gland until needed. The thyroid hor- largement of the thyroid may be enough to
mones are also crucial to the early develop- compensate for the scarcity of iodine. But if
ment of the foetus and child. A lack of hor- the iodine deficiency is severe, there will
mone will have serious repercussions on still not be enough iodine to keep up the
both the growth of the child and the devel- production of hormones. Such iodine defi-
opment of the brain. ciency does not cause one single disease, but
The pituitary gland which is located several disturbances in the body. These are
below the brain, controls the thyroid gland denoted by the term iodine deficiency dis-
by production of a thyroid-stimulating hor- orders (IDD).
mone (TSH). When there is too little iodine IDD range from increased mortality of
in the diet, the pituitary gland will stimulate foetuses and children to constrained mental
the thyroid gland to produce more thyroid development. Its worst form is called cretin-
hormones by increasing the levels of TSH. ism that designates a form of severe mental
Box 6.1
Iodine Deficiency Disorders (IDD)
Goitre Enlargement of the thyroid gland

Hypothyroidism Decreased production of thyroid hormones
Miscarriages Early death of foetuses in the womb
Stillbirths Late death of foetuses (the child is dead at birth)
C Perinatal mortality Stillbirths and deaths in newborn children (to seventh day of life)
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Congenital abnormalities Birth defects of the newborn child
Cretinism Mental and growth retardation, deaf-mutes and physical disability
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Decrease in IQ Reduced mental capacity
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every year with mental retardation as a re-

Cretinism: sult of iodine deficiency (cretinism). In addi-
16 million tion, an estimated annual total of at least
60 000 miscarriages, stillbirths and neonatal
Brain damage: deaths stem from severe iodine deficiency in
49 million early pregnancy.
The simple way of assessing whether an
area suffers from iodine deficiency is to per-
form a survey for goitre among school-aged
children by straightforward palpation based
on strict criteria (Peterson 2000). If 10 % or
more of school-aged children have goitre,
IDD is a public health problem that calls for
action. In Sweden, a similar survey was car-
ried out in the 1920s among 16 to 18-year
Goitre: 740 million
old men undergoing check-ups for military
service. It was found that in some areas up to
one-third of the population suffered from
goitre. Based on this survey, it was decided to
eliminate this micronutrient deficiency in
the population by fortifying salt with iodine.
Today, 70 years after the introduction of
universal salt iodisation iodine deficiency
has been eliminated as a public health prob-
Total population at risk: 1.6 billion lem in Sweden. This intervention must be
(30% of the world's population) maintained; the problem would re-occur if
salt iodisation were to be stopped in Sweden.
At the World Summit for Children in
1990, IDD was highlighted and a strong po-
Figure 6.6 The toll of iodine deficiency worldwide. litical will to eliminate IDD was demon-
strated. The main intervention strategy for
Source: Adapted from State of the Worlds Children.
UNICEF, 1995. control of IDD has become Universal Salt Io-
disation (USI). Salt was chosen for a number
of reasons: it is widely consumed in fairly
equal amounts by most people in a popula-
retardation. IDD results in impaired school tion. It is usually produced centrally or at a
performance and impaired socio-economic few production sites, and the cost of iodising
development. is relatively low, about US 5 cents per person
WHO has estimated that 1.6 billion peo- per year. Over the last decade, extraordinary
ple in a total of 130 countries live in areas progress has been made in increasing the
where they are at risk of becoming iodine- number of people consuming iodised salt. In
deficient. Goitre is present in 700 million 1998, more than 90 countries had salt iodi-
people, and some 300 million suffer from sation programmes. Now, more than two-
lowered mental ability as a result of a lack of thirds of households living in IDD-affected
C iodine (Fig 6.6). IDD today constitutes the countries consume iodised salt. Because of
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single greatest cause of preventable brain active programmes of salt fortification, io-
damage in the foetus and infant, and of re- dine deficiency disorders are rapidly declin-
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tarded psychomotor development in young ing in the world. In 1990 it was estimated
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children. At least 120 000 children are born that 40 million children were born with

Not a public
health problem
Mild
Moderate
Severe
No data abailable
Figure 6.7 Iodine deficiency disorders, 1996.

Source: The World Health Report, WHO, 1997.
mental impairment due to iodine deficiency. will evaporate in varying degrees. The actual
This number dropped substantially in just process of iodisation also requires a well
seven years. WHO has estimated that the functioning spraying machine that many
number of people with goitre will decrease salt producers in low-income countries do
to 350 million by the year 2025, due to io- not manage to maintain. The iodine solu-
dine enrichment and supplementation pro- tion is often sprayed on the salt with very
grammes. A challenge is to enforce the legis- simple spraying devices that cannot guaran-
lation that has been passed in most coun- tee the right concentrations. Quality control
tries of the world that have a recognised and monitoring of the salt iodisation proce-
iodine-deficiency problem. All salt produc- dures is therefore a continuous task related
ers, from large industries to small-scale pro- to the worlds most widespread preventable
ducers, need to be encouraged to use the cause of mental impairment (UNICEF 1998).
more expensive procedure to fortify their An international NGO called the Interna-
salt production, and the consumers also tional Council for the Control of Iodine De-
need to be informed. The difficulty in many ficiency Disorders (ICCIDD) is constantly
low income countries is that the salt is sold pushing for a sustainable elimination of
in a very coarse form that is more difficult to IDD. The organisation has several Web sites,
iodise compared to the fine granular forms one of which is www.indorgs.virginia.edu/
C of salt sold in richer countries. Another iccidd/.
M problem is that salt is often sold in poorer
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countries from open sacks; the purchaser
takes it in small quantities wrapped in paper
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or banana leaves and therefore the iodine

6.5 Other nutrition-related risks and physical inactivity
6.5 Other nutrition-related we might run into water intoxication. Be-

cause salt is relatively scarce for life forms
risks and physical inactivity that do not live in the ocean, all land-living
As pointed out in the beginning of this animals, including humans, like salt. So our
chapter, new nutritional disorders emerge physiology will not prevent us from eating
when under-nutrition decreases. The new too much salt, and salty food is palatable.
nutritional risks are obesity, high blood Processed food is typically high in salt con-
pressure, high cholesterol, low fruit and veg- tent to increase palatability.
etable intake, and increased physical inac- But what happens when we consume
tivity. The burden of disease caused by the more salt than we need? More sodium in the
over-nutrition is today of the same order of diet will increase the sodium content in the
magnitude as the diseases caused by under- blood, which is automatically balanced by
nutrition. The present trend is that the more water in the bloodstream. More water
world soon will have more health problems in the bloodstream results in a higher blood
from over-nutrition than from under-nutri- pressure, and this is the signal to the kidney
tion. WHO even speaks of a global epidemic to increase salt excretion. The kidney will
of obesity. excrete the salt excess over 12 days, and the
blood pressure will return to normal. But
what happens if too much salt is consumed
6.5.1 High blood pressure every day? The blood pressure will then be
More than 4 percent of the losses of DALYs slightly elevated every day, keeping the kid-
in the world are due to high blood pressure. ney informed of the need to excrete the
High blood pressure results in an increased extra salt.
risk of vascular disease, including myo- A recent US randomised cross-over trial
cardial infarction and stroke. Recent studies (Sacks 2001) demonstrates that, in a group
demonstrate that it is possible to reduce of 400 persons equally distributed between
the mean blood pressure in a population males/females, blacks/whites, with/without
through a reduction in salt intake. It is im- hypertension, it was possible to demon-
portant to note that high blood pressure oc- strate a significant reduction in blood pres-
curs across different types of countries and it sure through a reduction in salt intake. This
is not a disorder limited to affluent popula- was true irrespective of whether the subject
tions. Haemorrhages in the brain due to operated around the level of 9, 6 or 3 grams
high blood pressure occur in populations in of salt per day. So a reduction of salt intake
rural Africa and the advice on limited salt in- to below 6 grams per day could reduce the
take applies across all socio-economic levels. need for medication of high blood pressure
This applies both for the most common form by half in the population of the United
of hypertension without underlying diseases States.
as well as for those forms of hypertensions WHO has looked at the cost-effectiveness
that are secondary to kidney diseases. of different interventions to counteract high
Here, again, our physiology is prepared blood pressure. These have been grouped
for scarcity but not for abundance. For land- into non-personal interventions, personal
based life forms, the regulatory control interventions and combined interventions
(homeostasis) of the salt balance in the body with different amount of input. They con-
is crucial. If salt is scarce, the kidney will, on clude that non-personal health interven-
C hormonal command, begin to recycle the tions, including government action to stim-
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little salt there is and not let any salt leave ulate a reduction in the salt content of proc-
the body. Even the sweat glands will start essed foods, are a cost-effective way to limit
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saving salt, if sweating is profuse and the cardiovascular disease and could avert the
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diet low in salt. This is very useful; otherwise loss of over 20 million DALYs per year

worldwide. Combination treatment for peo- Overweight and obesity lead to adverse
ple whose risk of a cardiovascular event over metabolic effects on blood pressure, choles-
the next 10 years is above 35 % is also cost- terol and insulin resistance. The risks of cor-
effective, leading to substantial additional onary heart disease, ischaemic stroke and
health benefits by averting an additional 63 type 2 diabetes increase steadily with in-
million DALYs lost per year worldwide. creasing BMI.
Nutrition education and an increase in
physical activity have been suggested as the
6.5.2 High cholesterol main actions to decrease the risk. Avoiding
WHO has calculated that high concentra- hidden calories from sources such as soft
tions of blood lipids, of which cholesterol is drinks and fatty sauces, and replacing high-
one, contribute to 2.8 % of DALYs lost annu- fat products with low-fat products is logical.
ally. A total blood cholesterol above 3.8 But country-specific campaigns needs to be
mmol/1 accounts for about 18 % of strokes designed.
and 55 % of cases of ischaemic heart disease. Several web sites focus on the global epi-
This risk factor acts in synergy with high demic of overweight and obesity. On the
blood pressure. web site of the International Food Policy Re-
Cholesterol is a molecule used in the body search Institute1, a search for the word
as a precursor for hormones; it is involved in obesity brings up PDF files of books and pa-
fat metabolism and is a precursor for bile pers that deal with obesity in low-income
salts. The body is able to produce choles- countries. The Center for Disease Control
terol, but also uses the cholesterol that and Prevention in the US has a site on nutri-
comes from the diet. An elevation in blood tion and physical activity.2 WHOs nutrition
cholesterol indicates an increase in un- unit3 provides relevant documents, as does
healthy blood lipids. An increase in polyun- the International Obesity Task Force4. Easy-
saturated fat fraction in the diet has been to-use calculators for body mass index and
shown to lower the blood cholesterol level, menu planners are available at the National
as does a reduction in overall fat intake. In- Health, Lung and Blood Institute Obesity
tervention may increase the fraction of pol- Education Initiative.5
yunsaturated fat in the diet, and multi-factor
interventions with intensive health educa-
tion may include support to stop smoking 6.5.4 Low fruit and vegetable intake
and increase in physical activity. A low intake of fruits and vegetables con-
The nutrition transition from high-fat tributes 1.8 % of DALYs lost. Fruits and veg-
diet to reduced fat, to increased consump- etables are important components of a
tion of fruits and vegetables, and increased healthy diet, which seem to protect against
physical activity is advisable but not an easy cardiovascular diseases and cancers of the
task to achieve, not even in countries with gastrointestinal tract. A fruit contains sev-
well-educated populations. eral substances that prevent itfor some
time at leastfrom decomposing. These are
mainly compounds known as antioxidants
6.5.3 Obesity and are also capable of preventing oxidative
The current rate of global overweight con- DNA damage. Together with many other
tributes over 2 % of the worlds DALYs lost. substances, these may prevent cellular dam-
C The frightening thing is the speed of
M
change, where the percentage of overweight 1
www.ifpri.org
2
and obese people in all countries and on all www.cdc.gov/nccdphp
Y 3
www.who.int/nut
continents is increasing steeply, especially 4
www.iotf.org (and go to about obesity)
K
in the cities. 5
www.nhlbi.nih.gov/about/oei

6.5 Other nutrition-related risks and physical inactivity
age. The other advantage of increasing the Ghana VAST Study Team. Vitamin A supple-
intake of fruits and vegetables in the diet is mentation in northern Ghana. Lancet
that they are usually not so energy-dense, so 1993;345:712.
they are beneficial for the cholesterol con- Gibson RS. Principles of Nutritional Assess-
centration and body mass index. ment. Oxford University Press; 1990.
Greiner T. The concept of weaning: defini-
tions and their implications. Hum Lact
6.5.5 Physical inactivity 1996;12:1238.
Opportunities for people to be physically ac- King M, King F, Martodipoero S. Primary
tive exist in the four major domains of the child care: A manual for health workers.
daily life: at work, transport, domestic du- Oxford University Press 1978.
ties and leisure time. There is no agreed def- Mata LJ, Kromal RA, Urrutia JJ, Garcia B.
inition or measurement of physical activity, Effect of infection on food intake and the
but less than 2.5 hours of moderate activity nutritional state: perspectives as viewed
per week has been suggested as a cut-off for from the village. Am J Clin Nutr.
physical inactivity. Due to this lack of agree- 1977;8:121527.
ment, the estimates are uncertain, but ap- Murray CJL, Lopez A. Alternative projec-
proximately 1.3 % of DALYs lost are attrib- tions of mortality and disability by cause
uted to low physical activity. 19902020: Global Burden of Disease
Physical activity reduces the risk of cardi- Study. Lancet 1997;349:14981504.
ovascular disease and type 2 diabetes. Fur- Peterson S, Sanga AB, Bunga B, Eklof H,
thermore, it may improve musculoskeletal Taube A, Gebre-Medhin M, Rosling H.
health and control body weight. Physical ac- Estimation of thyroid size with ultra-
tivity in childhood and adolescence in- sound and palpation in field surveys.
creases the peak bone mass (the maximum Lancet 2000;355:10610.
bone mass), which is beneficial for the pre- Sacks M, et al. Effects on Blood Pressure of
vention of fractures in old age. Reduced Dietary Sodium and the Dietary
Approaches to Stop Hypertension (DASH)
Diet. New Engl J Med 2001;344:5355.
References and suggested further readings Sommer A. Vitamin A prophylaxis. Arch Dis
Antonsson-Ogle B, Gustafsson O, Ham- Child 1997;77:1914.
braeus L, Holmgren G, Tylleskr T. Nutri- Sommer A. Moving from science to public
tion, agriculture and health when health programs: lessons from vitamin A.
resources are scarce. 2nd ed. Uppsala: Am J Clin Nutr 1998;68(2 Suppl):5135
Swedish University of Agricultural Sci- 5165.
ences & Uppsala University; 2000. Sparn P, Vger D, Shestov DB, Plavinskaja
Black RE, Morris SS, Bryce J. Where and why S, Parfenova N, Hoptiar V, Paturot D,
are 10 million children dying every year? Galanti MR. Long term mortality after
Lancet 2003;361:222634. severe starvation during the siege of Len-
Caballero B, Popkin BM (eds). The nutrition ingrad: prospective cohort study. BMJ
transistion. Diet and disease in the devel- 2004;328:114.
oping world. Amsterdam: Academic UNICEF. Progress of Nations. 1998.
Press; 2002. UNICEF. State of the Worlds Children. 2001
Ezzati M, Lopez AD, Rodgers A, Vander and 2004.
C Hoorn S, Murray CJ. Comparative Risk As- WHO. Management of severe malnutrition:
M
sessment Collaborating Group: Selected a manual for physicians and other senior
major risk factors and global and regional health workers. 1999.
Y
burden of disease. Lancet 2002;360:1347 WHO. World Health Report. 1998, 2002,
K
60. 2004.

7 Non-communicable diseases (47 %)
7 Non-communicable diseases
(47%)*
We are not allowed to get sick anymore because
we have to pay for medication what with?
An older man, Bosnia Herzegovina
Diseases that are not caused by infectious sion and cancer are quite common causes of
agents are jointly referred to as non-commu- human suffering also in rural areas of Africa.
nicable diseases. This group of diseases has Stroke is not a rare disease among poor peo-
also been called chronic disease or degener- ple in rural Africa. Out of all healthy years of
ative diseases. But this division is a simplifi- life (DALYs) lost in the world due to non-
cation of a quite complex reality. The communicable diseases, the vast majority
boundary between diseases caused by infec- are in fact lost in the low and middle-in-
tious agents and those caused by other fac- come countries. The absolute number of
tors is unclear and keeps moving as research DALYs lost per 1 000 population through
advances. All forms of cancer are by conven- non-communicable diseases is at the same
tion classified as non-communicable dis- level in Africa and in high income countries.
eases, but today we know that both liver Most DALYs are lost in the low-and middle
cancer and cervical cancer are mainly income countries in Europe reflecting the
caused by chronic infections with the hepa- health transition (Figure 7.1). It is in relative
titis and papilloma viruses respectively. Re- terms that the non-communicable diseases
alising that the classification is far from per- are of lesser significance in poor countries.
fect, it can still be used to provide an over- The risk of a person developing cancer and/
view of the pattern of diseases. or a psychiatric disease is more or less the
Non-communicable diseases cause about same throughout the whole world if they do
47 % of the global burden of disability and not die at younger age from some other dis-
premature death. In high-income countries ease!
up to 80 % of all DALYs lost are from non- Estimates point at the increased impor-
communicable diseases. Successful reduc- tance of the non-communicable diseases in
tion of malnutrition and infections will in- all countries, in other words, the world pop-
evitably increase the relative importance of ulation will see more of lung cancer, diabe-
non-communicable diseases. Although the tes, depression and heart attacks. By 2020 it
populations of low-income countries still is estimated that the burden of non-commu-
mainly suffer from malnutrition and infec- nicable diseases will have risen to three-
tions, the non-communicable diseases now quarters of the total burden of disease in the
cause more than 40 % of their total burden world. This is partly due to the fact that the
of disease. In many middle income coun- population of the world is ageing. It is also
tries the non-communicable diseases are al- due to the decreasing mortality of commu-
ready a bigger burden than are malnutrition nicable diseases and to increased tobacco
C and infections. This is the situation in most smoking in some parts of the world, as well
M of the Middle East and Latin America. Some as increasing overweight and alcohol con-
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non-communicable diseases like hyperten- sumption. To avoid human suffering and to
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* % in parentheses is estimated share of global burden of disease.

7.1 Neuropsychiatric disorders (13 %)
160 spare economic resources in caring for the

costly non-communicable diseases, WHO
DALYs lost/1000 population
140
has started a campaign against tobacco and
120 obesity throughout the world. However, it is
100 difficult for individuals, families, communi-
80 ties and countries to pay attention to up-
60 coming health problems when they are fully
occupied avoiding hunger and deadly infec-
40
tions (Box 7.1)
20
The major contributors to the global bur-
0 den of disease among the non-communica-
Africa
income countries
The Americas middle and low
income countries
middle and low income countries
South East Asian region
middle and low income countries
Western Pacific region
High income countries

ble diseases are: neuropsychiatric disorders
(13 %), cardiovascular diseases (10 %), can-
cers (5 %) and respiratory diseases (4 %). In
this chapter, we briefly review the occur-
rence, causes, symptoms, diagnosis, treat-
ment and possible preventive measures for
the major non-communicable diseases.
7.1 Neuropsychiatric disorders

Figure 7.1 DALYs lost per 1 000 population due to (13 %)
non communicable diseases by region in 1998. Mental and neurological diseases caused
Source: The World Health Report, WHO, 1999. about 10 % of the global burden of disease
Box 7.1
Father and son discuss disease transition
A West African musician made a career in the family can eat good food every day
Europe and became a Swedish citizen. He and thereby stay healthy.
regularly sent money to relatives in his
No! The chemicals are dangerous, you
home village in Africa like most Africans res-
need to wear protection clothing, other-
ident in Europe do. On his first return visit
home to Africa his father was keen to show wise you will die from cancer, shouted
him how he had used the money. The proud the son.
father led his son to the rice field. He wanted
to show off his new pesticide-spraying ma- The father was saddened by his sons un-
chine; he was the first farmer in the village foreseen reaction. He stopped the machine,
to own one. With it strapped on his back he put it on the ground and responded with
proudly walked across the field leaving a anger:
cloud of nasty smelling chemicals that That is precisely what we want to do, die
drifted in the evening breeze into the face of from cancer! In our village we struggle to
his son.
get enough food to keep hunger away and
But father, shouted the son, stop spray- to avoid dying from malaria. If we succeed
C
ing, those chemical can be dangerous. we will live to old age and die from cancer
M
On the contrary my son these poisons like the rich people do. Whats the prob-
Y keep the pests away from our crop so that lem?
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in 1990, 13 % in 2002 and is estimated to that have the potential to relieve much
rise to 15 % by the year 2020. Psychiatric human suffering. Unfortunately, these treat-
diseases such as schizophrenia and depres- ments are usually affordable only to the rich
sion cause several times more DALYs lost populations of the world. In low-income
than do classic neurological diseases such as countries there are fewer chances of employ-
Parkinsons disease and multiple sclerosis. ment and survival for neuropsychiatric pa-
Neuropsychiatric disorders are observed in tients, because of a lack of medical treat-
all societies of the world. Contrary to popu- ment. The only relief may be for psychiatric
lar belief, all research indicates that the oc- patients to seek traditional practitioners.
currence of schizophrenia and bipolar affec- They have to rely heavily on their families
tive disorders (manic-depressive illness) is and social networks for daily support.
about the same in all countries. Often per- Europe and the Americas are the regions
sons with such severe psychiatric diseases with the highest proportion of DALYs lost
do not survive for long in poor communities due to neuropsychiatric disorders, 20 and
and therefore the percentage in the whole 25 % respectively. Is the burden of being a
population may be lower although the the modern human being too heavy? Is de-
incidence is the same in both poor and rich pression the price for being socio-economi-
countries. In each age group the occurrence cally developed and physically healthy? Or
of dementia also seems to be about the same do individuals vulnerable to psychiatric dis-
around the world. Countries with an ageing orders have a higher survival rate in rich
population and long life expectancy will ex- countries, resulting in a greater prevalence
hibit a much greater prevalence of Alzhe- of these disorders in the population? It
imers dementia because this disease is so seems as if, when we prevent and cure the
common in old age, and affected persons other diseases, we will be left with an in-
will die early from complications if they do creased relative importance of psychiatric
not have access to advanced care. In con- diseases. Much more research is needed to
trast to dementia, Parkinsons disease is understand the worrying trend of increased
more common in high-income countries, occurrence of neuropsychiatric disorders
but the reason for this remains to be discov- throughout the world. WHO dedicated its
ered. entire 2001 yearbook to mental health
It is estimated that a total of 450 million (WHO 2001).
people in the world suffer from neuropsy-
chiatric conditions. These include unipolar
depressive disorders, bipolar affective disor- 7.1.1 Unipolar depression (4 %)
ders, schizophrenia, epilepsy, alcohol and Unipolar depression, i.e. depression without
selective drug use disorders, Alzheimers and any manic periods, was ranked as the fourth
other dementia, post-traumatic stress disor- most significant disease in the world in
der, obsessive-compulsive disorder, panic terms of DALYs lost in 2002, causing 4 % of
disorder and primary insomnia. This consti- the healthy years lost. Depression is ex-
tutes a heavy burden of human suffering for pected to be the second most significant dis-
both the individuals and their families. Neu- ease in the world by the year 2020. In low
ropsychiatric disorders cause both a high in- and middle-income countries, depression is
direct and direct cost for the individual and projected to be the most significant cause of
for society. But even if neuropsychiatric dis- DALYs lost by the year 2020 (Murray and
C orders cause 13 % of all DALYs lost, most Lopez 1997). Already depression is the sec-
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countries dedicate less than 1 % of their ond most important disease in the world
health budgets to mental disorders. among those aged 1544 years. It is difficult
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There are effective neuropsychiatric drugs to rejoice in the victory over malnutrition
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and successful psychological treatments and infections when the outcome is such a

= 1 million DALYs
Map 7:1 Depression causes 65 million disability adjusted life years (DALY) lost per year.
Source: WHO, 2002.
high prevalence of depression. Urbanisation Unipolar depression may present differ-

in middle-income countries consists mainly ently in different cultures. The symptoms of
of young people who have attended school. depression tend to be more somatic and less
They have avoided hunger and death from psychological in many low and middle-in-
infection, but instead they find themselves come countries compared with in high-in-
unemployed in an urban slum with weak so- come countries. Patients with depression
cial identification and a high risk for drug often present at health facilities complain-
abuse or depression. ing of sleeping difficulties or somatic pain
Unipolar depression may be regarded as instead of saying that they are feeling sad. In
reactive, i.e. caused by sad events in a per- the short time available patients are often
sons life, or as endogenous, meaning with- not given the correct diagnosis and treat-
out apparent external cause, or a mixture of ment.
the two. The exact cause of the endogenous The use of new, effective anti-depressant
type of depression is not known, but there is drugs has been widespread in high-income
a decreased level of the neurotransmitter se- countries. Selective Seretonine Reuptake
rotonin in all types of depression, and this is Inhibitors (SSRI) the happy pill, is being
therefore utilised in pharmacological treat- prescribed and used in increasing amounts
ment. but this costly treatment is out of reach for
Symptoms are feelings of sadness and most of those who suffer from depression
hopelessness, with thoughts of guilt and su- in the world. The reason is that drugs are
icidal ideas. Patients develop psychomotor expensive and require long treatment peri-
C retardation, and facial expressions become ods as well as considerable amounts of pro-
M minimised. Sleeping disturbances, anorexia, fessional consultations. Cognitive behav-
weight loss and psychosomatic pain are also ioural therapy has been found to be almost
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common symptoms. The majority of people as effective as treatment with drugs. As this
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who commit suicide are depressed. therapy can be given in groups it may offer

a more cost-effective option for treatment tional medicine, where they may get good
of depression. help and support for these types of condi-
Individual prevention of depression is dif- tions. The effective behavioural treatment
ficult, since it has multi-factorial causes. Im- of phobias is almost exclusively accessible
proved social security and social networks, to patients in high-income countries and to
and early detection of cases for social and the rich in the rest of the world. This may
medical support are just some of the possi- become more accessible if provided as
ble paths. The prevention and treatment of group therapy.
depression will constitute an enormous
challenge to world health in the coming
decades. 7.1.3 Bipolar disorders (1 %)
The occurrence of bipolar disease, or manic-
7.1.2 Anxiety disorders (2 %) depressive illness, is remarkably similar all
over the world. It is an integrated aspect of
Anxiety disorders give rise to varying de-
human life across cultures and economic re-
grees of disability and exist in many forms.
sources. Bipolar disorders account for the
This group of diseases can be divided into
same proportion of healthy years lost per
generalised anxiety, obsessive-compulsive,
population on every continent. The clinical
phobias, panic, acute stress, post-traumatic
features and the treatment are also similar
stress disorder (PTSD) and psychosomatic
worldwide. The disease is characterised by
disorders.
periods of mania and periods of depression,
Many patients with anxiety disorders seek
which explains the name bipolar. The peri-
help for somatic reasons, and it may be dif-
ods of mania tend to be self-limiting, ceas-
ficult for them to accept that their symp-
ing after weeks or months, even without
toms have psychiatric causes. Anxiety may
treatment. Between periods of illness, the
start due to a tragic life event, or as a reac-
person can mostly live a normal social life.
tion to stress. Obsessive-compulsive disor-
There is a strong genetic factor in bipolar
der involves an excessive and unnecessary
disorders.
repetition of thoughts or actions, for exam-
Treatment may be given in the acute peri-
ple washing hands for many hours each day.
ods: tranquillisers against mania and antide-
A phobia is a strong fear that disrupts nor-
pressants during depressions. Long term
mal behaviour. A panic disorder is character-
treatment with the cheap drug lithium ef-
ised by bouts of a fast heartbeat, with sud-
fectively prevents acute episodes. Unfortu-
den fear for life, sometimes coupled with a
nately, lithium has a narrow therapeutic
feeling of breathing difficulty.
window, which means that the difference
The treatment of anxiety disorders has
between effective and toxic concentrations
improved considerably over the last decades
is small. This implies that, even if the drug is
with psychiatric drugs, psychotherapy
very cheap, it requires costly care and regu-
and psychosocial interventions. Benzo-
lar laboratory analysis to avoid side effects.
diazepines (e.g. Valium) are useful only for
Therefore, this therapy is still not available
short periods, because they induce depend-
for most patients in middle and low-income
ence. Antidepressants are useful in obsessive
countries.
and compulsive disorders, as well as panic
disorders and PTSD. Phobias can be success-
C fully treated with behavioural therapy. Even
in high income countries only a portion of 7.1.4 Schizophrenia (1 %)
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patients with anxiety disorders seek and get Schizophrenia caused about 1 % of the total
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the help they need from modern health DALYs lost in 2002. It is the most common
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care. Many all over the world turn to tradi- form of psychosis, i.e. severe psychiatric dis-

ease. The incidence of psychosis is similar all Dementia slowly manifests itself with loss
over the world. Psychosis can be caused by of memory. First recent events are forgotten,
schizophrenia, mania, depression, acute or- and later events further back in the history
ganic mental disorders or drug or alcohol in- of the individual. Thereafter dementia af-
toxication. fects the persons ability to take care of
Schizophrenia usually starts when the themselves and dressing as well as washing
person is between 15 and 30 years old. It is become difficult. Finally, all aspects of con-
probably caused by a complex combination sciousness, emotion, intellect and behav-
of genetic, biological and social factors. The iour deteriorate. In Alzheimers disease the
symptoms are the same all over the world. progress of the disease is earlier in onset and
The most prominent symptom is delusions the progress much more rapid than in the
and disturbed thinking, hearing of voices, vascular dementia of old age. The cause of
and inability to participate in social life. The Alzheimers dementia is not known, but an
patient may experience that an outside per- increased deposition of amyloid is seen in
son or organisation is controlling them. Par- the brain tissue of an Alzheimer patient.
anoid thoughts or megalomania may be Cerebrovascular dementia is thought to be
combined with other odd and inappropriate caused by small, repeated microemboli that
behaviour. One-third of cases recover com- cause infarctions in the brain.
pletely from the first psychotic episode, but Cerebrovascular dementia could be pre-
schizophrenia most often becomes a life- vented to some extent by life-style choices
long disease. and treatment of hypertension, but so far
Pharmacological treatment may help an Alzheimers disease cannot be prevented.
individual to integrate into the social life of Research efforts focusing on the aetiology
the community, but in most countries the and new pharmacological treatment for
health service cannot afford the life long Alzheimers disease are intense, but the cur-
supply of medicines, and the consultations rent treatment slows the progress of the dis-
with psychiatrists that is needed. Social ac- ease only slightly, without providing any ef-
ceptance of patients with this disease varies fective cure. All countries that manage to re-
across nations. An understanding and so- duce the prevalence of other diseases are
cially supportive network is important for prone to experience more dementia. De-
recovery and for prevention of new episodes mentia is a very costly disorder, as the pa-
of psychosis. Traditional healers can in tients are very sick and need a lot of care and
many cultures provide important support to surveillance for many years before they die.
patients with schizophrenia. A paradoxical effect of successful preven-
tion of diseases is thus that the health service
gets more expensive. Economic arguments
are often used to mobilize resources for pre-
7.1.5 Dementia (1 %) vention of cancer and hypertension. Al-
Dementia will invariably increase with the though such preventive programmes have
transition to an older population. The two enormous benefits by avoiding deaths in
most common types of dementia, Alzhe- upper middle age they will not reduce the
imers disease and cerebrovascular demen- cost for health services. Few diseases are as
tia, are leading causes of disability among costly as Alzheimer and osteoporosis. Caring
the oldest age groups in all countries. De- for the old is becoming a more and more
C mentia is estimated to have caused almost central part of human life and of the politi-
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1 % of the total DALYs lost in the whole cal debate. It takes a larger and larger part of
world. However, in high-income countries the economy in post-industrial high-income
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as much as 6 % of the DALYs lost were due countries. Many middle-income countries
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to dementia in 2003. with a good health policy are now rapidly

approaching the same demographic and abuse in the world. The Arab countries have
health care situation without having the low rates of alcohol use and dependence but
economic means to provide care for a grow- some have increasing problems with abuse
ing proportion of chronically ill old people. of narcotic substances.
Cuba is rapidly getting into this situation Alcohol dependence leads to both acute
and many of the former communist coun- and chronic diseases of the liver and nerv-
tries are already in this situation. The disease ous system. Another important health effect
panorama of these countries is similar to is that alcohol and substance abuse also lead
that of Sweden, the demographic profile is to an increased occurrence of injury, suicide
similar and is becoming the same, but the and violent behaviour, as well as adverse
countries have less than one tenth of the re- pregnancy outcomes. Most of these condi-
sources for health and social service for the tions will be discussed further elsewhere in
elderly. the book.
The prevention of alcohol dependence in-
cludes a range of interventions. These may
7.1.6 Alcohol and substance dependence include economic restrictions, with in-
(2 %) creased taxation on alcohol and control of
Alcohol dependence is a very serious medi- accessibility through placing limitations in
cal and public health problem in most parts time and location on the selling alcohol to
of the world. However, the severity and ex- the public, as well as awareness campaigns
tent of alcohol dependence varies with cul- about the adverse effects of alcohol use. The
tural, religious and socio-economic factors. same can be said for most types of substance
The occurrence of dependency on narcotic abuse. The early detection and treatment of
drugs varies even more between and within an individual who abuses alcohol or nar-
countries. The consequences of alcohol cotic drugs appear to be effective in prevent-
abuse range from direct toxicological effects ing dependence. Preventive actions could be
to injury and violence, as well as psycholog- implemented within the health service, but
ical and behavioural problems. community-based actions involving fami-
The gender differences are considerable. lies, work places and religious and non-gov-
Globally the direct burden of disability from ernmental organisations seem to be more ef-
alcohol is about eight times higher in men fective. The pattern of alcohol and sub-
than in women. Alcohol abuse is the leading stance abuse varies a great deal. Preventive
cause of disability for adult men in high-in- measures need to be broad in scope and yet
come countries, and number four in low adapted to each context. It is important to
and middle-income countries. In high-in- note that substance abuse is already a very
come countries, alcohol caused 4 % of all severe and rapidly growing problem in
DALYs lost, whereas in low and middle-in- many Asian and Middle East countries, such
come countries it only caused 1 % of the as Vietnam and Iran, partly due to the
DALYs lost. The trends for the last forty opium and heroin trade through these two
years have been a steady increase in alcohol densely populated countries. A number of
consumption almost all over the world. narcotic drugs are also becoming a public
Estimates of the prevalence of alcohol de- health problem in low-income countries in
pendence range from 2 to 19 % of the total Africa.
male population of the world and from 1 to The global alcohol policy alliance is one
C 9 % among women in different countries of the international organisations that try to
M
(Beaglehole 2003). The highest rate of alco- reduce the adverse effects of alcohol.1 Such
hol dependence in the world is in the Amer- actions work against enormous economic
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icas. The middle-income countries in Latin
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America have the highest burden of alcohol 1
www.alcohol-alliance.org

7.2 Cardiovascular diseases (10 %)
interest both in the legal alcohol trade and ascular disease mortality has shown an even
in the illegal drug trade. Sweden is a major sharper decline than coronary heart mortal-
exporter of alcohol in the world and the ag- ity in high-income countries. The reason for
gressive marketing of Absolute Vodka in this decline is an increased knowledge of the
countries like India is a prominent example risk factors in the population. The health
of the negative health effects of globalisa- services in rich countries are capable of trac-
tion. The multinational companies trading ing high-risk individuals to offer treatment
in alcohol often try to follow regulations to for hypertension and other predisposing
protect the health of especially vulnerable factors. This has also contributed to the de-
groups like young people. But with their un- cline in deaths from CVD. In Eastern Europe
fortunately effective marketing they coun- the trend is the opposite, an increasing mor-
teract such preventive efforts many times tality. CVD strikes at a younger age in low
over. A pathetic example can be seen on the and middle-income countries, where half
web page1 where the web user is told You the victims dying of CVD are under 70 years
must be of legal drinking age to use this of age. In contrast only a quarter of the CVD
Site. WHO has a special programme against victims in high-income countries occur
substance dependency2 but the commercial under 70 years of age (Reddy 1998). The
alcohol promotion has not been pursued main cardiovascular diseases in the world
with the same vigour as WHO has tried to are ischaemic heart disease and cerebrovas-
stop promotion of tobacco smoking. cular disease, leading to deaths in myocar-
dial infarction and stroke, respectively.
7.2 Cardiovascular diseases 7.2.1 Ischaemic heart disease (4 %)

(10 %) Ischaemic heart disease causes most deaths
Cardiovascular diseases (CVD) are estimated in the CVD group, about 7 million out of the
to cause one third of all deaths in the world, 57 million people who die in the world each
but only one tenth of all the healthy life year. In high-income countries ischaemic
years lost. The reason for this discrepancy is heart disease causes nearly a quarter of all
that the diseases of the heart and blood ves- deaths, and in low and middle-income
sels mainly kill late in life. In high-income countries it causes an estimated one eighth
countries a high percentage of the popula- of all deaths. Even if it mainly kills late in
tion dies from CVD, but it is important to life, ischaemic heart disease causes about 4 %
know that the low and middle-income of the DALYs lost, thus ranking sixth among
countries contribute to about 80 % of the the major diseases in the world according to
total number of deaths due to cardiovascu- the number of healthy life years lost.
lar disease in the world. Even in Sub-Saha- The burden of ischaemic heart disease var-
ran Africa, it is estimated that 10 % of all ies between countries according to peoples
deaths are due to CVD. Hypertension, ciga- habits and diet. The middle-income coun-
rette smoking, high-fat diet, diabetes and tries of Europe, i.e. the former Soviet Union
lack of physical activity are the main risk and Eastern Europe, have by far the heaviest
factors for CVD. burden of ischaemic heart disease in the
The mortality from cardiovascular dis- whole world. Africa and the Western pacific
eases is increasing fast in middle-income region have the lowest burden (Figure 7.2).
C
countries, while it has been falling in high- The main symptom of ischaemic heart dis-
M income countries since the 1960s. Cerebrov- ease is cardiac pain caused by impaired blood
flow to the heart, due to arteriosclerosis in
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1
http://absolut.com/
the arteries of the heart. Depending on se-
K
2
www.who.int/substance_abuse verity the pain may be reversible or develop

= 1 million DALYs
Map 7:2 Ischaemic heart disease causes 58 million disability adjusted life years (DALY) lost per year.
Source: WHO, 2002.
into an acute cardiac infarction, when the Asia, Middle East and Latin America. This ad-
blood flow to the heart muscle is blocked, re- vanced care is mainly provided by private
sulting in permanent damage to the heart. hospitals, and is definitely not accessible to
Death may be sudden, due to disturbances of the majority of the population in these
heart rhythm. Complications can also occur countries. Even the Ministers of Health in
later or after the patient has suffered a sec- the poorest low-income countries in Africa
ond or third heart infarction. The emergency are faced with a political demand for the pro-
care of acute infarction has improved con- vision of advanced care for heart attacks at
siderably over the last decades, but it in- the same time as they are trying to provide
volves very costly ambulance and intensive vaccination to all children. The availability
care services. Acute heart infarction can be of intensive care for heart diseases may how-
treated at great cost in ways that decrease ever be of importance for the development
mortality and damage to the heart, for in- of the tourist sector, as well as other forms of
stance through the use of fibrinolytic drugs. international investment and collaboration.
Preventive treatment against ischaemic Poor countries are faced with a truly difficult
heart disease ranges from lifestyle changes to policy dilemma, whether to provide ad-
pharmacological or surgical interventions. vanced care for the few while still hot pro-
Cessation of smoking, weight loss and in- viding basic care for the many.
creased physical activity may lower the risk
of ischaemic heart disease. Pharmacological
control of hypertension, high blood lipids 7.2.2 Cerebrovascular diseases (3 %)
C and diabetes mellitus are crucial. Surgical in- Cerebrovascular disease causes stroke, in-
M
terventions such as coronary by-pass oper- cluding both vascular occlusion and vascu-
ations are even more expensive. There is al- lar rupture leading to brain haemorrhage.
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ready a high demand for advanced preven- The most common cause of stroke is due to
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tion and treatment of acute heart attacks in vascular occlusion. The neurological signs

