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WHYGLOBALHEALTH?
Globalhealth,ithasbeennoted,isnotadisciplineitis,rather,acollectionofproblems.Nosinglereview
candomuchmorethanlayouttheleadingproblemsfacedinapplyingevidencebasedmedicinein
settingsofgreatpovertyoracrossnationalboundaries.Inthischapter,wefirstintroducethemajor
internationalbodiesengagedinaddressingtheseproblemsidentifythemoresignificantbarriersto
improvingthehealthofpeoplewhotodatehavenot,byandlarge,hadaccesstomodernmedicinesand
summarizepopulationbaseddataregardingthemostcommonhealthproblemsfacedbypeoplelivingin
poverty.ExaminingspecificproblemsnotablyAIDS(Chap.182),butalsotuberculosis(TB,Chap.158),
malaria(Chap.203),severeacuterespiratorysyndrome(SARSChap.179),andkeynoncommunicable
diseaseshelpstosharpenthediscussionofbarrierstoprevention,diagnosis,andcareaswellasmeans
ofovercomingthem.Wenextdiscussglobalhealthequity,drawingonnotionsofsocialjusticethatonce
werecentraltointernationalpublichealthbuthavefallenoutoffavoroverthepastseveraldecades.We
closebyacknowledgingtheimportanceofcosteffectivenessanalysislinkedtonationaleconomicdata,
whileatthesametimeunderliningtheneedtoaddressdisparitiesofdiseaseriskandaccesstocare.

HISTORYOFGLOBALHEALTHINSTITUTIONS
Concernabouthealthacrossnationalboundariesdatesbackmanycenturies,predatingtheBlackPlague
andotherpandemics.Beforetheadventofgermtheory,whenepidemicdiseasebegantobeunderstood
tobetheresultofmicrobesratherthanof"miasmas"orthewrathofadivinebeing,thechiefsocial
responsestosuchepidemicsoftenincludedaccusationsthatthisorthathumangroupwasresponsiblefor
propagatingtheafflictioninquestion.Similarlyinaccurateandineffectivebeliefsaboundedwhenthe
arrivalofEuropeancolonistsledtocatastrophicoutbreaksofcommunicablediseasesamongindigenous
populationsintheAmericas,andtheseviewpointscontinuedtoholdswayduringsubsequentpandemicsof
cholera.Manyhistorianstracemodernpublichealthandepidemiologytothedayin1851whenDr.John
Snow,havingdiscernedthelinkbetweencholeraoutbreaksinLondonandwatersourcesusedbythe
afflictedpopulace,removedthehandleoftheBroadStreetwaterpump.Thusonecholeraepidemicwas
stopped,butitwouldstillbeyearsbeforetheetiologyofcholerawasdiscovered.
Aproperunderstandingofetiologywasnecessarytothebirthnotonlyofepidemiologybutalsoofefforts
toapplypublichealthmeasuresacrossadministrativeboundariesindeed,withoutagreementupon
etiologyandcasedefinitions,therecouldbenosoundmetricsuponwhichtobaseeitherassessmentsof
diseaseburdenoreffectiveinterventions.Thecloseofthenineteenthcenturymarkedthebirthandrapid
growthofmicrobiologyandthedevelopmentofsomeofthefirsteffectivevaccines,which,alongwith
measurestopromotesanitation,werefordecadesthemainstayofmodernpublichealth.Beforethe
developmentofeffectiveantibioticsinthemidtwentiethcentury,internationalhealthendeavorsconsisted
largelyofthetransnationalapplicationofasmallnumberoflessonslearnedfromlocalorregional
campaigns.Perhapsthefirstorganizationfoundedexplicitlytotacklecrossborderhealthissueswasthe
PanAmericanSanitaryBureau,whichwasformedby11countriesintheAmericasin1902.Theprimary
goalofwhatwaslatertobecomethePanAmericanHealthOrganizationwasthecontrolofinfectious
diseasesacrosstheAmericas.Ofspecialconcernwasyellowfever,whichhadbeenrunningadeadly

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coursethroughmuchofSouthandCentralAmericaandposedathreattotheconstructionofthePanama
Canal.Theidentificationofamosquitovectorin1901ledpublicandprivatehealthauthoritiestofocuson
mosquitocontrolavaccinewasdevelopedinthe1930s.
Evenintheearlyheydayofvaccinedevelopment,noglobalinstitutionstackledthehealthproblemsofthe
world'spoor.Colonialpowersdidaddress(withvaryingdegreesofeffectivenessandsourcesof
motivation)therankinginfectiouskillersinregionsnowknownasthedevelopingworld,butuniversal
standardsorevenaspirationsforinternationalpublichealthandmedicinewerestillfarinthefuture.
AlthoughtheLeagueofNationsconcerneditselfwithhealthissuessuchasmalariaintheearlytwentieth
century,andalthoughvariousorgansofthenascentUnitedNationsincludingtheUnitedNations
DevelopmentProgramandtheUnitedNationsChildren'sFund(UNICEF)alsoaddressedhealthissues,the
WorldHealthOrganization(WHO)wasthefirsttrulyglobalhealthinstitution.Sinceitsfoundingin1948,
theWHOhaswitnesseddramaticshiftsinpopulationhealthandinitsownstatureasthepremierglobal
healthinstitution.Inlinewithalongstandingfocusoncommunicablediseasesthatreadilycross
administrativeandpoliticalborders,leadersinglobalhealth,undertheaegisoftheWHO,initiatedthe
effortthatledtowhatsomeseeasthegreatestsuccessininternationalhealth:theeradicationof
smallpox.Historiansofthesmallpoxcampaignnotethepreconditionsthatmadeeradicationpossible:
internationalconsensusregardingthepotentialforsuccess,aneffectivevaccine,andtheapparentlackof
anonhumanreservoirfortheoftenlethalandhighlyinfectiousetiologicagent.Theprimaryobstaclewas
thelackofeffectivedeliverymechanismsforthevaccineinsettingsofpoverty,wherehealthpersonnel
werescarceandhealthsystemsweak.Closecollaborationsacrossadministrativeandpoliticalborders
wereclearlynecessary.Naysayersweresurprisedwhenthesmallpoxeradicationcampaign,which
engagedpublichealthofficialsthroughouttheworld,provedsuccessfulattheheightoftheColdWar.
Theoptimismbornoftheworld'sfirstsuccessfuldiseaseeradicationcampaigninvigoratedthe
internationalhealthcommunity,ifonlybriefly.Globalconsensusregardingtherighttoprimaryhealthcare
forallwasreachedattheInternationalConferenceonPrimaryHealthCareinAlmaAta(inwhatisnow
Kazakhstan)in1978.However,thedeclarationofthiscollectivevisionwasnotfollowedbysubstantial
funding,nordidtheapparentconsensusreflectuniversalcommitmenttotherighttohealthcare.
Moreover,asistoooftenthecase,successparadoxicallyweakenedcommitment.Basicscienceresearch
thatmightleadtoeffectivevaccinesandtherapiesforTBandmalariafalteredinthelatterdecadesofthe
twentiethcenturyafterthesediseaseswerebroughtundercontrolintheaffluentcountrieswheremost
suchresearchisconducted.U.S.SurgeonGeneralWilliamH.Stewartdeclaredinthelate1960sthatit
wastimeto"closethebookoninfectiousdiseases,"andattentionwasturnedtothemainhealthproblems
ofcountriesthathadalreadyundergonean"epidemiologicaltransition"thatis,thefocusshiftedfrom
prematuredeathsduetoinfectiousdiseasestowarddeathsfromcomplicationsofchronic
noncommunicablediseases,includingmalignanciesandcomplicationsofheartdisease.
In1982,thevisionaryleaderofUNICEF,JamesP.Grant,frustratedbythelackofactionaroundtheHealth
forAllinitiativeannouncedinAlmaAta,launcheda"childsurvivalrevolution"focusedonfourinexpensive
interventionscollectivelyknownbytheacronymGOBI:growthmonitoringoralrehydrationbreast
feedingandimmunizationsforTB,diphtheria,whoopingcough,tetanus,polio,andmeasles.GOBI,which
waslaterexpandedtoGOBIFFF(toincludefemaleeducation,food,andfamilyplanning),was
controversialfromthestart,butGrant'sadvocacyledtoenormousimprovementsinthehealthofpoor
childrenworldwide.TheExpandedProgrammeonImmunizationwasespeciallysuccessfulandisthought
tohaveraisedtheproportionofchildrenworldwidewhowerereceivingcriticalvaccinesbymorethan
threefoldi.e.,from<20%toalmost80%(thetargetlevel).