7.2 Cardiovascular diseases (10 %)
Ischemic heart disease

High income countries Cerebrovascular disease



income countries

Africa
0 5 10 15 20 25 30
DALYs lost/1 000 population
Figure 7.2 DALYs lost per 1 000 population due to ischemic heart diseases and cerebrovascular diseases by
region in 1998.
and symptoms depend on which part and cannot afford the costly life-long treatment
how much of the brain has been affected by that has reduced the number of deaths from
the stop in blood circulation. The most cerebrovascular diseases in the high-income
common effects are complete or partial pa- countries.
ralysis of one half of the body. Besides hypertension, the main risk factors
Second to ischaemic heart disease, cere- for stroke are diabetes mellitus, high fat in-
brovascular diseases cause most deaths in take, obesity, smoking and alcohol depend-
the world, about 5 million per year or 10 % ence. The most important prevention is the
of all deaths. The heaviest burden of cere- early diagnosis and treatment of hyperten-
brovascular disease is found in middle-in- sion. However, the diagnosis and treatment
come countries in East Europe and in China. of hypertension and diabetes are costly, both
It may come as a surprise to some readers in terms of drugs, medical consultations, lab-
that the risk of death due to a cerebro-vascu- oratory tests and working days lost. There-
lar disease is greater for a middle-aged per- fore it is unlikely that the majority of those
son living in a poor country in Africa than it affected in middle-income countries will
is for a person living in a rich countries in have access to these preventive measures
Europe or North America. The main reason during the decades to come. What seems a
C is that the risk of cerebrovascular disease is more feasible preventive approach in coun-
M related to high blood pressure, a disease that tries with limited economic resources for
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does not spare the poor. However, poor peo- health service, is to focus on stopping smok-
ple have almost no access to diagnosis and ing and promoting physical activity. Like so
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treatment for high blood pressure. They many other pharmacological treatments, the

= 1 million DALYs
Map 7:3 Cerebrovascular disease causes 45 million disability adjusted life years (DALY) lost per year.
Source: WHO, 2002.
medical prevention of cerebro-vascular dis- 7.3 Cancer (5 %)

ease is too costly where it is most needed.
New treatments for stroke are being devel- It is estimated that 7 million people in the
oped to decrease brain damage in the acute world die of different types of cancer each
phase, but these are extremely costly, as year (WHO 2004). More than 50 million
they require fast access to well-functioning have been treated for cancer and about 10
emergency care. Otherwise treatment is million new cases are discovered each year.
concentrated on controlling complications. Cancer causes about 25 % of all deaths in
Rehabilitation and care of stroke patients is high-income countries and 10 % in low and
also costly, and in most parts of the world middle-income countries. As cancer mostly
rehabilitation is what the family and com- affects older people, it only causes 15 % of
munity can offer. All of the middle-income all DALYs lost in high-income countries,
countries that are now experiencing a de- and 5 % of healthy life years lost in low and
cline in the incidence of infectious diseases middle-income countries (Figure 7.3). With
and malnutrition are already facing a very the ageing population in the world and bet-
costly increase in the burden of cerebrovas- ter prevention and treatment of infections,
cular diseases. Cerebrovascular diseases will the world incidence of cancer will rise. An-
soon constitute a more prominent part of other reason for an increase in cancer is that
the disease panorama of middle-income smoking and other cancer inducing factors
countries than of high-income countries. are spreading in the world.
China and India will experience a higher Cancer is an uncontrolled growth of cells,
C proportion of heart attacks and stroke, while which may spread from the organ of origin
M Europe and North America will experience to surrounding tissues and distant organs of
more dementia and osteoporosis. There is a the body. The different types of cancer vary
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disease transition going on also among the according to site and cell type, the growth,
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non-communicable diseases. pattern of spread and treatment possibilities

7.3 Cancer (5 %)
= 1 million DALYs
Map 7:4 Cancer causes 78 million disability adjusted life years (DALY) lost per year.
Source: WHO, 2002.
vary greatly, as does the prognosis. The most leukaemia and lymphoma, is now successful
common types of cancer differ between in most cases due to new technologies and
countries. Men in low and middle-income drugs. However, these new treatments are
countries suffer mainly from cancer of the very costly in terms of drugs, technology
lungs, stomach, liver, and mouth/throat. and expertise. Although many cancers are
For men in high-income countries, the most curable today, most persons in the world
common types of cancer are lung, prostate, who are affected by these cancers will still
colon/rectum and stomach. Women in low die because the investigations and treat-
and middle-income countries suffer mainly ments are too costly. Today there is wide-
from cancer of the cervix, followed by spread awareness that most people in the
breast, stomach and lung. In high-income world who are infected with HIV do not
countries, the most common types of cancer have access to the new drugs. The same lack
for women are breast, colon/rectum, lung of access to life saving treatment is the real-
and stomach (WHO 1998). ity for a number of severe and common dis-
The major risk factors for the most com- eases in low-income countries, such as can-
mon types of cancer are diet, tobacco, alco- cer, hypertension and diabetes.
hol, occupational hazards, infection and The International Agency for Research on
hormones. These risk factors can be modi- Cancer (IARC) is part of the World Health
fied by prevention. The outcomes of cancers Organization. It is situated in Lyon and
also vary between countries, depending on leads research and actions to reduce the bur-
the ability of the health care sector to detect den of cancer in the world.1 IARC holds the
and treat cancer. Death from cancer of the best database on cancer in the world and as-
C cervix is largely preventable. In spite of this, sists countries to develop their cancer regis-
M most countries in Sub-Saharan Africa do not ters.
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have the financial resources to offer effective
cervical cancer screening programmes. Sim-
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1
ilarly, the treatment of cancers of the blood, www.iarc.fr


income countries

Africa
0 2 4 6 8 10 12 14 16 18 20
DALYs lost/1 000 population
Figure 7.3 DALYs lost per 1 000 population due to cancer by region in 1998.
7.3.1 Lung cancer (1 %) 1 million people are estimated to die from

Cancer of the lungs and airways is the most stomach cancer each year. The highest risk
common type of cancer in the world. More of dying in stomach cancer is in East Asia in-
than 1 million people die of lung cancer cluding Japan and in middle-income coun-
each year and tobacco smoking causes most tries in Europe. About half of all cases of
of these cancers. The occurrence of lung can- stomach cancer are estimated to occur in
cer in a population reflects the prevalence of China. This type of cancer is almost twice as
tobacco-smoking one to two decades earlier. common in males as in females. Since the
The heaviest burden of lung cancer is still in symptoms are sparse apart from unspecific
high-income countries, but the rapidly tiredness, weight loss and abdominal dis-
increasing number of smokers in middle- comfort, this cancer is often in an advanced
income countries in particular is now stage before it is diagnosed. The prognosis
changing the pattern of lung cancer in the remains poor even with surgery and chemo-
world. Of all cases of lung cancer, 75 % occur therapy.
in men, but with an increasing use of
tobacco by women, there is an increase in
7.3.3 Liver cancer (0.5 %)
lung cancer rates in women, mainly in high-
income countries. Screening programmes Liver cancer is the third most common form
for lung cancer, using chest x-rays and spu- of cancer in the world measured in terms of
tum cytology to detect early forms of cancer, both DALYs lost and number of deaths.
has not proven to be effective. Preventive More than half a million persons annually
actions should therefore focus entirely on die of liver cancer. This cancer is much more
the reduction of tobacco smoking. common in low and middle-income coun-
C tries. The highest incidences are found in
M China and the Pacific, South-East Asia and
7.3.2 Stomach cancer (0.5 %) Sub-Saharan Africa. Primary liver cancer
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Stomach cancer is the second most common (hepatocellular cancer) is mainly caused by
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type of cancer in the world. A little less than a chronic infection with the hepatitis B or C

7.4 Respiratory Diseases (4 %)
viruses. The variation in occurrence of liver symptoms may be diffuse before the cancer
cancer is largely explained by the prevalence has become widespread. Since this type of
of chronic infections by these two viruses. cancer is mainly a lifestyle-determined dis-
Contributing risk factors are a high dietary ease, the promotion of a low-fat, high-fibre
intake of a mould toxin called aflatoxin. diet and exercise may help. While the prev-
This toxin occurs in badly stored ground- alence of cancer of the stomach declines
nuts. Another risk factor is alcohol use. A with socio-economic development, cancer
vaccine exists against hepatitis B, but not of the colon and rectum increases with the
yet against hepatitis C. Early vaccination change in diet and population ageing, as we
against hepatitis B is now being included in have observed in high-income countries.
the vaccination programmes of several Todays high rate of stomach cancer in mid-
Asian countries. In summary liver cancer re- dle-income countries is expected to be re-
mains difficult to cure, it may be regarded as placed by a high rate of colorectal cancer
an infectious disease, which can be largely when these countries have gone through
prevented by vaccination. socio-economic improvements. The hope is
that results from research in todays high-in-
come countries can help to avoid lifestyles
7.3.4 Breast cancer (0.5 %) that contribute to the development of the
same type of diseases, when todays middle-
Breast cancer represents the most common
income countries become high-income
type of cancer in women in the world.
countries.
About half a million women are estimated
to die of breast cancer each year. In high-in-
come countries, 2 % of women die of breast
cancer, but in low and middle-income coun-
tries the proportion is only about 0.5 %. A 7.4 Respiratory Diseases (4 %)
risk factor for breast cancer is not having
given birth to children or starting childbear- The two most important respiratory diseases
ing late. Oral contraceptives, if used from a in the world are asthma and chronic ob-
young age and for prolonged periods, seem structive pulmonary disease (also known as
to slightly increase the risk of breast cancer chronic bronchitis and emphysema). To-
in younger women. Breast cancer screening gether, they cause almost 3 % of the total
may detect cancer and lead to early treat- DALYs lost, and together with some other
ment, thereby reducing mortality. But breast respiratory diseases, this group constitutes
cancer screening is expensive and not even 4 % of the global burden of disease (WHO
regarded as cost-effective for women under 2004).
the age of 50 in high-income countries.
Most women in the world have no access to
such screening programmes. The results of 7.4.1 Chronic obstructive pulmonary
treatment have improved in the last decades disease (2 %)
but most women in the world do not have
Chronic obstructive pulmonary disease was
access to these new advances.
ranked number five in causes of death in the
world in 2002. This severe disease is charac-
terised by slow but progressive destruction
C
7.3.5 Colon and rectum cancer (0.5 %) of the smaller airways in the lungs that is
M
Colorectal cancer also causes about half a mainly caused by tobacco smoking. It re-
million deaths per year. This cancer usually sults in chronic cough and a decreased
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appears after 50 years of age in persons who breathing capacity. The disease is much ex-
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have eaten a high-fat and low-fibre diet. The acerbated by acute infections, when the pa-

= 1 million DALYs
Map 7:5 Chronic obstructive pulmonary disease causes 29 million disability adjusted life years (DALY) lost
per year.
Source: WHO, 2002.
tient often requires acute hospital care. Due death. Thus, they place a huge burden of
to increased smoking chronic obstructive care on society.
pulmonary disease is expected to become Chronic bronchitis is defined as: in-
the third most common cause of death in creased mucus secretion in the airways caus-
the world by the year 2020. Chronic ob- ing a chronic cough for more than three
structive pulmonary disease caused about 2 months of the year during at least two con-
million deaths in 2002. secutive years, which cannot be explained by
China has by far the greatest burden of any other underlying disease of the lungs.
chronic obstructive pulmonary disease in Emphysema may occur alone or in combina-
the world. To stop the increase of cigarette tion with chronic bronchitis or asthma. Em-
smoking in China appears to be one of the physema is characterised by rupture and dis-
most important tasks for the improvement tension of the terminal portions of the air-
of world health. Out of all the healthy years ways. Chronic bronchitis leads to an
of life lost due to diseases in China, about increased susceptibility to pulmonary infec-
8 % are estimated to be lost due to chronic tion leading progressively to a severe reduc-
obstructive pulmonary disease. The most tion in physical activity due to respiratory
frightening aspect of the matter is that this insufficiency. Diagnosis is made on the basis
number is estimated to rise to 16 % by the of the clinical history, pulmonary x-ray and
year 2020 (Murray 1997). more advanced laboratory investigations.
Chronic obstructive pulmonary disease is Treatment of chronic obstructive pulmo-
C a disease of middle and old age. Chronic nary disease is partly the same as for asthma,
M
bronchitis and emphysema are the major although drugs that dilate the airways are
causes of chronic obstructive pulmonary usually more effective against asthma. Early
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disease. These chronic diseases cause long- antibiotic treatments of respiratory infec-
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term disability before ultimately leading to tions and cessation of smoking are the two

7.4 Respiratory Diseases (4 %)
CHINA, Hubei province, Yicheng district, Huang Jiapeng village. Worker in vegetable field taking a cigarette
break.
pillars of treatment. Oxygen therapy at smoking in China explains the increasing

home increases survival and quality of life, burden of respiratory diseases in that coun-
but demands great economic and human re- try. Smoking is declining in high-income
sources that will not be available for the ma- countries and the prevalence of respiratory
jority of people with this disease in a fore- diseases will be surpassed, and the percent-
seeable future. age of DALYs lost exceeded, by the former
Smoking is by far the most important risk socialist countries of Europe, Middle Eastern
factor for chronic obstructive pulmonary Crescent, India, Latin America and the Car-
disease. Other risk factors are chronic respi- ibbean. Smoking and its related diseases are
ratory infection, and air pollution. Smoking becoming a health problem of middle-in-
causes increased mucus secretion in the air- come countries in much the same way as
ways. The mucous membranes of the small traffic accidents today mainly affect middle-
airways are damaged and the immunity is income countries.
decreased, which leads to more respiratory
infections. Smokers usually have a bron-
chial hyper-reactivity and react to tobacco 7.4.2 Asthma (1 %)
smoke with contraction of the airways. Asthma is a common, disabling disease,
C Chronic obstructive pulmonary disease is which affects all ages but causes relatively
M more common in men than in women, but few deaths. About 240 000 persons are esti-
the rising trend in smoking among women mated to die each year from asthma (WHO
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worldwide will increase the prevalence of 2004). Most asthma deaths occur in middle-
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the disease among women. The increased income countries. Worldwide, about 150

million people live with asthma (WHO asthma in high-income countries may be re-
1998). The burden of disease due to asthma duced stimulation of the immune system
is relatively similar in all regions of the due to fewer and less severe infections early
world; it causes about 1 % of the DALYs lost in life. Asthma is also prevalent in middle-
in the world. But remember that the DALY income countries, but in these countries
measure reflects both incidence of a disease most patients cannot afford modern treat-
and the success of treatment. The increase in ment. This causes the paradoxical pattern of
occurrence of asthma in high-income coun- most asthma deaths in middle-income
tries in recent decades is not reflected by an countries, although the incidence is much
increased disease burden. The reason is that higher in high-income countries.
most asthma patients in high-income coun-
tries are successfully treated with the excel-
lent asthma medicines that are now availa-
ble to those who can afford them and to
those who live in a country where the drugs
7.5 Diabetes mellitus (1 %)
are subsidised. An epidemic of type 2 diabetes is spreading
Asthma causes periodic, reversible ob- across the world. Of the total world popula-
struction of the airways. In contrast, chronic tion, about 150 million currently suffer
bronchitis and emphysema, cause irreversi- from diabetes mellitus, and by the year 2025
ble and progressive obstruction of the air- this number is expected to double to 300
ways. The asthmatic obstruction may be million. This means that almost 5 % of the
triggered by for instance an allergic reaction, population of the world will have diabetes.
by infection, or by exercise. An inflamma- Diabetes is no longer a disease affecting only
tory reaction and increased secretions in the the high-income countries of Western Eu-
airways follow obstruction of the small air- rope and North America. Today most people
ways. Pharmacological treatment targets the with diabetes live in low- and middle-in-
airway obstruction and the inflammatory come countries, and this proportion will in-
and allergic reactions. Inhalation of bron- crease to 75 % by the year 2025 (WHO
chodilators and steroid hormones as sprays 1998). Diabetes type 2 will, like lung cancer
against inflammation has improved the and traffic accidents, become a disease with
quality of life for many asthmatic patients, its highest occurrence in middle-income
but this long-term treatment is expensive. A countries.
study of the availability of anti-asthmatic Diabetes mellitus is manifested by high
drugs in 24 countries in Africa and Asia blood glucose levels due to a defect in the
showed that the cost of steroid hormone in- production or effect of insulin, the main
halation treatment alone varied between 7 metabolic hormone. Long-term effects of di-
and 100 % of an average monthly salaryif abetes include cardiovascular disease, an eye
it was at all available (Watson 1997). disorder known as retinopathy, kidney fail-
The prevalence of asthma in children var- ure and disturbed blood circulation and sen-
ies between 2 and 12 %. There is a worrying sory functions in the legs leading to pain and
trend towards an increased prevalence of ulcers. The diagnosis is made from elevated
asthma all over the world. The reasons for blood sugar levels and urine sugar analysis.
the increase are not yet clearly understood, Diabetes mellitus occurs as type 1 or type
but studies comparing countries around the 2. Type 1 usually appears before 30 years of
C Baltic Sea indicate that crowding, lower age and requires insulin for treatment. Type
M
socio-economic standards and repeated in- 2 starts at an older age and can initially be
fections in early childhood protect against well managed by either dietary changes or
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allergic asthma (Brbck 1999). The driving oral medications, or both. Out of all diabe-
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force behind the increased incidence of tes patients 90 % have type 2 diabetes, but

7.5 Diabetes mellitus (1 %)
80
Year
Millions of persons with Diabetes Mellitus in the World.
1995
70
2000
2025
60
50
40
30
20
10
0
Africa Americas Eastern Europe South-East Western
Mediterranean Asia Pacific
Figure 7.4 Diabetes mellitus, regional estimates from 19952025.

30 % of them eventually need insulin to enough money to treat their disease. No at-
control their blood sugar levels. tempted preventive measure for type 1 dia-
The cause of diabetes mellitus is yet not betes has so far proven effective.
understood. It is thought that a combina- The treatment of diabetes is costly and
tion of environmental, genetic and immune life-long, which places a strain on the fi-
system factors jointly cause type 1 diabetes, nances and delivery of the health care sys-
while immunological factors are unlikely to tem. Insulin is expensive and difficult to ad-
be involved in type 2 diabetes. Some of the minister correctly in most families in low-
causes of the increase in prevalence of type 2 income countries. Insulin needs to be kept
diabetes are population ageing, obesity, un- cold in a refrigerator, something that most
healthy diets and physical inactivity. The families in a low-income country can never
lifestyle changes that follow with urbanisa- afford. If no treatment is available patients
tion and the alleviation of poverty rapidly will soon die. If insufficient treatment is
increase the risk of diabetes. In other words, available, patients will survive but will soon
as soon as people get out of hunger and pov- develop severe complications. If they are
erty many tend to sit down and eat too saved by an amputation, many of the survi-
much, thereby considerably increasing vors will require kidney dialysis or trans-
their risk of developing diabetes. The prob- plantation. Better treatment of diabetes re-
C lem is that a growing proportion of the pop- duces the risk for complications. Most mid-
M
ulation in middle-income countries and the dle-income countries do not achieve good
better-off low-income countries have treatment, which means that they will have
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enough income to develop diabetes, while to deal with the need for costly treatment of
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they and their countries do not yet have complications. This perspective argues for

CUBA, Havanna. Child getting insulin injection at a clinic.

strong primary preventive actions, espe- on the following three that are giving rise to
cially in middle-income countries. The pre- the most DALYs lost. The remaining disease
vention of type 2 diabetes involves healthy conditions each cause less than 0.5 % of the
diets and physical activity to maintain nor- total DALYs lost.
mal body weight. It is a great challenge to
design and implement prevention cam-
paigns with this message to populations 7.6.1 Osteoarthritis (1 %)
who have emerged out of poverty only ten The gradual destruction of joints with age,
years earlier. For the first time they can eat as known as osteoarthritis, exists all over the
much as they want and do not have to per- world. Of the DALYs lost in high-income
form physically hard work to survive (com- countries about 3 % are due to osteoarthri-
pare to the story told in Box 7.1). tis. This is not a lethal disease, but it is a very
painful and disabling condition. It mainly
affects older people. Osteoarthritis affects
mainly joints in the hands, feet, knees, hips
7.6 Other non-communicable and spine. The causes of the common type
of osteoarthritis that affect older people are
C
diseases (13 %) unknown. Treatment includes anti-inflam-
M
As much as 13 % of DALYs lost in the world matory drugs in combination with joint rest
are due to non-communicable diseases that and weight reduction.
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have not already been mentioned in this In the last decades surgical replacements
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chapter. In this remaining group we focus of the hip and knee joints have become a

7.6 Other non-communicable diseases (13 %)
very successful treatment. The prostheses creasing proportion of old people in high-
decrease the pain and improve function. income countries are having their lenses re-
Following surgery a time of rehabilitation placed. Although cataract is more common
with highly specialised staff is needed. in poorer countries, these patients can at
best afford to have their lens removed and
replaced with thick, expensive glasses. Still,
7.6.2 Cirrhosis of the liver (1 %) many people turn almost blind because they
Cirrhosis causes an estimated 800 000 cannot afford a cataract operation.
deaths per year around the world. It is three
A number of common non-communicable
times as common in males as in females. Al-
diseases that mainly affects old persons have
cohol explains up to two-thirds of all cirrho-
become curable in the last decades. The sur-
sis deaths. Hepatitis B and C are other main
gery for cataracts with replacement of the
causes. The pattern of liver cirrhosis thus
lens with a soft artificial lens is one of the
closely follows the pattern of alcohol con-
most successful of these new treatments.
sumption and of the occurrence of chronic
Hip replacement is another. These two oper-
life-long hepatitis B and C infections in the
ations mean a lot for the quality of life for
world.
old people. It also means that they can take
Cirrhosis is a progressive destruction of
care of themselves to a much higher degree
the liver tissue due to fibrosis, i.e. a type of
than if they would have suffered from a
silent scarification. This destruction leads to
painful hip or the inability to see clearly. It
an impaired blood flow from the gut via the
also means that they will live longer due to
liver to the heart. The liver increases in size,
the improved life situation. The improved
as does the amount of liquid in the abdo-
treatment of the diseases of the old makes
men at a later stage. A secondary effect is en-
them healthier and increases their life ex-
larged blood vessels in the oesophagus,
pectancy and thereby the need for further
which may result in lethal haemorrhages.
treatments and operations. This is far from
Because of impaired liver function, several
an exclusive medical issue. It is a central part
toxic metabolic substances accumulate in
of the economies of the high-income coun-
the blood and may cause hepatic coma and
tries where the retirement funds are becom-
death. Treatment involves avoiding further
ing a major owner in the stock market,
alcohol use and liver transplantation
where care for the old is becoming a major
needless to say, again only available to the
part of the labour market and where the care
few. Preventive measures are concentrated,
for the old is becoming the main issue in the
above all, on reducing alcohol consumption
political elections. It is interesting to note
and vaccination against hepatitis B in high-
that while the public debate in the last dec-
endemic areas.
ade has given the impression of cuts on
the health service more and more persons
7.6.3 Cataract (1.5 %) have had their hip, lens and coronary arter-
ies replaced and their life expectance keeps
Cataract is a progressive opacity of the lens
increasing. The expectation for a healthy
of the eye, causing a gradual, painless loss of
life in old age is increasing faster than the
vision. It causes about 1.5 % of the total bur-
continuous improvement of the medical
den of disease and is mainly a disease of late
and nursing care.
middle age and old age. Most of the cata-
C racts in the world occur in low and middle-
M
income countries. The majority of cataract
diseases are without known cause, but can
Y
be successfully cured by replacing the
K
opaque lens with an artificial lens. An in-

Key references and suggested further Murray C, Lopez A. Global mortality, disa-
reading bility, and the contribution of risk fac-
Beaglehole R, Yach D. Globalisation and the tors: Global burden of disease study. Lan-
prevention and control of non-commu- cet 1997; 349:143642 and 14981504.
nicable disease: the neglected chronic dis- Reddy KS, Yusuf S. Emerging epidemic of
eases of adults. Lancet 2003;362:9038. cardiovascular disease in developing
Brback L. Do infections protect against countries. Circulation 1998; 97:596601.
atopic diseases? Acta Paediatr 1999;88: Watson JP, Lewis AL. Is asthma treatment
7058. affordable in developing countries? Tho-
Manson P. Tropical Diseases, 21st edition. rax 1997; 52:605607.
London: Saunders; 2002. World Health Report, WHO 1998, 2001,
2002, 2004.

7.6 Other non-communicable diseases (13 %)

8 Injury (12 %)
8 Injury (12%)*
I do not know who to trust, the police or the crim-
inals. Our public safety is ourselvesI am afraid
that they might kill my son for something as irrel-
evant as a snack.
From a womens group, Brazil
Injuries have received increasing attention intentional and unintentional. Intentional

as a global health problem in the last two injuries, such as homicide, violence, suicide
decades. Injury is defined in Box 8.1. This and war, accounted for 1.6 million deaths.
major health problem was previously re- Unintentional injuries, such as road traffic
markably neglected. Injuries were regarded accidents, drowning, falls, fires and poison-
as something the health profession could ing, accounted for 3.5 million deaths. Most
not do much about, since the preventive of the deaths due to injuries (67 %) occurred
measures against injury lay largely in the en- in males (WHO 2004).
forcement of traffic laws and in raising com- The relative importance on a global basis
munity awareness. The opinion that acci- of each type of injury is shown in figure 8.1.
dents are inevitable eventsstrokes of bad Road traffic accidents are the number one
luckis changing, largely due to the in- type of injury in the world. Traffic accidents
creased attention of injury researchers. The cause about 2.6 % of all healthy life years
systematic collection of data about causes of lost in the world, followed by falls, violence
injuries in registers is still uncommon, and suicide. The pattern of injuries varies
particularly in low-income countries. Data substantially across regions (Table 8.1).
quality varies across countries. The Global High-income countries in the Eastern Medi-
Burden of Disease study indicates that in- terranean region, i.e. Gulf countries, have
jury represents about one tenth of the global the highest death rates per 100 000 popula-
public health problems (Murray and Lopez, tions from road traffic accidents, but the
1996). Its relative importance is projected to lowest death rates from self-inflicted inju-
increase as that of the communicable dis- ries. Low- and middle-income countries in
eases diminishes (Plitponkarnpim 1999). the Americas experience the highest death
In 2002 injuries caused about 5 million rates from interpersonal violence, but the
deaths, which correspond to about 9 % of all lowest death rates from poisoning. The mid-
deaths in the world. Injuries are divided into dle-income countries of Europe have the
Box 8.1
The definition of injury
a bodily lesion resulting from acute involuntary exposure to energy. The energy can be ei-
ther a mechanical, thermal, electrical, chemical or radioactive stimulus that interacts with
the body in amounts or rates that exceed the threshold of physiological tolerance. In some
cases, such as drowning, suffocation or freezing, the injury results from insufficiency of a
C
vital element. An accident is any unexpected event that leads to injury (Baker et al. 1984).
M
K
* % in parentheses is estimated share of global burden of disease.

8 Injury (12%)
Road traffic 50
Others injuries
accidents 21% 45
28%
DALYs lost/1000 population

40
35
30
Drowning 7%
25
War 5%
20
Falls 9% 15
Self inflicted Fires 6% 10
injury 11% 5
Poisoning 4%
0
Homicide and
Africa

income countries

violence 11%
Figure 8.1 DALYs lost by injury causes in 2001 glo-

bally.
highest death rates for poisoning and sui-

cides. Finally, the high-income countries of
Europe have the highest death rates for falls
that mainly affect the elderly. At the same
time these countries have the lowest for
Figure 8.2 DALYs lost per 1 000 population due to
fires, drowning, violence and road traffic ac-
injury by region in 1998.
cidents.
Of all the DALYs lost in 2002, 12 % were
lost due to injuries. Africa has by far the
highest burden of disability and premature ure 8.2). A large part of this great burden of
deaths due to injury, followed by low and injury in Africa is explained by the loss of
middle income countries in Europe, India young persons in road traffic accidents, vio-
and the Eastern Mediterranean region (Fig- lence and war. Road traffic accidents are the
Table 8.1 Deaths per 100 000 population by region and cause in 2000.
Region Road Falls Fires Drowning Poisoning Suicide Interper-

traffic sonal
accidents Violence
Europe high-income 11.2 11.3 1.0 1.0 1.3 12.9 1.0

Europe low and middle-income 16.1 6.6 4.0 9.2 21.5 28.2 15.4
Americas high-income 15.0 6.5 1.3 1.3 3.9 11.6 6.1
Americas low and middle-income 18.1 3.9 1.2 4.3 1.0 5.6 27.3
Western Pacific high-income 15.8 5.3 1.5 4.0 1.1 17.4 1.1
Western Pacific China 18.9 5.7 1.1 12.3 3.8 23.0 2.3
Western Pacific other low+middle-income 14.2 2.8 2.0 4.9 1.2 6.6 13.4
Eastern Mediterranean high-income 34.1 2.7 1.5 1.8 2.0 3.2 4.1
C
Eastern Mediterranean low+middle-income 18.7 4.3 4.8 4.2 3.8 4.9 6.3
South East Asia India 29.2 2.1 8.3 7.6 7.0 13.6 6.2
M
South East Asia other low +middle-income 26.6 3.4 8.2 3.8 2.2 5.9 2.9
Y
Africa low and middle-income 26.3 2.7 5.5 13.1 5.6 4.3 18.1
K
Source: The Injury Chart book: A global overview of the global burden of injuries. WHO 2003.

8 Injury (12 %)
fifth greatest cause of DALYs lost in the age rates due to injury (Plitponkarnpim 1999).
group 5 to 14 years. War injuries and inter- Below we describe the types of uninten-
personal injury are the second and third tional and intentional injuries that cause
largest causes of DALYs and deaths lost in the greatest disease burden in the world.
the productive age group 15 to 44 years, re-
spectively. Because of the wide difference in
injury pattern between countries, the pre- 8.1 Road traffic accidents
ventive measures need to be tailored to the
particular problems faced in each country
(3 %)
(Murray, Lopez 1996), or rather in each Road traffic accidents pose a serious public
community. health problem all over the world. Bicycles
There is evidence from a study of injuries are still the most common vehicles of trans-
in the age group 15 to 44 years in 54 coun- portation. Cyclists, along with the majority
tries that deaths due to unintentional injury of other road users, such as pedestrians, mo-
decreased with increasing socio-economic torcyclists, and operators and passengers of
development, as measured by GNP per cap- rickshaws and carts, lack protection when
ita. This relationship becomes even stronger hit by larger vehicles, such as cars, buses and
in older age groups. The injury transition trucks.
starts with a peak in unintentional injuries, The number of cars used in the world has
when countries have a GNP per capita of increased from 50 million in 1950 to more
700 to 3 000 USD. At higher national in- than 400 million in 1998 (Brown 1998). In
comes the mortality due to injuries declines low and middle-income countries, this in-
rapidly (Ahmed Andersson, 2000). Injuries crease in the number of cars has not always
in children also fall when GNP per capita in- been followed by improvements in road
creases. Most middle-income countries are quality. In other words, when countries
passing through this stage of high mortality begin to get richer, more cars are bought,
C = 1 million DALYs
M
Y
Map 8:1 Road traffic accidents cause 36 million disability adjusted life years (DALY) lost per year.
K
Source: WHO, 2002.

8.1 Road traffic accidents (3 %)
BANGLADESH, Dhaka. Evening traffic in Old Dhaka.

but roads remain bad and traffic regulation largely replaced by injuries, mainly from
weak. In these countries there are no pedes- traffic accidents. For the high-income coun-
trian safety measures, such as pavements tries, this evolution took a century, which
separating people from cars, or marked enabled them to adapt the infrastructure, as
crossroads with traffic lights and technical well as preventive and curative measures.
inspection of vehicles is missing. The Road traffic accidents affect teenagers and
number of accidents due to motor vehicles young men most severely. For men in the
continues to increase and is projected to rise age group 15 to 44 years, road traffic acci-
to become the sixth cause of death in the dents are the most common cause of prema-
world by the year 2020. ture death and disability in the world! The
In 1998 road traffic accidents were the gross national product per capita is posi-
fifth largest cause of DALYs lost in high-in- tively correlated to the traffic-related mor-
come countries, and the tenth largest cause tality per 100 000 population per year, but
in low and middle-income countries. What negatively related to the number of traffic
is most frightening is that it is estimated deaths per 1 000 registered vehicles. Traffic-
that traffic injuries will be the second most related mortality measured in crude death
prominent cause of DALYs lost in low and rates is actually highest in middle-income
C middle-income countries by the year 2020. countries, and in most high-income coun-
M A major reason for this projected increase is tries the fatality rate per vehicle has de-
Y
the rapid pace of urbanisation and industri- creased over the last two decades (Sderlund
alisation. In countries with rapid economic 1995). As noted in Box 2.9 in Chapter 2 the
K
growth, the fall in infectious diseases is same was the case when Sweden had a na-

8 Injury (12 %)
40
30 Togo
Deaths per 100 000 population/year
20
Deaths per 1000 vehicles/year

30 10
5 Republic
4
3 of Korea
20 2
.5
Madagascar
10
.4
.3
.2
0 .1
100 300 500 2000 4000 10 000 30 000 100 300 500 2000 4000 10 000 30 000
200 400 1000 3000 5000 20 000 200 400 1000 3000 5000 20 000
GNP per capita (US$ for 1990) GNP per capita (US$ for 1990)
R2 = 0.4100 R2 = 0.7235
Figure 8.3 Traffic related mortality rates per 100 000 population/year and per capita and traffic related
mortality per 1 000 vehicles/year and per capita GNP.
Source: Sderlund, Zwi, 1995.
tional income of contemporary middle-in- that the alcohol affected driver is slower to
come countries. The traffic deaths peaked react in emergencies and may drive too fast
around 1950 and it took much creative pre- and take more risks. As many as half of all
ventive action to bring the Swedish road deaths due to traffic accidents in Chile,
traffic death rate down to the low levels Zambia and the United States are alcohol re-
found in contemporary Sweden. Low-in- lated (Berger 1996).
come countries are expected to move Road traffic accidents can be prevented
through this same increasing trend of acci- and case fatality rates improved by a number
dents unless preventive measures are taken. of measures. These include better design,
The nature of motor vehicle accidents dif- construction and maintenance of roads and
fers around the world. In low-income coun- vehicles. The use of helmets for two-wheel
tries major causes of accidents are that pe- vehicles and the use of seat belts in cars have
destrians and cyclists are struck by motor ve- proved effective in reducing mortality and
hicles or that passengers fall off the back of morbidity due to accidents. Other measures
open trucks. A larger proportion of children include laws about alcohol consumption by
and younger people in low-income coun- drivers, speed limits, improvements in pub-
tries play on the roads or sell things in the lic transport and the use of clothing that is
street, and this naturally increases the risk of visible in the dark. The importance of pre-
accidents. In high-income countries acci- ventive measures against traffic accidents is
dents affecting drivers of cars, pedestrians a major priority for the improvement of the
struck by cars, farm tractor accidents and global health situation.
young people falling off recreational vehi-
cles are more common (Berger 1996). Mo-
C torcycle accidents are common all around
the world.
8.2 Falls (1 %)
M
Y
Alcohol intake and road traffic accidents Falls accounted for 1 % of the total loss of
are exponentially linked to each other. The healthy years in 2002 (WHO 2004). The
K
reasons for this increased risk of accidents is death rate due to falls has a positive correla-

8.3 Drowning (1 %)
tion with economic development. High-in- and middle-income countries. Africa has the
come countries have the highest death rates highest death rate from drowning. Drown-
for falls, followed by the former socialist ing is thus a major poverty-related cause of
countries of Europe. In high-income coun- death. It is related to the inability of parents
tries falls affect mainly elderly women who to spend time guarding their children and to
trip over or fall on ice or stairs. In high-in- people having to risk their life when fishing
come countries the incidence of falls in- (WHO 2004).
creases rapidly after the age of 70, and the In low and middle-income countries, chil-
location of the incident is in most cases the dren drown in open wells, rivers and ponds.
home. The elderly fall either because of in- Preventive measures may involve covering
ternal causes (acute or chronic illness, bad wells with metal or wooden lids, but this
sight, or gait problem) or external causes costs money.
(tripping over carpets, etc.) (Berger 1996). In high-income countries, drowning acci-
Hip fractures are the most serious conse- dents typically involve children falling into
quence of fall injuries in older individuals. swimming pools, leisure boat accidents and
Prevention of osteoporosis in old age has persons intoxicated with alcohol or other
been emphasised to avoid the adverse con- drugs falling into water (Berger 1996). Pre-
sequences of falls. Children in high-income ventive measures include fencing off pools
countries risk falling from apartment win- and teaching swimming skills and using
dows or in stairs. safety vests. Safety promotions to discour-
In low-income countries, falls may in- age the use of alcohol or drugs in the vicin-
volve workers falling from coconut trees, ity of water will also reduce casualty levels.
children falling from mango trees, roofs or
farm animals, and finally home construc-
tion accidents (Berger 1996). In low and
middle-income countries, falls rank number
8.4 Fires (1 %)
one in DALYs lost in the age group 5 to 14 In low-income countries, fires occur particu-
years, but they are negligible as a cause of larly in slums and poorly built houses. The
death in these countries. In poorer countries fast urbanisation in poor countries results in
falls causing fractures tend to result in disa- overcrowding. Fires spread quickly between
bility because emergency care and rehabili- shacks built of inflammable materials in
tation are not available to most people. slum areas. Additionally, poorly controlled
Preventive measures include modifying electricity systems pose a risk of fire. Death
the home and working environment, nurs- rates are highest among the youngest and
ing homes, playgrounds, etc. Safety meas- the oldest, due to difficulty in escaping
ures include safety equipment in industry, burning houses. India has the highest death
e.g. in construction work, good lighting, rates per 100 000 population from fires.
and non-slip floors without irregularities. Cigarette smoking is a major cause of do-
The modification of behaviour, e.g. to in- mestic fires in all countries. In low-income
duce people to avoid haste and dangerous countries, fire accidents occur most often in
forms of excitement, is always more difficult the home, with clothing catching fire from
to achieve. open cooking fires, kerosene lamps or pres-
surised stoves, or children falling onto open
fires (Berger 1996). Cooking food for the
C family over an open fire is a major poverty-
8.3 Drowning (1 %) related health risk for children.
M
About 400 000 people were estimated to
Y
have drowned in the world in 2002. About
K
98 % of drowning incidents occurred in low

8 Injury (12 %)
8.5 Poisoning (0.5 %) toxins, pesticides and illegal drugs in low,

middle and high-income countries, respec-
Poisoning is not as common as other physi- tively.
cal causes of injury in the world.
In low-income countries, kerosene, gaso-
line and pesticides stored at home often
cause poisoning. But poisoning also results 8.6 Homicide and violence
from naturally occurring toxins from snakes,
insects or plants like cassava. In low-income
(1 %)
countries, government control of the pro- Violence may be physical, sexual or mental.
duction, sale and use of highly toxic pesti- Intentional violence leading to death occurs
cides is inadequate. It is a tragic paradox that in the form of homicide or suicide. Suicide
people living in absolute poverty are at risk will be dealt with in section 8.8. WHO has
of diseases induced by natural toxins proposed a definition for interpersonal vio-
(Rosling 1995). When they become a little lence (Box 8.2)
wealthier they can avoid the risk of natural According to data from the WHO, vio-
toxin but then they are at risk of commer- lence is strongly associated with the availa-
cially acquired toxins. Products that have bility of firearms, urbanisation, family disin-
been banned in high-income countries can tegration, poverty (or perceived relative dep-
easily be found in markets in low-income rivation) and social stress. There is a link
countries. The protective measure of wear- between inequity and violence. Disadvan-
ing masks and gloves is too expensive for taged individuals in a society live under con-
poor rural populations (Berger 1996). How- ditions of disempowerment, physical and
ever, pesticides are not only an occupational mental insecurity, fear, frustration and de-
hazard; easy access to these products makes pression. All these factors contribute to vio-
suicide through the intake of pesticides a lent behaviour. In addition, the use of and
major and growing cause of severe poison- trade in illicit drugs is associated with a vi-
ing and death, particularly among young cious circle of theft and violence. Alcohol is
women in Asia. a very strong contributing factor to both
In high-income countries, in contrast, poi- homicide and domestic violence.
soning is rare, with the exception of inten- The statistics on the occurrence of vio-
tional abuse of alcohol and illegal drugs. lence are not very reliable. The reason is that
Fatal overdoses of illegal drugs like heroin violence is often not reported, because of
and cocaine have increased in, for instance, the victims powerlessness, stigmatisation or
the United States since the 1950s (Rivara fear. Violence statistics from hospitals, clin-
1997). The promotion of safe storage of ics and emergency rooms are a weak instru-
drugs and chemicals in the home, out of ment to measure the real health impact of
reach of children, has been very successful in violence, because the vast majority of vic-
reducing child mortality in high-income tims of violence do not seek care. Police reg-
countries. The major poisons are natural isters record only reported incidents of vio-
Box 8.2
C Violence is the intentional use of physical force or power, threatened or actual, against
oneself, another person, or against a group or a community, that either results in or has a
M
high likelihood of resulting in injury, death, psychological harm, mal-development or dep-
Y
rivation. (WHO)
K

8.6 Homicide and violence (1 %)
25
Homicides
Suicides
20
Rates per 100 000
15
10
0
African Americas South Europe Eastern Western
Region East Asia Mediterranean Pacific
WHO region
Figure 8.4 Suicide and homicide rate per 100 000 population in different regions of the world, 2000.
Source: World Report on Violence and Health. WHO, 2002.
lence. Mortality data, where it exists, is the that, as the demand for crack cocaine de-
most easily accessible indicator of violence, clined and economic conditions improved,
but it must be remembered that this repre- many young drug dealers switched to legal
sents only a minor portion of the problem. employment. Also, weapon searches in-
This is especially true for domestic violence creased, targeting high-risk individuals, and
against women and children. this deterred the carrying of handguns, so
In the United States, death rates due to that the incidence of homicide decreased
homicide doubled in the four decades up to (Cole 1999).
1994. The United States has the highest Younger men are the group most pro-
death rates due to homicide among high-in- foundly affected by violence. In 1998 inter-
come countries. About 20 000 people are personal violence in men was ranked
murdered each year in USA. It is those in the number three among causes of death, and
15 to 24-year age group who are most af- number five among causes of DALYs lost, in
fected, with homicide being the second the age group 15 to 44 years (WHO 1999).
most frequent cause of death in this group. For women interpersonal violence was
The risk of homicide in a household is in- ranked tenth among causes of death and did
creased by a factor of three if that household not even appear on the list of the fifteen
possesses a gun, and the risk of suicide is in- most common causes of DALYs lost. Africa
creased by a factor of five. The death rate has the second highest death rate due to in-
C from murder for men was 12 per 100 000, as terpersonal violence, far behind the coun-
M against 3.3 per 100 000 for women (Shahpar, tries in the low and middle-income Ameri-
1999). However, since 1993, homicide rates cas. In the low and middle-income countries
Y
in the United States have steadily declined. of the Americas, interpersonal violence
K
A probable explanation for this decline is ranks first as the cause of death in the age

8 Injury (12 %)
group 15 to 44 years, although the general prominent than direct war injuries. These
death rate is lower than in Africa. secondary effects are not included in official
Increasing attention is currently being war injury statistics. An estimated total of
paid to gender-related violence, and it may 170 000 people in the world died due to war
be fruitful to distinguish four different age injuries in 2002 (WHO 2004).
groups in which different aspects of vio- Sexual violence, including rape, is com-
lence are significant for women: a) pre-birth; mon in times of war. Reports from the former
b) childhood; c) reproductive age and d) old Yugoslavia, Bangladesh, Uganda, Rwanda,
age. During foetal life, pre-birth, violence is Burma and Somalia describe widespread sex-
directed towards the pregnant woman in ual abuse and systematic rape (Jennings,
the form of domestic battering. During Swiss 2001). This has long been used as a
childhood, violence is gender-related, partic- strategy in warfare. Sexual attacks on women
ularly in the form of female infanticide (the demoralise the cultural roots of a society,
killing of newborn baby girls), a phenome- leaving strong physical and mental wounds,
non corresponding to the selective abortion and one result may be ethnic cleansing.
of female foetuses (female foeticide). Be- There is a risk of stigmatisation in disclosing
yond the early neonatal period, the threat of wartime rape, and there is vast under-report-
female genital mutilation (FGM) is another ing.
form of selective violence directed against The injuries of war seem impossible to
girls during the first years of their lives. This prevent, but even in this difficult field there
practice occurs in a belt from north-eastern has been progress. As of October 2003 150
to mid-western Africa. FGM arises out of old countries have signed the 1997 treaty ban-
cultural concepts and is currently the sub- ning the use of antipersonnel landmines.
ject of much debate and international atten- This is a result of a most successful cam-
tion. In the reproductive age, gender-related paign by a non-governmental organisation.1
violence concerns above all sexual abuse,
prostitution and domestic violence directed
against women of childbearing age. Accord-
ing to a population-based survey from coun-
8.8 Suicide (1 %)
tries around the world, 10 to 69 % of women Every year about 900 000 persons commit
reported physical assault by an intimate suicide in the world (WHO 2004). This fig-
male partner at least once in their lives (He- ure probably reflects under-reporting, since
ise 1999). Women in old age may suffer from many suicides are reported as accidents. The
physical, sexual, psychological abuse or ne- incidence of suicide attempts is 10 to 20
glect. times higher than actual suicide. Attempted
suicide is three times more common in fe-
males than in males, while completed sui-
cide is three times more common among
8.7 War (0.5 %) males than females in most countries. How-
War is generalised violence. It causes dis- ever, in some countries, such as China, sui-
placement of populations and a general cide is more common in women. In most
breakdown in law and order, and thus an in- countries that report suicide data to the
crease in all kinds of violence. Direct war in- World Health Organisation there has been
juries consist of deaths and war wounds due an increase in suicide rates, especially
C to the direct conflict or mine injuries. Sec- among young men. Japan is one of the few
M
ondary effects, due to ruptured social and countries where there has been a decrease in
economic structures, splitting of families, suicide rates for both men and women over
Y
destroyed health and social services, and de-
K
struction of infrastructure, are usually more 1
www.icbl.org

8.8 Suicide (1 %)
the past 35 years. Of those countries that re- associated with increased suicide rates, espe-
port Hungary, Sri Lanka, Finland and China cially in young women. Various studies have
have the highest rates of 30 to 40 suicides shown that suicide rates increase in societies
per 100 000 population per year. Kuwait and with higher divorce rates, immigration and
Egypt have the lowest reported rates, at 0.8 dramatic declines in gross domestic product
and 0.04 per 100 000 population per year, (GDP), and decrease with high unemploy-
respectively (Lester 1997). In general, there ment rates, where there is a high percentage
are countries with low, middle and high of the population aged less than 15 years
rates of suicide in all continents where data and where there are high birth rates. Thus,
is kept: in the Americas, Asia and Europe. studies point to an association between eco-
The method used for suicide varies from nomic development and higher suicide rates
country to country. In low-income coun- (Lester 97).
tries it is common to ingest liquid pesticides,
while in high-income countries there is a
preference for the ingestion of medications References and suggested further readings
or the use of firearms (Wasserman 2001). Ahmed N, Andersson R. Unintentional
In most countries suicides are between injury, mortality and socio-economic
two to three times more common in old age development among 15 to 44-year olds:
than in youth (Diekstra 1993). This trend is in a health transition perspective. Public
very prominent in men. In high-income Health 2000;114:416422.
countries, suicide rates are highest for mid- Baker SP, ONeill, Karpf RS. The Injury Fact
dle-aged men; in middle-income countries, Book. Lexington Books. 1984.
it is the elderly who have higher rates; and Barss P, Smith G, Baker S, Mohan D. Injury
in the low-income countries, the younger prevention: An international perspective.
age groups have higher suicide rates (Lester Oxford University Press 1998.
1997). Since overall suicide rates are higher Berger LR, Mohan D. Injury Control. A Glo-
in old age, the suicide rate is sensitive to the bal View. Oxford University Press; 1996.
age structure of a population, which pro- Brown LR, Flavin C, French H. Worldwatch
duces a bias in global comparisons if the Institute. State of the World; 1998.
rates are not standardised for age. In the age Cole TB. Ebbing epidemic: Youth homicide
group 15 to 24 years suicide is not common, rate at a 14-year low. JAMA 1999;281:25
but because the relative mortality is rather 26.
low in this age group, suicide is still among Diekstra RFW, Gulbinat W. World Health
the five leading causes of death at the age of Stat. Quart 1993;46:5268.
20 in many countries (Diekstra 1993). Heise LL, Ellsberg M, Gottemoeller M. End-
Mental illness and substance abuse are re- ing violence against women. Baltimore,
lated to increased levels of suicide. Other su- MD: Johns Hopkins University School of
icide-associated conditions include easy ac- Public Health. Centre for Communica-
cess to the means of death, such as poison, tion Programs; 1999. (Population Reports
and media publicity for suicide. Religious af- Series L, No 11).
filiation is also clearly correlated to suicide Jennings PJ, Swiss S. Supporting local efforts
rates; Islamic countries have lower rates to document human rights violations in
than the Buddhist countries in Asia, and the armed conflict. Lancet 2001;357:304.
Protestant countries of North America and Lester D. Suicide and life-threatening behav-
C Europe have higher rates than the Roman iour 1997;27(1).
M
Catholic countries of Latin America and Murray C, Lopez A. Global Burden of Dis-
Southern Europe. However, there are excep- ease Study. 1996.
Y
tions. The general improvement in health in Plitponkarnpim A, Andersson R, Jansson B,
K
Iran has in recent years unfortunately been Svanstrm L. Unintentional mortality in

8 Injury (12 %)
children: a priority for middle-income Shahpar Cyrus, Li Guohua. Homicide mor-

countries in the advanced stage of epide- tality in the USA, 19351994. Am J of
miological transition. Injury Prevention Epid 1999;150:1213122.
1999;5:98103. Wasserman D edited. Suicide an unneces-
Rivara et al. Injury prevention. New Eng J sary death. London: Martin Dunitz; 2001.
Med 1997;337:613617. World Health Organization, World Health
Rosling H, Tylleskr T. Konzo. In: Tropical Report 2004.
neurology. Eds Shakir RA, et al. London: World Health Organization. Injury, a lead-
W.B. Saunders 1995; pp 35364. ing cause of the Global Burden of Disease.
Sderlund N. Traffic-related mortality in in- Report:WHO/HSC/PVI/99.11
dustrialised and less developed countries. World Health Organization. World report
Bull WHO 1995;73: 17582. on violence and health. 2002.

8.8 Suicide (1 %)

9 Sexual and reproductive health (9 %)
9 Sexual and reproductive health

(9%) *
Lack of public transportation and high costs of
private transportation are major constraint to
access.Stories are told about pregnant women
losing their babies on their way to the health
services.
Republic of Yemen 1998
The concept of reproductive health was of cultural and religious taboos, making
coined during the mid1980s. It refers to the them targets for both praise and condemna-
prevention and treatment of diseases that tion. Down through history, the control of
impair reproduction. The concept has both reproduction has been controversial, with a
male and female dimensions. Among males very wide global variation in acceptability.
the fertile age extends from puberty to old Two global conferences on population in
age. Among females the fertile age is defined Bucharest 1974 and in Mexico City 1984
by the more limited period between me- were followed by a paradigm shift in the fol-
narche and menopause. low-up in Cairo 1994, where the first Inter-
Reproduction denotes the process of pro- national Conference on Population and De-
ducing a new individual. The starting point velopment (ICPD) was arranged. ICPD con-
of reproduction can be said to be the pro- stituted in many ways a new era in the
duction of sperms and eggs, also known as global approach to reproductive health. For
gametogenesis. It is less clear which point the first time a human rights perspective
should be designated as the end-point of the was associated with sexual and reproductive
process of reproduction. It can be argued health. This has implied a most significant
that reproduction ends by delivery of the change in attitudes in many countries. (See
newborn. However, it has been argued that also chapter 10.)
the most vulnerable period in the life of the Many diseases affecting reproductive or-
newborn, infancy or even childhood up to 5 gans do not necessarily affect reproduction,
years, should be included in the scope of re- but have their significance in their sexual
productive health. The dependence of the transmission (e.g. HIV and other sexually
newborn on the mother for warmth and transmitted infections). Therefore, it is now
feeding makes it relevant and reasonable to common to refer to sexual and reproductive
include health of the mother and her new- health (SRH). After the Cairo conference
born at least up to the end of the perinatal where the human rights perspective became
period. This means reproductive health is more prominent, the acronym SRHR has
considered to be up to the end of the sev- come to stand for sexual and reproductive
enth day after birth. health and rights. It is important to note
C
Sexuality and reproduction belong to the that sexual and reproductive ill health refers
most private of human spheres. Hence, both not only to pregnancy-related disorders. In
M
issues have been subject to a great number addition to HIV/AIDS and other sexually
Y
K
* % of global disease burden consisting of maternal and perinatal disorders.

9.1 Childlessness and reproductive failure
transmitted infections (see chapter 5) there usually made between primary infertility
are reasons to subdivide this concept into and secondary infertility.
five other aspects of sexual and reproductive Primary infertility denotes an inability to
ill health: conceive within two years of unprotected
sexual intercourse and without any previous
1 childlessness and reproductive failure: successful conception, while secondary infer-
diseases affecting fertility or foetal out- tility refers to such inability after a previous
come among females and males, i.e. the successful conception. Primary infertility in
capacity of a couple to conceive and to many African settings is reported to be only
have a successful pregnancy; a few percent, while secondary infertility
2 maternal mortality: deaths during or may reach 20 to 30 % of couples in some
soon after the end of pregnancy (delivery populations. In Sweden, as in most high-in-
or abortion); come countries, the proportion of couples
3 maternal morbidity: diseases affecting not spontaneously capable of conceiving
women during or soon after the end of amounts to about 10 %. Many of these can
pregnancy; be helped with modern technologies such as
4 perinatal mortality and morbidity: deaths in-vitro fertilisation, hormonal medication,
and diseases affecting the foetus or new- antibiotic therapy and other measures. The
born; demand for such new reproductive technol-
5 conditions affecting reproductive organs ogies (NRT) is rapidly increasing in many
in both females and males, but not neces- middle-income countries, especially in the
sarily affecting fertility functions, or oc- Middle East. In Egypt alone nearly 40 in
curring outside the fertile age. vitro fertilization centres are in operation al-
though these techniques are very costly.
Major forces behind the global demand for
NRTs are linked to gendered roles and adop-
9.1 Childlessness and tion restrictions. This is a prominent exam-
reproductive failure ple where middle-income countries have to
Infertility is only one part of a greater global deal with strong demand for new medical
health problem, which should more cor- technologies at the same time as cheap and
rectly be called childlessness. This problem cost effective health actions that can pre-
can be subdivided into at least three princi- vent a considerable part of the problem
pal categories: have not yet been implemented (Inhorn
2003).
1 infertility; The health of a pregnant woman and the
2 pregnancy wastage and outcome of her pregnancy are threatened by
3 child loss. a number of infections and circulatory dis-
eases and adverse environmental conditions.
Infertility is a problem of global proportions, Some infectious agents, e.g. Rubella virus,
affecting on average 10 % percent of couples Syphilis, Herpes simplex virus, Cytomegalo-
worldwide. Several highly prevalent diseases virus, Streptococci bacteria and Chlamydia,
have far-reaching influences on female fertil- are related to adverse pregnancy outcomes.
ity, most of them through an effect on tubal Pregnancy wastage should be understood as
function. While infertility due to lack of egg any loss of the foetus from conception to
C formation, anovulatory diseases, are fairly delivery, including early and late miscar-
M
common worldwide, unilateral or bilateral riage, late foetal death and stillbirth. Several
tubal occlusion is particularly prevalent in pregnancy-specific circulatory diseases, most
Y
populations where gonorrhoea and Chlamy- of which are related to hypertension, also
K
dia infections are common. A distinction is increase the risk of pregnancy wastage.

The socio-economic determinants influ- 9.2 Maternal mortality: the tip

encing reproductive health can be seen
most clearly in the global pattern of child-
of the iceberg (2 %)
lessness. In affluent countries childlessness The crude birth rate in the world is 22 births
is almost exclusively an infertility problem. per 1 000 population. This corresponds to
In low-income countries infertility takes a 138 million births per year in the world. In
heavy toll, due to tubal obstruction in addition there are about 50 million induced
women and to obstruction of sperm trans- abortions and approximately 25 million rec-
port in men. In addition to this, however, ognisable spontaneous abortions per year.
infections such as syphilis and viral infec- The total number of pregnancies per year is
tions are widespread, resulting in much about 215 million.
higher figures for pregnancy wastage than in The burden of maternal disease and death
affluent countries. This is particularly true of has gradually become more obvious over
foetal death and ensuing stillbirth in the the last 15 years. Maternal conditions cause
second and third trimesters. Because of this, 2 % and perinatal disorders 7 % of all DALYs
perinatal mortality rates are much higher in lost in the world in 2002. The group of ma-
poor than in affluent countries. ternal disorders account for about the same
Male reproductive problems have been number of DALYs lost per year in the world
somewhat overshadowed by the otherwise as do TB, measles, malaria or chronic ob-
very appropriate and adequate focus on fe- structive pulmonary disease, namely about
male reproductive health. However, it is 2 to 3 % of the world total (WHO 2004).
well known that disorders affecting the Several far-reaching international commit-
male reproductive function are prevalent in ments have been proclaimed for the reduc-
most countries. In affluent countries the rel- tion of this burden. Reducing maternal mor-
ative contribution of the male to the aetiol- tality by 50 % by the year 2000 was thus put
ogy of a couples infertility problem is con- forth as a principal objective at five world
sidered almost as important as that of the fe- conferences during the 1980s and the
male. The male reproductive function 1990s. The problem of setting such a goal
depends on normal production and trans- for reduction in maternal mortality is that
port of sperm as well as of the sexual func- surveys hitherto have only been able to
tion. Widespread diseases in low-income establish grossly and very approximately
countries affect both sperm production and the worldwide magnitude of maternal mor-
transport. Inflammatory changes in testicu- tality.
lar tissues and in the epididymis may create A maternal death is the death of a woman
obstruction to sperm transport that result in from any cause while pregnant or within 42
male infertility. Diseases such as mumps and days of termination of the pregnancy by
gonorrhoea may affect male fertility by tes- abortion or delivery. Earlier incidental and
ticular inflammation and epididymitis that accidental causes were not counted, and
block sperm transport. Filariasis may create suicides, for instance, were not included.
lymphatic obstruction in the scrotum and With the increasingly evident problem of
the resulting warming of testicular tissue deaths caused by domestic violence, the
leads to impaired sperm production and in- concept of pregnancy-related death is now
fertility. in use, regardless of the cause of death.
The global variation in childlessness is in- The global variation in maternal mortality
C sufficiently known. It is dependent on the is extreme. Historically, data from both mid-
M
prevailing norms for sexuality and reproduc- dle and low-income countries are scarce.
tion, and on existing patterns of genital in- Sweden has one of the worlds oldest and
Y
fections, mainly sexually transmitted dis- most reliable registers of maternal deaths,
K
eases. dating back to around 1750. At that time,

9.2 Maternal mortality: the tip of the iceberg (2 %)
= 1 million DALYs
Map 9:1 Maternal disorders cause 31 million disability adjusted life years (DALY) lost oer year.
Source: WHO, 2002.
Sweden had a maternal mortality ratio, as the advent of modern technology such as
defined below, of around 1 000 per 100 000 blood transfusion, antibiotics, modern hos-
live births. This is the same figure as is esti- pital care, safe abortion, contraceptives and
mated for Mozambique today. Most high-in- antenatal care. During this period of indus-
come countries in northern Europe today trialisation, the most important single cause
have maternal mortality ratios below 10 per of maternal mortality decline was the crea-
100 000 live births. tion of the Swedish midwifery system. One
Globally, most recent estimates indicate example of the association between mater-
that there is an annual toll of maternal nal mortality decline and percentage of
deaths amounting to around 500 000, about midwifery assistance at birth is shown in fig-
1 % of the total number of deaths in the ure 9.2 (Hgberg 1986).
world in a year. An estimated 99 % of these The historical example of medium-level
deaths occur in low and middle-income health care providers in Sweden in the form
countries, implying that a maternal death is of midwives is important when considering
an extremely rare event in high-income the unmet need of safe motherhood where
countries. It is a cause of death that can be there are no doctors.
brought to almost zero.
An illustrative example of the decline in
maternal mortality in Sweden is presented 9.2.1 Measures of maternal mortality
in figure 9.1. It is noteworthy that the de- Maternal mortality ratio represents the
cline in maternal mortality ratio was from number of maternal deaths per 100 000 live
C around 1 000 in 1750 to about 5 today. The births. This ratio (MMR) measures the risk of
M
decline from about 1 000 in the year 1750 to death among pregnant and recently preg-
a maternal mortality ratio of about 150 per nant women after delivery or abortion. The
Y
100 000 live births around 1900 constitutes strength of this measure is that it expresses
K
a decline of 85 %. This occurred well before the quality of pregnancy care and delivery

1100
1000
500
100
50
Figure 9.1 Maternal mortal- 10
ity in Sweden between 1751

and 1980, deaths per
5
100 000 live births, five year
0
mean, logscale.
61 5
71 5
81 5
91 5
01 5
11 5
21 5
31 5
41 5
51 5
61 5
71 5
81 5
91 5
01 5
11 5
21 5
31 5
41 5
51 5
61 5
71 5
70 5
0
5
6
7
8
18 9
0
1
2
3
4
5
6
7
8
19 9
0
1
2
3
4
5
6
19 7
8
51
Source: Hgberg 1986.

17
care, safe motherhood. MMR is not sensi-

tive to fluctuations in fertility.
Maternal mortality rate represents the 500
Death rate per 100 000 live births
number of maternal deaths per year per 61/65

100 000 women aged 1549. This expression 400 66/70
is rarely used since it reflects both the risk of 71/75
death among pregnant and recently preg- 300
nant women after delivery or abortion and 76/80
81/85
the proportion of all women that become 200 86/90
pregnant in a given year. It can consequently
be reduced either by making a wanted preg- 91/94
100
nancy safer (as for MMR) or by lowering fer-
tility. It measures the contribution of mater-
0
nal mortality to the overall mortality among
10 20 30 40 50 60 70 80
women of reproductive age.
Percentage of deliveries assisted by midwife
Lifetime risk of maternal death measures the
risk over a womans entire reproductive life Figure 9.2 Maternal mortality (septic deaths ex-
C span and is also related to the total number cluded) as a function of the presence of a midwife at
M
of pregnancies. The total fertility rate tends home delivery in an area in nothern Sweden 1861
to be high in association with a high infant 1894 (the dots along the line indicate five-year in-
Y
and child mortality for two principal rea- tervals).
K
sons. Firstly, there is a psychological replace- Source: Hgberg 1986.

9.2 Maternal mortality: the tip of the iceberg (2 %)
ment effect, whereby compensation is made timates of maternal mortality are based upon
for the loss of a child through a new preg- available but deficient and non-representa-
nancy. Secondly, there is an endocrine ef- tive hospital data, which has little to do with
fect: when a breastfed infant dies, the suck- the maternal mortality at the community
ing stimulus on the nipple ends, with an en- level. In low and middle-income countries
suing reduction of circulating prolactin three specific survey methods are used for
hormone. Such a reduction facilitates the re- measurements of maternal mortality, each
turn of ovulation, enhanced fertility and a with specific advantages and disadvantages.
probable new pregnancy. The final result is To assess the magnitude of maternal mor-
that the lifetime number of pregnancies tality in countries where it is not reported,
tends to increase in societies with high in- the sisterhood method is a cost-effective way.
fant and child mortality. The lifetime risk of Persons are interviewed regarding maternal
maternal death is then increased, and the deaths among their adult sisters. It can be
individual risk of each pregnancy should be carried out as one part of a household sur-
multiplied by the lifetime number of preg- vey, which makes it a comparatively cheap
nancies. In the least developed countries, way of measuring maternal mortality. The
the lifetime risk may be as great as one in disadvantage, however, is that it is fairly im-
ten, while in Northern Europe it is in the precise, giving a range of uncertainty of up
order of one in 10 000. to 20 %. Furthermore, it reflects a reality
There are several hurdles in measuring that may be a decade or more out of date.
changes in maternal mortality. Firstly, the The most important disadvantage is, how-
MMR is most often below 2 % (2 000 per ever, that it does not give any clue to opera-
100 000 live births), even in the poorest tional activities or interventions to reduce
countries. Large samples are therefore maternal mortality, since it provides num-
needed to make reliable estimates, and the bers but not circumstances.
costs of large sampling are high. Secondly, Another method is the household survey,
where maternal mortality is high, the ma- which is costly and time-consuming. A few
jority of mothers die at home or at least out- household surveys on maternal mortality
side the health care system. These womens have been published. One of the best-
deaths are known to be under-reported and known examples is the Addis Ababa study,
in most low-income countries there is no which resulted in an estimated maternal
regular reporting of any deaths outside hos- mortality ratio of 566 maternal deaths per
pitals. Underestimates in the range of 30 to 100 000 live births. This study was based on
50 % are also found in high-income coun- 45 maternal deaths identified in a survey of
tries and in middle-income countries the 32 000 households. Even such a huge under-
under reporting is even higher. In many taking has a wide 95 % confidence interval,
cases we have to multiply publicly available which in this study was calculated to range
figures by a factor of 2 or 3 to estimate the from 374 to 758 deaths per 100 000 live
mortality. Thirdly, it is difficult to know births (Kwast 1986).
whether a death is maternal or non-mater- A more effective way of reaching valid
nal, and misclassification is a problem in all conclusions for interventions is the reproduc-
types of countries. The fact that the woman tive age mortality survey (RAMOS). Such stud-
was pregnant may be simply overlooked, ies imply the identificationfrom village
forgotten or not recognised. This is particu- surveys, from demographic sites, from vital
C larly probable when crime is involved, as in registration or from cemetery surveysof all
M
cases of clandestine abortion or homicide in deaths among women of reproductive age,
the context of domestic violence. often defined as 15 to 49 or 12 to 55 years,
Y
There are several ways to overcome the depending on prevailing patterns of repro-
K
problems mentioned. Very often, national es- duction. After identifying such deaths,

trained interviewers are sent to each identi- bed fever). Life threatening infections fol-
fied household of a female death and the cir- lowing abortion and delivery have been
cumstances of death are clarified, with an shown to be on the increase in areas with a
emphasis on the distinction between mater- high prevalence of HIV infection. Brain
nal and non-maternal deaths (verbal au- malaria during pregnancy and immediately
topsy). In demographic sites such verbal au- following the delivery is also a growing prob-
topsies are often done routinely for each lem, especially in Africa. The regional varia-
identified death. Empirically, this approach tion of the life threatening type of hyperten-
is the best method for subsequent interven- sion, eclampsia, is striking. There are a much
tion, since such autopsies often give infor- greater number of maternal deaths due to
mation about aspects of avoidability and eclampsia in lowland coastal areas, while
other practical circumstances, which can be eclampsia is rare or even non-existent in
applied to interventions. When using pro- most highland areas investigated.
spective registration of maternal death
among 77 000 women during six years in
the largest demographic site in Tanzania the 9.3 Maternal morbidity: the
confidence interval for MMR was 600 to
1 100 per 100 000 live births (Mswia 2003).
base of the iceberg
This clearly shows that maternal mortality is Maternal morbidity refers to all complica-
too rare to be affordable to monitor year by tions of pregnancy, delivery and abortion. It
year in low-income countries. It is probably is noteworthy that the major portion of ma-
only meaningful to make national estimates ternal ill health is found after pregnancy, be
for ten-year periods. it concluded by delivery or by abortion.
The global variation in maternal morbid-
ity is virtually unknown. This is particularly
9.2.2 The principal maternal killers? true for low-income countries, while statis-
Knowledge of the global proportions of the tics from high and middle-income countries
causes of maternal death is extremely lim- are better. Morbidity-specific figures are pre-
ited, but the main causes are well known sented below.
(Box 9.1). Haemorrhage following delivery An overview from low-income countries
and uterine rupture during delivery are com- has shown that around 40 % of women had
mon in remote areas, where life-saving hos- acute health problems during pregnancy, of
pital services are beyond reach. Hygiene at which 10 to 15 % developed chronic health
delivery, even when birth takes place under problems, including specific conditions
primitive conditions, may reduce the inci- such as fistulae, prolapse, or incontinence
dence of life threatening infections (child- directly resulting from the pregnancy. These
Box 9.1
The six prominent causes of maternal death
1 postpartal haemorrhage (bleeding due to the failure of the uterus to contract following
delivery)
2 post-abortion septicaemia (infection due to an unsafe abortion)
C 3 postpartal septicaemia (infection due to childbed fever)
M
4 eclampsia (circulatory death due to pregnancy-induced hypertension)
5 uterine rupture (bleeding due to obstructed labour)
Y
6 brain malaria (infection due to pregnancy-related deterioration of immunity)
K

9.3 Maternal morbidity: the base of the iceberg
seemingly high figures can best be under- last decades. If more serious pregnancy
stood if recognised that they include com- anaemia is considered (<70 gram/litre), the
mon but still serious conditions like preg- prevalence is below 5 %.
nancy anaemia, malaria, malnutrition, preg-
nancy-induced hypertension, pregnancy
induced diabetes, syphilis and a number of 9.3.2 Unsafe abortion-related diseases
other infectious diseases. The figures also At least 50 million induced abortions are
constitute a reminder that severe maternal performed in the world each year, and half
morbidity is a much more prevalent prob- of them constitute unsafe interventions.
lem than maternal mortality. This implies an unmet need for fertility reg-
In various projects aimed at improving ulation. It is a huge challenge to the world
maternal and perinatal outcome of preg- to counteract dangerous abortions carried
nancy, maternal morbidity has been sug- out by untrained persons and to prevent the
gested as a tool to measure the impact of pro- mortality and morbidity resulting from
grammes. Maternal morbidity is, however, them. Preventive measures include health
difficult to define and to interpret. There is a education and fertility regulation as well as
significant degree of inter-observer variation provision of safe abortion.
in diagnosing various maternal diseases, and The diseases associated with unsafe abor-
technologies are not always available to es- tion consist above all of ascending genital
tablish a correct diagnosis (e.g. measurement infections. These can be expected to occur in
of haemoglobin concentration for the diag- at least 30 % of cases, which would corre-
nosis of anaemia). Maternal morbidity can spond to close to 10 million women per year.
be divided into four categories: pregnancy- There is evidence that such post-abortion in-
related, unsafe abortion-related, delivery-re- fections frequently result in occlusion of the
lated and puerperium-related diseases. fallopian tubes, with resulting secondary in-
fertility. As a rough estimate, this much-
feared complication results in at least 2 mil-
9.3.1 Pregnancy-related diseases lion women each year becoming infertile as
Studies in the USA and in Canada show that a direct consequence of an unsafe abortion.
about 25 % of women with low-risk preg- The global variation in the occurrence of
nancies suffer from disease during preg- unsafe abortion is unknown. The criminal
nancy, mostly anaemia, hypertension or uri- nature of the intervention makes under-re-
nary tract infection. The latter is known to porting a significant factor both in routine
be associated with adverse pregnancy out- statistics as well as in special surveys. Mater-
comes such as early delivery, low birth nal deaths related to unsafe abortion are
weight at delivery and various infectious presumably most prevalent in Africa and in
complications involving the genital tract. Asia, each of which is estimated to account
The prevalence of hypertension varies for 40 to 45 % of all abortion-related mater-
considerarbly between different studies. Di- nal deaths, amounting to around 90 000 per
astolic pressures greater than or equal to year globally. It is almost impossible to find
90mm/Hg have been found in about 25 % in estimates of trends in numbers of unsafe
high-income, 15 to 20 % in middle-come abortions. The advent of cheap medical
and 5 to 10 % in low-income countries. abortion technologies such as the use of the
Anaemia is defined by the WHO as a hae- drug misoprostol will presumably contrib-
C moglobin level in the blood of less than 110 utes to a reduction in the occurrence of un-
M
gram/litre. WHO estimates that up to 60 % safe abortion. The increasing prevalence of
of pregnant women in several studied low- HIV infection would tend to make lay abor-
Y
income countries are anaemic. It seems that tions more dangerous, with more post-abor-
K
this prevalence has not changed over the tion infectious complications.

9.3.3 Delivery-associated diseases dle-income countries and almost non-exist-

The most typical morbidity occurring dur- ent in high-income countries.
ing labour and delivery results from abnor- One particularly significant puerperal dis-
mally prolonged labour due to constitu- order is uterine prolapse. Its prevalence is gen-
tional or functional disturbances. Depend- erally unknown, but studies in some coun-
ing on the exact definition, 10 to 15 % of tries (e.g. Egypt) have revealed that it is clin-
pregnant women suffer prolonged or ob- ically significant in more than 50 % of
structed labour. Underlying factors may in- women with previous childbirth. Another
clude youth, short stature, or diseases. Ec- tragedy is damage of the soft tissues of the
lampsia may deteriorate into convulsions birth canal due to prolonged labour. This
and severe anaemia may lead to acute car- can lead to a permanent hole between the
diac failure. bladder and the vagina, a so-called vesico-
vaginal fistula, or between the rectum and
the vagina, a recto-vaginal fistula. These
9.3.4 Puerperium-related diseases complications affect particularly young
Two problems predominate the period after short women during their first delivery, as
the delivery known as puerperium. These there is a risk that the not fully-grown pelvis
problems are bleedings and infections. Fail- leads to prolonged delivery.
ure of the uterus to contract adequately, due If an estimated 40 % of the 138 million
to uterine atony, may result in abnormal annual births involve complicated pregnan-
haemorrhage. This typically occurs shortly cies (around 55 million) and this figure is
after delivery and in approximately 10 % of added to the estimated number of spontane-
all deliveries. Abnormal bleeding is defined ous abortions (25 million), then a total of at
as a loss of more than half a litre of blood. If least 80 million pregnancies with acute
drugs promoting uterine contraction are problems occur each year in the world.
routinely used to prevent atony, the bleed-
ing prevalence can be brought down to ap-
proximately 5 %. On average, about the 9.4 Perinatal morbidity and
same prevalence is found for retained pla-
centa, often associated with excess haemor-
mortality (7 %)
rhage. Reference is often only made to before or
Postpartal bacterial infection of the uterus after birth. It should be noted that the con-
may lead to puerperal fever (childbed fever) cept perinatal alludes to the foetus/infant
and deteriorate into genital sepsis, a life and the mother. Current use of perinatal
threatening general infection. It may occur often excludes maternal aspects by focusing
several days after delivery and even beyond on foetal/infant events. Maternal morbidity
the first week after delivery, and is frequently or mortality is often not included in perina-
under-reported. In low-income countries it tal medicine; although more than 50 % of
is estimated to affect approximately 5 % of all maternal deaths occur in the perinatal
women after delivery, while it is rarer in mid- period. One reason is that two types of med-
Box 9.2
Definition of the perinatal period
C
M
The perinatal period is the period extending from the gestational age at which the average
foetus attains the weight of approximately 500gram (equivalent to 22 completed weeks of
Y
gestation) to the end of the seventh completed day of life.
K

9.4 Perinatal morbidity and mortality (7 %)
= 1 million DALYs
Map 9:2 Perinatal conditions cause 97 million disability adkjusted life years (DALY) lost per year.
Source: WHO, 2002.
ical specialists divide the responsibility for ship is approximately the same. In general,
the care of the mother and the child. stillbirths and neonatal deaths during the
It is obvious that the road to health in the first week of extra-uterine life tend to be ap-
perinatal period is dependent upon the proximately equal. The total number of peri-
health of the mother. Her health during preg- natal deaths annually in the world is esti-
nancy depends on her living conditions be- mated to be about 2.5 million, with the bulk
fore becoming pregnant. The young girl that of the problem occurring in Southern Asia,
suffers from malnutrition during childhood followed by Sub-Saharan Africa (WHO 2004).
will be at risk of skeletal stunting, deficiency
diseases such as rickets (Vitamin D defi-
ciency) and infections resulting in pelvic 9.4.1 Low birth weight
asymmetry. Such a girl will often run a high The health problems of the foetus/neonate
risk in later pregnancies. The road to perina- occurring in the perinatal period are almost
tal health for the young mother is threatened always associated with maternal disease.
by a number of complications potentially af- This is especially so for low birth weight
fecting both the mother and the foetus. Ei- (LBW), which is defined as a newborn
ther of the two may die from complications weight of up to 2499 gram. The proportion
originating in the womans early years. of newborns with a birth weight below 2500
The enormous global burden of perinatal gram varies considerably from country to
ill health is well illustrated by the fact that country. It is often used as an indicator of the
perinatal disorders top the list of conditions general health situation and living standard
C that cause most DALYs lost in the world in a given country. It has been calculated
M
(WHO 2004). The burden of perinatal disor- that about 95 % of all LBW births, or 20 out
ders is estimated to be more than three times of 21 million per year, occur in low and mid-
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as big as the burden of maternal disorders. If dle-income countries. This problem is partic-
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compared only among females the relation- ularly important in southern Asia, where 20

to 30 % of newborns have a birth weight fants, among whom the long-term prognosis
below 2500 gram. Any population with an may vary from severe persistent growth re-
LBW incidence above 7 % is at risk of having tardation and psychomotor retardation to
a high perinatal mortality, which could be completely normal growth and develop-
counteracted by analysing the roots of the ment. In many cases, it is not possible to
LBW problem. In low-income countries a predict the outcome before the child has
significant share of this problem is thought reached the age of 6 months or more. With a
to be associated with the problem of small- high prevalence of LBW, a high prevalence
ness for gestational age (SGA), due to a com- of developmental disorders may be ex-
bination of maternal malnutrition, anaemia, pected.
malaria, placental insufficiency, pre-eclamp- Asymmetrical growth retardation. The babys
sia and also unknown factors. Babies who weight is abnormally low in relation to its
are small for age (SGA) are those who have a length. Where severe maternal malnutrition
birth weight below the 10th percentile at any is prevalent, e.g. in parts of India and Africa,
gestational age. Very limited data exist, how- these infants constitute a significant propor-
ever, regarding the aetiological role of vari- tion of the LBW category. Their length and
ous maternal diseases for the development head circumference are in most cases normal
of SGA. Only a proportion of SGA newborns for full-term infants. These newborns have
suffer from intrauterine growth retardation for some reason suffered intrauterine malnu-
(IUGR), which is a condition associated with trition, frequently without any obvious ma-
disturbance of placental function. Some nor- ternal disease. This pattern is also encoun-
mally growing foetuses may still be in the tered in multiple pregnancies, in pre-ec-
SGA category for genetic reasons and may be lampsia and in other conditions featuring an
considered small but healthy. inadequate placental nutritional supply to
Among LBW newborns, there is a variety the foetus. These newborns may be born at
of causes of perinatal infant death. Vulnera- term or pre-term. They may also suffer from
bility to infection, particularly maternal gen- deficient access to oxygen from the umbili-
ital infections, seems to play a predominant cal cord during delivery and the first min-
role in some deprived populations. Such ma- utes of breathing following birth. This is
ternal infections may lead to uterine con- known as neonatal asphyxia and it may be
tractions and finally to expulsion of the the reason for late neurological complica-
baby, sometimes with intrauterine growth tions contributing to long-term disability.
retardation. Asphyxia, hypothermia and in- The prognosis in cases with late growth re-
fections, especially neonatal tetanus, are tardation is, however, good. With adequate
other causes of neonatal death. care, the child will grow fast and regain most
There are few tools available to predict of the initial weight loss. However, if prena-
LBW. Anthropometry is one useful approach tal malnutrition is followed by severe post-
in this regard (tape-measure obstetrics), by natal starvation, the situation rapidly be-
which the growing abdomen of the mother come precarious and the risk of permanent
can be measured at regular intervals. In this brain damage is high.
way the distance between the symphysis Genetically small newborns. Short mothers
bone and the upper part of the uterus can be and fathers often have small children. These
monitored to recognise early deviations in infants will remain small and their prognosis
foetal growth. is generally good. However, in this group,
C there is also a subgroup of infants with very
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early intrauterine growth retardation, due to
9.4.2 The small baby either diseases or parental genetic aberra-
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Newborns with a birth weight below the 10th tion, the true causes of which cannot be de-
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percentile consist of various groups of in- termined.