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Formanyreasons(including,perhaps,thesuccessoftheUNICEFledcampaignforchildsurvival),the
influenceoftheWHOwanedduringthe1980s.Intheearly1990s,manyobserversarguedthat,withits
vastlysuperiorfinancialresourcesandcloseifunequalrelationshipswiththegovernmentsofpoor
countries,theWorldBankhadeclipsedtheWHOasthemostimportantmultilateralinstitutionworkingin
theareaofhealth.OneofthestatedgoalsoftheWorldBankwastohelppoorcountriesidentify"cost
effective"interventionsworthyofinternationalpublicsupport.Atthesametime,theWorldBank
encouragedmanyofthesenationstoreducepublicexpendituresinhealthandeducationaspartof(later
discredited)structuraladjustmentprograms(SAPs),whichwereimposedasaconditionforaccessto
creditandassistancethroughinternationalfinancialinstitutionssuchastheBankandtheInternational
MonetaryFund(IMF).Onetrendrelated,atleastinpart,totheseexpenditurereductionpolicieswasthe
resurgenceinAfricaofmanydiseasesthatcolonialregimeshadbroughtundercontrol,includingmalaria,
trypanosomiasis,andschistosomiasis.Tuberculosis,aneminentlycurabledisease,remainedtheworld's
leadinginfectiouskillerofadults.Halfamillionwomenperyeardiedinchildbirthduringthelastdecadeof
thetwentiethcentury,andfewoftheworld'slargestphilanthropicorfundinginstitutionsfocusedonglobal
health.
AIDS,firstdescribedin1981,precipitatedachange.IntheUnitedStates,theadventofthisnewly
describedinfectiouskillermarkedtheculminationofaseriesofeventsthatdiscreditedthegrandtalkof
"closingthebook"oninfectiousdiseases.InAfrica,whichwouldemergeastheglobalepicenterofthe
pandemic,HIVdiseasefurtherweakenedTBcontrolprograms,whilemalariacontinuedtotakeasmany
livesasever.Atthedawnofthetwentyfirstcentury,thesethreediseasesalonekilledanestimated6
millionpeopleeachyear.Newresearch,newpolicies,andnewfundingmechanismswerecalledfor.Some
oftherequisiteinnovationshaveemergedinthepastfewyears.TheleadershipoftheWHOhasbeen
challengedbytheriseofinstitutionssuchastheGlobalFundtoFightAIDS,Tuberculosis,andMalariathe
JointUnitedNationsProgramonHIV/AIDS(UNAIDS)andtheBill&MelindaGatesFoundationandby
bilateraleffortssuchastheU.S.President'sEmergencyPlanforAIDSRelief(PEPFAR).Yetwithits193
memberstatesand147countryoffices,theWHOremainspreeminentinmattersrelatingtothecross
borderspreadofinfectiousandotherhealththreats.IntheaftermathoftheSARSepidemicof2003,the
InternationalHealthRegulationswhichprovidealegalfoundationfortheWHO'sdirectinvestigationofa
widerangeofglobalhealthproblems,includingpandemicinfluenza,inanymemberstatewere
strengthenedandbroughtintoforceinMay2007.
Evenasattentiontoandresourcesforhealthproblemsinresourcepoorsettingsgrow,thelackof
coherenceinandamongglobalhealthinstitutionsmayseriouslyundermineeffortstoforgeamore
comprehensiveandeffectiveresponse.WhileUNICEFhadgreatsuccessinlaunchingandsustainingthe
childsurvivalrevolution,theendofJamesGrant'stermatUNICEFuponhisdeathin1995wasfollowedby
alamentableshiftoffocusawayfromimmunizationspredictably,coveragedropped.TheWHOhasgone
throughtworecentleadershiptransitionsandisstillwoefullyunderfundeddespitetheevergrowingneed
toengageawiderandmorecomplexrangeofhealthissues.Inanotherinstanceoftheparadoxicalimpact
ofsuccess,therapidgrowthoftheGatesFoundation,whileclearlyoneofthemostimportant
developmentsinthehistoryofglobalhealth,hasledotherfoundationstoquestionthewisdomof
continuingtoinvesttheirmoremodestresourcesinthisfield.Wemayindeedbelivinginwhatsomehave
called"thegoldenageofglobalhealth,"butleadersofmajororganizationssuchastheWHO,theGlobal
Fund,UNICEF,UNAIDS,andtheGatesFoundationmustworktogethertodesignaneffectivearchitecture
thatwillmakethemostoftheextraordinaryopportunitiesthatnowexist.Tothisend,newandoldplayers
inglobalhealthmustinvestheavilyindiscovery(relevantbasicscience)inthedevelopmentofnewtools
(preventive,diagnostic,andtherapeutic)andinanewscienceofimplementation,ordelivery.

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THEECONOMICSOFGLOBALHEALTH
Politicalandeconomicconcernshaveoftenguidedglobalhealthinterventions.Asmentionedpreviously,
earlyeffortstocontrolyellowfeverweretiedtothecompletionofthePanamaCanal.However,theprecise
natureofthelinkbetweeneconomicsandhealthremainsamatterfordebate.Someeconomistsand
demographersarguethateconomicdevelopmentisthekeytoimprovingthehealthstatusofpopulations,
whileothersmaintainthatillhealthisthechiefbarriertodevelopmentinpoorcountries.Ineithercase,
investmentinhealthcare,andespeciallyinthecontrolofcommunicablediseases,shouldleadtoincreased
productivity.Thequestioniswheretofindthenecessaryresourcestostartthepredicted"virtuouscycle."
Internationalfinancialinstitutions,includingtheWorldBankandtheIMF,havecounseledlimited
investmentsandthecappingofsocialexpendituresinhealthandeducation.Thesocioeconomicargument
wasthatabalancedbudgetanda"friendlyinvestmentclimate"thatis,privatization,deregulation,
decreasedtradebarriers,devaluedcurrencies,anddebtrepaymentwouldfavordevelopmentandthus
improvehealthoutcomes.Thelimitationsonsocialsectorspendingrecommendedformanypoorcountries
bytheWorldBankandtheIMFfromthe1970sthroughthe1990stendedtoconfirmtheoppositeview.In
thepoorestcountries,alreadytinyhealthsectorbudgetswerefurtherconstricted.Moreover,healthsector
spendinginmanypoorcountrieschanneledamajorityofresourcestowardcityhospitalsthatserved
mostlyliteswhowereabletopayconsequently,inthepastquartercentury,littlespendingwenttoward
addressingtheproblemsthatmostaffectedpoorpeopleinpoorcountries.
Since1999,spurredbytheleadershipoftheGatesFoundationandthegrowinginterestinaddressing
novelandpersistentchallengessuchasAIDS,spendingonhealthinpoorcountrieshasincreased,with
$40billioninnewfundsearmarkedforthediscoveryanddevelopmentofdrugsanddiagnosticstargeting
diseasesofthepoorforcomprehensiveresponsestotheAIDS,TB,andmalariaepidemicsforvaccine
developmentanddeliveryandevenforimprovedmethodsofdatacollectioninresourcepoorsettings.
Nevertheless,inordertoreachtheUnitedNations'MillenniumDevelopmentGoals,whichincludetargets
forpovertyreduction,universalprimaryeducation,andgenderequality,spendinginthehealthsectorwill
havetobefurtherincreasedandsustained.Todeterminebyhowmuchandforhowlong,itisimperative
thatweimproveourabilitytoassesstheglobalburdenofdisease(GBD)andtoplaninterventionsthat
morepreciselymatchtheneed,whichisglaringbutoftenpoorlyunderstood.Refiningmetricsisan
importanttaskforglobalhealth:onlyrecentlyhavewehadsolidassessmentsoftheGBD.Such
assessmentsmayserveaspreliminariesorascorrectivestoeffectiveinterventionsamongthepoor.

LIFEEXPECTANCYANDGLOBALBURDENOFDISEASE
Sincethelate1980s,seriouseffortshavebeenmadetocalculatetheGBD.ThefirstGBDstudy,conducted
in1990,laidthefoundationforthefirstreportonDiseaseControlPrioritiesinDevelopingCountries
(DCP1)andfortheWorldBank's1993WorldDevelopmentReportentitledInvestinginHealth.These
effortsrepresentedamajoradvanceinourunderstandingofhealthstatusindevelopingcountries.
InvestinginHealthhasbeenespeciallyinfluential:itfamiliarizedabroadaudiencewithcosteffectiveness
analysisforspecifichealthinterventionsandwiththenotionofdisabilityadjustedlifeyears(DALYs).The
DALY,whichhasbecomeastandardmeasureoftheimpactofaspecifichealthconditiononapopulation,
combinesinasinglemeasurebothabsoluteyearsoflifelostandyearslostduetodisabilityforincident
casesofacondition.
ThesecondGBDanalysiswascarriedoutonhealthdatafrom2001.Thelatterreportreflectsgrowthinthe
availabledataonhealthinthepoorestcountriesandinourcapacitytomeasuretheimpactofspecific
conditionsonapopulation.Yet,evenin2001,only107of192nationssurveyedhadreliableinformation