9.4 Perinatal morbidity and mortality (7 %)
9.4.3 Pre-term birthbeing born too early 9.4.4 Hypothermia

The word pre-term refers to any gestational Over the last decade, hypothermia has been
age earlier than 37 completed weeks of preg- recognised as a problem in new-borns even
nancy. The word premature is not synony- in tropical countries. It is usually defined as
mous with pre-term. In actual practice, a temperature below 36.5C. Insufficient at-
premature is often (poor) jargon for less tention has previously been paid to the prob-
than 2,500 gram, which is correctly desig- lem of low temperature, since room temper-
nated LBW. The word premature should ature in these countries is usually high, at
therefore never be used, since it is obsolete, least during the day. Body temperature has
unclear and misleading. Reference should usually been measured with conventional
instead be made specifically to weight (e.g. rectal thermometers, which do not record
LBW) or gestational age (e.g. pre-term). temperatures below 35C. Thus, the temper-
It may be of clinical interest to know ature of a baby admitted to a neonatal ward
whether a LBW baby is born pre-term or at may be reported to be 35C, although the ac-
term. The estimation of gestational age is tual temperature may be much lower. Perina-
thus important, and if the maternal mental death is clearly associated with hypother-
strual data is reliable there is no problem in mia. It has been shown that pre-term babies
calculating it. If the data is absent or inaccu- with a rectal temperature of less than 36C
rate, it may be of some help to use a matura- had a mortality rate of more than 75 %. If
tion-scoring system. At present there is, un- they were kept warm, the mortality rate
fortunately, no maturity-scoring system dropped to less than 20 %. Avoiding hypo-
tested in both developed and developing thermia is probably the most important and
countries. No system gives a better estimate most feasible single factor in reducing neo-
of gestational age than 2 weeks. natal mortality among LBW newborns in re-
The global variation in the prevalence of source poor settings. It has been estimated
pre-term birth is substantial. In settings that during the last decades, the prevention
where ascending genital infections prevail, of hypothermia has contributed to a 25 % in-
up to 20 % of births may be pre-term. In set- crease in survival rate in high-income coun-
tings where such ascending genital infec- tries. The kangaroo method (see above) has
tions are less common, the prevalence may meant a most significant improvement in
be less than half of that. the maintenance of thermal control, partic-
In current practice in most settings where ularly for the smallest newborns.
resources are scarce, efforts to save pre-term
babies start when they have reached approx-
9.4.5 Perinatal infections
imately 28 weeks of gestation, correspond-
ing to a birth weight of around 1 000 gram. Worldwide, infections are one of the main
The mortality among newborns with a birth causes of maternal death and perinatal in-
weight of less than 1 000 gram is close to fant death. The availability of antibiotics
100 % in the general health service in low- was a major advance in reducing perinatal
income countries. But even with very scarce deaths. The anti-tetanus vaccine was an-
resources the survival can be improved by other major technical advance. Recently,
simple and cost-effective methods such as there has been some progress in research
the skin-to-skin (mother-newborn) method, into fairly low-cost medications aimed at re-
known as the kangaroo method (Chris- ducing the risk of vertical transmission of
C
tensson 1998). HIV infection from HIV-infected mothers to
M the newborn. However, huge logistical and
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motivational problems still remain for the
wide utilisation of these drugs. Puerperal en-
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dometritis with sepsis is a largely preventa-

= 1 million DALYs
Map 9:3 Congenital abnormalities cause 29 million disability adkjusted life years (DALY) lost per year.
Source: WHO, 2002.
ble complication, which kills many moth- the family is essential for the protective
ers. Unhygienic handling at birth is also an mechanisms of the infant. On the other
infection risk that may be fatal in combina- hand, the defence mechanisms of LBW and/
tion with other negative circumstances, or malnourished newborns are poor. The
such as LBW. threat of a serious infection is increased by
Both transplacental and transcervical in- the high risk of acquiring hypothermia and
fections are common during pregnancy in poor suckling ability, leading to starvation.
low-income countries. Many viruses that in- All this contributes to impaired defence
fect the mother may cross the placenta, mechanisms in the newborn. In such cases,
while only few bacterial or parasitic infec- overcrowded neonatal units are particularly
tions, such as syphilis and malaria, can pass dangerous places, since cross-contamina-
this route. Ascending infections make the tion from one infant to another or from
birth canal an important route of entry for staff members to the child is common.
any bacterial or occasionally even viral in- At birth, there is an increased risk of infec-
fection the mother may have in her vagina tion for the mother and for the infant. Infec-
or cervix. At birth, a baby may thus carry an tions are commonly transmitted from pa-
infection acquired during pregnancy or tient to patient in hospitals. It is important
while passing through the birth canal. that the newborn be colonised with mater-
The healthy, well-nourished, breast-fed, nal bacteria that are less harmful than the
term newborn that is kept warm enjoys hospital (nosocomial) bacteria. Some meas-
good protection against infections during ures, such as separation of the child from the
C the first few months of life. This is due in mother, care in closed neonatal units and
M part to the antibodies transferred to the in- the use of protective clothing, have proven
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fant through the placenta or via breastmilk. to be ineffective. Such routines have seri-
The colonisation of the skin and intestinal ously impaired opportunities to establish
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tract of the infant by the bacterial flora of close contact between the mother and new-

9.5 Other conditions associated with reproductive ill health
born and thereby optimal conditions for 9.5.2 Sexual and reproductive ill health
breastfeeding. among adolescent women
The global variation in perinatal infec- It is important to distinguish this age group
tions is substantial. Syphilis may reach only (up to 19 years), since young women have a
1 to 2 % prevalence in India, while corre- disproportionate share of the reproductive
sponding figures in many communities in mortality and morbidity. Unwanted preg-
Sub-Saharan Africa may reach ten times that nancy, sexual abuse and violence, genital
prevalence level. The implications of multi- mutilation, social marginalisation due to un-
ple infections in the mother during the peri- wanted pregnancy and complications of
natal period consist of both maternal (post- pregnancy, septic abortion and fistula com-
partal) and congenital infectionsacquired plications at delivery are pertinent examples.
in uteroof the newborn, delivered alive or It is rewarding to note that in some countries
stillborn. (e.g. Mozambique, Uganda, Kenya, and Tan-
zania) efforts are currently being made to es-
tablish youth clinics or adolescent centres
9.4.6 Congenital disorders (2 %)
to cater to teenage reproductive ill health.
Depending on the nature of the disorder,
the proportion of congenitally acquired ab-
normalities in the foetus varies between 5 9.5.3 Genital malignancies (0.5 %)
and 15 %, the most common being malfor- This category of diseases represents a signifi-
mation of the heart. The aetiology is ge- cant threat to female reproductive health
netic, environmental and in many cases un- unrelated to fertility and pregnancy as such.
clear. Traditional customs of marriage be- About 400 000 new cases of cancer of the
tween close relatives are known to increase uterine cervix are estimated to occur annu-
the risk of genetically induced perinatal ally in the world. In practice, screening
mortality, and presumably also of congeni- aimed at early diagnosis and cure is too
tal abnormalities. The number of congenital costly for low-income countries. Even if the
disorders leading to death is estimated at bulk of these women die outside the fertile
half a million, equal to the number of esti- age, cervical cancer has serious conse-
mated maternal deaths per year. quences for female reproductive health.
This is particularly pertinent in the light of
recent evidence that this disease is due to
human papilloma virus (HPV) infection,
9.5 Other conditions presumably transmitted sexually. In this
associated with perspective, it is noteworthy that long be-
reproductive ill health fore AIDS the world had this potentially fa-
tal, sexually transmitted disease selectively
9.5.1 Sexually transmitted diseases
killing women. Progress has recently been
The two categories of sexually transmitted made towards the development of a vaccine
infections (STIs) are fatal and non-fatal. against HPV.
Three potentially fatal STIs are HIV infec-
tion, cancer of the cervix and syphilis, the
last of which is also potentially fatal to the 9.5.4 Female genital mutilation
unborn foetus. The remaining STIs are non- Mutilation is defined as the removal of a
C fatal and include gonorrhoea, chlamydial part of the human body that is not diseased.
M infection and bacterial vaginosis. The STIs Female genital mutilation has previously
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are described in Chapter 5. been known as female circumcision.
Female genital mutilation (FGM) is a tra-
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ditional surgical procedure that involves the

Alger
Libya
Egypt
Mauritania
Mali Niger
Senegal Chad Eritrea
Gambia Sudan
Burkina
Benin
Guinea Guinea Faso Djibiouti
Bissau Ghana Nigeria Somalia
Sierra Central
Leone
Cote Togo African
Ethiopia
Divoire
Liberia Cameroon Republic
Uganda
Democratic Kenya
Gabon
Republic
of Congo
Tanzania
Angola Malawi
Zambia
Namibia Zimbabwe
Botswana Mozambique
Lesotho
South Africa
Figure 9.3 African countries in which female genital cutting has been reported since 1979. White areas have
reported cases, green areas no cases reported.
Source: Shell-Duncan 2001.
partial or total removal of clitoris and vulva to Nigeria and other West African countries.
(Box 9.3). It has emerged as a serious chal- It does not coincide with the distribution of
lenge in the area of reproductive health and any specific religion, though it has been
rights. FGM has currently achieved great argued that it is by and large an Islamic tra-
prominence in the sphere of human rights dition. This is not true, since for instance, it
worldwide. The precise origin of the practice is not practised in Saudi Arabia or in other
is unknown, but appears to date back to an- major Muslim countries. It is also encoun-
cient Egypt earlier than 2000 BC. FGM is tered in areas of other religious faiths. Female
deeply rooted in the local traditions and cul- genital mutilation is practised on 98 to 100 %
ture of the people practising it. It is part and of women in countries like Somalia and parts
parcel of their cultural heritage. of Sudan, while its occurrence is very variable
There are immediate and long-term com- in countries like Tanzania and Kenya. The
plications to FGM, due to bleeding, infec- variation in severity of mutilation is also sig-
tion and pain provoked by the intervention, nificant, even within countries.
often performed under primitive, unclean FGM has been classified as a violation of
conditions. childrens rights and as a violation of hu-
C The geographical variation in genital man rights. There is no doubt that FGM is a
M mutilation is significant. As can be seen from harmful traditional practice. It is well docu-
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the map in figure 9.3, genital mutilation in mented that FGM has both short-term and
different forms is concentrated in a belt long-term health complications. In the
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across Africa from Somalia in the northeast short-term perspective, bleeding and acute

9.5 Other conditions associated with reproductive ill health
Box 9.3
Classification of Female Genital Mutilation according to the WHO
Type IThe clitoral prepuce is removed, sometimes along with part or the entire clitoris.
Type IIBoth the clitoris and part or all of the labia minora are removed.
Type IIIThe clitoris is removed and the labia minora are amputated and incisions are made
on the labia majora to create a raw surface. These raw surfaces are either stitched (with silk
or thorns) or kept in contact until they seal (infibulation).
Type IVUnclassified FGM, e.g. pricking, piercing or incision of the clitoris and or labia, cau-
terisation, scraping and/or cutting of the vaginal entrance, or introduction of corrosive sub-
stances and herbs into the vagina.
infections are known to take place in a sig- benefit for the childunless, of course,
nificant proportion of cases. In a long-term there is some specific indication, and that it
perspective, pain on sexual intercourse (dys- is a violation of the UN Convention of the
pareunia) and complications of delivery are Rights of the Child.
among the more significant problems. In sharp contrast to these views from
A specific problem is the issue of re-infibu- pediatricians in high-income countries
lation. This involves the repetition of infibu- there is an increasing amount of epidemio-
lation after giving birth, i.e. the re-suturing logical evidence for a positive effect on HIV
of the vulva after cutting up the closed, in- prevention. The most recent major review
fibulated vulva. The law in several European from infectious disease specialists from Lon-
countries prohibits the performance of re- don School of Hygiene and tropical medi-
infibulation. The justification for this re- cine conclude There is compelling biological
strictive attitude is that re-infibulation after and epidemiological evidence of the protective
each birth implies a gradual worsening of effect of circumcision on the acquisition of HIV
the long-term complications of FGM. infection and ulcerative STDs. It is unlikely that
Recent research in Sudan indicates that any single control measure will reduce HIV
there has been a significant change in atti- transmission sufficiently and therefore circumci-
tudes and practice regarding FGM. New gen- sion needs to be investigated as part of a pack-
erations, and particularly males, have been age that includes education, condom promotion,
found to be negative to the continuation of and STD control. The potential adverse effects
FGM, and many African womens organisa- of promoting male circumcision need to be care-
tions are now active in abolishing FGM. fully monitored. In spite of the difficulties asso-
ciated with promoting male circumcision as a
measure to control HIV and STDs, this promis-
9.5.5 Male circumcision ing strategy should not be ignored. (Quigley
Male circumcision is one of the most com- 2001).
mon surgical interventions in the world. In A more recent Cochren review concludes
contrast to female genital mutilation there The results from existing observational studies
is evidence that it may have advantages in show a strong epidemiological association be-
C some contexts and the side effects are lim- tween male circumcision and prevention of HIV,
M
ited. In spite of this there are controversies especially among high-risk groups. However, ob-
around this procedure. The Canadian and servational studies are inherently limited by
Y
the American Association of Paediatricians, confounding which is unlikely to be fully ad-
K
have come to the conclusion that it has no justed for (Siegfried 2003). As three ran-

domised controlled trials of the effect of tal care needs staff, and in hospitals there
male circumcision are ongoing they recom- must be staff around the clock. Inexperi-
mend that active promotion of male cir- enced staff in inadequate numbers has little
cumcision should wait until a positive effect chance of solving the problems of over-
has been confirmed by these studies with a crowding and lack of drugs and equipment.
scientifically much stronger design. This Provision of reproductive health care is thus
seems to be a wise conclusion at the present a question of both rights and economic re-
state of knowledge. sources.
The improved status of women, womens
education and a focus on access to life-sav-
9.6 Sexual and reproductive ing skills and emergency care can signifi-
cantly reduce maternal mortality during the
health: the human rights coming decades in middle income countries
issue with adequate health policy. A 50 % reduc-
During the Cairo International Conference tion in neonatal mortality and the eradica-
on Population and Development (ICPD) in tion of neonatal tetanus within 5 years are
1994, the issue of reproductive rights was examples of goals formulated by WHO.
brought forward with success. Issues previ- These can be attained even in low-income
ously not discussed, such as unsafe abortion countries, provided affluent countries offer
and domestic violence, gained ground as im- substantial increases in support to the
portant examples of violations of rights. The health care budgets of these countries. How-
Cairo conference was followed by a womens ever, without economic development, sus-
conference in Beijing, at which these issues tainable fulfilment of human rights pertain-
were further promoted. A number of chal- ing to sexual and reproductive health will
lenges in reproductive health and rights remain unattainable.
began to be discussed in a light that had pre-
viously been impossible at international
meetings. References and suggested further reading
With the exception of maternal and peri- Bergstrm S. Reproductive failure as a health
natal health, the human rights challenges in priority in the Third World. East African
reproductive health care consist of the avail- Medical Journal 1992;69:174180.
ability of safe abortion, prevention of child- Bergstrm S, Hjer B, Liljestrand J, Tunell R.
lessness, prevention of transmission of HIV, (Eds.) Perinatal health care with limited
early detection and cure of STIs, and screen- resources. London: MacMillan; 1994.
ing for pre-cancerous lesions of the cervix. Christensson K, Bhat GJ, Amadi BC, Eriks-
There are many obstacles to enhanced son B, Hojer B. Randomised study of skin-
sexual and reproductive rights. One such to-skin versus incubator care for rewarm-
obstacle may be a lack of co-operation being low-risk hypothermic neonates. Lan-
tween obstetricians and paediatricians, and cet 1998;352:1115.
between doctors and other staff. All experi- De Brouwere V, Van Lerberghe W (Eds.). Safe
ence shows that a continuing dialogue in- Motherhood Strategies: A Review of the
volving all categories of staff, as well as cli- Evidence. Antwerpen: Itgp Press; 2001.
ents, patients and their families is a prereq- Eger B, Hammarskjld M, Munck L. AIDS:
uisite for good reproductive health care. the challenge of this century. Prevention,
C
In several low-income countries, the low care and impact mitigation. Department
M status of midwives and nurses constitutes a for Democracy and Social Development,
Y serious problem. Underpayment and irregu- Sida, Stockholm: 2001.
K
lar wages often lead to absence from work in Hgberg U, Wall S, Brostrm G. The impact
order to earn a living in other ways. Perina- of early medical technology on maternal

9.6 Sexual and reproductive health: the human rights issue
mortality in late 19th century Sweden. Int infection and other sexually transmitted
J Gyn Obst 1986;24:25161. diseases. Curr Opin Infect Dis 2001;14:
Inhorn MC. Global infertility and the glo- 715.
balisation of new reproductive technolo- Shell-Duncan B, Hernlund Y. Female Cir-
gies: illustrations from Egypt. Soc Sci Med cumcision in AfricaCulture, Contro-
2003;56:183751. versy and Change, edited by Shell Dun-
Kahlid SK et al. WHO analysis of causes of can and Hernlund. London: Lynne Riener
maternal death: a systematic review. Lan- Publisher; 2001.
cet 2006;367:106674. Siegfried N, Muller M, Volmink J, Deeks J,
Kwast BE, Rochat RW, Kidan-Mariam W. Egger M, Low N, Weiss H, Walker S, Wil-
Maternal morbidity in Addis Ababa, Ethi- liamson P. Male circumcision for preven-
opia. Stud Fam Plan 1986;17(6 Pt 1):288 tion of heterosexual acquisition of HIV in
301. men. Cochrane Database Syst Rev 2003;
Lawson JB, Harrison KA, Bergstrm S. (eds.) (3):CD003362.
Maternity care in developing countries. WHO. Female genital mutilation: report of a
London: Royal College of Obstetricians WHO technical working group meeting:
and Gynaecologists (RCOG); 2001. Geneva: 1719 July 1995. Geneva: World
Mswia R, Lewanga M, Moshiro C, Whiting Health Organisation; 1996.
D, Wolfson L, Hemed Y, Alberti KG, WHO. Interpreting Reproductive Health.
Kitange H, Mtasiwa D, Setel P. Commu- WHO/CHS/RHR/99.7, Geneva; 1999.
nity-based monitoring of safe mother- WHO. Maternal Mortality in 1995. WHO/
hood in the United Republic of Tanzania. RHR/01.9, Geneva; 2001.
Bull World Health Organ 2003;81:8794. WHO. Reproductive Health Indicators for
Mundigo A, Indriso C (Eds.) Abortion in the Global Monitoring. WHO/RHR/01.19,
developing world. New Delhi and Lon- Geneva; 2001.
don: Zed Books; 1999. WHO. World Health Report 2004.
Quigley MA, Weiss HA, Hayes RJ. Male cir-
cumcision as a measure to control HIV

10 Global population change

Having 10 daughters but no son is the same as
having no children.
Poor woman, Vietnam 1999
The new interest in the size of the human female education. Fertility declined, be-
population on our planet emanates from tween 1963 and 1972, from 6.2 to 3.2 chil-
the early 1950s. The reason was the rapid dren per woman. This unprecedented fertil-
population growth, particularly in southern ity decline was followed, in the 1980s, by
Asia and Africa. India was the first low-in- dramatic economic growth. Mauritius his-
come country in the world to have a na- tory challenges the belief that economic
tional family planning association in 1952. growth is an essential precondition for fer-
Incidentally, the International Planned Par- tility decline (Lutz 1994).
enthood Federation (IPPF) was founded the The fast drop in fertility rates, combined
same year, and the Rockefeller Foundation with falls in mortality rates, has had a dis-
in the United States established the Popula- tinctive effect on age structures in the popu-
tion Council. Many big international organ- lations of these Asian countries. There is a
isations, such as the World Bank, WHO and substantial lowering of child-dependency
UNICEF, initiated support activities in the ratios, in other words there are more adults
area of birth control in the 1960s. The in relation to children. At the same time
United Nations Fund for Population Activi- there are not so many old people in the pop-
ties (UNFPA) was formed in 1969. ulation. Later, there is a rapid aging of pop-
Today the fertility rate has decreased con- ulations. This ageing is now rapidly under-
siderably in most countries in Asia as well as way in many Asian countries with fast socio-
in the Middle East and Latin America. The economic development. Between the lower-
total fertility rate (TFR) in India has fallen ing of the proportion of children and the in-
from more than six children per woman in crease in the proportion of old, the coun-
1960 to about 3 per woman today. On the tries benefit from several decades with a
way from the unsustainable 6 children per highly favourable age distribution. This pe-
woman to the sustainable fertility rate of 2 riod is known as the demographic gift.
India has already achieved 75 % of the nec- The high proportion of workers in the pro-
essary change over a 40 year period. The ductive ages makes the economy grow faster
drop in fertility in Bangladesh from 6.5 to and makes it affordable to provide good
3.5 during the last two decades came unex- schools for all children (Chu 2000).
pectedly and was surprisingly fast in spite of Four to five decades ago many regarded
the prevailing high child mortality, illiter- the population growth as the main problem
acy and poverty. Major middle-income in the world. Today when the UN set the
countries like Brazil and Indonesia today Millennium Development Goals (table 1.5)
have less than 2.5 children born per woman. fertility is not even included among the 8
A large part of the economic success of a goals, 15 targets and 44 indicators that are
C number of Asian countries, the so-called selected for the monitoring of world devel-
M tiger economies, has been attributed to the opment. This constitutes a tremendous
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demographic gift. The African island coun- change in perspective. The change is mainly
try of Mauritius is a prominent example of due to the fast decline of fertility that has
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demographic gift following investments in taken place. But the change is also due to a

deeper understanding of the driving forces olation of basic reproductive rights. In the
behind development where the negative wake of the Bucharest conference, there was
and positive effects of population composi- also a growing alertness among leaders of
tion are given less importance today than 40 low-income countries regarding the nature
years ago. How did the view on population of the population growth. India and China
policy change? followed their own paths, opting for control
It is a characteristic of the early 1950s that in the name of national interests, while
the public debate in the rich countries saw a other countries opted for recognition of
rapidly increased commitment to popula- family planning as a human right to be inte-
tion issues. The understanding of fertility de- grated into maternal and child health care
terminants was limited. Rather, the popula- (MCH). Still others continued their prona-
tion growth was seen as a supply-demand talist stand and did not adhere to the idea of
problem, and governments and non-gov- birth control as a component of socio-eco-
ernmental organisations (NGOs) launched nomic improvement.
vigorous campaigns to achieve the widest Ten years later, in 1984, the next World
possible contraceptive coverage. Along with Population Conference was held in Mexico
improved contraceptive technology, several City. Now there was more agreement among
Western countries embarked upon extensive low-income countries and affluent countries
birth control projects, Sweden for many about the need to limit population growth
years being the biggest donor per capita in and to achieve development. A decade later,
this field. in 1994, the next population conference
The global interest in population issues took place in Cairo, the International Con-
culminated in 1974 with the World Popula- ference on Population and Development
tion Conference in Bucharest, when the (ICPD). This was the first population con-
controversy between affluent and poor ference to acknowledge the need to broaden
countries came to the surface. The majority the scope of the debate from merely demo-
of impoverished countries counterbalanced graphic issues to womens and mens repro-
the population control-oriented approach ductive health and rights. The Cairo confer-
of some experts and politicians. They called ence was, in theory, a true paradigm shift
for recognition of the problems of wide- away from birth control targets to a
spread poverty and injustice in global distri- womens rights perspective, encompassing
bution. The Indian minister of health, Dr controversial issues like abortion, sexual vi-
Karan Singh, stated: The best pill is devel- olence and womens empowerment. Far-
opment. In the years to come, influential reaching commitments were pronounced
circles gradually modified their positions by the rich countries. These commitments
and powerful Western debaters admitted were further enhanced by two following
profound changes of opinion. world conferences in 1995, the Social Sum-
In retrospect, it is instructive to note that mit in Copenhagen and the Womens World
while Karan Singh expressed the above slo- Conference in Beijing.
gan, the architects of the Indian emer- The Cairo conference was also innovative
gencyimplemented in the mid 1970s in that commitments were made to follow
were already well organised in several states up the plan of action of the conference with
in northern India. This emergency implied activities entitled Cairo Plus Five, which
essentially an abolition of several laws pro- took place in 1999. The idea was to investi-
C tecting human rights, so as to permit com- gate whether or not financial and legislative
M
pulsory sterilisation by law. In other words commitments had been implemented, and
the Indian government did consider popula- to review activities programmed as a conse-
Y
tion growth so alarming that a war-like state quence of the plan of action adopted in
K
of emergency was declared to permit the vi- Cairo. So far there have been more rhetori-

cal statements than discernible concrete action increased by about one billion from the
tions taken by the high-income countries. A early 1970s to 1987, and by another billion
concern is the lack of international funding by the year 2000. The projections foresee
for commitments, while many middle-in- the addition of another billion by 2010.
come countries make domestic priorities This is foreseen to occur in spite of the dra-
that change the fertility determinants and matic decline of the growth rate of the
provide family planning to the couples that planets population from 1960 to 2000. A
request it. good way to clarify the implications of pop-
ulation growth rates is to state the doubling
period, i.e. the number of years over which a
population will double in size at a specific
10.1 Global population growth growth rate (as mentioned in chapter 3.10).
A population growing at a constant percent- The formula used for estimating of the dou-
age growth rate will double in size at regular bling period in years is simple:
intervals. The mathematical representation
of this process on a graph is an exponential Doubling time of a population =
curve, theoretically ending in an almost in- 69 years
= ------------------------------------------------
finite population in a comparatively short % annual growth
period of time (Figure 10.1).
In the last thousands of years the world A growth rate of 1 % will result in a doubling
population increased at a rather slow rate, in 69 years, while a 3 % growth rate will
presumably amounting to an average of double the population in about 23 years. A
0.1 % per year. This rate is assumed to have growth rate of 3.8 %, which was the case in
prevailed until the late 17th century (table Kenya in the early 1990s, meants a doubling
1.1). The improvements in general living in 18 years. The latest estimate for Kenya in-
conditions following the industrial revolu- dicates that the growth rate is 2.3 %, corre-
tion have resulted in a slowly declining sponding to a doubling time of about 30
mortality and a rising global population years.
growth rate. This trend was accentuated Using merely currently available data may
during the 20th century. The world popula- be misleading. A simplistic application of
Billion Billion
10 10
6 6
Year 2000 2100 Year 2000 2100
C Figure 10.1 The exponential graphs of the 1960s and 1970s depicted the global population growth as an
M explosion (graph on the left). The currently valid graph takes into consideration the decline in global pop-
ulation growth (graph to the right), which by all probability implies the achievement of a stable world pop-
Y
ulation by the year 2100.
K
Source: Adapted from Lutz, Sanderson and Scherbov, 2001.

10.1 Global population growth
the doubling time mathematics earlier led Table 10.1 Global population change 19502050
to a frightening scenario and constituted the in percent.
basis of a doomsday perspective launched by
Age group 1950 2000 2050
Paul Ehrlich (1970). This theoretical litany (years)
has turned into a major success in global de-
014 34 30 21
velopment, the decreased rate of global pop-
1559 57 59 54
ulation growth. It is obvious that the expo-
6079 8 10 21
nential graph had to be corrected to corre-
spond to a forthcoming steady state. A >80 1 1 4
comparison of these two graphic models can Population in billions 2.5 6.0 9.3
be seen in Figure 10.1. Source: UN Department of Economic and Social Affairs
It is obvious that the exponential graph Population Division. World Population Prospects: The
2000 Revision. New York: UN 2001. See also: Diczfalusy
was almost correct in predicting the esti- 2002.
mate of around 6 billion inhabitants in the
world by the year 2000 and in making the
prognosis that the world will reach approxi- Table 10.2 Population change in high-income
mately 8 billion inhabitants by the year countries 19502050 in percent.
2020. These figures may appear threatening, Age group 1950 2000 2050
but they conceal the fact that fertility has (years)
fallen in recent decades in all countries ex-
014 27.3 18.3 15.6
cept in Sub-Saharan Africa. Globally, the
1559 60.0 59.2 41.3
population growth rate has declined from
6079 11.7 19.4 33.5
2.0 % in the 1960s to 1.5 % in the early
>80 1.0 3.1 9.6
2000s. The total fertility rate (TFR) in the
world was 6 children per woman in 1960, Population (millions) 814 1.191 1.181
reached 4 per woman in 1985 and has fallen Source: UN Department of Economic and Social Affairs
to 2.8 in 2002. In the most probable UN pro- Population Division. World Population Prospects: The
jection, the TFR will reach 2.3 children per 2002.
woman by the year 2025. This demonstrates
that the doubling time mathematic does not
make sense for the world any longer, since it mids will change significantly over the dec-
assume the growth rate to be constant. As ades to come. As can be seen from Tables
we have seen it is not. The replacement 10.1 and 10.2, the world will witness quite a
level of fertility when a population remains significant change, which is more pro-
stable in size over time is about 2.1 children nounced in high-income countries than in
per woman. This is the level it is assumed low-income countries. These examples indi-
that the world will have reached by between cate a powerful trend towards world popula-
2025 and 2050. The leading independent tion ageing, most clearly demonstrated in
demographer Wolfgang Lutzs (2001) best the case of Japan. From Table 10.3 we can
forecast is that the world population will see that in the year 2050 the number of chil-
stop growing in the second half of this cen- dren in Japan aged 0 to 14 years will have
tury and that the world at 2100 will have 8 declined over one century to only one-third
billion people but the uncertainty range will of what it was in 1950. During the same
be from 6 to 12 billion. More interesting time interval, the proportion of people
C than the exact number is that one third of above 60 years of age is estimated to in-
M
the world population in 2100 will be older crease from 8 % to 58 %, a seven-fold increase.
than 60 years. The corresponding global increase in people
Y
The rapid change in population growth above 60 years of age is three-fold, from
K
globally implies that the population pyra- 8.7 % in 1950 to an estimated 25.2 % in

Table 10.3 Population change in Japan 1950 high fertility and population growth in a
2050 in percent. more complex perspective (See chapter 1.1).
High fertility does constitute a part of the vi-
Age group 1950 2000 2050
(years) cious circle that keep the poor in poverty but
it must be realised that in the short perspec-
014 35.5 14.7 12.5
tive it is rational for poor families to give
1559 56.3 58.3 29.8
birth to several children (Caldwell 1999).
6079 7.7 23.2 42.3
In poor countries, rapid population
> 80 0.5 3.8 15.4 growth lowers and keeps earnings at survival
Population (millions) 84 127 109 level. The reason is that the poor have to
Source: UN Department of Economic and Social Affairs compete with each other for the scarce work
Population Division. World Population Prospects: The opportunities. Population growth forces
(2002).
small-scale farmers to compete for the scarce
land. Poverty and population growth will
overtax natural resources, leading to soil ero-
2050. The world will change tremendously sion that diminishes long-term productivity.
in the next 60 years. Remember that in con- In such a setting poor couples prefer having
trast to many other scientific disciplines de- large families due to a complex set of cir-
mography is good at predicting the future cumstances. In the constant struggle for sur-
many decades ahead. What was predicted vival, impoverished populations tend to see
30 years ago has largely come true. children not only as the meaning of life but
also as an economic asset. Poor families see
each additional child as an opportunity to
10.2 Poverty and the broaden, diversify and thereby strengthen
their means of support. More children mean
demographic trap better capacity to watch the goats, to keep
More than ten years ago, at the time of UNs the birds away from the rice field, to catch
meetings on the Convention on the Rights extra fish for the evening meal and to sell
of the Child and the Rio Conference on en- the tomatoes at the local market. When
vironment, the concept of the demo- times are bad for some of the children, they
graphic trap was launched by the British may be better for others in the family. This
specialist in international health, Maurice strength in numbers strategy may reduce
King. His trap analogy implied a priority set- the chances of pulling the whole family out
ting among prevailing global threats in of poverty, but that is a small price to pay if
strong favour of population control. it reduces the risk of falling into starvation.
It is known that fertility decisions depend High fertility is thus a rational strategy for
on a number of determinants and it would the survival of the family. Thus poor families
therefore be more adequate to address any do not want many children in order to be
alleged trap as constituted by the constella- taken care of at old age. They want many
tion of the most important fertility determi- children in order to live to old age.
nants. Considering such determinants, there
is general agreement that poverty, high child
mortality, female illiteracy and the low sta- 10.3 Population growth and
tus of women are directly related to high fer-
C tility. The arguments by King 10 years ago
natural resources
M may have been the last time someone seri- Population projections by the UN for the
ously suggested isolated focus on population year 2050 range from 7 to 11 billion. The fer-
Y
control in low-income countries. The theo- tility rate in the world has over the last 40
K
ries on poverty by Amartya Sen have put years fallen from 6 to 3. Young people in-

10.3 Population growth and natural resources
creasingly want to wait to have children, Fisheries: in 1997, global fish production
and want to have smaller families even in climbed only modestly, almost entirely
low-income countries. Still, more people because the farming of fish expanded in
and higher incomes worldwide are multiply- the world, notably in China. Most fisher-
ing humanitys impacts on the environment ies worldwide are considered to be fully
and on the natural resources that are essen- exploited or in decline. More food will
tial to life. In some parts of the world, fresh not be extracted from the sea, unless the
water, fisheries, forests and the atmosphere fishes are fed artificially.
are already strained. Based on these observa-
tions, it is obvious that in the era of the 21st Forests: based on the current number of
century we shall witness even greater pres- people living in countries with forest
sures on natural resources. Let us take a scarcity, and on a medium population
closer look at some of these resources: water, growth projection, this population could
cropland, fisheries, forests and climate. triple from about 1.7 billion people to
around 4.5 billion in 40 countries with
Water: an estimated 500 million people less than 0.1 hectare of forested land per
face relative water scarcity. It has been capita. This figure is an indicator of a crit-
calculated that, by the year 2025, between ically low level of forest cover.
2 and 3 billion people may be living in
Climate: the world has seen a continued
areas where potable water is scarce. For
upward trend of carbon dioxide emis-
some millions of people in the Middle
sions. The increased per capita emission
East and in parts of Africa today, the lack
accelerated the accumulation of green-
of available fresh water is a concern that is
house gases in the global atmosphere.
going to become more acute and more
With 4.6 % of the worlds population, the
widespread. Much of the fresh water now
United States accounted for about 22 % of
used in water-scarce regions comes from
all emissions from fossil fuel combustion
deep-water sources, which are not being
and cement manufacture, by far the larg-
refreshed by the natural water cycle. In
est CO2 contributor among nations.
some countries, where the water shortage
Emissions remained grossly inequitable,
is severe, high rates of population growth
with one-fifth of the worlds population
may exacerbate the declining availability
accounting for more than 60 % of all
of fresh water.
emissions in 1996, while another, much
Cropland: in countries where arable land is poorer fifth accounted for less than 2 %.
scarce, the number of people is projected
to increase between 0.5 and 1.0 billion by One of the main arguments for poverty alle-
the year 2025. The soil on todays crop- viation in the world is that this is the only
land must remain fertile to keep food pro- way to stabilise the world population be-
duction secure. The minimum amount of cause birth control without poverty allevi-
land needed to supply a vegetarian diet ation is doomed to fail. At the same time
for one person without the use of any arti- contraceptives should be made available for
ficial chemical inputs or loss of soil and all, so that men and woman can make ra-
soil nutrients is estimated to be 0.07 hec- tional choices to keep their families small as
tare or slightly less than a quarter of an soon as their life conditions so allow.
acre. An estimated 420 million people
C
today already live in countries that have
M
less than that per person. Increased food
Y production must come from increased
K yield per hectare.

10.4 Migration: the push and pull factors tend to reflect push factors. For
instance, differences in salary/wealth may
the pull factors constitute both push and pull factors. Re-
The main human solution to population laxed immigrant regulations in some attrac-
growth has been migration (see chapter 1.5 tive countries may represent an important
6). Today people may migrate from one area pull factor. Such factors may change in the
to another area for various reasons. A dis- future, due to a potentially significant future
tinction has been made between push fac- demand for labour in richer countries. Today
tors and pull factors. The former term re- people migrate from collapsed countries to
fers to factors forcing people away from an low-income countries, from low-income to
area of origin, and a further subdivision has middle income and from middle income to
been made between hard and soft push high income countries. There is also migra-
factors (Box 10.1). tion from high-income to higher income
The hard push factors are well known as countries such as medical doctors moving
such, though their migratory consequences from Sweden to the richer neighbour Nor-
may not be well known, as regards magni- way. Such a stipulated demand of labour
tude and direction. War and starvation be- where there is money, should be seen against
long to tragic events which force people to the background of the quickly ageing popu-
flee. Environmental disasters occur mostly lation in many countries, to which reference
in middle and low-income countries. has previously been made (see section 10.1).
Floods, drought, soil erosion and desertifica- In high-income countries, attitudes to-
tion are widespread and recurrent problems. wards immigration are generally in favour
A report from the International Organisa- of strong regulations and increasing limita-
tion for Migration has disclosed that envi- tions on the numbers that are allowed to en-
ronmental migration will be caused by sev- ter. The same attitude can be found in Costa
eral serious disruptions affecting the living Rica against immigration from Nicaragua
conditions of millions of people: elemental, and in South Africa against immigration
biological, slow-onset accidents; disruptions from Mozambique. The complex pattern of
caused by development, and environmen- interacting push and pull factors will in
tal warfare. all probability increase international migra-
Among the soft push factors, increasing tion in the foreseeable future.
hardship due to economic recession may act
in combination with persecution to increase
migration in many parts of the world. Su-
dan, Burma, the former Yugoslavia and El
10.5 Fertility determinants
Salvador are examples of areas where this The concept of fertility determinant is
factor has contributed to migration. Along complex. A number of different, interacting
with the push factors, some authors have phenomena, sometimes mutually reinforc-
also distinguished pull factors. Obviously, ing, sometimes not, constitute the reality of
Box 10.1
Push factors for migration
C
Hard factors Soft factors
War Persecution
M
Starvation Poverty
Y Environmental catastrophes Social loneliness
K

10.5 Fertility determinants
which the level of fertility is a consequence. sufficient attention has hitherto been paid:
For instance, if the prevalence of secondary induced abortion. In one study comparing
infertility (see chapter 9) is high, as in sev- the development of fertility in Egypt and
eral central African countries, the average Zimbabwe, it was found that the observed
total number of children a woman will have declines in fertility over the years 1988 to
over a lifetime may be low. In such settings, 1994 are most probably due to increases in
however, widespread sexually transmitted abortion rates. As the availability of safe in-
infections (STIs), leading to secondary infer- duced abortion is limited in both countries,
tility, may run parallel with other diseases of the conclusion is that abortions induced
poverty tending to increase perinatal mor- under unsafe circumstances are on the in-
tality and thus infant mortality. High infant crease. Several studies involving in depth in-
mortality figures are empirically related to terviews with women admitted to hospitals
high fertility rates (Caldwell 1999). for allegedly spontaneous abortions have
One recent study from India, based on Na- shown that more than 50 % of them had un-
tional Family Health Survey (NFHS) data, dergone induced abortion.
demonstrates that fertility levels in India can Country-specific analyses of fertility de-
be explained by four major direct determi- terminants indicate that dramatic changes
nants: the proportion of females who are have occurred. It is noted in one study that
married; the incidence of induced abortion; fertility in Bangladesh has declined by
the fertility-inhibiting effect of breastfeed- 44 %. This decline is brought about by in-
ing; and the prevalence of contraceptive use. creased age at marriage, delayed childbear-
The NFHS data suggest that without these ing, breastfeeding with lactation amenor-
listed determinants, fertility levels would rhoea, and increased contraceptive use.
have risen to higher levels than at present. It It is not possible to single out any specific
was concluded that if the effect of delayed fertility determinant as being crucial for fer-
marriage had been removed, without any tility decline over time and across all coun-
other change in fertility behaviour, the fer- tries. It is obvious, for example, that over
tility level would have increased. the period 1900 to 1960 Europe saw a very
In Sub-Saharan Africa, a panorama similar steep fertility decline in the absence of
to the Indian one has been demonstrated in modern contraceptives. A critical review of
recent overviews of fertility determinants. achievements in the area of population
Data from the Demographic and Health Sur- control in the last decades, indicates that
veys (DHS) during 1986 to 1995 indicate a the initial focus on contraceptive technol-
distinctly decreasing trend to lower fertility ogy has been criticised as an obsession with
in Southern Africa, transitional fertility de- a technique that implies that fertility is re-
cline in East Africa, and a less dramatic de- garded as a disease, requiring particular
cline in West Africa. In the analyses, it was remedies. This has conveyed a research ori-
noted that Central Africa has surprisingly entation towards technical solutions to es-
low fertility, a finding that should be seen in sentially motivational problems. In contrast
the light of the high figures found for sec- to this technical focus it has been found
ondary infertility in these countries. For Sub- that when the motivation exists, couples
Sahara Africa, it was concluded that major find ways to control their fertility whether
fertility determinants were: age at marriage, a strong family planning programme exists
postpartum factors such as breastfeeding in the country or not. It is interesting that
C and sexual abstinence, postpartum amenor- the fertility rates have fallen from more
M
rhoea, education, child survival and contra- than 6 children per woman in 1970 to less
ceptive use. than three in 2000 in countries as different
Y
Recent research has also focused on one as Indonesia, Vietnam, Iran, Morocco, and
K
specific fertility determinant, to which in- Peru.

It has been further argued that the one-

sided approach did not recognise one partic-
ularly perceived need in the impoverished
populations targeted: reproductive failure
and childlessness. Childlessness in low-in-
come countries is a three-pronged problem
comprising infertility, pregnancy wastage
and child loss. Infections killing children
under five years significantly contribute to
child loss, thereby making such diseases im-
portant in the area of reproductive failure
and childlessness. The latter concepts thus
cover much more than gynaecological prob-
lems.
Another experience gained is that the mo-
tivational aspect has been given insufficient
attention. It remains a fact that, for the
poorest families in low-income countries,
children may be the only tangible capital
available, not only as child labour and as an
economic guarantee, but also as security in
old age. It has often been overlooked that
childrenhowever malnourished and de-
prived of decent living conditionsmay
BANGLADESH, Chittagong province. Poster propa-
still imply a net advantage in poor families.
gating the small nuclear family.
However deplorably they are cared for, they
may still produce a net surplus of income
and social status. The problem of child la-
bour has gradually come into focus, and it
has been demonstrated that having many
that insufficient motivation results in low
children in employment, seen from a mere
acceptance of fertility regulation. In order to
capital-generating point of view, can be a ra-
overcome this hurdle, campaigns have been
tional decision.
launched to generate demand. This shows
The so-called Caldwell hypothesis has
clearly the conflict between perceived and
gained widespread recognition. It postulates
alleged needs. The conflict allows us to raise
that human reproduction (number of chil-
a number of critical questions:
dren born) is associated with capital flow
from children to parents and vice versa. If 1 Does family planning/birth control in a
the net capital flow from children to parents given setting enhance the self-determina-
is positive, children may constitute an eco- tion and well being of women, or does it
nomic advantage resulting in more obvious remove control of fertility from women,
unwillingness to limit fertility. On the other placing it in the hands of birth control
hand, when children cost (e.g. in school fees providers?
and clothes, child labour being illegal), par- 2 Is there a difference between birth con-
C ents may tend to limit their number. trol needs as perceived by potential recip-
M
It has been learnt that a key concept in ients and by birth control providers?
the freedom of fertility decisions is per- 3 Can alleged needs (not perceived by
Y
ceived need. In campaigns to force couples potential recipients) be discerned in pro-
K
to accept contraception, it has been noted gramme documents?

10.6 Will AIDS stop population growth?
4 Does family planning/birth control exist woman. With a population growth rate of
as a means of reducing social pressures 2.5 to 3 %, which is a common figure in Sub-
resulting from economic and political Saharan Africa, a prevalence of 50 % will be
inequities that family planning pro- required in order to reduce population
grammes are unwilling to confront? growth to zero. Only a few locations in Af-
5 Is family planning/birth control a substi- rica currently exceed 50 % HIV prevalence,
tute for economic and political reforms and only in such areas can one foresee a de-
responsive to the self-perceived needs of cline in population. It is, however, clear that
the poor? prevalence rates around 20 to 25 % may
have a quite clear demographic impact and
may half the population growth, for in-
10.6 Will AIDS stop population stance from 3 % to 1.5 %. It is important,
however, to recognise that such calculations
growth? may be misleading. Except for purely AIDS-
In countries characterised by rapid popula- related deaths, there is a parallel phenome-
tion growth, both fertility and mortality non related to deteriorating socio-economic
trends will be decisive for changes in popu- conditions among the surviving older gen-
lation growth. In settings with a high preva- eration and among non-infected children
lence of HIV/AIDS, mortality rates among left as orphans (about 12 million in Africa
sexually active, mostly young people, has in- alone) or migrating for survival. Social net-
creased considerably, and because of mater- working and support from various non-gov-
nal-foetal transmission, the numbers of in- ernmental organisations may reduce this
fected new-borns have also increased. The parallel mortality risk. The demographic im-
combined risk of intrauterine, intrapartal pact of HIV will thus depend not only of the
and postpartal transmission of HIV for an Af- direct effect of the virus but perhaps as
rican newborn is in the range of 40 %, while much on the indirect effects.
the risk for a newborn in an affluent country In summary, it is clear that AIDS-affected
may be only half. The explanation is un- communities will experience deaths directly
clear, but it seems that the coexistence of due to AIDS and indirectly due to other dis-
genital wounds and concomitant sexually eases among groups made vulnerable by
transmitted infections enhance the trans- malnutrition, poverty and abandonment.
mission from maternal tissues to foetal tis- The deterioration may be aggravated by the
sues during passage through the birth canal. non-availability of drugs and health care in
With anti-retroviral medication, now widely units already overburdened by a large
available in high-income countries, vertical number of AIDS cases. Even more important
transmission can be reduced. In other words, is whether the highly affected countries will
the vast majority of newborns of infected be able to maintain a general progress in
parturient women can avoid infection. How- economic and social terms in the presence
ever most of these children will be or be- of such a strong impact from HIV.
come orphans and run a considerable risk of
dying from other causes. They are also likely
to remain completely or partly illiterate, as
there are no parents that can pay for their 10.7 Fertility control: a human
education right or a human
C Even if the consequences of a high HIV
prevalence may seem far reaching, it is still
obligation?
M
obvious that prevalence rates around 20 % The concept of control is that it has an im-
Y
will not stop population growth in the pres- plication of setting limits to or checking and
K
ence of fertility rates around 5 children per intervening at a defined stage of develop-

ment. In one sense, the word is positive: to vide welfare only in the limited sense of
keep an eye on the undesirable. There are female contraceptive surgery, which in
few who would question the inherent good actual fact consists of twoand only two
in pollution control, pesticide control, nu- activities: abortion and sterilisation. It is
clear arms control, etc. But when it comes to important to note that when the coercion
birth control or population control, the stopped in India fertility continued to
issue becomes more controversial. In whose decline. During many decades the Chinese
interest is the control to be executed? To government has put a continuous pressure
whom is it desirable to control numbers of on couples to reduce the number of chil-
impoverished individuals rather than to dren. It seems as if coercion was more suc-
control impoverishment? It may be argued cessful in China either because it was com-
that potential threats should be controlled bined with a stronger reduction of child
and limits should be set to avoid undesirable mortality or just because there was no free-
events. Such a threatening event would be dom of speech to protest against the politi-
over-population or too many births. In this cal force put upon families reproductive
sense control implies intervention in one of decisions.
the most private of spheres. Much of the Family planning is undoubtedly a valua-
controversy surrounding population con- ble asset, particularly in the process of
trol undoubtedly stems from control meas- womens emancipation. It is laudable that it
ures taken without due attention to the in- is considered a human right. However, there
tegrity and the privacy of fertility decisions, is historical evidence that the provision of
particularly among the poorest in the world, this human right has implied the depriva-
for whom children often represent security, tion of freedom. A look into the process of
hope and an asset for the future. freedom in fertility decisions may raise
Few, except those who are opposed for some doubts.
religious reasons, would deny the great In the early era of birth control cam-
value of fertility regulation technology, if paigns in South-East Asia, much attention
used appropriately. There are, however, rea- was given to information, education and com-
sons for concern. The resistance among munication (IEC) campaigns in order to
impoverished populations to comply with spread the message of the advantages of
population policies formulated at the family planning. Due to unresponsiveness
national level and executed in a manner among the poor and the unsatisfactory out-
unrelated to health priorities at the local come of these campaigns, they were intensi-
level has led to severe conflicts. India pro- fied to also include persuasion and more
vides an illustrative example of this renam- aggressive interventions to convince resist-
ing process. After the compulsory sterilisa- ant individuals in the target population to
tions of the mid-1970s, the concept of fam- accept family planning. With selective pay-
ily planning became so strongly associated ments to those who accepted family plan-
with coercion that it could hardly be used at ning but not to maternal and child health
all. The prevalence of contraception sank to care (MCH) attendees, to family planning
extremely low levels in the population and a workers but not to MCH care providers,
process took place in which the word plan- some improvement in the birth control
ning was substituted by the word welfare. campaigns were achieved. When persuasion
Consequently, books on the subject of fam- through incentives (and subsequently disin-
C ily welfare methods mention condoms, centives) did not produce the desired
M
pills, IUDs, sterilisation, and so on, while results, the next logical step was to increase
saying nothing about other aspects of fam- the pressure on families with many children
Y
ily welfare in the more common sense of the to include compulsory sterilisation by law.
K
word. Likewise, family welfare centres pro- The human right to family planning was

10.8 Birth control versus motherhood control
provided to the population by coercion in 1970s, the de facto coercion did not result in
more countries than China and India. a fall in birth rate but rather a fall of govern-
The resistance that was met by these birth ment. The political implications of depriva-
control campaigns entailed extensive mation of freedom in fertility decisions can
nipulative measures, which were all geared hardly be illustrated more succinctly.
towards the creation of demand where this Today, India has changed its population
was insufficient. Through this approach, the policy completely, at least on paper. The
governments and even foreign donors did overriding principle is now the target-free
not pay due attention to the perceived (ver- approach, implying a focus on reproductive
sus alleged) needs of poor people: health in general and on maternal and peri-
natal health in particular. The previous de-
1 intensive mass communication aimed at
mographic target-oriented approach has
target audiences;
been abandoned and incentives have been
2 persuasion efforts with incentives (such
virtually abolished. The future will show
as the distribution of food to a starving
whether this new orientation will be sus-
population in order to achieve sterilisa-
tained.
tion targets); and
In todays Asia, China remains a promi-
3 coercion in the form of legalised violence.
nent example of a country in which strong
The three levels were related to each other, pressure is exerted on the population to com-
even if the degree of violation of the needy ply with the one child ideal. This coercion
poor populations became progressively is also associated with a system of incentives
more brutal. The isolation of perceived needs and disincentives in order to achieve demo-
(recipients opinion) from alleged needs (do- graphic goals. Other countries in the Far East
nors opinion) runs parallel with a clearly where far-reaching demographic targets
visible tendency to the status quo, giving have influenced reproductive health care are
most family planning programmes the char- Vietnam and Thailand. There are more abor-
acter of no-change programmes. tions per capita in Vietnam than in any other
The concept of an incentive would pre- country in the world, and pregnancy inter-
sumably seem like a positive word to most ruption has in reality come to play an impor-
people, implying an encouragement of ef- tant role as a fertility regulation method. In
forts, e.g. made in the assumed societal inter- Bangladesh, a country in which abortion leg-
est for the common good. In impoverished islation is extremely restrictive, the applica-
societies with extremely small margins for tion of the concept of menstrual regulation
survival, incentives may have much more is widespread. Without knowing whether a
controversial implications. In such societies, woman whose menstruation has ceased is
there are areas of widespread poverty and pregnant or not, a suction device can be in-
starvation, where incentives undoubtedly serted into the uterine cavity to induce
can be coercive. If incentives really were an menstruation. In most of these women an
attempt to enhance interest in maternal and early pregnancy has already been estab-
child health (including family planning) in lished, and in these cases menstrual regula-
the population, incentives should naturally tion is in reality an induced abortion.
be paid to support the broad concept of
MCH/FP. Instead selective fertility regula-
tion incentives (and disincentives) have 10.8 Birth control versus
C been introduced in several poor countries,
questioning the only tangible capital the
motherhood control
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poor may be able to generate: their children. While it is self-evident that zero fertility will
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In the escalated form that incentives/disin- automatically mean zero maternal mortal-
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centives issues took in India in the mid- ity, it is less clear what impact family plan-

ning will have on the maternal mortality ra- shown in various data-simulation studies,
tio. This ratio is defined as the number of that elimination of all women with more
maternal deaths per 100 000 live births. In a than 5 children may mean a less than 5 %
study from Bangladesh in the early 1980s, it reduction in maternal deaths. This and sim-
was shown that the impact of family plan- ilar findings indicate the limited value of
ning was unexpectedly limited. Two villages targeting grand multiparous women for ster-
were compared; one was subjected to in- ilisation in order to reduce the overall ma-
tense family planning promotion over sev- ternal mortality. However, it must be em-
eral years, while in the other no family plan- phasised that, beyond all doubt, a signifi-
ning propaganda was distributed. In the vil- cant number of women with many children
lage where family planning was promoted, want fertility control. It can be concluded
fertility was reduced by 26 % in relation to that it is not the age/parity distribution of
the reference village. Unexpectedly, the ma- births that explains the low maternal mor-
ternal mortality ratio was identical in the tality in the developed world. It is a well-
two villages. documented fact that grand multiparity is
The explanation was that the intensive associated with high maternal mortality fig-
family planning drive had not conveyed ures in impoverished countries, but not in
any increase in safety at birth. The findings more affluent countries. An illustration is
imply that wanted pregnancies did not the very low maternal mortality in the high
enjoy any better protection in the family parity range in Sweden and other developed
planning village than in the reference vil- countries. It has been shown in Nigeria that
lage. Family planning could even have been high parity is associated with high maternal
counterproductive to safer motherhood, be- mortality, but only if child mortality is high.
cause the few resources (doctors and nurse- This has been confirmed in historical epide-
midwives) available may have been co- miological studies in Sweden 18001900:
opted to family planning activities. In fact, what kills the mother is not parity but pov-
in the area studied, 75 % of women dying in erty.
childbirth did not see a doctor before their In Sweden, the maternal mortality ratio
death and almost 90 % had no access to has dropped from levels of around 1 000 to
modern health facilities. about 5 maternal deaths per 100 000 live
It is a well-known fact that most maternal births over a period of 250 years. The bulk of
deaths occur at medium parity (one to four this decline (more than 90 %) occurred be-
births) and at medium age (20 to 35 years). fore any kind of modern contraception was
This is derived from various findings, of available. It is true, however, that the com-
which one, from a study in Bangladesh bined effect of increased availability of con-
1968 to 1970, is particularly revealing. It traceptives and access to safe, legal abortion
was calculated that if all births had been services meant a very important contribu-
averted in women below the age of 20 or tion to the final reduction in maternal mor-
above the age of 39, and beyond a parity of tality over the last 50 to 60 years in Sweden.
6, the maternal mortality ratio would only A similar pattern has been found in several
have declined from 570 to 430 per 100 000 other industrialised countries.
live births. Even with this extremely non- The need for health-oriented empower-
realistic achievement of virtually cutting off ment of women and men to plan for opti-
all births in these groups of women, a very mal reproductive health and voluntary
C limited gain in maternal mortality would spacing of births is uncontroversial. The
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have resulted. controversial point lies in the priority given
Even if we assume an impoverished coun- to birth control relative to more compre-
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try with a high maternal mortality in the hensive maternal health care. In a review as
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high parity range, we can still conclude, as early as 1987, Winikoff and Sullivan con-

10.8 Birth control versus motherhood control
cluded, efficient health care is more effec- International Institute for Applied Sys-
tive than family planning in preventing ma- tems Analyses. London: Earthscan Publi-
ternal deaths. cations Ltd.; 1994.
Lutz W, Sanderson W, Scherbov S. The end of
world population growth. Nature 2001;
References and suggested further reading 412:543545.
Caldwell J. Paths to lower fertility. BMJ Lutz W, Qiang R. Determinants of popula-
1999;319:9857. tion growth. Philos Trans Royal Soc Lond
Chu CY, Lee R (eds). Population and Eco- B Biol Sci 2002;357:11971210.
nomic Change in East Asia. New York: Sen G, Germain A, Chen LC (eds). Popula-
Population Council, 2000. Supplement to tion Policies Reconsidered: Health, Em-
Population and Development Review, powerment and Rights. Harvard Univer-
vol. 26, 2000. sity Press; 1994.
Diczfalusy E. Population growth: too much, Sen G, George A, stlin P. Engendering
too little or both? IPPF Medical Bull 2002; International Healththe Challenge of
36:12. Equity. MIT Press; 2002.
Eger B, Hammarskjld M (eds). Under- UNFPA The State of World Population.
standing Reproductive Change: Kenya, (www.unfpa.org)
Tamil Nadu, Punjab, Costa Rica. Lund: UN Department of Economic and Social
Lund University Press; 1994. Affairs Population Division. World Popu-
Helig G. DemoGraphics software 1998. lation Prospects: The 2000 Revision. New
(www.magnet.at/heilig) York: UN; 2001.
Lutz W. Mauritius finds the magic mix. Peo- UN population division. (www.un.org/
ple Planet 1994;3:102. popin)Information on current publica-
Lutz W (ed.). The Future Population of the tions in the UN system on population
World: What Can We Assume Today? development.

11 Health policy and health systems

We do not go to the hospital because it is neces-
sary to bring our own linen, dishes and some-
times even a bed.
A young woman, Mauynak, Uzbekistan
Since time immemorial, humans have had become part of all modern societies.
made joint efforts to control diseases. A re- The elucidation of modes of transmission of
view of health policy might therefore start parasitic diseases like malaria and bacterio-
in any ancient civilisation. For example the logical diseases such as tuberculosis also
Greek goddesses Hygeia and Panacea repre- facilitated new forms of disease control.
sent the two major health policy options: The reduction of malaria occurrence was
to prevent diseases or to treat the diseases achieved by actions against mosquito breed-
that appear. By challenging magical expla- ing sites and tuberculosis could partly be
nations, Hippocrates directed interest to prevented by the pasteurisation of milk.
the environmental causes of diseases. He ar- The first attempts to build the Panama
gued that regulations and public actions by Canal were stopped by severe outbreaks of
communities could reduce the occurrence yellow fever in the labour camps. Before an-
of diseases. He also claimed that the prac- yone knew that a virus caused the disease,
tice of curative medicine requires codes of the Cuban researcher Carlos Finley discov-
conduct. In other words, he suggested ered in 1881 that mosquitoes transmit yel-
health policies for his society. Health policy low fever and that public measures against
concerns the ways societies organise pre- mosquito breeding could reduce the trans-
ventive actions, sets codes for curative prac- mission of the disease. The application of
tice, and how health considerations are in- vector control enabled the construction of
tegrated into all types of political deci- the canal. A memorial of Finleys discovery
sions. The corresponding professional and stands at the Pacific end of the canal as a
scientific field is known as public health. permanent reminder of the importance of
evidence-based health policy for human
progress and economic growth.
The advances in understanding infectious
11.1 The birth of modern disease that occurred in the last century
gradually increased the separation of the cur-
public health ative and preventive approaches of medi-
In the 19th century the new understanding cine. Different public organisations emerged
of the causes of infectious diseases led to for hospital service and disease control in the
new options to prevent these diseases. In industrialised countries of Europe and North
1801 Jenner published his classical work on America, as well as in the countries under
vaccination against smallpox, and publicly colonial administration. In the last 50 years,
organised vaccination programmes fol- there has been a further organisational split
C lowed. In most of Europe public provision in high-income countries between control of
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of safe drinking water in urban areas fol- infectious diseases and the prevention of
lowed soon after John Snows elucidation of non-communicable diseases. Most high-
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the mode of transmission of cholera in Lon- income countries, including Sweden, have a
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don in 1855. By 1900 sanitary legislation national institute for the control of infec-

11.2 Vertical approaches to disease control (1946 to 1977)
tious diseases and a separate national insti- cialists at WHO guided similar national
tute for public health with a focus on non- groups of disease experts in the Ministries of
communicable diseases. The institutes for Health of the member states. Each of these
infectious diseases are generally laboratory- groups organised separate national control
oriented and focused on correct diagnosis, or eradication programmes for each disease.
whereas the public health institutes are dom- Each disease programme had separate of-
inated by behavioural sciences and attempts fices in different parts of each country, with
to change behaviour associated with disease their own mobile teams visiting every com-
risks. Therefore the prevention of HIV is, in a munity in their part of the country. This
country like Sweden, largely taken care of by type of organisation is known as vertical
the National Institute of Public Health. disease control.
The explosive developments in curative The vertical control strategy became a
medicine in the 20th century led to a rapid complete success for the viral disease small-
increase in curative health services, espe- pox that had been causing repeated epidem-
cially hospitals. The curative services gradu- ics in the world for thousands of years. Fol-
ally consumed a larger and larger share of lowing systematic vaccinations against
the gross national product of the richer na- smallpox in all countries and a final inten-
tions and employed a growing proportion of sive search for the last cases in Somalia,
the labour force. In the second part of the smallpox could be declared eradicated from
20th century, the health sector had become the world in 1978. In contrast to the success
an important part of the economies of the with smallpox, and in spite of initially
richest nations, and the pharmaceutical in- promising results, WHO failed to eradicate
dustry an important part of the industrial the parasitic disease malaria and the bacte-
sector. While the impact of health policy rial disease tuberculosis. Most of the failures
rapidly improved the health status in the in- regarding these two diseases were later at-
dustrialised countries, the improvements in tributed to the vertical organisation of the
health in the poorer countries under colo- programmes. So why was the vertical strat-
nial dominance were modest before the Sec- egy a successful policy for smallpox but not
ond World War. Following the formation of for malaria and tuberculosis? And why is the
the World Health Organization and the in- same vertical control strategy now being
dependence of most former colonies health successful in eradication of the poliovirus.
dramatically improved in most parts of the The fight against smallpox and polio re-
world. The main changes in international lied entirely on an effective vaccine. The
health policy in the last half century are fight against malaria relied on both an effec-
chronologically reviewed in the following tive drug, chloroquine, which was given
sections. after blood tests had identified malaria para-
sites, and an effective insecticide (DDT)
against the vector, i.e. the mosquito that
transmitted the disease from human to hu-
11.2 Vertical approaches to man. Tuberculosis was to be controlled by
disease control (1946 to detecting cases early using x-rays taken in
mobile laboratories that could bring the
1977) new technology to the villages, and by pre-
The policy and organisational structure of scribing new effective drugs that could cure
C the World Health Organization was initially the disease: isoniazid, which was taken as
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disease-oriented. In the WHO headquarters tablets, and streptomycin, which had to be
in Geneva, there was one department for injected.
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each major disease, e.g. smallpox, tuberculo- Let us consider what these campaigns
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sis and malaria. Each group of disease spe- looked like from the perspective of a family

VIETNAM, My Van, on the road to Haiphong. Pharmacist at the regional hospital. Here principally tradi-
tional medicines are being used, some produced locally.
in an Indian village in the 1960s. One day, half a minute. Side effects were rare and lim-
the smallpox team would arrive in the vil- ited. People knew about smallpox and noted
lage. After a brief explanation, they asked with satisfaction that those vaccinated were
everyone to line up for vaccination. Those completely protected against the disease.
who could prove that they had previously A few days later the malaria team would
been vaccinated against smallpox, by pre- arrive. Following a brief explanation, a
senting the typical scars on their arms, were health officer with a mobile DDT spraying
exempted. The others were vaccinated by apparatus on his back would enter the first
scratching the vaccine into the skin. The home and all the walls would be sprayed
newly developed freeze-dried smallpox vac- with a gluey film containing DDT. The ra-
cine was cheap and did not have to be kept tionale was that the Anopheles mosquitoes,
in continuous refrigeration. The simple bi- after feeding on the blood of a family mem-
furcated needle made it possible to get ex- ber, would die from the DDT when resting
actly the right amount of vaccine for each on the wall to digest the blood after the
inoculation, and one inoculation was meal. Other malaria team members would
enough to provide long-term immunity, ask the village population to line up for cap-
C and the successful vaccination left a scar. illary blood sampling. The blood slides were
M The absence of a scar later helped to identify examined for malaria parasites and the bit-
anyone who had not been vaccinated. The ter tasting chloroquine tablets would be
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only thing required of the persons was to lift given to treat those found to have malaria
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a shirtsleeve and tolerate minimal pain for parasites in their blood, even if they had no

11.2 Vertical approaches to disease control (1946 to 1977)
symptoms. Although malaria was a severe earlier proved easy to administer to the
problem, the population often perceived entire population of the world. The fact
that the attempt to eradicate malaria caused that refrigeration was not needed and that
more problems than the disease itself. the scar made monitoring of vaccination
Some weeks later, the TB team would coverage easy, were immensely important
come to the village for a one-day visit in for the success. The simplicity of the pre-
their bus. They asked people to queue for an ventive action and the low degree of com-
x-ray of their chests taken with a mobile x- munity participation required, explain why
ray machine. Those with TB-suspected le- smallpox eradication succeeded. The other
sions on the X-ray film would be prescribed programmes failed because they consisted
injections with streptomycin for two of more complicated actions that required
months and tablets against TB for a full year. much more participation by the popula-
When the team had left, there was no one to tion.
consult about side effects of the drugs. The At the same time as the eradication of ma-
fact that many improved within a month, laria and TB failed, the wealthiest countries
and thereafter were not motivated to con- of the world were facing similar difficulties
tinue taking the long course of tablets, in controlling their new health problems.
meant that many initially cured TB patients These were the problems induced by in-
relapsed within months. Relapses of the dis- creased tobacco smoking and intensified
ease were common, and resistance to the traffic. In spite of intensive attempts to
drugs developed fairly fast. screen for pulmonary cancer, operate early
It was frustrating for the families in most and combine surgery with chemotherapy,
villages around the world that these vertical the pulmonary cancers continued to kill
visits would only treat one disease at a time. more and more people. Attempts to prevent
Resources for handling most of their dis- the carcinogenic effect of cigarette smoking
eases and for the promotion of health by by putting filters on cigarettes also proved
improving hygiene and nutrition were not futile. The only remaining policy option
made available to them. However, the rea- was widespread health education aiming at
son for the failure to eradicate malaria and reduced smoking. This behaviour change
control tuberculosis was not only that the became even more important when the role
populations tried to avoid the actions or of smoking in cardiovascular diseases was
stopped treatment too early. The unex- gradually revealed through epidemiological
pected problem was the development of re- studies. Advances in trauma surgery could
sistance among mosquitoes to DDT, among only cure a part of all the injuries resulting
malaria parasites to chloroquine, and from increased automobile traffic. The only
among tubercle bacteria to the first genera- policy option left was prevention: to regu-
tion of drugs against tuberculosis. Strains of late the traffic through speed limits, promo-
the Anopheles mosquito that flew out the tion of safety belts and actions against
window without resting on the DDT drunk driving.
sprayed walls took over the role of transmit- Disease-oriented curative care was not
ting malaria from the strains that were killed available for many of the new diseases in the
by DDT while resting on the wall. Medical rich countries. Curative treatment existed
science, as well as science in general, had yet but could not be afforded for most of the in-
to learn about ecology. fectious diseases in the poorer countries.
C Smallpox, which for many years had Technical prevention without behavioural
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been looked upon as the good example of change failed in the rich countries and
how diseases should be eradicated, soon could often not even be tried in the poorer
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became the exception. The amazingly effi- countries, as their meagre health budgets
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cient vaccine developed by Jenner 180 years were consumed by a few rapidly growing

hospitals in the major cities. At the end of emphasised the need for equity, i.e. a fair
the 1970s, the time had come to change the possibility for everyone to access health
vertical disease oriented approach as it, for services and achieve a healthy life. Seen in
different reasons, was failing across the hindsight it is interesting that no emphasis
world. was placed on gender issues and almost
nothing was said about how the health care
activities should be financed. Governments
11.3 Primary health care were assumed to take the full responsibility
for providing health care. The content of
strategy (1978 to 1982) primary health care was defined in eight el-
In 1978 it was possible for the Director Gen- ements that are listed in Box 11.1.
eral of WHO, Dr Halfdan Mahler from Den- In many rich countries the primary health
mark, to gather an international consensus care strategy led to a new focus on general
for the need to change health policy. He did practitioners as the backbone of health serv-
so by arranging an international meeting in ices. Family medicine developed as a special-
the Asian part of the Soviet Union. In this ity of its own for physicians in many coun-
1978 conference, held in Alma-Ata in tries, which increased public investments to
present Kazakhstan, the ministers of health achieve better coverage by family doctors. A
of the world agreed that WHO should focus on preventive aspects could also be
launch a primary health care strategy. The found in the richer countries. The actions
strategy was presented with the bold slogan: that increased traffic safety in the richer
Health for all by the year 2000. countries can be seen as one of the most suc-
The primary health care strategy was con- cessful applications of the new primary
ceptualised in some basic principles. Health health care policy. The decrease in the pro-
care should be made accessible to all and be portion of the population that smoke ciga-
designed in a way that the communities rettes and the successful promotion of
could afford. It should be based on commu- breastfeeding are other examples of success-
nity participation, i.e. the population ful implementation of the intersectoral as-
should be made active in promoting health pect of the primary health care strategy.
rather than acting as receivers of services. In the less affluent countries, the main ef-
The policy emphasised that intersectoral fect of the primary health care strategy was
actions for health, involving other sectors to inspire governments to reorganise health
of society such as education and agriculture, services in order to make it accessible to the
were as important as the actions performed whole population. This effort was partly
by the health sector itself. The strategy also supported by development aid from the
Box 11.1
The eight elements of primary health care
E ducation
L ocal disease control
E xpanded Programme of Immunisation against childhood diseases
M aternal and child health care, including family planning
C E ssential drugs
M
N utrition and food supply
T reatment of common diseases and injuries
Y
S anitation and safe water supply
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11.4 Selective primary health care (1983 to 1992)
richer countries. In the first years following 11.4 Selective primary health
the Alma-Ata conference, many of the new
efforts focused on training village health
care (1983 to 1992)
workers, also known as barefoot doctors in The wishful thinking in the primary health
the Chinese version of the Primary Health care strategy soon became obvious in the
care strategy (Anonymous 1977). This in- least developed countries. In fact it was not
cluded attempts to achieve safe deliveries until the study of macroeconomics and
through collaboration between the modern health was published in 2001 that WHO
health service and traditional birth attend- really calculated what basic primary health
ants. Although some positive effects came care would cost (Sachs 2001). When as-
out of these efforts, it soon became obvious sessing available interventions that could
that there are only a few low-cost shortcuts achieve measurable results, UNICEF
available for the improvement of health. launched its GOBI-FFF policy in 1982. This
Barefoot doctors did not function without was in a way a return to a more vertical ap-
strong political organisation of the local proach, but no longer with a focus on single
community as in China, or with financing diseases. The strategy met with criticism
from the government budget as in Iran. from those liking the ideology of primary
Local communities in the least developed health care, but the focused policy of
countries, failed to provide economic sup- UNICEF proved to be very useful for ac-
port to their newly trained community tions. The GOBI-FFF components listed in
health workers. For economic reasons many Box 11.2 affected a number of diseases
of these health workers eventually worked through each of a few specific actions.
mainly with curative care for which their UNICEF organised effective promotion
training was insufficient. The most success- campaigns for this policy at global, national
ful implementation of the primary health and local levels. Jim Grant mobilised exten-
care strategy occurred in middle-income sive external funding for all the compo-
countries like Costa Rica and Iran. In most nents of the policy, and most developing
low-income countries, the public budget for countries implemented all the actions. Fol-
health failed to provide trained health staff lowing the first intensive debate about ideo-
in peripheral health centres and health logical aspects, a productive discussion fol-
posts with acceptable salaries. Many began lowed about evaluation of the coverage and
to sell the drugs that should have been dis- impact achieved by the different compo-
tributed free of charge to patients, and nents. While the coverage became relatively
many governments failed to purchase suffi- high, the impact differed, due to different
cient drugs for free distribution. These fail- inherent effects of each bullet.
ures of community-based health services in Growth monitoring of children at regular
the poorest countries yielded an urge among visits to child health clinics was widely im-
donor organisations in the richer countries plemented but proved largely to be a failure.
to focus support on a few essential aspects of Although it achieved high coverage, it had
primary health care that could make an im- limited impact on the health and nutrition
pact on global health within a matter of of the children of the poor. The weighing
years. UNICEF became the organisation that was done, but it was recorded and inter-
took the lead in this policy of selective pri- preted with poor quality. The emerging ad-
mary health care. The leader of UNICEF, vice was difficult or impossible for poor
C Jim Grant (Jolly 2003) focused on a few mothers to follow. Studies in poor commu-
M
golden bullets, as the concept was coined nities showed that health education alone,
in the donor jargon of that period. without growth monitoring, was just as suc-
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cessful in promoting good health and nutri-
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tion among children.

Box 11.2
The golden bullets of the selective primary health care policy
Growth chart, for monthly monitoring of the weight increase of infants and
young children.
Oral rehydration, against the dehydration caused by watery diarrhoea.
Breastfeeding, to improve nutrition and protect against infectious diseases.
Immunisation, against tuberculosis, tetanus, diphtheria, whooping cough, polio
and measles
Female education, mainly to increase primary school enrolment for girls
Feeding programmes, especially dietary supplements to vulnerable groups
Family planning, provision of both education and anti-conception methods
Oral rehydration therapy to combat acute Immunisation, mainly against polio and
diarrhoea seems to have contributed to a re- measles, became a major success. Following
duction of child mortality worldwide. How- the joint efforts by WHO, UNICEF and na-
ever, not as much as expected, because most tional governments the proportion of vacci-
of the diarrhoeal deaths were found to be nated children increased from 5 % to about
due to chronic diarrhoea linked to malnutri- 70 % in a 15-year period. Once more, this
tion rather than to acute dehydration. The was done by a dynamic policy process in
process of diarrhoea management in middle which health system research played a very
and low-income countries has been a dy- important role. Through regular evaluations
namic process, where evaluations and re- and applied research, small but decisive ad-
search have resulted in changes in policy, justments were made concerning when chil-
and above all in an ability to apply policy dren should be vaccinated against different
according to local circumstances. Therefore diseases, and how vaccination should be or-
the focus on oral dehydration eventually be- ganised in each country. The development
came a successful action. of new ways of delivering vaccination in dif-
Breastfeeding was successfully promoted ferent social settings also helped to improve
and protected throughout the world. This the coverage. UNICEF also facilitated a
may be considered as the most successful number of technical improvements such as
application of the primary health care pol- kerosene refrigerators, high quality cold
icy at a global level, in both its comprehen- boxes and other materials required for
sive and selective forms. The reason may be reaching remote rural populations in poor
that most mothers like breastfeeding and countries. Finally the UN organisations
the vigorous promotion in all countries met helped to implement a cost reducing pur-
with a positive response at the grass roots chasing system, where the annual need of
level. In addition there was strong scientific vaccines for several countries was purchased
support for the benefits of breastfeeding at the same time. The resulting reduced
that could counteract opposition from com- price for vaccines constituted an important
mercial forces. However, the emergence of part of the success.
C the HIV epidemic and the contributing role The World Health Assembly decided to
M of breastfeeding in its transmission from eradicate polio in 1988, following the suc-
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mother to child (so called vertical trans- cess of the vaccination programme for most
mission) has now created great difficulties in of the worlds children. This focus on one
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the protection of breastfeeding. disease at a time brought global health pol-

11.5 Health system reforms (1993 to 2000)
icy back to the aspirations it had before the other donor organisations paid not only for
primary health care strategy was launched. vaccines and refrigerators but also for trans-
Now, 15 years later, WHO has come very port. In many low-income countries the pri-
close to the eradication of polio. This shows mary health care staff were given allow-
that global disease eradication is possible ances, i.e. supplements to salaries for ad-
when a cheap, effective and easily adminis- ministering the vaccines.
tered vaccine is available (WHO 2003). By the beginning of the 1990s, it had be-
The three Fs were gradually added to come obvious that the main obstacles to ac-
UNICEFs policy. They have enjoyed differ- cess to health care in low-income countries
ent levels of success. The enthusiasm for were financial and managerial. Centralised
feeding programmes for children based on public health systems could not effectively
screening for malnutrition by growth moni- provide these services. Most evaluations
toring has faded due to lack of measurable showed that coverage had been achieved at
effects. Female education remains a major the cost of quality, and that quality could
priority but it is slow to implement, as it re- not be restored without more money. The
quires major changes to occur at both na- World Bank was, surprisingly, the interna-
tional and local level. Recent years have tional organisation that took the initiative
seen a much deeper understanding of the in promoting policies to meet these new
determinants of the health situation of challenges.
women. The right of girls to education re-
mains a top priority, although it is difficult
to measure the health impact of this core di-
mension of social development in isolation. 11.5 Health system reforms
The last F, Family planning, has been
adopted rapidly in most middle-income
(1993 to 2000)
countries, and fertility rates in the world are In the last decades of the past century the
falling everywhere, except in some coun- international health policy discussions were
tries in Sub-Saharan Africa. The reduction of focused on health system reforms. This term
the number of children born per woman summarises all forms of change in organisa-
stands as one of the major successes in tion, delivery and financing of health serv-
human development during recent decades. ices with the aim to improve the quality of
The economic constraints of the least de- and access to health care. Such health sys-
veloped countries were, however, found to tem reforms are still ongoing in many, if not
be so severe that the achievements of the se- most low- middle- and high-income coun-
lective primary health care strategy could tries. The reforms include a number of meas-
only be sustained by continued external fi- ures, the main ones summarised in Box
nancing of recurrent costs. UNICEF and 11.3.
Box 11.3
Four major components of health system reforms
1 A decentralisation of management and financial responsibility in the public system from

national to local level.
C
2 An increase and diversification of fees in the public system
3 A shift of the public-private mix of services to more privately financed and privately pro-
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vided services.
Y 4 An improved cost awareness and use of cost-benefit analysis
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Concerns about the rising costs of health sumables as well as maintenance and acqui-
care and the aim of structural adjustment sition of the necessary buildings and equip-
programmes to reduce public spending have ment.
largely driven these health system reforms. But it is obviously difficult to put all the
In most countries they formed part of the proposed technical interventions into prac-
general political process of this period. tice, if the health system is malfunctioning,
Health reforms have focused on a reduction even if the vertical interventions provide
in bureaucratic planning. Budgeting and fi- targeted financial support to low-income
nancing systems were changed in favour of countries. It has also been noted that exter-
introducing competition and more need- nal funding of many special projects tend to
based methods of allocating resources. disrupt the activities that function in weak
Changes in financing, decentralisation and health systems. The staff got very little sal-
increased competition appear to be three ary for doing their regular job such as at-
functions most commonly associated with tending deliveries, treating the sick and run-
health system reforms. ning the health education. Therefore they
For the poorest countries, in particular would attend any short course whether rele-
those in Africa, different international or- vant or not just to get the sitting allow-
ganisations have tried to diagnose the ail- ances offered by the external donor agency
ments of the health systems and they have that financed each of these courses as a de-
imposed a variety of prescriptions. Over the velopment project. In many weak health
last 20 years, UNICEF and WHO have pro- systems in low-income countries staff
posed priority programmes such as GOBI- earned more money from participating in
FFF and the integrated management of short externally funded project activities
childhood illness (IMCI), respectively. The than they did by doing their job during the
World Bank prescribed a different list of the rest of the year.
most cost-effective public health and clini- Faced with these effects on failing health
cal interventions in the book Better health systems with too many vertical projects,
in Africa (World Bank 1994). The effective- new ways of international co-operation
ness of the different interventions were dis- were planned. This was made possible in
cussed in more general terms by the World low-income countries that decentralised the
Bank in the World Development Report of economic management from national to
1993, which has to be considered as a land- district level. They have adopted a new way
mark in global health policy analysis. Other to use donor funding that is known as sec-
comprehensive interventions recently pro- tor-wide approaches (SWAps). Instead of
posed by WHO are the Roll back malaria in- donor agencies putting funds into a number
itiative and Stop TB programme. All of of specific projects the SWAp concept entails
these programmes have broad objectives but putting donor funds together into one bas-
are vertical interventions with both curative ket for each district, to be used during the
and preventive components. Such exter- year according to local needs. This gives the
nally funded projects and programmes re- responsibility and possibility for district
quire a functioning health system in order health authorities to prioritise health inter-
to achieve the effect of all the evidence- ventions using resources provided by the
based interventions suggested by WHO and government and/or the basket provided by
other international organisations. Function- a group of donor agencies. First impressions
C ing health systems mean well educated and of these SWAp programmes are positive. It
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reasonably paid staff that are wisely de- has also become clear how limited the inter-
ployed in relation to where the population national financial support is to the health
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lives. It also means good management, i.e. services in the poorest countries. Most of
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regular provision of drugs and other con- the money for health services is paid by na-

11.5 Health system reforms (1993 to 2000)
tional governments and the patients them- former missionary health service is gradu-
selves. ally providing service mainly to the middle
The health reforms have often been ac- and upper class in low-income countries. In
companied by attempts to introduce vary- contrast privately operated outpatient clin-
ing levels of user fees to relieve the govern- ics are rapidly increasing in number in these
ment budgets of some of the costs for the countries and relatively low trained staff
health care system. However, poor commu- work in these institutions. Paradoxically
nities have often reacted negatively, some- these private-for-profit facilities often have a
times even violently, when governments higher proportion of poor patients than do
have introduced charges for services that the former missionary health clinics. Many
were previously offered free of charge. In of the poorest patients do not consult any
many low-income countries unofficial fees trained staff before buying their medicines
were already being charged and the intro- from unofficial drug sellers at the local mar-
duction of official fees often caused a con- ket. The services provided by traditional
fusing situation where the patients had to healers are also changing in character in
pay both unofficial and official fees. many countries and are partly becoming
The main conclusion from the ongoing very commercialised. In many low-income
health system reforms in low-income coun- countries the different forms of health serv-
tries is that the general effectiveness of gov- ices are difficult to categorise into conven-
ernance in the country is the limiting factor. tional private, public or modern-traditional
Important aspects of this are the degree to categories. Most governments therefore,
which authorities in districts can handle have great difficulties in predicting how
public funds effectively and correctly. This their reforms will affect the whole health
largely depends on having competent ad- system, which is composed of a dynamic
ministrative staff available. It also partly de- mix of services by government, non-govern-
pends on how well the public audit system ment, private-for-profit and traditional pro-
functions and how free the mass media are. viders. Both policy analysis and operational
Good governance depends largely on the research runs the risk of dealing with minor
transparency of how decisions are made and parts of the health system since the poor
implemented regarding health at local and majority of the population mainly use infor-
national level, and to what extent the qual- mal or illegal provision of drugs and serv-
ity and coverage of services are reported and ices, which are the only means that are af-
debated in the mass media. This means that fordable to them.
improvements in a countrys public health In conclusion, we find that while WHO
service are very difficult to achieve without has set global targets for health, it is only
improvements in the general management after 50 years that the organisation has pre-
of public services and, perhaps, changes in pared systematic numeric estimates of how
the political system. much it will cost to achieve these goals
In many of the poorest countries non- (Sachs 2001). WHOs commission on macr-
governmental organisations such as reli- oeconomics and health (WHO 2002) con-
gious organisations and charity foundations cluded that a sum corresponding to 30 USD
operate hospitals and peripheral health per capita is needed to provide basic health
service in a more effective way than do the services. At present most low-income coun-
public institutions. However, these former tries only manage to invest 5 USD per capita
C missionary hospitals and clinics charge in- of public money per year and the popula-
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creasing fees to finance their services. These tion pay on average another 5 USD out of
non-governmental institutions tend to in- their own pocket when they are sick. The
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crease the quality of services rather than the contribution from international develop-
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number of hospitals and clinics. Hence the ment aid is only a few additional dollars.