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onthecausesofdeathswithintheirownborders.Itisessentialtoexpandeffortstocollectthemostbasic
healthdatathistaskfallstotheWHO,nationalgovernments,andcertainacademicinstitutions.Thelack
ofcompletedatahasledtoconsiderableuncertaintyinestimatesofoverallmortality.Thelevelof
uncertaintyrangesfromaslowas1%forestimatesofallcausemortalityindevelopedcountriestowell
over50%fordisabilityresultingfromdiseasesforwhichsurveillancemechanismsareincomplete.As
analyticmethodsanddataqualityhaveimproved,however,importanttrendscanbeidentifiedina
comparisonofGBDestimatesfrom1990and2001.
Ofthe56milliondeathsworldwidein2001,onethirdwereduetocommunicablediseases,maternaland
perinatalconditions,andnutritionaldeficiencies.Whiletheproportionofalldeathsattributabletothese
causeswasunchangedfrom1990,theshareofalldeathsduetothecommunicablediseaseHIV/AIDS
grewfromjust2%toanastonishing14%.Ifthesedeathswereexcluded,thefractionofalldeathsrelated
tocommunicablediseases,maternalandperinatalconditions,andnutritionaldeficienciesdroppedfrom
onethirdtoonefifth.Ofthedeathsmakingupthatonefifthofthetotalfigure,97%occurredinmiddle
andlowincomecountries.Theleadingcauseofdeathamongadultsin2001wasischemicheartdisease,
accountingfor17.3%ofalldeathsinhighincomecountriesandfor11.8%inmiddleandlowincome
countries.Insecondplacewascerebrovasculardisease,whichaccountedfor9.9%ofdeathsinhigh
incomecountriesandfor9.5%ofdeathsinmiddleandlowincomecountries.Whilethethirdleading
causeofdeathinhighincomecountrieswastracheal,bronchial,andlungcancers(whichaccountedfor
5.8%ofalldeaths),theseconditionsdonotevenregisterinthetop10placesinmiddleandlowincome
countries.Ofthe10leadingcausesofdeathinpoorercountries,5werecommunicablediseasesinhigh
incomecountries,however,only1communicablediseaselowerrespiratoryinfectionwasrankedamong
thetop10causesofdeath.
Nearly20%(10.6million)ofthe56milliondeadin2001werechildren<5yearsofagewhodiedofacute
respiratoryinfections,measles,diarrhea,malaria,andHIV/AIDS(Fig.21).Ofthesedeaths,99%
occurredinmiddleandlowincomecountries,andfully40%occurredinsubSaharanAfrica.Ifstillbirths
arecounted,thenumberofchildhooddeathsrisesto13.5millionworldwide(~25%ofalldeaths
worldwide),ofwhichmorethanhalf(i.e.,oneeighthofalldeaths)occurredbeforethefirstbirthday.
Between1990and2001,underfivechildhoodmortalitydroppedby 30%inhighincomecountries,Latin
America,theCaribbean,theMiddleEast,NorthAfrica,andthemiddleandlowincomecountriesofEurope
andCentralAsia.Notably,thetotalnumberofdeathsfromdiarrhealdiseasesdroppedfrom2.4millionin
1990to1.6millionin2001,probablyasaresultoftheincreaseduseoforalrehydrationtherapyinpoor
countries.MalariaandHIVinfectionweretheonlytwoconditionsforwhichchildhooddeathratesincreased
between1990and2001.

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Deathratesamongchildrenfrombirththrough4yearsofage,bydiseasegroupandregion,in1990
and2001.Causespecificdeathratesfor1990,estimatedfromMurrayandLopez(1996),maynotbecompletely
comparabletothosefor2001becauseofchangesindataavailabilityandmethodsaswellassome
approximationsinmapping1990estimatestothe2001regionsofEastAsiaandPacific,SouthAsia,andEurope
andCentralAsia.Forallgeographicregions,highincomecountriesareexcludedandareshownasasinglegroup
atthetopofthegraph.Thegeographicregionsthereforerefertolowandmiddleincomecountriesonly.
(ReprintedfromLopezetal,withpermissionfromElsevier.)

Amongpersons1559yearsofage(Fig.22),noncommunicablediseasesaccountedformorethanhalfof
alldeathsinallregionsexceptSouthAsiaandsubSaharanAfrica,wherecommunicablediseases,
maternalandperinatalconditions,andnutritionaldeficienciestogetheraccountedforonethirdandtwo
thirdsofalldeaths,respectively.The15to59yearoldswithnoncommunicableconditionsinlowand
middleincomecountriesfaceda30%greaterriskofdeathfromtheirconditionsthandidtheirpeersin
highincomecountries.Inthisagegroup,injuriesaccountedfor25%ofalldeathsEuropeandCentral
Asiaregisteredevenhigherrates,withinjuriesaccountingforonethirdofalldeaths.Overall,deathrates
inthisagegroupdeclinedbetween1990and2001inallregionsexceptEuropeandCentralAsia,where
cardiovasculardiseasesandinjurieshavecausedincreasedmortality,andsubSaharanAfrica,wherethe
impactofHIV/AIDSinthisagecohorthasbeenparticularlydevastating.

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Deathratesamongpersons1559yearsold,bydiseasegroupandregion,in1990and2001. *Includes
respiratoryinfections.Causespecificdeathratesfor1990,estimatedfromMurrayandLopez(1996),maynotbe
completelycomparabletothosefor2001becauseofchangesindataavailabilityandmethodsaswellassome
approximationsinmapping1990estimatestothe2001regionsofEastAsiaandPacific,SouthAsia,andEurope
andCentralAsia.Forallgeographicregions,highincomecountriesareexcludedandareshownasasinglegroup
atthetopofthegraph.Thegeographicregionsthereforerefertolowandmiddleincomecountriesonly.
(ReprintedfromLopezetal,withpermissionfromElsevier.)

Noncommunicablediseasesaccountedforalmost60%ofalldeathsin2001but,becauseofthelateronset
ofthesediseases,accountedforonly40%ofyearsoflifelost.Incontrast,becausetheyoccurmoreoften
inyoungerpeople,injuriesaccountedfor12%ofyearsoflifelostbutforonly9%ofdeaths.Overall,
maleshadan11%higherdeathratethanfemalesaswellasa15%higherrateofyearsoflifelostthese
figuresreflecttheearlierageofdeathofmalesworldwide.Notably,almosthalfofthediseaseburdenin
middleandlowincomecountriesin2001derivedfromnoncommunicablediseaseanincreaseof10%
since1990.
Comparedwithyearsoflifelost,thereisgreateruncertaintyincalculatingyearsoflifelivedwithdisability
forspecificconditions.Bestestimatesfrom2001revealthat,whiletheprevalenceofdiseasescommonin
olderpopulations(e.g.,dementiaandmusculoskeletaldisease)washigherinhighincomecountries,the
disabilityexperiencedasaresultofcardiovasculardiseases,chronicrespiratorydiseases,andthelong

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termimpactofcommunicablediseaseswasgreaterinlowandmiddleincomecountries.Thus,
predictably,inmostlowandmiddleincomecountries,peoplebothlivedshorterlivesandexperienced
disabilityandpoorhealthforagreaterproportionoftheirlives.Indeed,45%oftheoverallburdenof
diseaseoccurredinSouthAsiaandsubSaharanAfrica,whichtogethercompriseonlyonethirdofthe
globalpopulation.
Initsanalysisofriskfactorsforillhealth,theGBDprojectfoundthatundernutritionwastheleadingcause
oflossofDALYsinboth1990and2001.Inanerathathasseenobesitybecomeamajorhealthconcernin
somanydevelopedcountries,thepersistenceofundernutritionissurelycauseforgreatconsternation.
Ourinabilitytofeedthehungryindictsmanyyearsoffaileddevelopmentprojectsandmustbeaddressed
asaproblemofthehighestpriority.Indeed,nohealthcareinitiative,howevergenerouslyfundedand
scientificallyjustified,willbeeffectivewithoutadequatenutrition.
TheGBDanalysiswasusedasthebasisforthesecondeditionofDiseaseControlPrioritiesinDeveloping
Countries(DCP2).Publishedin2006,DCP2isadocumentofstunningbreadthandambition,providing
costeffectivenessanalysesfor>100interventionsandincluding21chaptersfocusedonstrategiesfor
strengtheninghealthsystems.Costeffectivenessanalysesthatcomparetworelativelyequalinterventions
andfacilitatethebestchoicesunderconstraintareimportanthowever,asbothresourcesandambitions
forglobalhealthgrow,costeffectivenessanalyses(particularlythosebasedonpastconditions)mustnot
hobbletheincreasedworldwidecommitmenttoprovideresourcesandaccessibleservicestoallwhoneed
them.Toillustratethispoint,weturningreaterdetailtoAIDS,whichhasbecome,inthecourseofthe
lastthreedecades,theworld'sleadinginfectiouscauseofdeathduringadulthood.

AIDS
Chapter182providesanoverviewoftheAIDSepidemicintheworldtoday.Herewewilllimitourselvesto
adiscussionofAIDSinthedevelopingworld.LessonslearnedintacklingAIDSinresourceconstrained
settingsarehighlyrelevanttodiscussionsofotherchronicdiseases,includingnoncommunicablediseases,
forwhicheffectivetherapieshavebeendeveloped.Wehighlightseveraloftheselessonsbelow.
IntheUnitedStates,theavailabilityofhighlyactiveantiretroviraltherapy(ART)forAIDShastransformed
thisdiseasefromaninescapablyfataldestructionofcellmediatedimmunityintoamanageablechronic
illness.Indevelopingcountries,treatmenthasbeenofferedmorebroadlyonlysince2003,andonlyinthe
summerof2006didthenumberofpatientsreceivingtreatmentexceed25%ofthenumberwhocurrently
needit.(ItremainstobeseenhowmanyofthesefortunatefewarereceivingARTregularlyandwiththe
requisitesocialsupport.)Before2003,manyargumentswereraisedtojustifynotmovingforwardrapidly
withARTprogramsforpeoplelivingwithHIV/AIDSinresourcelimitedsettings.Thestandardlitany
includedthepriceoftherapycomparedtothepovertyofthepatient,thecomplexityoftheintervention,
thelackofinfrastructureforlaboratorymonitoring,andthelackoftrainedhealthcareproviders.Narrow
costeffectivenessargumentsthatcreatedfalsedichotomiespreventionortreatment,ratherthanboth
toooftenwentunchallenged.Thegreatestobstacleatthetimewastheambivalence,ifnotoutright
silence,ofpoliticalleadersandexpertsinpublichealth.Thecumulativeeffectofthesefactorswasto
condemntodeathtensofmillionsofpoorpeopleindevelopingcountrieswhohadbecomeillasaresultof
HIVinfection.
TheinequitybetweenrichandpoorcountriesinaccesstoHIVtreatmenthasrightlygivenriseto
widespreadmoralindignation.Inseveralmiddleincomecountries,includingBrazil,visionaryprograms
havebridgedtheaccessgap.Otherinnovativeprojectspioneeredbyinternationalnongovernmental
organizations(NGOs)indiversesettingshaveclearlyestablishedthataverysimpleapproachtoART,