Table 11.1 Estimates for domestic public and private spending on health service compared to funding from
international organisations.
Country group Public Private Donor Total

spending spending spending spending
(per person, (per person, (per person, (per person,
1997, USD) 1997, USD) 1997, USD) 1997, USD)
Least developed countries 6 3 2 11

Other low income countries 13 9 1 23
Lower-middle income countries 51 41 1 93
Upper-middle income countries 125 115 1 241
High income countries 1 356 551 0 1 907
Source: Sachs 2001.
The present contribution of development the 19th and early part of the 20th century
co-operation financing from high-income had a much greater impact on life expect-
countries is almost negligible as shown in ancy than modern medical care. In fact, a
Table 11.1. steep reduction in morbidity and mortality
Two questions arise when it becomes clear from a variety of infectious diseases was
that the funding needed to enable basic shown by McKeown (1979) to have taken
health care to effectively reduce avoidable place even before the identification of the
mortality requires an increase in donor relevant pathogens and the introduction of
funding that is several times larger than the any effective treatment or preventive meas-
current level. ures. The identification of determinants of
health and general socio-economic progress
Will the rich countries be willing to con-
were found to have had a greater signifi-
tribute the money?
cance for health than many of the technical
If the money is made available in an opti-
medical interventions, such as antibiotics.
mal form and given the organisational
Today poverty is regarded as the main
difficulties, how many low-income coun-
cause of ill health or, as sometimes stated,
tries will be able to absorb the new
poverty is the most dangerous pathogen in
money appropriately, without increased
the world. About 20 percent of the worlds
waste and corruption?
population live in absolute poverty with an
income of less than USD 1 per day. The first
11.6 Health status and health of the UN Millennium Development Goals
is to reduce poverty. More specifically the
care goal for 2015 is to have reduced by half the
High expenditure on medical and health proportion of people that in 1990 lived on
care does not necessarily lead to good popu- less than the purchasing power of one US
lation health. Japan spends 6.5 % of GDP on dollar a day. Poverty reduction is now taking
health care, while the United States spends place in different parts of the world, but
more than twice as much. Still the US popu- there has been very little positive develop-
lation has a shorter life expectancy than Ja- ment in Sub-Saharan Africa. Undoubtedly
C pans (Evans 1994). The effect of health care poverty causes diseases and diseases cause
M
upon health status has been a hotly debated poverty but the role of the health sector in
issue. It has been shown that improved diet, alleviating poverty is by no means clear. To
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better housing and sanitation, and general provide health services for the poor, to legis-
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socio-economic progress in the latter part of late for better health, to provide information

11.7 Health economics
CUBA, San Salvador de Los Banios. Pharmacy with nearly empty shelves.
Eric Miller/PHOENIX.
and to target diseases that specifically affect enough. The analyses also have to include
the poor are actions that have been, and are all socio-economic factors that have other
being, tried: results so far are largely disap- main objectives but that have strong indi-
pointing. It is much easier to improve health rect effects on health such as education, eco-
for those with a better economic situation nomic growth, human rights and gender eq-
(Gwatkin 1999, Victora 2003). uity.
With a more traditional disease oriented Thus, the definition of a health system be-
analysis, and studying diseases for which comes all-important when it comes to as-
there are effective treatments, it has been sessing its impact on health. It seems that
consistently found that preventable deaths more evidence is available on how to best
have fallen at a faster rate than other deaths. spend money and resources in the health
In a large sample of low and middle-income sector than on how to optimally allocate
countries, scientific and technical progress money between health, education, and
have been shown to explain almost half of other social sectors.
the reduction in mortality between 1960
and 1990. To analyse the impact of a health
system focusing on the health sector alone
C would therefore provide a different result
11.7 Health economics
M from that of a health system that includes The health sector constitutes almost 10 % of
public health interventions such as im- the world economy. Economics is obviously
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proved water and sanitation, and the pro- a central discipline for the analysis of what
K
motion of healthy lifestyles. Yet this is not is effective in improving health. Health eco-

nomics covers many aspects of health, from in very low-income countries. This finding
defining the meaning and value of health, that the prevention of child deaths from
to studies of how well resource utilisation malaria in Africa requires substantial assist-
within health services function. Like other ance from external donors was a major rea-
health sciences research, health economics son for the recent focus on increasing inter-
has mainly focused on the situation in high- national funding for health by creation of
income countries. Studies have focused on the Global Fund for the fight against Aids,
large-scale insurance markets, on the differ- TB and malaria (see chapter 12).
ences between private for-profit and non- Health economics has had an important
profit hospitals, and on mechanisms for reg- influence on approaches to health service
ulating highly complex health systems. provision and national governments as well
However, important advances have also as health service managers have adopted the
been made in the analysis of how resources methods and tools of health economics. The
are best used in middle and low-income international comparisons of health sys-
countries (Culyer 1999). tems, which highlight the impact of differ-
Health economics is especially demand- ent institutional arrangements on health
ing to apply in low-income countries, as outcomes as well as methods of assessing
substantial parts of the economic transac- the health impact, are of great importance
tions in the health sector are informal. It for global health policy. The same could be
requires a thorough understanding of the said about the economic analysis of public
complex context to do an economic analysis health interventions to control infectious
in poor countries, however when this is car- and nutritional diseases in different socio-
ried out it can contribute immensely to economic contexts.
rational policy. Health economics is poten- The best advice we can give to a young
tially most useful where the resources are health professional wanting to make a ca-
most scarce. The discovery that the provi- reer in international health is to study some
sion of impregnated bed nets could reduce economics. Yet the development of health
the malaria deaths in children in low- services and health systems also requires
income African countries at first gave an methods and concepts from other academic
impression that the malaria problem in disciplines outside the conventional health
Africa could easily be reduced by this pre- sciences. These are political sciences, sociol-
ventive method. A simplistic saying is that ogy, anthropology, economics and system
prevention is better than cure, but the and managerial analysis of different kinds.
question for the poor is of course is preven- The combined application of a range of
tion cheaper than cure?. Health economic methods to understand the functioning of
analysis (Goodman 1999) unfortunately the health sector is called health system re-
revealed that the cost for saving one healthy search and health economics is a central
year of life by provision of insecticide component of this area of research.
treated bed nets was 19 to 85 USD. However,
the cost for saving one DALY by improve-
ment of curative services was estimated to be
only 1 to 8 USD. The treatment of the sick
11.8 Health system research
child therefore remains a ten times more Earlier analyses of health systems focused
cost-effective approach, even if the preven- on how a health system was organised and
C tion of malaria by using bed nets intuitively how resources were allocated to and within
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appears more cost-effective. Sadly the health that system. The objectives of the health
economic analysis showed that the neces- system were generally taken to be cost-effec-
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sary package of interventions to decrease the tiveness, including both technical and oper-
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bulk of the malaria burden is not affordable ational efficiency as well as in most in-

11.8 Health system research
Table 11.2 Matrix of health systems.
Economic level Health systems policies (degree of market intervention)

Entrepreneurial Welfare- Universal and Socialist and centrally
and permissive oriented comprehensive planned
High-income United States Germany Great Britain
Japan New Zealand
Middle-income or Thailand Brazil Israel Cuba
transitional Philippines Egypt
Low-income Nepal, Vietnam India Sri Lanka
Tanzania
Source: Roemer 1993.
stances equity. Roemer (1991, 1993) defines the entrepreneurial and permissive;
a health system as the combination of re- the welfare-oriented;
sources, organisation, financing and man- the universal and comprehensive;
agement that culminates in the delivery of the socialist and centrally planned.
health services to the population. WHO de-
With a classification based on economic re-
fines a health system as all actions in a so-
sources, a matrix could be constructed (Table
ciety that are primarily intended to improve
11.2) with countries at different levels of eco-
health (WHO 2000). Consequently, the
nomic development fitted into the different
main functions of the health system are re-
categories of health systems. With the recog-
source production, organisation of pro-
nition that the informal and traditional
grammes, economic support, management
medicine sectors are excluded, this analysis
and delivery of services.
led to the conclusion that public systems
Resource production comprises the differ-
dominate in Asia and Africa, as well as in the
ent groups of manpower, the health facili-
formerly socialist countries and a few high-
ties, drugs and medical equipment and
income countries. The poorer countries are
knowledge. The basis for organisation is the
often characterised by government provi-
ministry of health, around which are
sion of medical care in generally under-fi-
grouped other government ministries and
nanced and overcrowded facilities.
agencies, voluntary agencies, professional
Health insurance systems dominate in the
associations and enterprises. The economic
high-income countries of Western Europe
support to the health system comes in vary-
and North America, Australia and parts of
ing proportions from (1) taxation, (2) com-
Latin America. Most of these have a combi-
pulsory social insurance, (3) voluntary in-
nation of private and public insurance sys-
surance, (4) fees and (5) charitable dona-
tem. Various systems of user fees are applied.
tions. Within the management function
The United Kingdom and Sweden are some-
falls health planning, administration, regu-
times seen as intermediate forms with their
lation and legislation. The delivery of serv-
combination of national health services and
ices, i.e. running hospitals and other health
a national health insurance systems. The
facilities, is mostly subdivided into three
British National Health Service covers the
levels: primary, secondary and tertiary
entire population, but general practitioners
health care. The levels may also be called
C have a contractual relationship with the
primary health care, local hospitals and spe-
M government, and consultant doctors may
cialised hospitals.
have private patients in special pay beds in
Y Roemer distinguished four major types of
government hospitals. Sweden had a similar
K health systems:
system until the 1990s, although for most

practical purposes private practice played an countries. In fact even with this new defini-
insignificant role. But from the 1990s tion of a health system many major health
onwards, the Swedish system is being gradu- determinants, such as education, housing
ally changed. Health system reforms that and human rights, are not even theoreti-
change the provision and financing of cally included because even if they have
health care are being carried out in many strong positive effects on health their main
countries in order to contain costs and/or purpose is not to improve health. The WHO
improve quality and access to health serv- year 2000 definition of a health system does
ices. The carry home message is that health not merge health services and public health;
systems vary in many respects even between it includes all of the health services but not
countries that are relatively similar in other all aspects of public health. Bearing that in
aspects and the systems also continuously mind the new definition still has advanced
change over time in each country. the analysis of the health sector and its role
in development. The new definition of
health system has been criticised for draw-
ing the focus away from public health to-
11.9 New approach to health wards the financing of curative services that
are the economically dominant part of all
systems health systems. In response to this Christo-
The World Health Organization in its World pher Murray, the leading researcher behind
Health Report 2000 launched a new ap- the definition, says well the health system
proach to the measurement of the perform- as now defined constitutes 10 % of the eco-
ance of a health system. The name of the re- nomic activity of the world and we need sys-
port was Health Systems: Improving Per- tematic ways to assess if the spending of all
formance. In this report, the health system those resources delivers what we want. In
was for the first time defined as comprising this view (WHO 2000), the three fundamen-
all the organisations, institutions and re- tal objectives of a health system are:
sources that produce health actions. A health
action is defined as any effort whose primary To improve the health of the population
purpose is to improve health, whether hos- (health attainment);
pital service, primary health care, public To respond to peoples expectations (re-
health services or intersectoral initiatives. sponsiveness);
The methodology used and the concepts in- To provide financial protection against
troduced have been well described by Chris- the costs of ill health (fairness of finan-
topher Murray (2003). cing).
This means in effect, that a given action
can be counted as part of the health system A health system must not only achieve the
or not, depending on the motivation be- best possible level of health. The system
hind it. If a set of traffic lights at a dangerous should also achieve the smallest feasible dif-
road junction is set up in order to reduce ac- ference between individuals and groups re-
cidents that cause injuries and possibly garding attained health. It is thus not only a
deaths, that action becomes part of the question of the average life expectancy in a
health system. On the other hand, if the country but also how life expectancy varies
lights are set up primarily to achieve a more between different groups in the country. To
C even pattern of traffic flow, then it does not achieve the three objectives the health sys-
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become part of the health system, even if it tem needs four basic functions, delivery of
may save lives. This definition is theoreti- services, resource generation, financing and
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cally attractive but it remains difficult to use stewardship. These four concepts are re-
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when analysing resource allocations in most viewed below in section 11.9.14.

11.9 New approach to health systems
11.9.1 Delivery of health services ico, for example, the proportions are re-
The delivery of health services requires cost versed.
effective organisation with the optimal con- Another resource is pharmaceuticals that
tent. Cost-effectiveness means choosing the represent up to 40 % of government and
interventions that give most value for private out-of-pocket expenditures in low-
money, and giving lower priority to those income countries (World Bank 1993,
that contribute little to improving peoples Govindaraj 1997). If expenditures on salaries
health. Cost-effectiveness analysis is but one are excluded, then pharmaceutical expendi-
tool in the improvement of the health sys- ture often dominates the public health budg-
tem, but it is a tool that is more under than ets even in middle-income countries. In
overutilised. In the health service, the cost high-income countries drugs usually repre-
per healthy life-year saved in a rich country sent less than 10 % of the costs of health
could vary between USD 250 for screening services. The most efficient resource mix will
and treating newborns with sickle-cell anae- vary over time and across countries, depend-
mia, and USD 5 million for control of radio- ing on relative prices among inputs, coun-
activity emission. In a poor country in try-specific health needs and national prior-
Africa, the cost for a life-year saved through ities. But it is clear that there is considerable
short-course drug therapy for malaria can be waste and inefficiency in most national
as low as USD 3 (Goodman 1999), while health systems. A study of pharmaceuticals
other interventions like anti-retroviral treat- in Africa (Shaw and Elmendorf 1993) con-
ment may cost many hundreds of dollars cluded that waste and inefficiency were so
per healthy year saved (Creese 2002), i.e. to great in the procurement, storage, prescrip-
get the same result. Combining calculations tion and use of drugs that only about 12 % of
of cost with measures of effectiveness of the total amount spent by governments
interventions and using them to guide pol- actually resulted in the right type of treat-
icy decisions is a very recent development. ment for a patient.
11.9.2 Resource generation 11.9.3 Financing

This entails the training of staff and their The third major function is financing. Glo-
deployment, the production of drugs and bal health care expenditures are estimated
medical equipment, and the provision of fa- to have risen from 3 % of total world income
cilities for health care. In the end, it is the (GDP) in 1948 to 8 % in 1997. The present
combination of human and physical capital cost of health service in the world corre-
and consumables within the public and pri- sponds to a total of around USD 2.5 trillion
vate sectors that is important. The combina- ($2 500 000 000 000). This makes health care
tion of these different types of resources, one of the major economic sectors in the
known as the health care resource profile, world.
varies widely between countries. For exam- The main purpose of financing is, of
ple, the US spends more than any other course, to pay for health care and to ensure
country on any resource input, with a par- access to health care for all individuals. The
ticularly large amount for medical technol- system of financing should ensure equitable
ogy. Sweden has a large stock of human re- access to health care for all citizens in a
sources and beds, and together with Den- country. In order to do this, the financing
C mark, high spending on drugs. Mexico has a system has to take care of three distinct fi-
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high ratio of physicians, while in contrast nancing functions: revenue collection, pool-
Thailand and South Africa have a low ratio ing of resources and purchasing health inter-
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of physicians. In South Africa, nurses greatly ventions. The five main sources of funds for
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outnumber physicians. In Egypt and Mex- revenue collection are (1) general taxation,

(2) compulsory health insurance, (3) volun- pay for the treatment of the sick. Pooling is
tary health insurance, (4) out-of-pocket pay- essential to avoid catastrophic health ex-
ment (user fees) and (5) donations. Most penditures in cases of serious illness. When
high-income countries rely heavily on either people pay out-of-pocket, there is no pool-
general taxation or compulsory social health ing. When a poor woman needs a caesarean
insurance contributions. General taxation in section, it becomes a catastrophe for the
the OECD countries on average accounts for family economy. It should be noted that in-
more than 40 % of GDP. However, the corre- surance systems do not imply that the rich
sponding figure in the low-income countries will pay for the poor.
is on average less than 20 %. Therefore, tax Purchasing involves the choice of method
revenues in low-income countries are usu- to pay the providers of health care. It has
ally not sufficient to finance necessary been shown, for example, that a fee-for-
health care expenditures. service system, in which patients pay the
By necessity, the health systems in low-in- provider for each visit and service rendered,
come countries rely to a high degree on out- encourages the provision of unnecessary
of-pocket financing. This means that pa- services. A major division can be made be-
tients have to pay cash when they are sick, tween systems that rely on prepayment and
whether they need antibiotics or a caesarean those that do not. Out-of-pocket payment is
section. For countries relying mainly on usually the most socially destructive way to
general taxation the ministry of finance finance for health service. Such systems are
manages the collection of money and the al- making the poor pay more in relation to
location to the ministry of health is per- their income than the rich. Health service
formed through the government budgetary fees expose people to the greatest financial
process. During the health care expansion risk and health service may save lives at the
phase of the 1970s and 1980s, many coun- cost of pushing a family into poverty. Chil-
tries built up health care systems that re- dren may no longer go to school because
quired heavy government financing. their mother needed a caesarean section
Free health care was declared the aim during the last delivery. Thus, the way reve-
even in the poorest countries. This was the nues are collected largely determines the de-
time when the belief in the state capability gree of equity of any health system. Here,
to finance and provide health care was at its WHO is unequivocal in its advocacy of pre-
peak. But in hindsight, we can now see that payment as a means of protecting the poor,
these countries, especially those in Africa, who otherwise might not be able to pur-
never acquired the capacity to finance the chase health care when needed.
health care systems they had started to de-
velop. Salaries fell to levels that were much
less than the value of the drugs the staff was 11.9.4 Stewardship
supposed to administer for free. A large pro- Stewardship means leadership through pol-
portion of the staff sold the drugs that icy, regulation and co-ordination. It is a new
should have been distributed for free or notion in health policy. The concept itself
started to demand envelope money as un- has religious roots. In the Old Testament of
official fees. In this way many public health the Bible, Joseph became Potiphars and
services were unofficially privatised to a very then Pharaohs steward: the self-less servant
high degree. who manages assets in the best interest of
C Pooling of resources is an insurance func- the master without owning them. In WHOs
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tion, whereby the risk of having to pay for language, stewardship as the effective trus-
health care is borne by all the members of teeship of national health is a major role of
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the pool and not by each contributor indi- governments. Stewardship requires a long-
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vidually. In other words the healthy have to term vision and influence, primarily by

11.9 New approach to health systems
ministries of health. This role implies set- countries were ranked relatively poorly: 11
ting rules and ensuring their compliance by (Iceland), 15 (Norway), 23 (Sweden), 31
the public as well as the private sectors. (Finland) and 34 (Denmark). The United
Stewardship is both about providing the es- States ranked only number 37, despite
sential drugs free for the poor in the public spending far more per person for health care
sector and assuring that no fake drugs are than any other country. Not surprisingly, Si-
sold in the private sector. Few countries erra Leone came last. But the uncertainty in-
have developed effective strategies to deal tervals were considerable.
with the private sector in health care, mak- This serious attempt to analyse the per-
ing this area a priority in most countries. formance of health systems is a clear step
With these factors included in the analy- forward. With its more inclusive definition
sis, WHO also compares countries according of health systems, it comes closer to the ac-
to what they achieve as measured in health tual determinants of health. But in the ab-
status, in their responsiveness to peoples ex- sence of sufficient quality data, efforts to
pectations and in their fairness of financing. rank countries were premature. The study
A complex system for numeric measurement (WHO 2000) was based on complex statisti-
was developed and the first calculations in cal analyses of hundreds of assumptions and
the World Health Report 2000 relied partly values, interviews with thousands of people,
on very weak data. Yet, two main rankings including many WHO staff, and on assign-
were developed, the first one being for over- ing weights to the different parameters,
all attainment or what WHO terms good- which in the end were compressed into a
ness and fairness combined. This was in- few simple indices. The statistical basis for
tended to reflect how well a health system these complex calculations was obviously
achieves a long, disability-adjusted life ex- deficient, in particular for the poorest coun-
pectancy, or a high level of responsiveness tries.
(or a high degree of equality in either or Some critics have referred to the high
both) or a fair distribution of the financing French and Italian rankings as the olive oil
burden. These factors were weighted after a effect, the possible result of the renowned
survey of 1 000 respondents, so that health and presumably healthy Mediterranean
(disability-adjusted life expectancy) received diet, rather than as a function of the health
half the weight, and responsiveness and fair system as such. Even with this broader defi-
financial contribution 25 % each. nition, curative health services are given a
The ranking of health attainment resulted heavy weight. For example, fairness in fi-
in a list with the high-income countries all nancing and responsiveness apply only to
coming high up on the list, while the poor- the curative part of the health system. It is
est countries are found at the bottom. What likely that the emergence of new data will
WHO terms performance, i.e. achievement result in changes, possibly great changes, in
relative to resources, is the ultimate measure the country rankings.
of the analysis. In colloquial terms: who It is interesting to note that WHO in the
gets most bang for their buck. yearbook of 2003 is returning to the pri-
The ranking of performance thus gives a mary health care concept from 1978 (WHO
different ranking from that of attainment as 2003). This is a more political than techni-
described above, although the two measures cal framework for health policy. It may take
tend to be quite closely associated. The rich several years to generate the data that is
C countries still figure in the upper part of the needed to make the more evidence based
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table, and the poorest countries still end up assessments of health system performance
far down the list. that were suggested in the 2000 report. An-
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In this ranking, France was number one, nual publishing by WHO of national health
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followed by Italy. Surprisingly, the Nordic accounts, that means the basic economic

data about the health systems of all coun- cepts of traditional and modern medicine.
tries, will create a basis for such assess- However, this changed radically during the
ments. 1980s and 1990s. The World Bank and others
pointed to government failures such as
bureaucratisation and inefficiencies in the
11.10 Public and private health public provision of health service. The sug-
gested alternative was to introduce more
care market mechanisms in health care. Those ar-
Today, the balance between public and pri- guing for health systems based on govern-
vate health care provision and financing is a ment provision and financing of services,
major health policy issue in almost all coun- such as those found in Sweden and the
tries. It is generally referred to as the issue of United Kingdom emphasised the market
public/private mix. But in global health pol- failures associated with health markets.
icy this is a debate of fairly recent origin. The They claimed that market solutions that
Primary Health care Strategy from 1978 did function in other sectors would result in
not even mention private provision of market failures if applied in the health sector.
health care. It was taken for granted that gov- In essence, the three causes of market fail-
ernments were the sole or main providers of ure presented in Box 11.4 speak against view-
health care. If two types of health care were ing most parts of health care as a commodity
discussed it was mostly regarding the con- to be bought and sold in the marketplace.
Box 11.4
Market failure
Market failure is a concept in economic the- service. Consequently, measles vaccina-

ory. The background is the theory that a to- tion presents a good case for govern-
tally free market, in which suppliers and cus- ment involvement.
tomers meet at the marketplace, is the most 2 Public goods are those products or serv-
effective mechanism to make products and ices that cannot be divided and sold, and
services available at prices customers are where the consumption by one individ-
willing and able to pay. Economists recog- ual does not prevent other individuals
nise three situations where the free market is from enjoying the benefits. Clean air and
not the most effective mechanism to allo- defence are typical examples of public
cate resources and to decide what and how goods, and the eradication of a disease
much to produce. such as smallpox is another. Polio will
1 Externalities are effects, positive or nega- never be eradicated if individuals are
tive, which occur outside the actual asked to buy immunisations for polio at
transaction. Immunisation against mea- market prices; the global community has
sles is a typical example of a health action to step in to ensure the benefits that will
with strong positive externalities. If I vac- ensue for all of mankind to achieve the
cinate my child, I protect not only my goal.
child but also my neighbours child and 3 Information asymmetry occurs if the med-
visitors children from contracting this po- ical professional knows more about the
tentially lethal disease. Society as a whole need for and probable benefits from a
C benefits from parents who choose to im- certain treatment than the patient; the
munise their children against measles. In latter will then not be in the best position
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a pure free-market situation, this would to assess whether the price for the service
Y lead to under-provision of this particular is what is worth paying.
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11.10 Public and private health care
THAILAND, Bangkok. Street dentist.

Jean-Lo Dugast/PHOENIX.
Even for the most hard-nosed neo-liberal contributed to several of the government
economist, there is a clear case for govern- failures.
ment involvement in health care, in partic- In theory, the definitions of public and
ular with regard to the financing and regula- private should be clear. Public refers to gov-
tory aspects. The public/private issue is often ernment ownership, and private to every-
confusing, unless the differences between thing else. In reality, the picture is more ob-
health services provision or health services scure. Government may involve public enti-
financing is made clear. Examples are given ties at different levels, from the national
in Table 11.3 (Newbrander 1992). level down to the districts or municipalities.
All kinds of public and private combina- Shared ownership between public bodies
tions are possible, and there are develop- and private interests is also possible. Former
ments in each country in different direc- government staff may take over and collec-
tions. In many countries public provision of tively run former government clinics.
financing-dominated health care formerly The private sector in itself has many faces.
tended to be sanctified, and it was seen as For-profit bodies, i.e. companies, own and
inappropriate to do business in this connec- run facilities in some countries for the pur-
tion. Costs were seen as unimportant, and it pose of making a profit. In other countries,
C was even considered unethical to introduce religious societies or foundations may dom-
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economic considerations in the choice of inate private ownership of health facilities.
treatment and in the organisation of health Large not-for-profit organisations tend to
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services. The best possible care was supposed act more like government bodies. Individual
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to be provided to all citizens. This attitude profit motives in the formally not-for-profit

Table 11.3 The components of public/private mix.
Provision
Public Private
Financing
Not-for-profit For-profit
Public Free health care in a Government subsidy Contracted private provid-
government facility to a church hospital ers of free care
Private User fees in a Private insurance Paying for surgery in a
government hospital private hospital
Source: Adapted from Newbrander 1992.
sector may influence policies through what ise its contribution to the health of the pop-
is known as rent-seeking. ulation.
The international health debate has hith- The stewardship role of the government,
erto been dominated by discussions about including its regulatory institutions, be-
governments role in the provision of health comes all-important in guiding the health
care. These discussions have often not system to maximum efficiency within each
reflected reality. The private sector tends to given context.
be more important in both the provision
and financing of health services in low-
income countries than in the high-income
countries. In a country like China, 80 % of 11.11 Is it possible to construct
health financing is private. In most coun- an effective health
tries, between 30 and 90 % of total pharma-
ceutical spending comes from private
system?
sources. Traditional medicine is mostly a There is no simple and clear guide of how to
private activity and in some countries infor- organise health systems. It is difficult, prob-
mal provision of services and sale of drugs ably even impossible, to assess a health sys-
dominates the government and officially tem in a scientific way and arrive at clear
registered private services. conclusions as to where it is better or worse.
Today, efforts are being made to find new What is clear is that, with a public health
and more effective relationships between budget of less than USD 10 per person per
the public and private sectors, e.g. in the year, it is impossible to provide decent basic
form of contractual relationships or man- health service for all of the citizens in a
aged markets, with services of various kinds country. And, indeed, today many low-
being contracted out to the private sector. income countries are to be found in this sit-
No one has been able or willing to provide uation. A Minister of Health in one of
a prescription for the role of the private sec- Africas poorest countries used to tell the
tor that could be applied in different coun- allegory about a man that was trying to sleep
tries. Apart from historical political influ- during a cold night with a very small blanket
ences, the differences in culture, social and (Box 11.5).
economic factors make for different solu- For countries spending a hundred times
tions in different countries. But there ap- or more on their health care, it seems clear
C pears to be one common conclusion: that al- that they should be able to organise their
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though the private sector can complement health systems in such a way that all of their
public health provision and provide some people have access to reasonable health
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types of service better, it cannot lead the care. But even in such cases, it is hard to
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health sector in a direction that will maxim- come to any definite conclusions. And cer-

11.11 Is it possible to construct an effective health system?
Box 11.5
Trying to sleep under a small blanket
It was a cold night. The man first covered his the blanket was not elastic and his stretch-
legs and feet with his small blanket, but he ing resulted in him tearing the blanket into
could not fall asleep because his head was useless small pieces. With a number of use-
too cold. He moved the blanket to cover his less minute pieces of blanket he suffered
head but then his whole body started to sleepless throughout the cold night.
shiver. He decided that it was wiser to place
An allegory about the available choices for a
the blanket over his body, but in vain, his
Minister of Health in an African low-income
feet and head remained too cold to enable
country.
him to sleep.
In panic he then decided to stretch the blan-
ket so that it covered his whole body. But
tainly cultural and socio-economic variables References and suggested further reading
have great significance for the appreciation Anonymous. A barefoot doctors manual
of the services by the population. Neverthe- (Translation into English) Philadelphia:
less, the evidence seems to point to the fol- Running Press; 1977.
lowing conclusions, as a preliminary guide- Berman P (ed). Health Sector Reform in
line for policy-makers. Developing Countries. Making Health
1 There is no set optimal ratio between Development Sustainable. Boston: Har-
public and private provision of health vard School of Public Health; 1995.
services; it varies depending on circum- Creese A, Floyd K, Alban A, Guinness L.
stances. Cost-effectiveness of HIV/AIDS interven-
2 Governments have an important role to tions in Africa: a systematic review of the
play as stewards of the health care system, evidence. Lancet 2002;359:163543.
including responsibility for regulation of Culyer AJ, Newhouse JP (eds). Handbook of
private providers. Health Economics. Elesvier; 1999.
3 Equitable access to health care can only Dubos R. Mirage of Health. Utopias, Progress
be achieved when the government takes a and Biological Change. New York: Harper
major responsibility for the financing of Colophon Books; 1979.
health care, raising revenue through tax- Evans RG, Barer ML, Marmor TR (eds). Why
ation or through compulsory health are some people healthy and others not?
insurance schemes. The determinants of health of popula-
4 Out-of-pocket payment for health care tions. New York: Aldine de Gruyter; 1994,
should be limited to a minimum. Prepay- p. 201.
ment is preferable to out of pocket pay- Goodman CA, Coleman PG, Mills AJ. Cost-
ment. Pooling of resources is essential in effectiveness of malaria control in sub-
order to distribute risks and avoid cata- Saharan Africa. Lancet 1999;354:37885.
strophic health care costs. Govindaraj R, Chellaraj G, Murray CJL.
5 Fee-for-service payment encourages over- Health expenditures in Latin America
C
treatment and unnecessary interventions. and the Caribbean. Soc Sci Med 1997;
M 6 Fragmented purchasing functions create 44:157169.
Y inefficiency. Gwatkin DR, Guillot M, Heuveline P. The
burden of disease among the global poor.
K
Lancet 1999;354:5869.

Jolly R (ed). Jim Grant UNICEF visionary. Roemer, MI. National Health Systems of the
Jim Grant foundation; 2001. World, Volume II. The issues. Oxford Uni-
Koop CE, Pearson CE, Schwarz MR (eds.). versity Press; 1993.
Critical Issues in Global Health. San Fran- Saltman RB, Ferroussier-Davis O. The con-
cisco: Jossey-Bass, A Wiley Company; cept of stewardship in health policy. Bul-
2001. letin of the World Health Organisation,
Lee K, Buse K, Fustukian S (eds). Health Pol- 2000;78:73239.
icy in a Globalising World. Cambridge: Sachs J. Report of the commission on macro-
Cambridge University Press; 2002. economics and health. WHO; 2001.
McKeown T. The Role of Medicine, Basil Shaw RP, Elmendorf AE. Better health in
Blackwell; 1979. Africa. Experiences and lessons learned.
Nitayarumphong S (ed). Health care Reform. World Bank; 1994.
At the frontier of research and policy deci- Townsend P, Davidson N. Inequalities in
sions. Bangkok: Office of Health care Health (The Black Report). Harmonds-
Reform, Ministry of Public Health; 1997. worth: Penguin Books; 1982.
Newbrander W, Parker D. The public and pri- Victora CG, Wagstaff A, Schellenberg JA,
vate sectors in health: economic issues. Gwatkin D, Claeson M, Habicht JP. Apply-
International Journal of Health Planning ing an equity lens to child health and
and Management 1992;1:3749. mortality: more of the same is not
Powell F, Wesser AF. Health care Systems in enough. Lancet 2003;362:23341.
Transition. SAGE Publications; 1999. Walt G. Health Policy: an introduction to
Lees DS. Health through choice. Institute of process and power, London: Zed Books;
Economic Affairs, Hobart Paper no. 14, 1994.
London; 1961. Wildavsky, A. The art and craft of policy
Sachs JD. Report of the Commission on analysis. MacMillan Press; 1979.
Macroeconomics and Health. 2001. World Bank. World Development Report.
www.cmhealth.org Investing in health. Oxford University
McPake B, Mills A. What can we learn from Press; 1993.
international comparisons of health sys- World Bank. Better Health in Africa: Experi-
tems and health system reforms? Bulletin ence and Lessons Learned. The Interna-
of the World Health Organisation 2000; tional Bank for Reconstruction and Devel-
78:811820. opment, Washington, DC: 1994.
Murray CJL, Evans DB. Health System Per- WHO. Primary Health care. Report of the
formance Assessment debates, methods International Conference on Primary
and empiricism. WHO; 2003. health care, Alma-Ata, USSR, 612 Sep-
Roemer MI. National Health Systems of the tember 1978.
World, Volume I. The countries. Oxford WHO. World Health Report 2000. Health
University Press; 1991. Systems: Improving Performance.
WHO World Health Report 2003.

11.11 Is it possible to construct an effective health system?

12 Global health collaboration
For older readers the yellow vaccination cer- sis is put on what previously was called aid
tificate that not very long ago had to accom- relationships, nowadays termed interna-
pany any intercontinental travel was the tional development co-operation. But it
most visible example of international health should be remembered that much of these
collaboration. The certificate with the logo collaborations originate from self-interest
of the World Health Organization, stands such as the need to combat infections in
for one very obvious justification for co-op- other countries. This may however not be a
eration in health. Preventing the spread of bad motivation. Other forms of collabora-
infectious diseases was one of the original tion may also be motivated by reasons other
reasons and remains a major reason for than altruism, such as a quest for profit or
countries around the world to work together political influence.
in the field of health.
To some the eradication of smallpox in
1977 under the leadership of WHO, the suc- 12.1 The role of global health
cessful work of UNICEF to reduce childrens
deaths and suffering through cost-effective
collaboration
interventions and protection of breastfeed- The health sector today represents one of
ing, and the enormous power of the World the largest sectors in the world economy,
Bank, to guide countries expenditure on having a total turnover that is today around
health care stand as visible examples of mul- two and a half trillion US dollars and it
tinational health collaboration over the last employs some 35 million people worldwide
decades. For others membership in organi- (table 12.1). The health sector constitutes
sations such as the Red Cross or one of the almost 10 % of the world economy.
many faith-based organisations that are Out of the 6 billion people in the world 5
heavily involved in health service all over million live in low and middle income
the world, may provide the framework for a countries. These 5 billions suffer from 93 %
personal involvement in global health col- of the global burden of disease but have
laboration. only access to 11 % of the total resources for
Sometimes these efforts appear important health care. More than 40 % of the worlds
or even vitalsuch as the teams that are health care resources are spent in the United
sent out to deal with outbreaks of Ebola or States. In 2001 the health care spending in
the Severe Atypical Respiratory Syndrome the US accounted for an unprecedented
(SARS). In other cases the bureaucratic proc- 14.1 % of the total US economy. This means
esses in international organisations or an average of over USD 5 000 per person,
doubtful policies merit criticism. What mer- which is some 500 times more than the
its most critique is that the world has not amount spent on health care per person in
C managed to do more to reduce the suffer- the poorest countries in the world. The most
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ings from diseases. important message in this chapter is that
This chapter provides an overview of the the entire international health collabora-
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need for global health collaboration and re- tion only accounts for 6 billion USD. Even
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views the main current players. An empha- in the low-income countries the interna-

12.1 The role of global health collaboration
Table 12.1 Summary of the economic size of the health sector in world economy.
Total sum in current USD Percent of the above
Total global income 30 000 000 000 000

Global health care costs 2 400 000 000 000 8%
Health care in low & middle-income countries 106 000 000 000 4%
Global development aid health care 6 000 000 000 6%
Source. Commission for Macro Economics and Health, WHO 2001.
tional contribution to the health sector is The overall official development assist-
only 10 % of the total health spending. The ance (ODA) in the world has continued to
relative insignificance of this contribution fall, by almost 20 % in real terms, from USD
in relation to total health spending in the 62 billion to USD 53 billion since 1992. To-
poorest countries, tells us that by far the day, it has reached an unprecedented low of
greatest share of the costs of health care is 0.22 % of the combined national product of
borne by the individuals and countries the high-income countries that contribute
themselves. This is true for practically all money to international development assist-
countries, and particularly the large ones, ance. This statistics is compiled by Organisa-
such as China and India, where external tion for Economic Co-operation and Devel-
support accounts for only a minute share of opment (OECD) that has a Development
their total health care costs. In China the in- Assistance Committee (DAC) providing sta-
ternational health collaboration only ac- tistics on international development assist-
counts for less than 1 % of the expenditure ance.1 The share of the health and popula-
in the health sector. (Pouiller 2002). tion sectors has risen from 7 % in 1990 to
For all of Sub-Saharan Africa, excluding 11 % in 1997 (Musgrove 2001, DAC 2002).
South Africa, 20 % of health expenditure When it comes to the health services as
comes from external sources. There are a few such, certain areas have traditionally been
countries in Africa where the contributions popular for donors, such as programmes
from external agencies and organisations ac- against leprosy or blindness as well as hospi-
count for a greater share of total health care tal constructions. Today external assistance
costs. An extreme example is Mozambique, tends to prioritise preventive rather than
where foreign aid accounts for 70 % of the curative programmes, rural areas rather than
health budget. cities, and specific interventions rather than
However, the flow of money between general reinforcement of systems. Highly
countries is likely to have a greater signifi- visible actions, for example the initiative to
cance than one might think. The aid funds eradicate polio, have been particularly at-
are not obligated beforehand for salaries or tractive areas for donor financing, while it
other fixed costs, and can therefore be used has been more difficult to get support for
more flexibly and for strategic purposes. general health systems infrastructure, except
They can also help to propagate new ideas, from the development banks. At present
to finance pilot projects and to disseminate support for HIV drugs is getting considerable
and try out ideas and solutions across na- funding in spite of a lower cost effectiveness
tional borders. These aspects enhance the compared to many other possible health in-
C value of the international flow of funds in terventions.
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relation to ordinary health budgets. It has
been suggested that their role in influencing
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priorities and policies is greater than the fig-
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ures may lead us to believe. 1
www.oecd.org/dac

12.1.1 History in the period between the two world wars.

Modern efforts to deal with epidemics can be The international sanitary convention was
traced back to the City of Venice in 1423. In revised in 1926 to include provisions against
that year the city established a permanent smallpox and typhus, and in the 1930s a
quarantine station for infected crews and new sanitary convention for aerial naviga-
goods on naval vessels. Ships arriving in Ven- tion came into force.
ice from infected ports were required to sit at During the Second World War the interna-
anchor for forty days before landing. This tional health work was neglected. However,
practice, called quarantine, was derived from in 1945 the United Nations Conference on
the Latin word quadraginta, meaning forty. International Organisation in San Francisco
The station was placed on an island with a unanimously approved a proposal by Brazil
monastery called San Lazaretto Nuovo out- and China to convene an International Con-
side Venice. The quarantine station became ference of members of the United Nations
known as in lazaretto and this word devel- with a view to establishing a new, autono-
oped a wider meaning. Lassarett is the mous, international health organisation.
word for public hospital in Swedish and in The ensuing International Health Confer-
many other languages. More far-reaching ence that was held in New York in the sum-
measures, in the form of pest houses, mass mer of 1946 approved, on its final day, the
house quarantines and cordons sanitaires constitution of the new World Health Or-
around metropolitan areas, were taken to ganization, replacing the pre-existing inter-
prevent the spread of bubonic plague in national health organisations. On 7 April
Europe in the 1630s. 1948, a date that is now marked as the
Modern health collaboration between World Health Day, the WHOs Constitution
countries is a consequence of the first Euro- came into force.
pean outbreaks of cholera starting in Lon- As will be described below WHO has
don 1832.1 Cholera constituted the immedi- largely focused on reducing the global bur-
ate reason for the convocation of the first in- den of diseases with a focus on the poorer
ternational sanitary conference in Paris in countries. The traditional reasons for health
1851. But it took almost 40 years and a co-operation across borders, such as con-
number of international health conferences tainment of infectious diseases and func-
to produce the first agreement: the Interna- tions to make international comparisons
tional Sanitary Convention, in 1892. such as a unified disease classification, are
Another international convention dealing still valid. But the global environment is
with plague was adopted five years later, but changing faster than ever before, providing
then it took only a few more years for the new opportunities as well as posing new
first structures for a continuous interna- threats that require new forms of collabora-
tional co-operation in health to be estab- tion. As this chapter shows there is a grow-
lished. It was the International Sanitary Bu- ing number of international health organi-
reau for the Americas, the forerunner of to- sations and initiatives.
days Pan American Health Organization Many nations now face the double bur-
(PAHO), which was founded in 1902 in den of both tackling the largely preventable
Washington DC, and the Office Interna- and curable health problems affecting their
tional dHygine Publique (OIHP), which poor, while, at the same time facing the new
was established by eight countries in Paris in disease burden associated with ageing popu-
C
1907. The latter remained even when the lations. In addition, the health problems of
M League of Nations was created and set up its development, such as pollution and altered
Health Section in Geneva, which was active lifestyles, entail new health threats.
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Globalisation and increased international
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1
www.ph.ucla.edu/epi/snow/snowbook trade expose people to health risks that stem