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basedonintensivecommunityengagementandsupport,canachieveremarkableresults.In2000,the
UnitedNationsAcceleratingAccessInitiativefinallybroughttheresearchbasedandgeneric
pharmaceuticalindustriesintoplay,andAIDSdrugpriceshavesincefallensignificantly.Atthesametime,
easiertoadministerfixeddosecombinationdrugshavebecomemorewidelyavailable.
Buildingontheselessons,theWHOadvocatedapublichealthapproachtothetreatmentofpeoplewith
AIDSinresourcelimitedsettings.Thisapproach,whichwasderivedfrommodelsofcarepioneeredbythe
NGOPartnersInHealthandothergroups,proposedstandardfirstlinetreatmentregimensbasedona
simplefivedrugformulary,withamorecomplex(and,uptonow,moreexpensive)setofsecondline
optionsinreserve.Commonclinicalprotocolswerestandardized,andintensivetrainingpackagesfor
healthandcommunityworkersweredevelopedandimplementedinmanycountries.Theseeffortswere
supportedbyunprecedentedfundingthroughtheWorldBank,theGlobalFund,andPEPFAR.In2003,the
lackofaccesstoARTwasdeclaredaglobalpublichealthemergencybytheWHOandUNAIDS,andthe
twoagencieslaunchedthe"3by5initiative,"settinganambitioustarget:having3millionpeoplein
developingcountriesontreatmentbytheendof2005.Manycountrieshavesincesetcorresponding
nationaltargetsandhaveworkedtointegrateARTintotheirnationalAIDSprogramsandhealthsystems
andtoharnessthesynergiesbetweenHIV/AIDStreatmentandpreventionactivities.TheG8(Gleneagles)
2005communiquendorsinguniversalaccesstoHIVtreatmentby2010wasanothermajorstepforward.
ItisclearbynowthattheclaimsmadefortheefficacyofARTarewellfounded:intheUnitedStates,such
therapyhasprolongedlifebyanestimated13yearsperpatientonaverageasuccessratethatwould
comparefavorablywiththatofalmostanytreatmentforcancerorforcomplicationsofcoronaryartery
disease.Furtherlessonswithimplicationsforpolicyandactionhavecomefromeffortsthatarenowunder
wayinthedevelopingworld.Duringthepastdecade,throughexperiencesin>50countriesthusfar,the
worldhasseenthatambitiouspolicygoals,adequatefunding,andknowledgeaboutimplementationcan
dramaticallytransformtheprospectsofpeoplelivingwithHIVinfectionindevelopingnations.

Tuberculosis
Chapter158offersaconciseoverviewofthepathophysiologyandtreatmentofTB,whichiscloselylinked
toHIVinfectioninmuchoftheworld.Indeed,asubstantialproportionoftheresurgenceofTBregistered
insouthernAfricamaybeattributedtoHIVcoinfection.EvenbeforetheadventofHIV,however,itwas
estimatedthatfewerthanhalfofallcasesofTBindevelopingcountrieswereeverdiagnosed,muchless
treated.
PrimarilybecauseofthecommonfailuretodiagnoseandtreatTB,internationalauthoritiesdeviseda
singlestrategytoreducetheburdenofdisease.TheDOTSstrategy(directlyobservedtherapyusingshort
courseisoniazidandrifampinbasedregimens)waspromotedintheearly1990sashighlycosteffective
bytheWorldBank,theWHO,andotherinternationalbodies.Passivecasefindingofsmearpositive
patientswascentraltothestrategy,andanuninterrupteddrugsupplywas,ofcourse,deemednecessary
forcure.DOTSwasclearlyeffectiveformostuncomplicatedcasesofdrugsusceptibleTB,butitwasnot
longbeforeanumberofshortcomingswereidentified.First,thediagnosisofTBbasedsolelyonsmear
microscopyamethoddatingfromthelatenineteenthcenturyisnotsensitive.Manypatientswith
pulmonaryTBandallpatientswithexclusivelyextrapulmonaryTBaremissedbysmearmicroscopy,asare
mostchildrenwithactivedisease.Second,passivecasefindingreliesontheavailabilityofhealthcare
services,whichisuneveninsettingswhereTBismostprevalent.Third,patientswithmultidrugresistant
(MDR)TBarebydefinitioninfectedwithstrainsofMycobacteriumtuberculosisresistanttoisoniazidand
rifampinthusexclusiverelianceonthesedrugsisineffectiveinsettingsinwhichdrugresistanceisan

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establishedproblem.
ThecrisisofantibioticresistanceregisteredinU.S.hospitalsisnotconfinedtotheindustrializedworldor
tobacterialinfections.Insomesettings,asubstantialminorityofpatientswithTBareinfectedwithstrains
resistanttoatleastonefirstlineantiTBdrug.AsaneffectiveDOTSbasedresponsetoMDRTB,global
healthauthoritiesadoptedDOTSPlus,whichaddsthediagnosticsanddrugsnecessarytomanagedrug
resistantdisease.EvenbeforeDOTSPluscouldbebroughttoscaleinresourceconstrainedsettings,
however,newstrainsofextensivelydrugresistant(XDR)M.tuberculosisbegantothreatenthesuccessof
TBcontrolprogramsinalreadybeleagueredSouthAfrica,forexample,wherehighratesofHIVinfection
haveledtoadoublingofTBincidenceoverthepastdecade.

TUBERCULOSISANDAIDSASCHRONICDISEASES:LESSONSLEARNED
StrategieseffectiveagainstMDRTBhaveimplicationsforthemanagementofdrugresistantHIVinfection
andevendrugresistantmalaria,which,throughrepeatedinfectionsandalackofeffectivetherapy,has
becomeachronicdiseaseinpartsofAfrica.Indeed,examiningAIDSandTBtogetheraschronicdiseases
allowsustodrawanumberofconclusions,manyofthempertinenttoglobalhealthingeneral(Fig.23).

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AnHIV/TBcoinfectedpatientinRwanda,before(left)andafter(right)6monthsoftreatment.

First,chargingfeesforAIDSpreventionandcarewillposeinsurmountableproblemsforpeoplelivingin
poverty,manyofwhomwillalwaysbeunabletopayevenmodestamountsforservicesormedications.
LikeeffortstobattleairborneTB,suchservicesmightbestbeseenasapublicgoodforpublichealth.
Initially,thisapproachwillrequiresustaineddonorcontributions,butmanyAfricancountrieshaverecently
settargetsforincreasednationalinvestmentsinhealthapledgethatcouldrenderambitiousprograms
sustainableinthelongrun.Meanwhile,aslocalinvestmentsincrease,thepriceofAIDScareisdecreasing.
ThedevelopmentofgenericmedicationsmeansthatARTcannowcost<$0.50(U.S.)perday,andcosts
continuetodecreasetoaffordablelevelsforpublichealthbodiesindevelopingcountries.
Second,theeffectivescaleupofpilotprojectswillrequirethestrengtheningandsometimesrebuildingof
healthcaresystems,includingthosechargedwithdeliveringprimarycare.Inthepast,thelackofhealth
careinfrastructurehasbeencitedasabarriertoprovidingARTintheworld'spoorestregionshowever,
AIDSresources,whichareatlastconsiderable,maybemarshaledtorebuildpublichealthsystemsinsub
SaharanAfricaandotherHIVburdenedregionspreciselythesettingsinwhichTBisresurgent.
Third,alackoftrainedhealthcarepersonnel,mostnotablydoctors,isinvokedasareasonforthefailure
totreatAIDSinpoorcountries.Thelackisreal,andthe"braindrain,"whichisdiscussedbelow,continues.
However,onereasondoctorsleaveAfricaisthattheylackthetoolstopracticetheirtradethere.AIDS

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fundingprovidesanopportunitynotonlytorecruitphysiciansandnursestounderservedregionsbutalso
totraincommunityhealthworkerstosupervisecareforAIDSandmanyotherdiseaseswithintheirhome
villagesandneighborhoods.Suchtrainingshouldbeundertakeneveninplaceswherephysiciansare
abundant,sincecommunitybased,closelysupervisedcarerepresentsthehigheststandardofcarefor
chronicdisease,whetherintheFirstWorldortheThird.
Fourth,extremepovertymakesitdifficultformanypatientstocomplywiththerapyforchronicdiseases,
whethercommunicableornot.Indeed,povertyinitsmanydimensionsisfarandawaythegreatestbarrier
tothescaleupoftreatmentandpreventionprograms.Itispossibletoremovemanyofthesocialand
economicbarrierstoadherence,butonlywithwhataresometimestermed"wraparoundservices":food
supplementsforthehungry,helpwithtransportationtoclinics,childcare,andhousing.Inmanyrural
regionsofAfrica,hungeristhemajorcoexistingconditioninpatientswithAIDSorTB,andthese
consumptivediseasescannotbetreatedeffectivelywithoutadequatecaloricintake.
Finally,thereisaneedforarenewedbasicsciencecommitmenttothediscoveryanddevelopmentof
vaccinesofmorereliable,lessexpensivediagnostictoolsandofnewclassesoftherapeuticagents.This
needappliesnotonlytothethreeleadinginfectiouskillersagainstnoneofwhichaneffectivevaccine
existsbutalsotomanyotherneglecteddiseasesofpoverty.

Malaria
Weturnnowtotheworld'sthirdlargestinfectiouskiller,whichhastakenitsgreatesttollamongchildren,
especiallyAfricanchildren,livinginpoverty.

THECOSTOFMALARIA
Malaria'shumantollisenormous.Anestimated250millionpeoplesufferfrommalarialdiseaseeachyear,
andthediseaseannuallykillsbetween1millionand2.5millionpeople,mostlypregnantwomenand
childrenundertheageof5.Thepoordisproportionatelysuffertheconsequencesofmalaria:58%of
malariadeathsoccurinthepoorest20%oftheworld'spopulation,and90%areregisteredinsubSaharan
Africa.Thedifferentialmagnitudeofthismortalityburdenisgreaterthanthatassociatedwithanyother
disease.Likewise,themorbiditydifferentialisgreaterformalariathanfordiseasescausedbyother
pathogens,asdocumentedinastudyfromZambiathatrevealeda40%greaterprevalenceofparasitemia
amongchildrenunder5inthepoorestquintilethanintherichest.
Despitesufferingthegreatestconsequencesofmalaria,thepoorarepreciselythoseleastabletoaccess
effectivepreventionandtreatmenttools.Economistsdescribethecomplexinteractionsbetweenmalaria
andpovertyfromanoppositebutcomplementaryperspective:theydelineatewaysinwhichmalaria
arrestseconomicdevelopmentbothforindividualsandforwholenations.Microeconomicanalysesfocusing
ondirectandindirectcostsestimatethatmalariamayconsumeupto10%ofahousehold'sannual
income.AGhanaianstudythatcategorizedthepopulationbyincomegrouphighlightedtheregressive
natureofthiscost:theburdenofmalariarepresentsonly1%ofawealthyfamily'sincomebut34%ofa
poorhousehold'sincome.
Atthenationallevel,macroeconomicanalysesestimatethatmalariamayreducethepercapitagross
nationalproductofadiseaseendemiccountryby50%relativetothatofanonmalarialcountry.The
causesofthisdragincludehighfertilityrates,impairedcognitivedevelopmentofchildren,decreased
schooling,decreasedsaving,decreasedforeigninvestment,andrestrictionofworkermobility.Giventhis
enormouscost,itislittlewonderthatanimportantreviewbytheeconomistsSachsandMalaney
concludesthat"wheremalariaprospersmost,humansocietieshaveprosperedleast."

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ROLLINGBACKMALARIA
Inpartbecauseofdifferencesinvectordistributionandclimate,resourcerichcountriesofferfew
blueprintsformalariacontrolandtreatmentthatareapplicableintropical(andresourcepoor)settings.In
2001,AfricanheadsofstateendorsedtheWHORollBackMalaria(RBM)campaign,whichprescribes
strategiesappropriateforsubSaharanAfricancountries.RBMrecommendsathreeprongedstrategyto
reducemalariarelatedmorbidityandmortality:theuseofinsecticidetreatedbednets(ITNs),
combinationantimalarialtherapy,andindoorresidualspraying.
ITNsareanefficaciousandcosteffectivepublichealthintervention.Ametaanalysisofcontrolledtrials
indicatesthatmalariaincidenceisreducedby50%amongpersonswhosleepunderITNscomparedwith
thatamongthosewhodonotusenetsatall.Evenuntreatednetsreducemalariaincidencebyone
quarter.Onanindividuallevel,theutilityofITNsextendsbeyondprotectionfrommalaria.Severalstudies
suggestthatallcausemortalityisreducedamongchildrenunder5toagreaterdegreethancanbe
attributedtothereductioninmalarialdiseasealone.Morbidity(specificallythatduetoanemia)
predisposingchildrentodiarrhealandrespiratoryillnessesandpregnantwomentothedeliveryoflow
birthweightinfantsisalsoreducedinpopulationsusingITNs.Insomeareas,ITNsofferasupplemental
benefitbypreventingtransmissionoflymphaticfilariasis,cutaneousleishmaniasis,Chagas'disease,and
tickbornerelapsingfever.Atthecommunitylevel,investigatorssuggestthattheuseofanITNinjustone
householdmayreducethenumberofmosquitobitesinhouseholdsuptoseveralhundredmetersaway.
ThecostofITNsperDALYsavedisestimatedat$10$38(U.S.),whichqualifiesITNsasa"veryefficient
useofresourcesand[a]goodcandidateforpublicsubsidy."1
SomeRBMprogramshavehadlimitedsuccess,butoveralltheburdenofmalarialdiseasehascontinuedto
grow.Infact,annualmalariaattributablemortalityincreasedbetween1999and2003.WhiletheRBM
campaign'sownreportfromthatyearisquicktonotethatmorbidityandmortalitydatacollection
methodsinsubSaharanAfricaareinadequateandindicatorsmaythuslagbehindactualoutcomesof
ongoingcampaigns,theyneverthelessacknowledgethat"RBMisactingagainstabackgroundofincreasing
malariaburden."
LimitedsuccessinscalingupITNcoveragereflectstheinadequatelyacknowledgedeconomicbarriersthat
preventthedestitutesickfromaccessingcriticalpreventivetechnologies.Despiteprovenefficacyandwhat
areconsidered"reasonablecosts,"the2003RBMreportrevealsdisappointinglevelsofITNcoverage.In
28Africancountriessurveyed,only1.3%(range,0.24.9%)ofhouseholdsownedatleastoneITN,and
<2%ofchildrensleptunderanITN.WhyhastheRBMcampaignfailedtoachieveitsgoals?DoAfricans
notwanttousebednets?Dotheynotrecognizemalariaasahealthrisk?Orhaveprojectmanagersand
donorsmiscalculatedmostAfricans'abilitytoobtainbednets?
Thesearenotrhetoricalquestions.TheRBMstrategyinitiallyemphasizedtheimportanceofcommercial
marketsassourcesofITNsforAfricanpopulations.Aprecedentsupportingthisemphasisistheprior
existenceincountriessuchasMadagascarandMalioflocalmarketsforuntreatedbednets.Presumably,
therefore,ademandforbednetsexistedpriortotheRBMcampaign,asdidadistributionsystemwith
pointsofsale.However,evenwiththeapplicationofsubsidizedsocialmarketingstrategies,thismarket
approachhasnotresultedinlargeincreasesincoverageduringthefirstyearsoftheRBMcampaign.
Severalstudieshaveattemptedtodefinewillingnesstopay(WTP)andactualpaymentforITNsinAfrican
countriesandtherebytodeterminewhymarketbasedstrategieshavebeenunsuccessful.Policymakers
oftenuseWTPfigurestodetermineappropriatepricingforsocialmarketingprojectsandtoproject
revenueanddemand.AcrosssectionalstudyinaruralNigeriancommunityadministeredtwo

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questionnaires,1monthapart,toexaminecommunitymembers'WTPforITNs,actualpurchaseofITNs
(withthesecondquestionnaireaccompaniedbytheopportunitytobuyasubsidizedITN),andfactors
(suchassocioeconomicstatusandrecenthistoryofmalarialillness)contributingtohypotheticaland
actualITNpurchase.Amongthe453personsansweringbothsurveys,thepoorestquintileperceiveda
greaterriskofmalariathantheotherquintiles(27.3%vs.12.921.6%,p<.05).However,thepoorest
quintilewasleastlikelytoownanet,purchaseanet,orexpressahypotheticalWTP.Eventhemostwell
offquintilewaswillingtopayonly51%ofthegovernmentsetpriceforanITN.Thisfindingsuggeststhat
eventherelativelywelloffmaynotbewillingorabletopayforbednetsatsetprices.Theauthorsofthis
studyconcludedthatrelianceonthesaleofnetsalonemayproveinadequateandthatfurtherstudiesare
neededtodefinethedegreestowhichcostscanbeloweredand/ordemandincreased.
A2002studyinhighlandKenyacomparedtheattitudesofpeoplelivinginhomesteadsprovidedwith
heavilysubsidizedITNs(n=190)withthoseofresidentsofhouseholdsthathadnoITNsandhadnot
beentargetedbyotherhealthcareinitiatives(n=200).Ofallhouseholds,97%expressedwillingnessto
payforITNs.However,only4%ofthosewillingtopayofferedspontaneouslytomeetthesuggestedprice
of350Kenyanshillings.Afterbeingpromptedthat"netsareexpensive,"26%ofrespondentsexpressed
willingnesstopaythefullprice.Thisstudydidnotoffernetsforsaletherefore,thenumberofnetsthat
wouldactuallyhavebeenpurchasedisunknown.However,thestudydidcontextualizethehypothetical
WTPforITNsbycomparingtheircostwithotherhouseholdcosts:thepriceofoneITNisequaltothecost
ofsendingthreechildrentoprimaryschoolforayear.Byplacingthenets'relativecostincontext,the
authorsofthisstudycallintoquestionthelikelihoodthatfamiliesinthisdistrict,overhalfofwhomfall
belowtheKenyanpovertyline,wouldactuallybeabletopurchaseITNs.
GiventhedocumentedbarrierstopurchasingITNs,especiallyamongthepoorestofthepoor,many
researchersanddevelopmentprofessionalsinvolvedinmalariaprogramshavecalledforthefree
distributionofITNs,comparingtheirimportanceasapublichealthmeasurewiththatofchildhood
vaccination.TheadoptionoffreeITNdistributionstrategieshasbeenlimited,however,byconcernsabout
theirfeasibilityandpotentialITNmisuse(forexample,asnetsforfishing).Evidencefromatargetedfree
distributionprogramdiscountsbothconcerns.In2001,aKenyanprogramsponsoredbyUNICEFsoughtto
distribute70,000ITNstopregnantwomenthroughantenatalclinics.Within12weeks,>50%oftheITNs
hadreachedtheirintendedrecipients.A1yearfollowupevaluationof294womenwhohadreceivedbed
netswhilepregnant152womenfromahightransmissionareaand142fromalowtransmissionarea
revealedthat84%ofwomeninthehightransmissionareausedtheITNsthroughoutpregnancy.Oneyear
later,77%continuedtousethebednets.Inthelowtransmissionarea,57%ofwomenusedtheITNs
duringpregnancy,and46%continuedtousethemayearlater.Theseresultscontradictsuppositionsthat
freenetsmaynotbeusedbecauserecipientsdonotvaluethem.
Giventhescopeandmagnitudeofthechallengeposedbymalaria,itisunlikelythatanyonestrategywill
workforeveryregionorpopulationwithinacountryoracrosstheworld.Encouragingresultsfroman
employerbasedITNdistributionsysteminKenyahighlightthepotentialroleofpublicprivate
partnerships.Potentialsynergiesbetweenantimalariaprogramsandmeaslesvaccinecampaignsor
possiblylymphaticfilariasiseradicationcampaignshavebeenreportedorsuggested.Concernsabout
discomfortassociatedwithsleepingunderITNsoraboutinsecticidetoxicitiesmustbeaddressedthrough
educationalcampaigns.
Meetingthechallengeofmalariacontrolwillcontinuetorequirecarefulstudyofappropriatepreventive
andtherapeuticstrategiesinthecontextofourincreasinglysophisticatedmolecularunderstandingofthe
pathogen,vector,andhost.However,anappreciationfortheeconomicandstructuraldevastationwrought