12.1 The role of global health collaboration
from causes that are trans-national in na- proliferation of UN organs, multilateral de-
ture, such trade in food and hazardous prod- velopment banks (MDBs) and national
ucts, and environmental changes in climate, agencies for international development co-
as well as air and water quality. Trade is im- operation. Although not semantically cor-
portant for health not only due to trade in rect the latter are often known as bilateral
health-related goods but also with regard to agencies. Though USAID in the US, DFID in
trade in health services and migration of U.K., Norad in Norway and Sida in Sweden
trained health staff. The consequences of IT may have bilateral agreements with other
and the Internet have only begun to countries they are definitely national agen-
emerge. There are health risks from unregu- cies that are responsible to their respective
lated sales of pharmaceuticals and other governments.
products over the Internet, as well as un- Regional international organisations such
tapped opportunities for health systems to as the EU are becoming more important as
become more responsive and effective and are the philanthropic foundations based
for health education to have greater impact. largely in the US. The result is a complex
The future is characterised by increasingly web of players and public-private partner-
complex health challenges, globalisation and ships, with sometimes confusing and over-
increasing interdependence, a dramatic in- lapping mandates and functions. These or-
crease in ease of communications, a vastly ex- ganisations come in many shapes and
panded traffic in goods, services and persons forms. For clarity it may be useful to struc-
across borders, and the emergence of new ture them in categories as show in box 12.1.
players in the international health arena. In reality, the situation is not as clear-cut
as indicated above. There may be combina-
tions, for example, an NGO working on a re-
12.1.2 A classification of organisations gional or international basis. An ongoing
A whole new range of players are entering globalisation of NGOs has yielded the term
the international health arena, on top of the INGOs, for International Non- Governmen-
Box 12.1
Categories of organisations with international health activities
International ernments in bilateral co-operation agree-

Organisations based on several governments.
ments, such as those belonging to the UN
family. Can be sub-divided into UN pro- Non-governmental
grammes and funds, and UN specialised Private, not-for-profit and non-governmen-
agencies. The programmes and funds are tal organisations (NGOs) that may be na-
not member organisations with assessed tional or international. They may either be
contributions from member states. Used to member organisations (with individuals as
be called multilateral organisations. members) or umbrella organisations (with
other organisations as members).
Regional
Organisations based on collaboration be- Philanthropic foundations
tween governments in one geographical Expression used mainly in the US for institu-
area. tions handling considerable private dona-
C tions for international development.
National
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Government agencies in one country that Industry & corporations
Y deal directly (one-to-one) with other gov- For-profit entities.
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tal Organisations. National governments work. It is also one of the largest specialised
have no control of the INGOs that mostly agencies in the United Nations family.
also stand independent and outside demo- WHOs role as a specialised agency is based
cratic control. They are most often regis- on the United Nations Charter and its objec-
tered as a charity foundation in each coun- tives, as expressed in Article 55 as a pledge to
try and operate under the leadership of self- promote solutions of international, eco-
nominated boards. nomic, social, health, and related problems.
Industry is usually taken to be private, but WHOs founding fathersand it was,
there are also companies with a greater or indeed, an exclusively male club at the
lesser degree of government ownership. timeprovided the organisation with a Con-
Many national agencies also commission the stitution which defined health more broadly
implementation of their bilateral collabora- than ever before, in the now famous words:
tion with low and middle-income countries
Health is a state of complete physical,
to private consulting companies. NGOs may
mental and social well-being, not merely
be organised in different ways and classified the absence of disease or infirmity.
according to the laws of different countries.
There are also institutes and organisations The organisation that was set up was pro-
that are semi- or partly owned or influenced vided with a headquarters in Geneva and six
by governments, although appearing as regional offices: in Alexandria (recently
NGOs. The term civil society organisations moved to Cairo), Brazzaville, Copenhagen,
(CSOs) is sometimes used in a broad sense to Manila, New Delhi and Washington. Its
include NGOs as well as looser networks and highest policy-making body was determined
other types of non-state collaboration. to be the World Health Assembly, WHA,
which consists of representatives of all the
member states and which usually meets in
Geneva in May every year. The Assembly
12.2 International elects an Executive Board with 32 members,
representing the various regional groupings.
organisations The day-to-day affairs of the WHO are han-
12.2.1 World Health Organization, WHO dled by the Secretariat and tasks are distrib-
(UN specialised agency) uted between the headquarters, the regional
offices and country offices in low-income
Established 1948 countries, which are headed by the World
192 member states
Health Organization representatives, known
Annual budget: Regular budget USD 428 million,
extra-budgetary resources USD 690 million as WRs.
(annual average of biannual budget 2002 to In 1998, WHO celebrated its 50th anni-
2003) versary. The organisation could then look
Staff: 3,800 back upon a period of unprecedented health
Web site: www.who.int
gains in the countries of the world, includ-
World Health Report available on-line at:
http://www.who.int/whr ing the first ever eradication of a disease
pathogen from the earth (the smallpox vi-
rus). However, it was also a period of major
WHO is the truly global health organisation setbacks, such as the failed attempt to eradi-
for the worlds nations. It is the specialised cate malaria, and even more importantly, a
C agency within the UN system that is en- period that saw an increasing disparity in
M trusted to handle health and medical issues. health between the richest and the poorest
It has, according to its Constitution, the countries.
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function to act as the directing and co-ordi- The backbone of WHOs finances are the
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nating authority on international health assessed contributions which could be seen

12.2 International organisations
as the membership fees from the member role is to direct international health work
states. Applying the UN scale of assessment, and to set global standards for health ac-
each country has to pay an amount in pro- tions. These functions are generally referred
portion to its gross national product. These to as the normative functions. WHO also has
contributions make up the regular budget, an important role, as foreseen in the Consti-
which finances the basic structure and work tution, to co-operate with governments to
of WHO. reinforce national health programmes and
The regular budget is allocated with to develop and transfer appropriate health
roughly one-third to global and interre- technology and information.
gional work, including the cost of the head- Among todays priority programmes, the
quarters with the remainder divided among Roll Back Malaria Initiative (RBM) and the
the regions. On top of that come the extra- Tobacco Free Initiative (TFI) are prominent
budgetary funds, which are voluntary con- among continued efforts in areas such as
tributions for specific purposes from mem- tropical diseases and tuberculosis, injury
ber states and, for that matter, from organi- prevention, non-communicable diseases
sations or even private individuals. The vast and immunisation, including polio eradica-
majority of these contributions originate tion, for which WHO is the lead agency.
from the development co-operation budgets The World Health Assembly in May 2003
of the rich countries. A problem has been unanimously adopted the Framework Con-
the policy of zero growth of the regular vention on Tobacco Control which is the
budget that was established by the World first of its kind, further strengthening
Health Assembly in the early 1980s WHOs role in global health development.
(Vaughan et al., 1996). Therefore, the organ- The International Agency for Research on
isation has had to rely increasingly on extra- Cancer in Lyon is closely affiliated with
budgetary contributions. These extra-budg- WHO.
etary resources have in recent years come to It should also be mentioned that WHO
exceed the regular budget and now consti- has strengthened its capacity to analyse and
tute well over 60 % of the funds made avail- work with health policies in a broad sense,
able for WHO. including economic aspectswhich became
Together with the United States, the Nor- dominated by the World Bank in the last
dic countries were for many years the major decade. There is also an effort to connect
contributors of extra-budgetary funds, WHOs work to an analysis of the relation-
which were channelled to some of the major ship between poverty and health, and be-
programmes of WHO, such as the pro- tween health and poverty.
grammes for research on human reproduc- A new step in this direction was taken in
tion and on tropical diseases. Today, other 2001, through the work of the Commission
countries, such as Japan and Italy, have also on Macroeconomics and Health, chaired by
become important donors to WHO. Extra- Jeffrey Sachs. The commission has come far
budgetary funds have been channelled pre- from the ideological vision of WHOs Pri-
dominantly to large and vertically managed mary Health Care Strategy in 1978, although
programmes in the areas of disease control, it basically discusses the same issues. The ar-
health promotion and human reproduc- gument for health is no longer only that
tion. By contrast, about 70 % of the regular health is a goal in itself but also that health
budget expenditure has been for organisa- is an important factor for economic growth.
C tional expenses and for the support of pro- The commission calculated the overall addi-
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grammes in the area of health systems. tional resource needs for the low and mid-
It should be remembered that WHO is not dle-income countries to reach the millen-
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primarily a donor or technical assistance nium development goals (MDGs). This was
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agency for the poorest countries. Its main estimated to be possible with an increase of

their budgetary outlays for health with 1 % what extent the new directions will bear
of GNP by 2007, and 2 % of GNP by 2015 rel- fruit. Clearly the organisation is moving into
ative to current levels, and to increase donor areas that are more or less new to it. But if
spending for health to USD 27 billion in health is accepted as a concept that stretches
2007 and USD 38 billion in 2015. These cal- beyond the biomedical sphere, then these
culations were based on a cost for a package changes are necessary, and indeed overdue.
of essential health interventions of USD 34 In July 2003 Dr. Jong-wok Lee from South
per capita, a modest sum compared to the Korea succeeded Dr. Gro Harlem Brundtland
more than USD 2 000 per capita expendi- as Director General of WHO. He has particu-
tures in the high-income countries. The ad- larly committed himself to increasing the
ditional sum needed from abroad constitute country focus of the organisation, to inte-
only about 0.1 % of the GNP of the high-in- grate specific disease programmes into a
come countries. It would, however, consti- comprehensive effort to strengthen health
tute a considerable increase in relation to systems and to work towards the achieve-
what is today spent in the least developed ment of the Millennium Development
countries. From a present total of USD 13 per Goals. However, the major new initiative,
capita, of which public spending is USD 7 to launched in December 2003, has been the
a minimum of 34 USD per capita (Sachs very medically oriented so-called three by
2001). In its 2003 annual report WHO con- five initiative; an effort to ensure drug treat-
nects this analysis with a revival of the prin- ment for three million AIDS victims in the
ciples of the primary health care strategy developing world by 2005 (WHO 2003).
(WHO 2003).
It is inherently difficult for an organisa-
tion such as WHO to set clear priorities.
12.2.2 United Nations Childrens Fund,
Member states have different interests and
UNICEF (UN fund)
biases for different types of activities. The
United States has always been a strong sup- Founded in 1946
porter of technological interventions such Fund under UNDP, no members.
as immunisation and eradication pro- Executive board with 41 members representing
grammes. Russia has a particular interest in governments, elected by ECOSOC
Annual budget: USD 1,218 million (2001), of
chronic diseases. The Nordic countries have
which USD 336 million for direct health activi-
often advocated stronger action by WHO in ties
areas such as pharmaceuticals, alcohol and Staff: around 6 000, 85 % of which located in the
tobacco, while countries with strong indus- field offices
trial interests in these areas have tended to Web site: www.unicef.org
resist such actions. Thus, the Nordic coun-
tries were instrumental in the development
of the Code of Marketing of Breastmilk Sub- With its special mandate to work with chil-
stitutes in the early 1980s, while the only dren, UNICEF is a unique organisation. In
country to vote against this resolution to the very beginning, the mandate was specif-
protect breastfeeding was the United States. ically to help children in war-torn Europe
In spite of its broad definition of health, during the bitter winter of 1946/7. Its origi-
WHO has in the past tended to view health nal acronym was ICEF, for the International
from a predominantly medical perspective. Childrens Emergency Fund. When it was
C This could possibly be traced to the almost due to close down in 1950, nations from the
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total dominance of medical doctors among developing world mounted an effort to save
the professional staff. Under the Brundtland it, and succeeded. It then became the United
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administration (1998 to 2003), a change Nations Childrens Fund, but was given the
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began to appear. It is still too early to say to acronym UNICEF.

There is little doubt that UNICEF is the come, close to 64 % originates from govern-
best-known member of the UN family. This ments, and the remainder from private con-
is because it has a high media profile, with tributions, mainly through the national
a well-developed marketing function. committees and the sale of UNICEF greeting
UNICEF has an organisation that reaches cards and other products.
out to all countries through its national In the early 1980s, a few years after the pri-
committees, and it has consistently worked mary health care concept was launched, the
with problems where its impact can be competing concept of selective health inter-
measured and demonstrated. The organisa- ventions was developed. The essence of this
tion was awarded the Nobel Peace Price in strategy was to focus on a few essential
1965. health interventions in situations where a
With James Grant as its Executive Director more comprehensive solution might not be
between 1983 and 1995, UNICEF made a within reach. UNICEF immediately grasped
strong investment in health relative to its this idea and began a strong push for what it
two other main sector activities, education termed GOBI, an acronym standing for
and water/sanitation. In its promotion of growth monitoring, oral rehydration, breast-
the Child Survival Revolution in the 1980s feeding and immunisation.
and early 1990s, UNICEFs health activities After an immediate clash with WHO,
focused strongly on two particular technical which was promoting a broader vision of
interventions: oral rehydration (ORS) to primary health care, both parties reached an
treat diarrhoea, and immunisation. agreement. This agreement included that
UNICEF is organised with headquarters in UNICEF broadened its initially narrow GOBI
New York and eight regional offices, which approach to include three Fs: female educa-
have a more technical role, relative to the tion, food supplements and family plan-
WHO regional offices. UNICEFs presence is ning. WHO made adjustments and gave its
particularly strong in low and middle-in- wholehearted support to the interventions
come countries, with representation in over advocated by UNICEF that eventually be-
125 countries, with both international and came quite successful during the 1980s.
national employees. The supply division of The explicit link made by UNICEF be-
UNICEF, located in the Freeport of Copen- tween operations and advocacy for children
hagen, effectively procures a variety of prod- has probably been a contributing factor be-
ucts for developing countries, especially hind its successes. It seems clear that
drugs and vaccines. From a very small and UNICEFs critique has helped to mediate the
modest office in this major Danish port Structural Adjustment Programmes of the
UNICEF procures 40 per cent of the worlds International Monetary Fund in the direc-
doses of vaccine for children. tion of more protection of the social sectors,
A special feature of UNICEF is the exist- a policy called Adjustment with a Human
ence of national committees for the organi- Face. In recent years the advocacy function
sation. The main role of these committees is has developed in the direction of childrens
to inform the general public about UNICEF rights. Children in war situations have been
and its work, to raise awareness and interest of particular concern to UNICEF, including
in childrens issues, and to collect money for those affected by landmines or psychologi-
the organisation. As a UN fund, UNICEF re- cally traumatised by experiences of armed
lies wholly on voluntary contributions. The conflicts.
C United States has always been a strong sup- UNICEFs publications contain a wealth of
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porter of UNICEF and is the largest contrib- information about children, as well as annu-
utor in financial terms. The Nordic coun- ally updated statistics. The State of the
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tries are also important contributors on a Worlds Children, which is published annu-
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per capita basis. Out of UNICEFs total in- ally on 8 December, is a particularly useful

publication that 20 years ago initiated a sys- drawal of US funding in 1985, the US having
tematic monitoring of health and social de- previously been the largest contributor to
velopment in all the countries of the world. UNFPA.
In later years, and especially after the In-
ternational Conference on Population and
12.2.3 United Nations Population Fund, Development (ICPD) in Cairo in 1994,
UNFPA (UN fund) which was organised by UNFPA, the organi-
sation has become active in a broad range of
Established 1969 Sexual and Reproductive Health issues.
Annual budget: USD 396 million (2001)
Staff: About 1 000
Web site: www.unfpa.org 12.2.4 United Nations Development
Programme, UNDP (UN
programme)
Demographic statistics have always been
part of the work of the United Nations, The major technical co-operation programme of
which has a specialised population division the United Nations
Open to all members of the specialised agencies
in its New York headquarters for that pur-
and commissions
pose. However, the concern of the rapidly Founded in 1965
growing world population that started to Annual budget: USD 283 million (average of
emerge in the 1950s, and the consequent in- 20022003)
terest in family planning activities was for a Staff: 5 300
Web site: www.undp.org
long time too politically sensitive an issue
for the United Nations. Thus, it was not
until 1969 that the United Nations Fund for
United Nations Development Programme is
Population Activities, UNFPA (today United
the major organisation dealing with devel-
Nations Population Fund), was created.
opment issues in the UN system. It works
UNFPA is a fund comprised solely of volun-
under the auspices of the Economic and So-
tary contributions, working under the aus-
cial Council, ECOSOC, of the central UN ad-
pices of the UNDP. UNFPAs mandate is four-
ministration. UNDP is the worlds largest
fold:
voluntarily funded international technical
1 to build knowledge and capacity to re- assistance organisation.
spond to needs in population and family UNDPs overriding priority is poverty
planning; eradication. The main activities today are
2 to promote awareness of population prob- human resources and institutional develop-
lems; ment. The organisation does not generally
3 to assist developing countries, on request, deal with specific health issues, although it
to deal with their population problems; is an active partner in some of WHOs spe-
4 to play a leading role in the UN system to cial programmes, especially in the pro-
co-ordinate projects in population. gramme for Research and Training in Tropi-
cal Diseases (TDR). It is also a major partner
In its early years, UNFPA focused strongly in UNAIDS (see below).
on support for family planning pro- UNDPs history has been marked by criti-
grammes, in addition to its population sta- cism for weak performance and by recurrent
C tistics work. Some of its activities, especially funding crises. However, with offices in 132
M its large-scale support for the population countries, it does have a special role in co-
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programme in China that had coercive as- ordinating UN activities. This role may be-
pects, have been heavily criticised. Among come more important with the new mecha-
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other things, this resulted in the total with- nisms for UN agency collaboration, such as

UNDAF (United Nations Development As- well as some others. IBRDs cumulative lend-
sistance Framework). ing as of mid-1999 had reached USD 454 bil-
UNDP annually produces the Human De- lion.
velopment Report1, which in recent years IDAs goal is to reduce poverty in low-in-
has featured ranking lists of countries ac- come countries. IDA is different from the
cording to their general development status WB, as it is financed by grants from donor
and not just their economic power. This countries, which are replenished every three
Human Development Index has become years. IDA lends money at heavily subsi-
well known in large parts of the world. dised rates, through what are known as soft
UNDP has been given a special role to co-or- loans. The real value of an IDA loan ap-
dinate the UN effort to monitor progress to- proaches an outright grant.
wards the Millennium Development Goals The focus of IDA operations is on the
and to assist member countries to set and poorest countriesthose with a per capita
monitor their own development goals. income of less than USD 1,500 and not con-
sidered creditworthy for commercial loans.
In practice, the limit is lower, around USD
12.2.5 World Bank, including IDA
930. Above that limit there are a number of
Usually known as the World Bank, WB countries that are eligible both for IDA and
Established: 1945 IBRD loans and above that category there
Owned by its member countries, which have vot- are countries that are eligible only for IBRD
ing rights according to the size of their contribu- loans. Countries with a per capita income
tions.
above USD 5,445 will not receive any sup-
Annual budget: Disbursements of USD 1 046
million for health (1997) port from the World Bank group. Countries
Web site: www.worldbank.org may graduate from one category to an-
other. Thus, China was removed from the
list of eligible countries for both IBRD and
The World Bank group, or as it also is called, IDA loans and moved into the category of
the Bretton Wood institutions, originated in only IBRD loans on 30 June 1999.
1944, and developed in the aftermath of the With the exception of population
Second World War. Today, this group con- projects, which emphasised family plan-
sists of five associated institutions with the ning activities, the World Bank did not enter
International Bank for Reconstruction and the health field for a long time. Many coun-
Development (IBRD) and the International tries have also thought that it would be
Development Association (IDA) being the wrong to borrow money for health care pur-
major ones. The term the World Bank is poses. However, this has now changed.
often loosely used to include the IDA. Since the early 1980s, the Bank has become
IBRDs aims are to promote sustainable more and more involved in the health and
economic development and to reduce pov- social sectors. Today, it is the most impor-
erty, primarily by providing loans at basically tant player in the international financing of
commercial interest rates. Borrowing on the health services in low and middle-income
ordinary financial markets finances IBRD. countries.
Obviously, the banks activities have to be fo- The Bank has also become more active in
cused on infrastructure and on economically health policy issues, as marked by the publi-
viable projects. IBRD only lends money to cation in 1993 of its annual World Develop-
C countries that are considered to be creditwor- ment Report under the theme: Investing in
M thy, i.e. able to pay back their loans. This Health. This publication has been hailed as
principle excludes the poorest countries, as a landmark report. For the first time it em-
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ployed a combination of burden-of-disease
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1
www.undp.org/hdr2003 and cost-effectiveness arguments to propose

a health policy agenda for countries in vary- Global AIDS Strategy. Other UN organisa-
ing circumstances. tions started their own AIDS initiatives, al-
The World Bank has been heavily criti- though, as commonly occurs, the co-ordina-
cised for its support of the Structural Adjust- tion of policies, strategies and support activ-
ment Programmes (SAPs) that the Interna- ities rapidly became a problem. With time it
tional Monetary Fund (IMF) imposed on was found that HIV/AIDS, as a threat to
countries as a condition for lending money health, concerned many sectors in society
to support or save their macroeconomic sta- outside the health sector, which so far has
bility. The SAPs involved a requirement to not been in a position to provide a cure for
cut down on government expenditures, the disease. Thus, it was thought that HIV/
often in the social sector, thereby hurting AIDS, rather than remaining the responsi-
the poor most. Such criticism has also been bility of the health sector, as a WHO pro-
levelled by other UN agencies. UNICEF programme, it should be a joint responsibility
duced a report entitled Adjustment with a within the UN system.
Human Face, advocating structural reforms After a lengthy investigation, it was fi-
which would not have such a negative effect nally agreed in 1996 to dismantle the old
on the poor. structures and establish a new, joint, co-
Gradually the Bank has listened to the cri- sponsored UN programme, the Joint United
tique, and the adjustment programmes have Nations Programme on HIV/AIDS, bringing
been modified in order to better protect the together six agencies: WHO, UNDP,
poor. At the end of the 1990s the term UNICEF, UNFPA, UNESCO and the World
heavily indebted poor countries, HIPC, was Bank, today expanded by two more UN or-
coined in connection with the emerging dis- ganisations.
cussions on debt relief. The idea of this is The aim of this programme, entitled UN-
that, instead of having to repay excessive AIDS, is to lead, strengthen and support an
debts, countries will instead finance essen- expanded response aimed at preventing HIV
tial social services, as agreed with the credi- transmission and alleviating the impact of
tors through what are known as Poverty Re- the epidemic. Four objectives have been set
duction Strategy Papers, PRSP. This process to fulfil its role:
is still in an early stage, but in some coun-
tries, such as Tanzania, considerable to foster an expanded national response,
amounts of local funds have been injected particularly in developing countries;
into the health sector through the debt re- to promote strong commitment by gov-
lief process. ernments to an expanded response to
HIV/AIDS;
to strengthen and co-ordinate UN action
on HIV/AIDS at the global and national
12.2.6 UNAIDS (UN co-sponsored
levels;
programme)
to identify, develop, and advocate inter-
national best practice.
Established 1996
Headquarters in Geneva
Annual budget: around USD 30 million UNAIDS has been successful in lowering the
Staff: over 250 prices on antiretroviral drugs and on im-
Web site: www.unaids.org
proving the monitoring of the HIV pan-
C demic. Regarding the main task to curb the
When the threat of HIV/AIDS became a real- epidemic through preventive measures the
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ity in the mid 1980s, WHO established a challenge remains.
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unit to deal with the pandemic, the Global
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Programme on AIDS (GPA), and launched a

12.3 Regional organisations
12.2.7 World Trade Organisation, WTO conventions and codes dealing with nuclear
safety, with particular relevance to the pro-
Established 1995 as a successor to GATT tection of public health.
Main objective: to help international trade to
The United Nations Environmental Pro-
flow smoothly, freely, fairly and predictably.
More than 130 member countries gramme, UNEP, deals with environmental
Annual budget: USD 80 million matters of obvious concern to health, while
Secretariat based in Geneva with 500 staff. the United Nations High Commissioner for
Web site: www.wto.org Refugees has a mandate that encompasses
health for refugees. The UN Commissioner
for Human Rights is becoming increasingly
Outside the UN family, the World Trade Or- important as rights issues gain prominence
ganisation, WTO, in its aim to reduce barri- on the health agenda. The United Nations
ers to trade, is becoming increasingly impor- Educational, Scientific and Cultural Organi-
tant in dealing with trade in health-related sation, UNESCO, deals with the area of re-
goods and in products that can influence search and science, with a particular empha-
health. In the Doha agreement of 2001, it sis on biomedical science.
was agreed that developing countries might
obtain patented drugs of particular public
health importance (especially for HAART
treatment of HIV/AIDS) on special condi- 12.3 Regional organisations
tions, through what is known as parallel im- Examples of regional organisations involved
port or compulsory licensing. This is to off- in health co-operation include the regional
set the effects of the current rules on intel- development banks (MDBs), which have in-
lectual property rights in the world trading creased their lending for health projects
system, knows as TRIPS (trade-related as- with a method of operation that resembles
pects of intellectual property rights) that the World Bank group.
makes patented drug inaccessible to the The UN regional economic commissions,
poor in the world. one for each continent, also have a role to
play, albeit a minor one in health.
One of the particular aims of The Euro-
12.2.8 Other international organisations pean Union is the protection of public
To deal in detail with all the principal organ- health within the Community. It encour-
isations in international health lies beyond ages co-operation between the Member
the scope of this book. However, it should States in the field of health. It comprises one
be mentioned that a large number of other of the larger development co-operation
organisations besides those mentioned agencies under its Development Directo-
above carry out activities with a direct or in- rate-General, although it is heavily criticised
direct impact on health. Within the UN sys- for inefficiency and bureaucratic proce-
tem, the Food and Agriculture Organisation, dures. This has provided an average of USD
FAO, is concerned with food supply and 400 million in health aid per year to low-in-
food safety aspects, and with improving the come countries.
conditions of rural people, and the Interna- The member states of the Organisation of
tional Labour Organisation, ILO, is con- African Unity, established in 1963, and the
cerned with workers issues and safety at African Economic Union, established under
C work. A substantial number of the existing the auspices of OAU, have an agreement to
M 182 ILO conventions and 190 recommenda- promote and increase co-operation in the
tions have dealt with issues related to field of health.
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health. The International Atomic Energy
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Agency, IAEA, has developed a number of

12.4 National agencies called Macro International Inc., which in a

highly professional way implements these
Most high-income countries are involved in studies in conjunction with national agen-
development co-operation with low and cies. All data obtained is freely available on
middle-income countries through bilateral, the Internet.2
country-to-country relationships. For this USAID is, in financial terms, by far the
purpose national development co-operation most important bilateral player in global
agencies have been set up, and some of health, with a commitment of USD 917
these are listed below. million in the fiscal year 2001. Its main
The greater part of official development areas have been family planning, reproduc-
assistance, ODA, originates from the Euro- tive health, child survival, maternal health,
pean and North American member states of HIV/AIDS and infectious diseases.3 How-
the Organisation of Economic Co-operation ever, USAID has significantly reduced its
and Development, OECD. Its Development support to reproductive health issues such
Assistance Committee, DAC, has a particu- as abortion and contraceptives due to the
lar role to produce statistics on develop- conservative influence within the current
ment co-operation. DAC collects data and US administration.
publishes annual reports on aid flows.1
The share of the bilateral aid allocated to
the social sectors increased during the 1990s
to some 29 % in 1997. In real terms, bilateral 12.4.2 Department for International
health assistance had reached USD 2.7 bil- Development, DFID (U.K.)
lion in 1997. Some few examples of bilateral Under previous governments, the DFID and
development co-operation agencies are its predecessor, ODA, emphasised economic
mentioned below. and financial issues and accountability, ex-
pressed as value for money. Under the Blair
government, the focus has shifted to the al-
leviation of poverty4 with a strong increase
12.4.1 United States Agency for
of the developmental aid budget. DFID pos-
International Development, USAID
sesses considerable professional expertise in
USAID is the main official US development the health sector.
co-operation agency. It is an offshoot of the
Marshall Plan for Europe after the Second
World War and the Act for International De-
velopment passed by Congress in 1949. The 12.4.3 Swedish International
US assistance programme has often been Development Co-operation Agency
closely connected with commercial, political (Sida).
and military interests, and it is exposed to a Sida was established in 1965 as a successor
detailed regulation by the US Congress, to an earlier government agency (NIB). In its
which occasionally decides on specific con- early phase, Sida had a strong focus on pop-
ditions for the provision of assistance. USAID ulation and family planning issues. From
also supports some very important initia- the mid-1970s, this emphasis was gradually
tives. One outstanding example is the Demo- replaced by a broad-based primary health
graphic Health Surveys that provide much of care strategy and strong support for multi-
the information about the health status of lateral actions. From the late 1990s, the
C
children in low-income countries. These sur- health sector priorities of Sida have been
M veys are commissioned to a private company
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www.measuredhs.com
3
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www.usaid.gov
1 4
www.oecd.org/dac www.dfid.gov.uk

12.5 Non-governmental organisations (NGOs)
health planning and management and available. Other organisations, such as the
sexual and reproductive health. Sweden is International Committee of the Red Cross,
today among those donor countries which were also active in health activities.
provide the smallest amount of health aid, In the early post-colonial era, health was
in relative terms (only 2.2 % of total bilateral placed high on the agenda of official de-
aid in 2001) but with a sharp increase in velopment co-operation. The expectation
overall development aid to reach the one that the governments of the newly inde-
percent of GNP target.1 pendent states would quickly become capa-
ble of running their ownat that time
mostly freehealth services was strong. The
role of NGOs was seen as complementary,
at most.
12.5 Non-governmental At the same time many NGOs did receive
organisations (NGOs) support from their home countries in order
The demarcation line between public, i.e. to provide more and better services for
governmental organisations and the private groups that were not easily reached by gov-
sector is not always clear-cut. Institutes such ernments. The importance of the NGOs in
as the Pasteur institutes in many countries health was vastly different between regions
often occupy a semi-governmental position. and countries. In most Asian countries, they
In other countries, especially the former so- were insignificant in terms of funding and
cialist countries, NGOs were often regarded activities, while in some African countries
with mistrust and not permitted to operate they actually ran, and still run, a considera-
except in close alliance with governments. ble part of the health services, sometimes
For example the Red Cross association in more than half.
some countries can still be seen as a semi- Today, the NGOs constitute a varied
governmental entity. group. The traditional NGOs, such as
By and large the organisations below are churches and missions, are still active, al-
international non-governmental organisa- though now more often through their local
tions (INGOs), with a global scope. How- partner churches or through special disaster
ever, purely national NGOs are playing an relief organisations, such as Caritas Interna-
increasingly important role in many coun- tional Medical Mission Board (Catholic) or
tries, sometimes in collaboration with inter- the Church World Service (Protestant and
national organisations or as member organ- Orthodox). Among the best-known human-
isations of global federations. itarian organisations, we find the Red Cross
Long before any official development co- (considered to be the worlds largest NGO),
operation was even considered, NGOs were the Save the Children associations in many
active in health activities in different coun- countries, Mdecins Sans Frontires, World
tries. Since the late 19th century, especially Vision, Oxfam, PATH, Rotary International,
in Africa, a variety of churches and mission- and CARE.
ary societies have been heavily involved in In specific areas NGOs are prominent at a
health and education projects, in addition global level; for example, the International
to their main religious objectives. As the co- Planned Parenthood Federation, IPPF, pro-
lonial powers tended to neglect the health motes responsible parenthood, family plan-
of the indigenous peoples in their colonies, ning and nowadays also broader reproduc-
C
the health care provided by missions was tive health action. In some countries NGOs
M often the only form of western health care constitute a special form for recognised ac-
tivities, for instance in Nepal, where more
Y
than 10 000 NGOs are reported to exist.
K
1
www.sida.se

Examples of NGOs which are important 12.5.4 Mdecins Sans Frontires, MSF
in global health (out of hundreds of thou- (Doctors Without Borders)
sands of NGOs) are:
Established in 1971 in France as a medical
humanitarian organisation
12.5.1 International Committee of the Red Now with 5 operational branches (France, Bel-
gium, Holland, Switzerland, Spain) and support-
Cross, ICRC
ing organisations in 13 other countries
Annual budget: 300 million US
Founded in 1863 as a Swiss organisation, gov- Staff: 3 000 international volunteers, 15 000
erned by a committee of 15 to 25 Swiss nation- national staff, working in more than 80 countries
als, with headquarters in Geneva. Web site: www.msf.org
Active in war and disaster situations, and
increasingly in conflict prevention.
Annual budget (2000): USD 700 million
Expatriate field staff: 1 000 to 1 200
Web site: www.icrc.org
12.5.5 World Council of Churches (WCC)
Established 1948
WCC is a fellowship of 348 churches in more
than 120 countries in all continents mainly from
12.5.2 International Federation of Red the Orthodox, Anglican, Reformed, Methodist
Cross & Red Crescent Societies and Lutheran traditions.
(IFRC) Its headquarter in Geneva supports member-
churches as well as other churches and faith-
(Previously the League of Red Cross and Red based organisations in their health service
Crescent Societies) projects around the world, mainly through
Federation of 177 national Red Cross and Red studies, training and advice.
Crescent societies, founded in 1919 with head- Web site: www.wcc-coe.org
quarters in Geneva. Total of 97 million members
and volunteers, and 300 000 employees.
Main tasks are to co-ordinate international
assistance from national societies to disaster vic- 12.5.6 Caritas Internationalis
tims, promote the establishment of national soci-
eties and act as a body for liaison, co-ordination Founded in 1951
and study for national societies. Caritas is a network of Catholic relief, develop-
Web site: www.ifrc.org ment and social service organisations supporting
and running health service and development
projects over 200 countries.
Caritas works without regard to creed, race,
12.5.3 International Planned Parenthood gender, or ethnicity, and is one of the worlds
Federation, IPPF largest humanitarian networks.
Web site: www.caritas.org
Established in 1952,
Federation of national family planning or sex
education organisations
Around 180 member organisations
Annual turnover of the whole system around
USD 850 million, central organisation around 12.6 Philanthropic foundations
USD 80 million
Staff (volunteers): Several million The philanthropic foundations constitute a
Web site: www.ippf.org particular form of work, particularly promi-
C nent in the United States. Some of them
M have long been active in international
Y
health work, e.g. the Rockefeller Foundation
(established in 1913) and the Ford Founda-
K
tion, both of which have been and are heav-

12.7 Industry & corporations
ily involved in health work at different lev- new trend is towards greater involvement in
els, e.g. research, training and epidemiologi- society through contributions to health and
cal work. The Aga Khan Foundation is well welfare activities, possibly as an aspect of
known for its support to promote social de- what is considered good business practice.
velopment in low-income countries, and for
its educational institutions.
12.8 The future of global health

12.6.1 The Rockefeller Foundation
collaboration
Established: 1913
As the mechanisms for international health
Assets: USD 3.5 billion
Grants for health 2000: USD 197 million collaboration have appeared to be insuffi-
Web site: www.rockfound.org cient to meet the newand the oldthreats
to health, new entities have emerged, re-
placing or complementing the old institu-
tions. There are already about 70 health ini-
12.6.2 The Bill and Melinda Gates tiatives in which WHO is participating.
Foundation The prime example of this is UNAIDS (see
section 12.2.6 above). More recently, the
Established 1999
Assets: over USD 30 billion
Global Forum for Health Research has been
Grants for global health 2001: USD 856 million formed as a focal point for new efforts to
Health, especially immunisation, HIV/AIDS, and intensify health research. Another example
reproductive and child health with a special focus of such collaboration is the Global Alliance
on innovation. for Vaccines and Immunisation (GAVI).1
Financing of the Childrens Vaccine Program
Web site: www.gatesfoundation.org
This alliance was created in 1999 as a part-
nership between WHO, UNICEF, the World
Bank, bilateral agencies, countries, Bill &
The Gates Foundation has in only a few Melinda Gates foundations and the pharma-
years become one of the major actors in glo- ceutical industry, in order to promote
bal health collaboration. It can be expected immunisation of children in a rights per-
that this and other similar philanthropic or- spective (the right of every child to be pro-
ganisations will play an increasingly impor- tected against immunisation-preventable
tant role in world health co-operation in the diseases). With a Vaccine Fund of over USD
future. 1.3 billion at its disposal through grants
from the Gates Foundation and countries
such as Norway, Netherlands, Sweden, the
UK and the US, GAVI has in less than five
12.7 Industry & corporations years committed over USD 1.2 billion in
Industrys role in health care is complex and support to 70 of the worlds poorest coun-
not easy to interpret. It has an obvious role tries.
to play on the supply side for clinical serv- Most recently, the Global Fund to Fight
ices (increasingly an area for private enter- AIDS, Tuberculosis and Malaria (GFATM)
prise in many areas of the world), pharma- started to provide its first support to coun-
ceutical products and equipment. For exam- tries in 2002, with the goal of mobilising up
C ple, private industry is today the only sector to USD 10 billion per year for its activities.2
that can translate basic research into prod- In the start the fund has mobilised about 1
M
Y
uct development for new pharmaceuticals.
The provision of health services for em- 1
www.vaccinealliance.org
K
2
ployees is a traditional area of activity. A www.globalfundatm.org

billion USD per year, and it has created a Frameworks, UNDAFs, as a means of joint
seemingly efficient and transparent mecha- programming. The World Bank, for its part,
nism for assessing applications and dis- is establishing Comprehensive Develop-
bursements of funds. In the honourable at- ment Frameworks (CDFs), which aim to in-
tempt to raise new money for health im- tegrate WB loans and support from other
provements for those in greatest need the external partners in different sectors. A vari-
Global Fund is facing a dilemma, which it ety of working groups and committees
shares with similar initiatives. In order to strengthen the multilateral work in many
mobilise substantial amounts of new funds sub-sectors of health. One example is the
the Fund must focus on issues and actions Interagency Pharmaceutical Co-ordination
that coincide with the perceptions of the Group (IPC), consisting of senior pharma-
potential contributors. However, contribu- ceutical advisers of WHO, WB, UNAIDS,
tors conceptions may not coincide with the UNFPA and UNICEF who meet regularly to
cost-effective and evidence-based actions co-ordinate pharmaceutical policies and
that are first needed in low-income coun- prepare interagency statements and techni-
tries. One such example is the provision of cal documents.
free anti-retroviral drugs. With a scientifi- A more crucial issue will be how interna-
cally highly qualified leader for the Global tional contributions to the health sector
fund and a transparent mechanism for as- should match the national health budgets.
sessing applications one can hope that this There are governments such as the one in
new institution will manage to strike the Uganda that has considered the interna-
best balance between what is most needed tional contributions to their health sector to
and what is easiest to find money for. It be so big that the countries have to cut
seems that it remains easier to raise money down their own health budget to secure the
for drugs to treat the sick rather than to pre- macroeconomic stability. Many assumed
vent diseases to occur. that this was due to foreign pressure from
Another large-scale initiative that was IMF, but it has to be realised that all serious
launched in July 2003 is the Health Metrics governments will adjust their budgets in re-
Network as a collaborative effort between lation to the size of foreign contributions in
WHO, the Gates Foundation and others to different sectors. The main issue regarding
improve health measurements. future international support to the health
UNAIDS, GAVI and the global fund are sector in low-income countries may be how
probably only the start. There is a growing the national government assesses the invest-
awareness that previous competition and ment need in health in relation to the needs
turf wars between international agencies in the other social sectors.
must be replaced by collaborative efforts Another emerging aspect of the globalisa-
and, whenever possible, joint programming. tion of health with the focus on middle-in-
New linkages, networks and joint pro- come countries is that international compa-
grammes can be expected to emerge from nies start to operate curative hospital service
this insight, complementing or replacing around the world. Other trans-actional
existing structures. companies also start to offer health insur-
In addition to these new organisational ance at an international level. It is notewor-
forms, reform efforts are under way within thy that the governments in China and Vi-
the UN system to make collaboration be- etnam have embarked on a very market ori-
C tween the agencies more effective. The ented policy for hospital services that may
M
United Nations Development Groups, open for international trade both in operat-
UNDG, is working in a number of pilot ing hospitals and providing hospital services
Y
countries to develop what are known as to patients. Hospitals services are very la-
K
United Nations Development Assistance bour intensive and middle-income coun-

12.8 The future of global health collaboration
tries with high medical qualifications international capital transactions), environ-

among their staff may start to provide cura- mental taxes, global lotteries etc. For the
tive services in a much larger scale than to- moment the most realistic of these appears
day. A number of new examples are emerg- to be an idea rasied by the British Chancel-
ing every year. These types of trans-national lor of the Exchequer, Gordon Brown, about
curative services will need regulations and the creation of a so called International
policy decisions both in the country of the Finance Facility (IFF). This idea implies the
patient and the country of the hospital. sale of bonds in the capital markets backed
Countries in the former Soviet Union and up by donor pledges to provide funding
South Africa are already providing cosmetic over a 15 or 20 year period. This is a simple
surgery to patients from West Europe on a idea although technically complex; the goal
regular basis. It is not surprising that Cuba is being to double international development
one of the countries that is leading the proc- aid from currently about USD 50 billion
ess of commercial international provision of annually, thereby being able to invest more
curative services as the country has an abun- to help the world attain the MDGs.
dance of highly qualified medical practi- As a pilot of this large scale IFF it has been
tioners that work on low salaries. proposed to raise USD 4 billion for a specific
The number of international contacts in immunization project, to be handled by
what we might call international health co- GAVI. Strongly backed by Britain and France
operation is increasing in all fields. The mul- this initiative may actually be realized early
tilateral system centred on the United Na- in 2005.
tions continues to be of significance, civil so- The recent reorganisation of WHO shows,
ciety and a variety of organisations are meet- if nothing else, a growing sense that the
ing, combining or working together, and multilateral organisations must be more re-
research contacts are multiplying. Training sponsive to their constituencies, their mem-
and work by young people across national ber states. They cannot continue to work ac-
borders is rapidly becoming a necessary part cording to old prescriptions. They will have
of their careers, rather than an exotic adven- to compete with other possible solutions,
ture. such as regional organisations or private sec-
Some of the developments of the last few tor activities.
years deserve further discussion and action. Clearly, these developments do not re-
The multi-sectoral nature of emerging place the original purpose of international
health problems so clearly demonstrated by health collaboration: to prevent the spread
the HIV/AIDS pandemic is one of them. of communicable diseases across national
Whether the solution to that is specialised borders. A few years ago, a man that lived in
organisations outside the traditional ones is the neighbourhood of Geneva Airport died
another matter. It may be that the existing of malaria caused by a mosquito that had
organisations will have to broaden the scope apparently been brought there by a plane
of their work to cater for new needs for co- from an endemic area. This was not a public
operation. health problem, but it shows that, as dis-
It seems now rather clear that the Millen- eases know no national borders, interna-
nium Development Goals that were set by tional health co-operation will continue to
the global community will not be reached have to deal with trans-national health is-
by 2015. In fact if developments continue as sues.
C now it will take many decades before some If present trends continue, civil society
M
of the goals will be met. and private players are bound to become
A number of ideas to increase overall more prominent. It is not just the fact that
Y
development aid have been presented in wealthy individuals are likely to continue
K
recent years, the Tobin tax (taxation on donating large amounts of money to health

programmes. There also seems to be a grow- Sachs JD. Macroeconomics and Health:
ing sense of corporate social responsibility Investing in Health for Economic Devel-
from companies, including possible in- opment. Report of the Commission on
volvement in health programmes outside Macroeconomics and Health (CMH) to
their own work sector. It is difficult to pre- WHO: 2001. www.cmhealth.org
dict the final outcome of the directions of Musgrove P, Zeramdini. A. Summary Descrip-
international health collaboration as de- tion of Health Financing in WHO Member
scribed above. One may see the diversifica- States. CMH Working Paper Series, Paper
tion of global health initiatives as a sad No. WG3:3. www.cmhealth.org
weakening of the UN system leading to- Pouiller JP, Hernandez P, Kawabata K, Saved-
wards a commercial globalisation of the off WD. Patterns of Global Health Expen-
health sector; or as an evidence based move ditures: Results for 191 Countries. EIP/
towards a more effective enlightened self-in- HFS/FAR Discussion Paper No. 51. WHO,
terest that will benefit the health of all in 2002 (mimeo).
this world. It is partly up to the readers of Reich MR, Marui E. International Co-opera-
this book to make sure that collaboration for tion for Health. Problems, Prospects and
better global health goes the right way. Priorities. Auburn House Publishing Com-
pany; 1989.
Vaughan JP, Mogedal S, Kruse S-E, Lee K,
References and suggested further reading Walt G, de Wilde K. Financing the World
Basch PF. A Historical Perspective on Inter- Health Organisation: global importance
national Health. Infectious Disease Clin- of extra budgetary funds. Health Policy
ics of North America, 1991;5:18396. 1996;35:229245.
Development Assistance Committee, Devel- WHO. The World Health Report 2000.
opment Co-operation Report. Paris: Health Systems: Improving Performance.
OECD; 2002. WHO; 2000.
WHO. Facts about WHO. Geneva: World WHO. The World Health Report 2003.
Health Organization; 1990. World Development Report 1993. Investing
Lucas A, Mgedal S, Walt G, Hodne SS, Kruse in Health. Published for the World Bank.
SE, Lee K, Hawken L. Co-operation for Oxford: Oxford University Press; 1993.
Health Development. WHOs support to
programmes at country level. WHO: 1997.