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bymalarialikethatinflictedbydiarrhea,AIDS,andTBonthemostvulnerablepopulationsshould
heightenourcommitmenttothecriticalanalysisofwaystoimplementprovenstrategiesforthe
preventionandtreatmentofthesediseases.
1

NuwahaF:ThechallengeofchloroquineresistantmalariainsubSaharanAfrica.HealthPolicyPlan16:1,
2001.

ChronicNoncommunicableDiseases
WhiletheburdenofcommunicablediseasesespeciallyHIVinfection,tuberculosis,andmalariastill
accountsforthemajorityofdeathsinresourcepoorregionssuchassubSaharanAfrica,closeto60%of
alldeathsworldwidein2005wereduetochronicnoncommunicablediseases(NCDs).Moreover,80%of
deathsattributabletoNCDsoccurredinlowandmiddleincomecountries,where85%oftheglobal
populationlives.In2005,8.5millionpeopleintheworlddiedofanNCDbeforetheir60thbirthdaya
figureexceedingthetotalnumberofdeathsduetoAIDS,TB,andmalariacombined.By2020,NCDswill
accountfor80%oftheGBDandfor7ofevery10deathsindevelopingcountries.Therecentrisein
resourcesforandattentiontocommunicablediseasesisbothwelcomeandlongoverdue,butdeveloping
countriesarealreadycarryinga"doubleburden"ofcommunicableandnoncommunicablediseases.

CARDIOVASCULARDISEASE
UnlikeTB,HIVinfection,andmalariadiseasescausedbysinglepathogensthatdamagemultipleorgans
cardiovasculardiseasesreflectinjurytoasingleorgansystemdownstreamofavarietyofinsults.The
burdenofchroniccardiovasculardiseaseinlowincomecountriesrepresentsoneconsequenceofdecades
ofhealthsystemneglectfurthermore,cardiovascularresearchandinvestmenthavelongfocusedonthe
ischemicconditionsthatareincreasinglycommoninhighandmiddleincomecountries.Meanwhile,
despiteawarenessofitshealthimpactduringtheearlytwentiethcentury,cardiovasculardamagein
responsetoinfectionandmalnutritionhasfallenoutofviewuntilrecently.
Theperceptionofcardiovasculardiseasesasaproblemofelderlypopulationsinmiddleandhighincome
countrieshascontributedtotheirneglectbyglobalhealthinstitutions.EveninEasternEuropeandCentral
Asia,wherethecollapseoftheSovietUnionwasfollowedbyacatastrophicsurgeincardiovasculardisease
deaths(mortalityratesfromischemicheartdiseasenearlydoubledbetween1991and1994inRussia,for
example),themodestflowsofoverseasdevelopmentassistancetothehealthsectorfocusedonthe
communicablecausesthataccountedfor<1in20excessdeathsduringthisperiod.
PredictionsofanimminentriseintheshareofdeathsanddisabilitiesduetoNCDsindevelopingcountries
haveledtocallsforpreventivepoliciestorestricttobaccouse,improvediet,andincreaseexercise
alongsidetheprescriptionofmultidrugregimensforpersonswithhighlevelsofvascularrisk.Althoughthis
agendacoulddomuchtopreventpandemicNCD,itwilldolittletohelpthosewithestablishedheart
diseasestemmingfromnonatherogenicpathologies.
Theepidemiologyofheartfailurereflectsinequalitiesinriskfactorprevalenceandtreatment.Heartfailure
asaconsequenceofpericardial,myocardial,endocardial,orvalvularinjuryaccountsforasmanyas1in
10admissionstohospitalsaroundtheworld.Countrieshavereportedaremarkablysimilarburdenofthis
conditionatthehealthsystemlevelsincethe1950s,butthecausesofheartfailureandtheageofthe
peopleaffectedvarywithresourcesandecology.Inpopulationswithahighhumandevelopmentindex,
coronaryarterydiseaseandhypertensionamongtheelderlyaccountformostcasesofheartfailure.
Amongtheworld'spoorestbillionpeople,however,heartfailurereflectspovertydrivenexposureof
childrenandyoungadultstorheumatogenicstrainsofstreptococciandcardiotropicmicroorganisms(e.g.,

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HIV,Trypanosomacruzi,enteroviruses,M.tuberculosis),untreatedhighbloodpressure,andnutrient
deficiencies.Themechanismsofothercausesofheartfailurecommoninthesepopulationssuchas
idiopathicdilatedcardiomyopathy,peripartumcardiomyopathy,andendomyocardialfibrosisremain
unclear.
Ofthe2.3millionannualcasesofpediatricrheumaticheartdisease,nearlyhalfoccurinsubSaharan
Africa.Thisdiseaseleadstomorethan33,000casesofendocarditis,252,000strokes,and680,000deaths
peryearalmostallindevelopingcountries.ResearchersinEthiopiahavereportedannualdeathratesas
highas12.5%inruralareas.Inpartbecausethepreventionofrheumaticheartdiseasehasnotadvanced
sincethedisappearanceofthisdiseaseinwealthycountries,nopartofsubSaharanAfricahasyet
eradicatedrheumaticheartdiseasedespiteexamplesofsuccessinCostaRica,Cuba,andsomeCaribbean
nations.
Strategiestoeliminaterheumaticheartdiseasemaydependonactivecasefindingconfirmedby
echocardiographyamonghighriskgroupsaswellaseffortstoextendaccesstosurgicalinterventions
amongchildrenwithadvancedvalvulardamage.Partnershipsbetweenestablishedsurgicalprogramsand
areaswithlimitedornonexistentfacilitiesmayhelpdevelopcapacityandprovidecaretopatientswho
wouldotherwisesufferanearlyandpainfuldeath.Alongtermgoalistheestablishmentofregional
centersofexcellenceequippedtoprovideconsistent,accessible,highqualityservices.
Instarkcontrasttotheextraordinarylengthstowhichpatientsinwealthycountrieswillgototreat
ischemiccardiomyopathy,youngpatientswithnonischemiccardiomyopathiesinresourcepoorsettings
havereceivedlittleattention.Theseconditionsaccountforasmanyas2530%ofadmissionsforheart
failureinsubSaharanAfricaandincludepoorlyunderstoodentitiessuchasperipartumcardiomyopathy
(whichhasanincidenceinruralHaitiof1per300livebirths)andHIVcardiomyopathy.Multidrug
regimensthatincludeheartfailurebetablockers,ACEinhibitors,andotherneurohormonalantagonists
candramaticallyreducemortalityriskandimprovequalityoflifeforthesepatients.Lessonslearnedinthe
scaleupofchroniccareforHIVinfectionandTBmaybeillustrativeasprogressismadeinestablishing
meanstodelivercardiactherapiesoverabackgroundofcarefulfluidmanagementwithdiureticdrugs.
BecausesystemicinvestigationofthecausesofstrokeandheartfailureinsubSaharanAfricahasbegun
onlyrecently,littleisknownabouttheimpactofelevatedbloodpressureinthisportionofthecontinent.
Modestlyelevatedbloodpressureintheabsenceoftobaccouseinpopulationswithlowratesofobesity
mayconferlittleriskofadverseeventsintheshortrun.Incontrast,persistentlyelevatedbloodpressure
above180/110goeslargelyundetected,untreated,anduncontrolledinthissetting.IntheFramingham
cohortofmen4574yearsold,theprevalenceofbloodpressuresabove210/120declinedfrom1.8%in
the1950sto0.1%inthe1990swiththeintroductionofeffectiveantihypertensiveagents.Whiledebate
continuesaboutappropriatescreeningstrategiesandtreatmentthresholds,ruralhealthcentersstaffedby
nonphysiciansmustquicklygainaccesstoessentialantihypertensivemedications.
In1960,PaulDudleyWhiteandcolleaguesreportedontheprevalenceofcardiovasculardiseaseinthe
regionneartheAlbertSchweitzerHospitalinLambarn,Gabon.Althoughthegroupfoundlittleevidence
ofmyocardialinfarction,theyconcludedthat"thehighprevalenceofmitralstenosis[sic]isastonishing...
.Webelievestronglythatitisadutytohelpbringtothesesufferersthebenefitsofbetterpenicillin
prophylaxisandofcardiacsurgerywhenindicated.Thesameresponsibilityexistsforthosewith
correctablecongenitalcardiovasculardefects."2 LeadersfromtertiarycentersinsubSaharanAfricaand
elsewherehavecontinuedtocallforpreventionandtreatmentofthecardiovascularconditionsofthepoor.
Thereconstructionofhealthservicesinresponsetopandemicinfectiousdiseaseoffersanopportunityto

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identifyandtreatpatientswithorgandamageandtoundertakethepreventionofcardiovascularandother
chronicconditionsofpoverty.
2

MillerDCetal:SurveyofcardiovasculardiseaseamongAfricansinthevicinityoftheAlbertSchweitzer
Hospitalin1960.AmJCardiol19:432,1962.

CANCER
Lowandmiddleincomecountriesaccountedfor53%and56%,respectively,ofthe10millioncasesand7
milliondeathsduetocancerin2000.By2020,thetotalnumberofnewcancercaseswillriseby29%in
developedcountriesandby73%indevelopingcountries.Alsoby2020,overallmortalityfromcancerwill
increaseby104%,andtheincreasewillbefivefoldhigherindevelopingthanindevelopedcountries.
"Western"lifestylechangeswillberesponsiblefortheincreasedincidenceofcancersofthebreast,colon,
andprostate,buthistoricrealities,socioculturalandbehavioralfactors,genetics,andpovertyitselfwill
alsohaveaprofoundimpactoncancerrelatedmortalityandmorbidity.Whileinfectiouscausesare
responsiblefor<10%ofcancersindevelopedcountries,theyaccountfor25%ofallmalignanciesinlow
andmiddleincomecountries.Infectiouscausesofcancersuchashumanpapillomavirus(cervicalcancer),
hepatitisBvirus(livercancer),andHelicobacterpylori(stomachcancer)willcontinuetohaveamuch
largerimpactindevelopingcountries.Environmentalanddietaryfactors,suchasindoorairpollutionand
highsaltdiets,alsohelpaccountforincreasedratesofcertaincancers(e.g.,lungandstomachcancers).
Tobaccouse(bothsmokingandchewing)isthemostimportantsourceofincreasedmortalityfromlung
andoralcancers.Incontrasttodecreasingtobaccouseinmanydevelopedcountries,thenumberof
smokersisgrowingindevelopingcountries,especiallyamongwomenandyoungpeople.
Formanyreasons,outcomesofmalignanciesarefarworseindevelopingcountriesthanindeveloped
nations.Overstretchedhealthsystemsinpoorcountriessimplyarenotcapableofearlydetection80%of
patientsalreadyhaveincurablemalignanciesatdiagnosis.Treatmentofcancersisavailableforonlyavery
smallnumberofmostlywealthycitizensinthemajorityofpoorcountries,and,evenwhentreatmentis
available,therangeandqualityofservicesareoftensubstandard.

DIABETES
TheInternationalDiabetesFederationreportsthatthenumberofdiabeticsintheworldisexpectedto
increasefrom194millionin2003to330millionby2030,when3ofevery4suffererswilllivein
developingcountries.Becausediabeticsarefarmorefrequentlyundertheageof65indevelopingnations,
thecomplicationsofmicroandmacrovasculardiseasetakeafargreatertoll.In2005,anestimated1.1
millionpeoplediedofdiabetesrelatedillnesses,and>80%ofthesedeathsoccurredinlowandmiddle
incomecountries.

OBESITYANDTOBACCOUSE
In2004,theWHOreleaseditsGlobalStrategyonDiet,PhysicalActivityandHealth,whichfocusedonthe
populationwidepromotionofhealthydietandregularphysicalactivityinanefforttoreducethegrowing
globalproblemofoverweightandobesity.PassingthisstrategyattheWorldHealthAssemblyproved
difficultbecauseofstrongoppositionfromthefoodindustryandfromanumberofWHOmemberstates,
includingtheUnitedStates.Whileglobalizationhashadmanypositiveeffects,onenegativeaspecthas
beenthegrowthinbothdevelopedanddevelopingcountriesofwellfinancedlobbiesthathave
aggressivelypromotedunhealthydietarychangesandincreasedconsumptionofalcoholandtobacco.
Foreigndirectinvestmentintobacco,beverage,andfoodproductsindevelopingcountriesreached$327
millionin2002afigurenearlyfivetimesgreaterthantheamountspentduringthatyeartoaddress

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NCDsbybilateralfundingagencies,theWHO,andtheWorldBankcombined.

THETHREEPILLARSOFPREVENTION
TheWHOestimatesthat80%ofallcasesofcardiovasculardiseaseandtype2diabetesaswellas40%of
allcancerscanbepreventedthroughthethreepillarsofhealthydiet,physicalactivity,andavoidanceof
tobacco.Whilethereissomeevidencethatpopulationbasedmeasurescanhavesomeimpactonthese
behaviors,itissoberingtonotethatincreasingobesitylevelshavenotbeensuccessfullyreversedinany
population,includingthoseofhighincomecountrieswithrobustdietindustries.Nonetheless,inMauritius,
forexample,asinglepolicymeasurethatchangedthetypeofcookingoilavailabletothepopulationledto
afallinmeanserumcholesterollevels.Tobaccoavoidancemaybethemostimportantandmostdifficult
behavioralmodificationofall.Inthetwentiethcentury,100millionpeoplediedworldwideoftobacco
relateddiseasesitisprojectedthat>1billionpeoplewilldieofthesediseasesinthetwentyfirstcentury,
withthevastmajorityofthesedeathsindevelopingcountries.Today,80%oftheworld's1.2billion
smokersliveinlowandmiddleincomecountries,and,whiletobaccoconsumptionisfallinginmost
developedcountries,itcontinuestoriseatarateof~3.4%peryearindevelopingcountries.TheWHO's
FrameworkConventiononTobaccoControlwasamajoradvance,committingallofitssignatoriestoaset
ofpolicymeasuresthathavebeenshowntoreducetobaccoconsumption.However,mostdeveloping
countrieshavecontinuedtotakeapassiveapproachtothecontrolofsmoking.

EnvironmentalHealth
Inarecentpublicationthatexaminedhowspecificdiseasesandinjuriesareaffectedbyenvironmental
risk,theWHOdeterminedthat~24%ofthetotalGBD,onethirdoftheGBDamongchildren,and23%of
alldeathsareduetomodifiableenvironmentalfactors.Manyofthesefactorsleadtodeathsfrom
infectiousdiseasesothersleadtodeathsfrommalignancies.Increasingly,etiologyandnosologyare
difficulttoparse.Asmuchas94%ofdiarrhealdisease,whichislinkedtounsafedrinkingwaterandpoor
sanitation,canbeattributedtoenvironmentalfactors.Riskfactorssuchasindoorairpollutionduetouse
ofsolidfuels,exposuretosecondhandtobaccosmoke,andoutdoorairpollutionaccountfor20%oflower
respiratoryinfectionsindevelopedcountriesandforasmanyas42%ofsuchinfectionsindeveloping
countries.Variousformsofunintentionalinjuryandmalariatopthelistofhealthproblemstowhich
environmentalfactorscontribute.Some4millionchildrendieeveryyearfromcausesrelatedtounhealthy
environments,andthenumberofinfantdeathsduetoenvironmentalfactorsindevelopingcountriesis12
timesthatindevelopedcountries.

MentalHealth
TheWHOreportsthatsome450millionpeopleworldwideareaffectedbymental,neurologic,orbehavioral
problemsatanygiventimeandthat~873,000peoplediebysuicideeveryyear.Majordepressionisthe
leadingcauseoflostDALYsintheworldtoday.Oneinfourpatientsvisitingahealthservicehasatleast
onemental,neurologic,orbehavioraldisorder,butmostofthesedisordersareneitherdiagnosednor
treated.Mostlowandmiddleincomecountriesdevote<1%oftheiralreadypaltryhealthexpendituresto
mentalhealth.
Increasinglyeffectivetherapiesexistformanyofthemajorcausesofmentaldisorder.Effective
treatmentsformanyneurologicdiseases,includingseizuredisorders,havelongbeenavailable.Oneofthe
greatestbarrierstodeliveryofsuchtherapiesisthepaucityofskilledpersonnel.MostsubSaharanAfrican
countrieshaveonlyahandfulofpsychiatrists,forexamplemostofthempracticeincitiesandare
unavailablewithinthepublicsectorortopatientslivinginpoverty.Ofthefewpatientswhoarefortunate

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enoughtoseeapsychiatristorneurologist,fewerstillareabletoadheretotreatmentregimens:several
surveysofalreadydiagnosedpatientsostensiblyreceivingdailytherapyhaverevealedthat,amongthe
poor,fewcantaketheirmedicationsasprescribed.Thesamebarriersthatpreventthepoorfromhaving
reliableaccesstoinsulinorARTalsopreventthemfrombenefitingfromantidepressant,antipsychotic,and
antiepilepticagents.Toalleviatethisproblem,someauthoritiesareproposingthetrainingofhealth
workerstoprovidecommunitybasedadherencesupport,counselingservices,andreferralsforpatientsin
needofmentalhealthservices.
WorldMentalHealth:ProblemsandPrioritiesinLowIncomeCountriesoffersacomprehensiveanalysisof
theburdenofmental,behavioral,andsocialproblemsinlowincomecountriesandrelatesthemental
healthconsequencesofsocialforcessuchasviolence,dislocation,poverty,andthedisenfranchisementof
womentocurrenteconomic,political,andenvironmentalconcerns.