12.8 The future of global health collaboration

Abbreviations
Abbreviations
AIDS Acquired Immune Deficiency MDG Millennium Development Goals

Syndrome MGM Male Genital Mutilation
ARV Anti Retro-Viral drugs MMR Maternal Mortality Ratio
BCG Bacille Calmette-Gurin (Tuberculo- NAIDS Nutritionally Acquired Immune
sis vaccine) Deficiency Syndrome
BMI Body Mass Index NGO Non-Governmental Organization
CBR Crude Birth Rate PHC Primary Health Care
CDR Crude Death Rate PPP Purchasing Power Parity
CMH Commission on Macroeconomics PVO Private Voluntary Organizations
and Health OAU Organization for African Unity
CVD Cardiovascular Disease ODA Official Development Assistance
DAC Development Assistance Commit- OECD Organization for Economic
tee (of OECD) Co-operation and Development
DALY Disability Adjusted Life Years OPV Oral Polio Vaccine
DHS Demographic and Health Survey ORT Oral Rehydration Therapy
DTP Diphteria-Tetanus-Pertussis SAP Structural Adjustment Program
EPI Expanded Program on Immuniza- SARS Severe acute respiratory syndrome
tion SF Symphysis Fundus distance
FGM Female Genital Mutilation STI Sexually Transmitted Infection
GAVI Global Alliance for Vaccines and SWAps Sector Wide Approach
Immunization TFR Total Fertility Rate
GDP Gross Domestic Product TRIPS Trade Related Aspects of Intellectual
GFATM Global Fund to fight AIDS, Tubercu- Property Rights
losis and Malaria U5MR Under Five Mortality Rate
GNP Gross National Product UNAIDS Joint United Nations Program on
HALE Health Adjusted Life Expectancy HIV/AIDS
HFA Height For Age UNDP United Nations Development
HIV Human Immunodeficiency Virus Program
HPV Human Papilloma Virus UNFPA United Nations Population Fund
IBRD International Bank of Reconstruc- UNICEF United Nations Childrens Fund
tion and Development USD US dollars
ICD International Classification of YLL Years of Life Lost
Disease VAD Vitamin A Deficiency
IDA International Development Associa- WB World Bank
tion (part of WB group) WDR World Development Report (World
IDA Iron Deficiency Anemia Bank)
IDD Iodine Deficiency Disorders WFA Weight For Age
IEC Information Education Communi- WFH Weight For Height
cation WHA World Health Assembly (WHOs
IMF International Monetary Fund annual meeting of member states)
C
IUD Intrauterine device WHO World Health Organization
M IMR Infant Mortality Rate WDR World Development Report (by WB)
Y IPV Inactivated (killed) polio vaccine WHR World Health Report (by WHO)
K
LBW Low Birth Weight WTO World Trade Organization
LE Life Expectancy (at birth)
8012 13 Abbreviations 11 October 2006 13.40:03 sida 309 av 310

8012 13 Abbreviations 11 October 2006 13.40:03 sida 310 av 310

Appendix 1
Appendix 1
Regional summaries in all Unicef statistics referred to
in this book
Regional averages given at the end of each Micronesia, Federated States of; Mongolia;
table are calculated using data from the Myanmar; Nauru; Niue; Palau; Papua New
countries and territories as grouped below. Guinea; Philippines; Samoa; Singapore;
Solomon Islands; Thailand; Tonga; Tuvalu;
Sub-Saharan Africa Vanuatu; Viet Nam.
Angola; Benin; Botswana; Burkina Faso;
Burundi; Cameroon; Cape Verde; Central Latin America and Caribbean
African Republic; Chad; Comoros; Congo; Antigua and Barbuda; Argentina; Bahamas;
Congo, Democratic Republic of the; Barbados; Belize; Bolivia; Brazil; Chile;
Cte dIvoire; Equatorial Guinea; Eritrea; Colombia; Costa Rica; Cuba; Dominica;
Ethiopia; Gabon; Gambia; Ghana; Guinea; Dominican Republic; Ecuador; El Salvador;
Guinea-Bissau; Kenya; Lesotho; Liberia; Grenada; Guatemala; Guyana; Haiti;
Madagascar; Malawi; Mali; Mauritania; Honduras; Jamaica; Mexico; Nicaragua;
Mauritius; Mozambique; Namibia; Niger; Panama; Paraguay; Peru; Saint Kitts and
Nigeria; Rwanda; Sao Tome and Principe; Nevis; Saint Lucia; Saint Vincent and the
Senegal; Seychelles; Sierra Leone; Somalia; Grenadines; Suriname; Trinidad and Tobago;
South Africa; Swaziland; Tanzania; United Uruguay; Venezuela.
Republic of; Togo; Uganda; Zambia;
Zimbabwe. CEE/CIS and Baltic States
Albania; Armenia; Azerbaijan; Belarus;
Middle East and North Africa Bosnia and Herzegovina; Bulgaria; Croatia;
Algeria; Bahrain; Cyprus; Djibouti; Egypt; Czech Republic; Estonia; Georgia; Hungary;
Iran, Islamic Republic of; Iraq; Jordan; Kazakhstan; Kyrgyzstan; Latvia; Lithuania;
Kuwait; Lebanon; Libyan Arab Jamahiriya; Moldova, Republic of; Poland; Romania;
Morocco; Occupied Palestinian Territory; Russian Federation; Slovakia; Tajikistan;
Oman; Qatar; Saudi Arabia; Sudan; Syrian the former Yugoslav Republic of Macedonia;
Arab Republic; Tunisia; United Arab Turkey; Turkmenistan; Ukraine; Uzbekistan;
Emirates; Yemen. Yugoslavia.
South Asia High-income countries

Afghanistan; Bangladesh; Bhutan; India; Andorra; Australia; Austria; Belgium;
Maldives; Nepal; Pakistan; Sri Lanka. Canada; Denmark; Finland; France;
Germany; Greece; Holy See; Iceland;
East Asia and Pacific Ireland; Israel; Italy; Japan; Liechtenstein;
C Brunei Darussalam; Cambodia; China; Cook Luxembourg; Malta; Monaco; Netherlands;
M
Islands; East Timor; Fiji; Indonesia; Kiribati; New Zealand; Norway; Portugal;
Korea, Democratic Peoples Republic of; San Marino; Slovenia; Spain; Sweden;
Y
Korea, Republic of; Lao Peoples Democratic Switzerland; United Kingdom;
K
Republic; Malaysia; Marshall Islands; United States.
8012 14 Appendix.fm 11 October 2006 13.40:04 sida 311 av 320

Appendix 1
Low- and middle-income countries Guinea; Paraguay; Peru; Philippines; Qatar;

Afghanistan; Algeria; Angola; Antigua and Rwanda; Saint Kitts and Nevis; Saint Lucia;
Barbuda; Argentina; Armenia; Azerbaijan; Saint Vincent/Grenadines; Samoa;
Bahamas; Bahrain; Bangladesh; Barbados; Sao Tome and Principe; Saudi Arabia;
Belize; Benin; Bhutan; Bolivia; Botswana; Senegal; Seychelles; Sierra Leone; Singapore;
Brazil; Brunei Darussalam; Burkina Faso; Solomon Islands; Somalia; South Africa;
Burundi; Cambodia; Cameroon; Cape Sri Lanka; Sudan; Suriname; Swaziland;
Verde; Central African Republic; Chad; Syrian Arab Republic; Tajikistan; Tanzania,
Chile; China; Colombia; Comoros; Congo; United Republic of; Thailand; Togo; Tonga;
Congo, Democratic Republic of the; Cook Trinidad and Tobago; Tunisia; Turkey;
Islands; Costa Rica; Cte dIvoire; Cuba; Turkmenistan; Tuvalu; Uganda; United Arab
Cyprus; Djibouti; Dominica; Dominican Emirates; Uruguay; Uzbekistan; Vanuatu;
Republic; East Timor; Ecuador; Egypt; Venezuela; Viet Nam; Yemen; Zambia;
El Salvador; Equatorial Guinea; Eritrea; Zimbabwe.
Ethiopia; Fiji; Gabon; Gambia; Georgia;
Ghana; Grenada; Guatemala; Guinea; Least developed countries
Guinea-Bissau; Guyana; Haiti; Honduras; Afghanistan; Angola; Bangladesh; Benin;
India; Indonesia; Iran, Islamic Republic of; Bhutan; Burkina Faso; Burundi; Cambodia;
Iraq; Israel; Jamaica; Jordan; Kazakhstan; Cape Verde; Central African Republic; Chad;
Kenya; Kiribati; Korea, Democratic Peoples Comoros; Congo, Democratic Republic of;
Republic of; Korea, Republic of; Kuwait; Djibouti; Equatorial Guinea; Eritrea;
Kyrgyzstan; Lao Peoples Democratic Ethiopia; Gambia; Guinea; Guinea-Bissau;
Republic; Lebanon; Lesotho; Liberia; Libyan Haiti; Kiribati; Lao Peoples Democratic
Arab Jamahiriya; Madagascar; Malawi; Republic; Lesotho; Liberia; Madagascar;
Malaysia; Maldives; Mali; Marshall Islands; Malawi; Maldives; Mali; Mauritania;
Mauritania; Mauritius; Mexico; Micronesia, Mozambique; Myanmar; Nepal; Niger;
Federated States of; Mongolia; Morocco; Rwanda; Samoa; Sao Tome and Principe;
Mozambique; Myanmar; Namibia; Nauru; Senegal; Sierra Leone; Solomon Islands;
Nepal; Nicaragua; Niger; Nigeria; Niue; Somalia; Sudan; Tanzania, United Republic
Occupied Palestinian Territory; Oman; of; Togo; Tuvalu; Uganda; Vanuatu; Yemen;
Pakistan; Palau; Panama; Papua New Zambia.

Appendix 2
Appendix 2
Regional summaries of World Health Organization statistics
referred to in this book
Below are the regions of the world listed by Kuwait, Lebanon, Libyan Arab Jamahiriya,
country used for WHO statistics in this book. Morocco, Oman, Pakistan, Qatar, Saudi
WHO also divides some of its health data Arabia, Somalia, Sudan, Syrian Arab
into high-income and Low- and middle- Republic, Tunisia, United Arab Emirate,
income countries. Sometimes China and Yemen.
India are referred to separately because of
their large population. European Region (EUR)
Albania, Andorra, Armenia, Austria,
African region (AFR) Azerbaijan, Belarus, Belgium, Bosnia and
Algeria, Angola, Benin, Botswana, Burkina Herzegovina, Bulgaria, Croatia, Czech
Faso, Burundi, Cameroon, Cape Verde, republic, Denmark, Estonia, Finland,
Central African Republic, Chad, Comoros, France, Georgia, Germany, Greece, Hungary,
Congo, Cte dIvoire, Democratic republic Iceland, Ireland, Israel, Italy, Kazakhstan,
of Congo, Equatorial Guinea, Eritrea, Kyrgyzstan, Latvia, Lithuania, Luxembourg,
Ethiopia, Gabon, Gambia, Ghana, Guinea, Malta, Monaco, Netherlands, Norway,
Guinea-Bissau, Kenya, Lesotho, Liberia, Poland, Portugal, Republic of Moldova,
Madagascar, Malawi, Mali, Mauritania, Romania, Russian Republic, San Marino,
Mauritius, Mozambique, Namibia, Niger, Slovakia, Slovenia, Spain, Sweden,
Nigeria, Rwanda, Sao Tome et Principe, Switzerland, Tajikistan, The former Yugoslav
Senegal, Seychelles, Sierra Leone, South Republic of Macedonia, Turkey,
Africa, Swaziland, Togo, Uganda, United Turkmenistan, Ukraine, United Kingdom,
Republic of Tanzania, Zambia, Zimbabwe. Uzbekistan, Yugoslavia.
Region of the Americas (AMR) South East Asia Region (SEAR)

Antigua and Barbuda, Argentina, Bahamas, Bangladesh, Bhutan, Democratic Peoples
Barbados, Belize, Bolivia, Brazil, Canada, Republic of Korea, India, Indonesia,
Chile, Colombia, Costa Rica, Cuba, Maldives, Myanmar, Nepal, Sri Lanka,
Dominica, Dominican republic, Ecuador, Thailand.
El Salvador, Grenada, Guatemala, Guyana,
Haiti, Honduras, Jamaica, Mexico, Western Pacific Region (WPR)
Nicaragua, Panama, Paraguay, Peru, Saint Australia, Brunei Darussalam, Cambodia,
Kitts and Nevis, Saint Lucia, Saint Vincent China, Cook Islands, Fiji, Japan, Kiribati,
and the Grenadines, Suriname, Trinidad and Lao Peoples Democratic Republic, Malaysia,
Tobago, United States of America, Uruguay, Marshall Islands, Federated States of
C Venezuela. Micronesia, Mongolia, Nauru, New Zealand,
M
Niue, Palau, Papua New Guinea,
Eastern Mediterranean Region (EMR) Philippines, Republic of Korea, Samoa,
Y
Afghanistan, Bahrain, Cyprus, Djibouti, Singapore, Solomon Islands, Tonga, Tuvalu,
K
Egypt, Islamic Republic of Iran, Iraq, Jordan, Vanuatu, Viet Nam.


Appendix 3
Appendix 3
Regional summaries of the world according to
the World Bank
East Asia and Pacific South Asia

American Samoa, Cambodia, China, Fiji, Afghanistan, Bangladesh, Bhutan, India,
Indonesia, Kiribati, Dem. Rep. Korea, Maldives, Nepal, Pakistan, Sri Lanka.
Rep. Korea, PDR Laos, Malaysia, Marshall
islands, Fed. Sts. Micronesia, Mongolia, Sub-Saharan Africa
Myanmar, Palau, Papua New Guinea, Angola, Benin, Botswana, Burkina Faso,
Philippines, Samoa, Solomon Islands, Burundi, Cameroon, Cape Verde, Central
Thailand, Tonga, Vanuatu, Vietnam. African Republic, Chad, Comoros,
Dem.Rep. Congo, Rep Congo, Cte dIvoire,
Europe and Central Asia Equatorial Guinea, Eritrea, Ethiopia, Gabon,
Albania, Armenia, Azerbaijan, Belarus, Gambia, Ghana, Guinea, Guinea-Bissau,
Bosnia and Herzegovina, Bulgaria, Croatia, Kenya, Lesotho, Liberia, Madagascar,
Czech Republic, Estonia, Georgia, Hungary, Malawi, Mali, Mauritania, Mauritius
Isle of Man, Kazakhstan, Kyrgyz Republic, Mayotte, Mozambique, Namibia, Niger,
Latvia, Lithuania, FYR Macedonia, Moldova, Nigeria, Rwanda, Sao Tome and Principe,
Poland, Romania, Russian Republic, Slovak Senegal, Seychelles, Sierra Leone, Somalia,
Republic, Tajikistan, Turkey, Turkmenistan, South Africa, Sudan, Swaziland, Tanzania,
Ukraine, Uzbekistan, FR Yugoslavia. Togo, Uganda, Zambia, Zimbabwe.
Latin America and the Caribbean High income OECD

Antigua and Barbuda, Argentina, Belize, Australia, Austria, Belgium, Canada,
Bolivia, Brazil, Chile, Colombia, Costa Rica, Denmark, Finland, France, Germany,
Cuba, Dominica, Dominica Republic, Greece, Iceland, Ireland, Italy, Japan,
Ecuador, El Salvador, Grenada, Guatemala, Luxembourg, Netherlands, New Zealand,
Guyana, Haiti, Honduras, Jamaica, Mexico, Norway, Switzerland, Portugal, Spain,
Nicaragua, Panama, Paraguay, Peru, Sweden, Switzerland, United Kingdom,
Puerto Rica, St. Kitts and Nevis, St. Lucia, United States.
St.Vincent and the Grenadines, Suriname,
Trinidad and Tobago, Uruguay, Venezuela. Other High Income
Andorra, Aruba, Bahamas, Bermuda, Brunei,
Middle East and North Africa Cayman Islands, Channel Islands, Cyprus,
Algeria, Bahrain, Djibouti, Egypt Arab Rep., Faeroe Islands, French Polynesia,
Islamic Rep. Iran, Iraq, Jordan, Lebanon, Greenland, Guam, Hong Kong China, Israel,
Libya, Malta, Morocco, Oman, Saudi Arabia, Kuwait, Liechtenstein, Macao China,
C Syrian Arab Republic, Tunisia, West Bank Monaco, Netherlands Antilles, New
M
and Gaza, Rep Yemen. Caledonia, Northern Mariana Islands, Qatar,
San Marino, Singapore, Slovenia, United
Y
Arab Emirate, Virgin Islands.
K


Appendix 4
Appendix 4
Websites
Website Organisations Contents
Medical journals:
www.ajph.org/cgi/etoc American Journal of Public Health
http://bmj.com/ Brittish Medical Journal
www.who.int/bulletin/ Bulletin of the World Health
tableofcontents.htm Organization
www.thelancet.com Lancet Homepage Many free articles accessible,
some require subscription
www.nlm.nih.gov National Library of Medicine Home of Medline
www.ncbi.nlm.nih.gov/PubMed/ PubMed Search medical articles
medline.html
www.elsevier.com/locate/ Elsevier Science ContentsDirect, where you can
ContentsDirect subscribe for free to emails with
Tables of Content for several
journal
Health topics:
www.aidsinfo.nih.gov National Institute of Health, US HIV/AIDS
www.aidsmap.com HIV/AIDS
www.ctu.mrc.ac.uk/penta/ Paediatric European Network for AIDS treatment
the Treatment of AIDS
www.comminit.com Health communication
www.cdc.gov/nccdphp The Centers for Disease Control Nutrition and physical activity
and Prevention in the US
www.fao.org FAO, Division of Nutrition Nutrition
WHO/PAHO Health Library for disasters
www.hsph.harvard.edu/hcpds/ Harvard School of Public Health Gender issues
workingpapers. html
www.hsph.harvard.edu/ Global Reproductive Health Forum, Reproductive Health issues
Organizations/healthnet/ Harvard School of Public Health
www.iapac.org (International Association of ARV treatment
Physicians in AIDS Care) ARV
treatment guidelines
www.idf.org International diabetes federation Diabetes
www.ids.ac.uk/bridge/ Bridge Gender and Health
www.ifpri.org International Food Policy Research Obesity
Institute
C
www.inacg.ilsi.org International Nutritional Anemia Iron deficiency anaemia
M Consultative Group (INACG)
Y
www.iotf.org International Obesity Task Force Obesity

Appendix 4
www.izincg.ucdavis.edu International Zinc Nutrition Zinc deficiency

Consultative Group (IZINCG)
www.ivacg.ilsi.org International Vitamin A Vitamin A issues
Consultative Group (IVACG)
www.measuredhs.com Demographic and Health Survey Demography and health
www.paho.org/genderandhealth/ PAHO Gender issues
#Gender Equity
www.people.virginia.edu/~jtd/ International Council for the Iodine deficiency
iccidd Control of Iodine Deficiency
Disorders (ICCIDD)
www.pitt.edu/~super1/ The Supercourse lectures on
health topics for self learning
www.qweb.kvinnoforum.se Kvinnoforum in Stockholm. Womens health and gender
issues.
www.reproductiverights.org. Center for Reproductive Rights. Legal aspects of the implemen-
tation of reproductive rights
and its Violations.
www.unesco.org Education
www.unsystem.org/scn United Nations System Standing Nutrition
Committee on Nutrition
www.unaids.org (epidemiology)
www.und.ac.za/und/heard/ The Health Economics & HIV/AIDS AIDS info
Research Division (HEARD) South
Africa
www.who.int/child-adolescent- WHO Integrated management of
health childhood illnesses
www.who.int/nutgrowthdb WHO Global Database on Child
Growth
www.who.int/nut WHO Nutrition
Organisations:
www.usaid.gov The United States Agency for US governmental aid agency
International Development
www.arrow.org.my ARROW, an NGO based in Kuala Reproductive health.
Lumpur, Malaysia
www.gatesfoundation.org The Bill and Melinda Gates
Foundation
www.ifrc.org The International Federation of Red
Cross and Red Crescent Societies
(IFRC)
www.vaccinealliance.org/home/ Global Alliance for Vaccines and
index.php Immunization
www.globalforumhealth.org/ Global Forum for Health Research Health research
pages/index.asp
www.icrc.org International Committee of the Red
Cross
C
www.msf.org/ Medcins Sans Frontires International Humanitarian
M Organisation
Y
www.oecd.org/dac OECD

Appendix 4
www.ippf.org International Planned Parenthood

Federation
www.rockfound.org The Rockefeller Foundation
www.sida.se Swedish International Development Swedish governmental aid
Cooperation Agency agency
www.unaids.org The Joint United Nations Programme
on HIV/AIDS
www.undp.org United Nations Development
Programme
www.unicef.org/ The United Nations Childrens Fund
www.dfid.gov.uk The (British) Department for Inter- Brittish governmental aid
national Development, DFID agency
www.unfpa.org United Nations Population Fund
www.wcc-coe.org World Council of Churches
www.caritas.org Caritas Catholic relief network
www.wto.org World Trade Organisation
www.wfp.org/index2.html World Food Program
www.who.int WHO- World Health Organization
www.worldbank.org The World Bank
Universities:
www.phs.ki.se/ihcar/ Karolinska Institute Department of
Public Health, Division of International
Health
www.jhsph.edu/ John Hopkins School of Public Health
www.hsph.harvard.edu Harvard School of Public Health
www.lshtm.ac.uk/ London School of Hygiene and
Tropical Medicine
www.dcp2.org Disease Control Priorities Project Update for cost effective actions
World Bank, WHO and others for global health


Index
abortions 240 Bitots spots 191

absolute poverty 60 blindness 190
acid rain 83 Body Mass Index (BMI) 117, 177, 181
Acquired Immuno Deficiency Syndrome bottle-feeding 71
(AIDS) 92, 129, 143, 149 breast cancer 212
acupuncture 94 breastfeeding 63, 67, 71, 73, 271
acute lower respiratory tract infections 138 breastmilk 63
acute stress 203 bronchiolitis 139
acute watery diarrhoea 155
adult literacy rate 64 cancer 209
Agenda 21 42 cardiovascular diseases (CVD) 206
agriculture 12, 23 cataract 84, 218
agro-ecological zones 26 CD4 T-lymphocyte 148
air pollution 83 cerebrovascular disease 207
alcohol 8687 Chagas disease 173
abuse 86 child
dependence 86, 205 feeding 73
Alma-Ata 269 malnutrition 182
alveolitis 139 mortality 65, 89
Alzheimers disease 126, 204 survival 65
anaemia 240 childcare 63
annual population growth rate 116 childlessness 234
anthropometrical indicators 116 chlorofluorocarbons (CFCs) 84
anthropometry 117 cholera 28, 67, 69, 75, 85, 265, 291
antibiotics 139 cholesterol 197
antipersonnel mines 70 chronic bronchitis 213
antiretroviral therapy 152 chronic obstructive pulmonary disease 212
antiretroviral treatment 90 circumcision 66
anxiety 203 cirrhosis of the liver 218
disorders 203 civil registration 99
armed conflicts 6869 civil society 38, 306
ARVs to prevent mother-to-child climate 19, 84, 256
transmission 153 collapsed countries 12
asphyxia 243 colon cancer 212
asthma 212, 215 colonialism 33
asymmetrical growth retardation 243 colostrum 71
Ayurvedic system 94 communicable diseases 137
community participation 269
C Bacille Calmette-Gurin (BCG) 170 complementary foods 74
M
bacteria 75 complementary medicine 93
bacterial meningitis 174 Comprehensive Development Frameworks
Y
beriberi 189 (CDFs) 305
K bipolar disorders 203 congenital disorders 246
8012IX.fm 11 oktober 2006 13.40:05 sida 321 av 326

Index
cost-effectiveness 280 employment 82

countries empowerment 65
collapsed 12 energy 70
developing 12, 47 energy production 83
high-income 12 environmental problem 83
industrialised 12, 47 epidemics 85
low-income 12 epidemiological transition 123
middle-income 12 equity 269
crime rates 82 essential life-saving medicines 91
cropland 256 ethnic cleansing 68
crude birth rate 113 ethnicity 56, 61, 67
crude death rate 113 evidence-based 68, 89
culture 66 evidence-based review 12
evidence-based worldview 11
DDT 167 Expanded Programme on Immunisation
dementia 204 (EPI) 158
demographic externalities 283
gift 40, 251
surveillance sites 100 fairness 282
transition 123, 126 family planning 261, 271272
trap 255 family welfare 261
Department for International Development, DFID famine 178, 182
(U.K.) 301 feeding programmes 271272
developing countries 12 female education 271272
development 1213 female genital mutilation (FGM) 229, 246
Development Assistance Committee (DAC) 290, fertility control 260
301 fertility determinants 252, 257
development of health 9 financing 280
diabetes mellitus 215 fires 226
Diamond, Jared 24 fisheries 256
diarrhoea 55, 95, 153 floods 85
diarrhoeal diseases 75 food 70
diet 71 food security 7071
diphtheria 164 food supply 70
diphtheria-tetanus-pertussis (DTP) 162 forced displacement 68
disability-adjusted life years (DALY) 109 forests 256
discrimination 62 fossil fuels 83
disease transition 123124
disempowerment 56 gender 56, 6061, 64
domestication 12, 24 gender equity 56
drought 85 gender inequity 61
drowning 226 genetic disease 56
drugs 9192 genetic factors 68
dysentery 75, 155 genital sepsis 241
Gini-coefficient 5960
earthquakes 85 Global Alliance for Vaccines and Immunisation
Ebola 289 (GAVI) 304
eclampsia 239 Global Burden of Disease study 130
C Economic Co-operation and Development Global Forum for Health Research 304
(OECD) 290 Global Fund to Fight AIDS, Tuberculosis and
M
education 56, 63 Malaria (GFATM) 304
Y
eflornithine 92 global warming 84
K emphysema 213 globalisation 12, 14, 43, 46, 95, 291, 307

Index
globesity 177 household survey 238

GNP per capita 58 housing 79
GOBI-FFF 270 Human Development Index (HDI) 48
goitre 193194 Human Immunodeficiency Virus type 1 (HIV-
good governance 38 1) 143
goodness 282 human rights 56
governance 274 humanitarian crisis 69
greenhouse effect 84 hunger 181
Gross Domestic Product (GDP) 59 hunters and gatherers 2122
Gross National Product (GNP) 59 hurricanes 85
group hydroelectric power 83
high-income 49 hygiene 70
lower middle-income 49 hypertension 239240
low-income 49 hypothermia 243244
upper middle-income 49
growth chart 188, 271 ignorance 56
growth monitoring 188, 270 illicit drugs 8687
illiteracy 68
haemorrhage 239 immunisation 65, 159, 162, 271
health 55, 61, 293 import substitution 34
determinants 53, 65 incidence 107
economics 276277 income inequality 59
expenditure 93 income poverty 56
indicators 99 industrial revolution 32
inequalities 61 industrialisation 83
policy 265 industrialised countries 12
service 89 inequity 61
system reforms 272 infant mortality 65
systems 89, 265, 278 infant mortality rate 102
transition 123, 134 infanticide 229
health care 89 infertility 234
Height-For-Age (HFA) 118 influenza 27
hepatitis B 158, 175 information asymmetry 283
hepatitis C 175 infrastructure 69
hepatitis viruses 175 injury 221
herbalists 95 Integrated Management of Childhood Illnesses
high blood pressure 196 (IMCI) 140
high body mass index 180 integrated management of the sick child 273
high cholesterol 180, 197 intellectual property 45
high-income countries 12 Interagency Pharmaceutical Co-ordination Group
high-income group 49 (IPC) 305
HIV 7374, 127 internally displaced people 68
epidemic 145 International Bank for Reconstruction and
infection 239 Development (IBRD) 298
prevalence 144 International Committee of the Red Cross
tests 150 (ICRC) 303
transmission 150 International Development Association
HIV/AIDS 129, 143, 260 (IDA) 298
C homeopathy 94 International Federation of Red Cross & Red
homicide and violence 227 Crescent Societies (IFRC) 303
M
Homo sapiens 22 International Planned Parenthood Federation
Y
hookworm 174 (IPPF) 303
K hospital and health facility registers 100 Intrauterine Growth Retardation (IUGR) 243

Index
iodine 179, 192 Millennium Development Goals (MDGs) 11, 43,

iodine deficiency 180 50, 275, 306
iodine deficiency disorders (IDD) 193 modern medicine 90
iron 189 monsoon 85
iron deficiency 180 Murray, Christopher 99
iron deficiency anaemia (IDA) 189
ischaemic heart disease 206 national census 100
national household sample survey 100
Jenner, Edward 158 natural disasters 85
natural resources 256
Kerala 63 neonatal tetanus 243
kwashiorkor 187 neuropsychiatric disorders 201
non-communicable diseases 199
lactation amenorrhoea 72 Non-Governmental Organisations (NGOs) 302
landmines 70 nuclear power 84
leishmaniasis 173 nutrition 75
leprosy 21, 84 transition 177, 197
life expectancy 106 nutritional disorders 177
at birth 105 Nutritionally Acquired Immune Deficiency
lifetime risk of maternal death 108, 237 Syndrome (NAIDS) 181
literacy 9
literacy rate 64 obesity 118, 177, 196197
liver cancer 211 occupation 82
Lomborg, Bjrn 43 official development assistance (ODA) 290, 301
Lopez, Allan 99 oil 83
low birth weight (LBW) 121, 242 Oral Polio Vaccine (OPV) 159
low fruit and vegetable intake 180, 197 oral rehydration therapy (ORT) 153, 271
lower middle-income group 49 Organisation of African Unity (OAU) 300
low-income countries 12 Organisation of Economic Co-operation and
low-income group 49 Development (OECD) 301
lung cancer 211 osteoarthritis 217
lymphatic filariasis 172 osteoporosis 126
outcome indicator 108
Macroeconomics and Health 58 overdiseasing 182
malaria 19, 75, 92, 165, 266267 overweight 118, 177, 197
brain malaria 239 ozone 84
male circumcision 248 ozone layer 84
malnutrition 75, 139, 177, 182
marasmus 186 panic 203
Marx, Karl 34 parasites 75
maternal patents 45
disorders 235 pellagra 189
morbidity 239 perinatal
mortality 235 disorders 235
mortality rate 107, 237 infections 244
mortality ratio 107, 236 mortality 102
measles 27, 69, 80, 161 persistent diarrhoea 155
measles virus 54 pertussis 163
C Mdecins Sans Frontires (MSF) 303 pesticides 76, 82, 84
micronutrient deficiency 189 pharmaceuticals 280, 304
M
middle-income countries 12 philanthropic 303
Y
Mid-upper Arm Circumference (MUAC) 118 phobias 203
K migration 16, 257 physical inactivity 198

Index
plague 27 road traffic accidents 223

pneumonia 139 Rockefeller Foundation 304
poisoning 227 roundworm 173
polio 266
poliomyelitis 164 safe motherhood 107
poliovirus 54 safe water 70
population growth 81, 253 sanitation 78
population growth rate 116 SARS 289
post-traumatic stress disorder (PTSD) 203 schistosomiasis 75, 172
poverty 13, 53, 56, 58, 60, 68, 81, 179, 255, 275 schizophrenia 203
powerlessness 62 school enrolment 65
premature 244 scurvy 189
pre-term 244 secondary infertility 234
prevalence 107 Sector-Wide Approaches (SWAps) 273
preventive interventions 90 security 68
primary sentinel systems 100
education 57, 64 Severe Atypical Respiratory Syndrome
health care 14 (SARS) 289
healthcare service 57 sex 87
healthcare strategy 269, 283 Sexual and Reproductive Health (SRH) 233
infertility 234 sexual and reproductive health and rights 233
schooling 54 sexually transmitted diseases 246
private 284 Sexually Transmitted Infections (STIs) 171
private healthcare 91 Simian Immunodeficiency Viruses (SIV) 149
private healthcare financing 92 sinusitis 139
process indicators 108 sisterhood method 238
prolonged labour 241 skin cancer 84
prostitution 82 skin infections 75
psychosis 204 sleeping sickness 92, 173
psychosomatic disorders 203 Smallness for Gestational Age (SGA) 243
public goods 283 smallpox 27, 129, 158, 265266, 268, 289
public health system 90 Smith, Adam 34
public healthcare financing 92 smoking 86
puerperal fever 241 Snow, John 265
puerperium 241 social support network 63
purchasing power 58 socio-economic determinants 56
Purchasing Power Parity (PPP) 5859 de Soto, Hernando 38
stage of
quarantine 291 delayed degenerative diseases 126
quinine 167 non-communicable diseases 125
pestilence and famine 125
rapes 68 receding pandemics 125
recto-vaginal fistula 241 Standard Deviation scores (SD scores) 119
rectum cancer 212 starvation 85, 178
refugee camps 113 stewardship 281, 285
refugees 68 stomach cancer 211
Reproductive Age Mortality Survey Stone Age 12
(RAMOS) 238 stroke 207
C reproductive health 233 structural adjustment programmes 35
reproductive rights 249 stunting 117118, 182, 184
M
respiratory diseases 212 suicide 229
Y
rickets 189 sulfadoxine-pyrimethamine 166
K river blindness 173 sustainable development 42

Index
Swedish International Development Co- unsafe abortion 240

operation Agency (Sida) 301 upper middle-income group 49
urbanisation 8081
technology 31 urinary tract infection 240
tetanus 163 uterine prolapse 241
The Bill and Melinda Gates Foundation 304 uterine rupture 239
tiger economies 38
tobacco 86 vesico-vaginal fistula 241
tonsillitis 139 virus 75
tornadoes 85 vitamin A 71, 143, 179, 190
total fertility rate 111 vitamin A deficiency 180, 190
toxicological contamination 76 vitamin B1 thiamine 189
trachoma 75 vitamin B6 nicotinic acid 189
trade 30 vitamin C deficiency 189
traditional birth attendants 95 vitamin D deficiency 189
traditional Chinese medicine 94 volcanic eruptions 85
traditional healers 274 vulnerability 56
traditional medicine 65, 93, 285
traditional practitioners 95 war 69, 229
traffic 88 wasted 117, 185
tropical diseases 137 wasting 117, 182, 184
tuberculosis 21, 84, 92, 146, 168, 170, 266 water 75, 256
typhoons 85 safety 77
supply 77
UNAIDS 299, 304 weaning 74
uncertainty interval 101 Weight-for-age (WFA) 119
under and over nutrition 117 Weight-for-height (WFH) 118
under-five mortality rate 103 World Bank 298
under-nutrition 182 World Health Chart 11
underweight 117, 119, 177, 180181 World Health Organization (WHO) 57, 293
unipolar depression 201 World Trade Organisation (WTO) 300
United Nations Childrens Fund (UNICEF) 270, worms 75
295
United Nations Development Assistance xerophthalmia 190
Frameworks (UNDAFs) 305
United Nations Development Groups yellow fever 20, 265
(UNDG) 305
United Nations Development Programme zinc 191
(UNDP) 297 deficiency 180, 192
United Nations Population Fund (UNFPA) 297 z-scores 119
United States Agency for International
Development (USAID) 301

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8012.

book Page 1 Wednesday, October 11, 2006 1:40 PM

Ann Lindstrand Staffan Bergstrm Hans Rosling

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All rights reserved. No part of this publication may be reproduced or

The papers and inks used in this product are eco-friendly.

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Preface 5 4 Health transition 123

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7.6 Other non-communicable diseases 11.4 Selective primary health care

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The authors and Studentlitteratur 5

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In Chapters 5 to 9, we describe the diseases The growing number of international or-

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Authors ant to Sida, the World Council of Churches

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8 The authors and Studentlitteratur

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The authors and Studentlitteratur 9

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Development Goals Targets

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1.1 Definitions of development

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1.2 Four levels of development

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Family in a high-income country (daily income about USD 50 per person)

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1.2 Four levels of development

Family in a middle-income country (daily income about USD 10 per person)

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Family in a low-income country (daily income about USD 2 per person)

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1.2 Four levels of development

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1.4 Hunters and gatherers (up to 10 000 years ago)

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1.5 Agriculture (10 000 to 5 000 years ago)

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