HEALTHSYSTEMSANDTHE"BRAINDRAIN"
Asignificantandoftinvokedbarriertoeffectivehealthcareinresourcepoorsettingsisthelackofmedical
personnel.Inwhatistermedthebraindrain,manyphysiciansandnursesemigratefromtheirhome
countriestopursueopportunitiesabroad,leavingbehindhealthsystemsthatareunderstaffedandill
equippedtodealwiththeepidemicdiseasesthatravagelocalpopulations.TheWHOrecommendsa
minimumof20physiciansand100nursesper100,000persons,butrecentreportsfromthatorganization
andothersconfirmthatmanycountries,especiallyinsubSaharanAfrica,fallfarshortofthosetarget
numbers.Morethanhalfofthesecountriesregisterfewerthan10physiciansper100,000population.In
contrast,theUnitedStatesandCubaregister279and596doctorsper100,000population,respectively.
Similarly,themajorityofsubSaharanAfricancountriesdonothaveevenhalfoftheWHOrecommended
minimumnumberofnurses.Inadditiontotheseappallingnationalaggregates,furtherinequalitiesin
healthcarestaffingexistwithincountries.Ruralurbandisparitiesinhealthcarepersonnelmirror
disparitiesofbothwealthandhealth.In1992,thepoorestdistrictsinsouthernAfricareported5.5doctors,
188.1nurses,and0.5pharmacistsper100,000population.Thesamesurveyfound,intherichest
districts,35.6doctors,375.3nurses,and5.4pharmacistsper100,000population.Nearly90%ofMalawi's
populationisrural,but>95%ofclinicalofficerswereaturbanfacilities,and47%ofnurseswereat
tertiarycarefacilities.Evencommunityhealthworkers,trainedtoprovidefirstlineservicestorural
populations,oftentransfertourbandistricts.In1989inKenya,forexample,therewereonly138health
workersper100,000personsintheruralNorthEasternProvince,whereastherewere688per100,000in
Nairobi.
Inadditiontointerandintranationaltransferofpersonnel,theAIDSepidemiccontributestopersonnel
shortagesacrossAfrica.AlthoughdataontheprevalenceofHIVinfectionamonghealthprofessionalsare
scarce,theavailablenumberssuggestsubstantialandadverseimpactsonanalreadyoverburdenedhealth
sector.In1999,itwasestimatedthat1732%ofhealthcareworkersinBotswanahadHIVdisease,and
thisnumberisexpectedtoincreaseinthecomingyears.Arecentstudythatexaminedthefatesofasmall
cohortofUgandanphysiciansfoundthatatleast22ofthe77doctorswhograduatedfromMakerere
UniversityMedicalSchoolin1984haddiedby2004most,presumably,ofAIDS.Similarnumbershave
beenregisteredinSouthAfrica,whereasmallstudybytheHumanSciencesResearchCouncilfoundan
HIVseroprevalenceamonghealthprofessionalssimilartothatamongthegeneralpopulationinthiscase,
15.7%ofallhealthcareworkerssurveyed.Theshortageofmedicalpersonnelintheareashardesthitby
HIVhasprofoundimplicationsforpreventionandtreatmenteffortsintheseregions.Thecycleofhealth
sectorimpoverishment,braindrain,andlackofpersonneltofillpositionswhentheyareavailable
conspiresagainstambitiousprogramstobringARTtopersonslivingwithbothAIDSandpoverty.The

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presidentofBotswanarecentlydeclaredthatoneofhiscountry'smainobstaclestorapidexpansionof
HIV/AIDStreatmentis"adearthofdoctors,nurses,pharmacists,andotherhealthworkers."3 InSouth
Africa,thedepartureofnearly600pharmacistsin2001,coupledwithstandingvacanciesfor32,000
nurses,hasputcontinuedstrainonthatrelativelyaffluentcountry'sabilitytorespondtocallsfor
expandedtreatmentprograms.InMalawi,only28%ofestablishednursingpostsarefilled.Furthermore,
theeducationofmedicaltraineesisjeopardizedastheranksofthehealthandacademiccommunities
continuetoshrinkasaresultofmigrationordisease.Thelongtermimplicationsaresobering.
Aproperbiosocialanalysisofthebraindrainremindsusthattheflightofhealthpersonnelalmostalways,
asmostreviewssuggest,frompoortolesspoorregionsisnotsimplyaquestionofdesireformore
equitableremuneration.Epidemiologictrendsandaccesstothetoolsofthetradearealsorelevant,asare
workingconditionsingeneral.Inmanysettingsnowlosingskilledhealthpersonnel,theadventofHIVhas
ledtoasharpriseinTBincidenceintheeyesofhealthcareproviders,otheropportunisticinfectionshave
alsobecomeinsuperablechallenges.Together,theseforceshaveconspiredtorendertheprovisionof
propercareimpossible,asthecommentsofaKenyanmedicalresidentsuggest:"RegardingHIV/AIDS,it
isimpossibletogohomeandforgetaboutit.Eventhesimplestopportunisticinfectionswehavenodrugs
for.Evenifwedo,thereisonlyenoughforashortcourse.Itisimpossibletoforgetaboutit....Just
becauseofthenumbers,Iamafraidofgoingtothefloors.Itisanightmarethinkingofgoingtoseethe
patients.Youareafraidoftheriskofinfection,diarrhea,urine,vomit,blood....Itisfrighteningtothink
aboutreturning."4 Anotherresidentnoted,"Beforetrainingwethoughtofdoctorsassupermen....[Now]
weareonlymortuaryattendants."5 Nursesandotherprovidersare,ofcourse,similarlyaffected.
Giventhedifficultconditionsunderwhichthesehealthcarepersonnelwork,isitanysurprisewhenthe
U.S.government'sappointedGlobalAIDSCoordinatornotesthattherearemoreEthiopianphysicians
practicinginChicagothaninallofEthiopia?InZambia,only50ofthe600doctorstrainedsincethe
country'sindependencein1964remainintheirhomecountry.Norisitsurprisingthata1999surveyof
medicalstudentsinGhanaintheirfinalyearoftrainingrevealedthat40of43studentsplannedtoleave
thecountryupongraduation.Whenprovidingcareforthesickbecomesanightmareforthoseatthe
beginningofclinicaltraining,physicianburnoutsoonfollowsamongthosewhocarryoninsettingsof
impoverishment.Inthepublicsectorinstitutionsputinplacetocareforthepoorestpeople,the
confluenceofepidemicdisease,lackofresourceswithwhichtorespond,andunrealisticallyhighuserfees
hasledtowidespreadburnoutamonghealthworkers.Patientsandtheirfamiliesarethosewhopaymost
dearlyforproviderburnout,justastheybeartheburdenofdiseaseandwiththeintroductionofuser
feesmuchofthecostofresponding,howeverinadequately,tonewepidemicsandpersistentplagues.
3

DuggerC:Botswana'sbraindraincrippleswaronAIDS.NewYorkTimesA10(13November2003).

4RaviolaGetal:HIV,diseaseplague,demoralization,and"burnout":Residentexperienceofthemedical

professioninNairobi,Kenya.CultMedPsychiatry26:55,2002.
5

Ibid.

CONCLUSION:TOWARDASCIENCEOFIMPLEMENTATION
Publichealthstrategiesdrawlargelyonquantitativemethodsfromepidemiologyandbiostatistics,but
alsofromeconomics.Clinicalpractice,includinginternalmedicine,drawsonarapidlyexpanding
knowledgebasebutremainsfocusedonindividualpatientcareclinicalinterventionsarerarelypopulation
based.Infact,neitherpublichealthnorclinicalapproachesalonewillproveadequateinaddressingthe
problemsofglobalhealth.Thereisalongwaytogobeforeevidencebasedinternalmedicineisapplied
effectivelyamongtheworld'spoor.ComplexinfectiousdiseasessuchasAIDSandTBhaveprovendifficult

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butnotimpossibletomanagedrugresistanceandalackofeffectivehealthsystemshavefurther
complicatedsuchwork.Beyondcommunicabledisease,inthearenaofchronicdiseases(e.g.,
cardiovasculardisease),globalhealthisanascentendeavor.Effortstoaddressanyoneoftheseproblems
insettingsofgreatscarcityneedtobeintegratedintobroadereffortstostrengthenfailinghealthsystems
andtoalleviatethegrowingpersonnelcrisiswithinthesesystems.
Forthesereasons,scholarlyworkandpracticeinthefieldonceknownasinternationalhealthandnow
oftendesignatedglobalhealthequityarechangingrapidly.Suchworkisstillinformedbythetension
betweenclinicalpracticeandpopulationbasedinterventions,betweenanalysisandaction.Oncemetrics
arerefined,howmighttheyinformeffortstolessentheprematuremorbidityandmortalityregistered
amongtheworld'spoor?Asinthenineteenthcentury,humanrightsperspectiveshaveprovenhelpfulin
turningattentiontotheproblemsofthedestitutesicksuchperspectivesmayalsoinformstrategiesof
deliveringcareequitably.Anumberofuniversityhospitalsaredevelopingtrainingprogramsforphysicians
withinterestsinglobalhealth.InmedicalschoolsacrosstheUnitedStatesandinotherwealthycountries,
interestinglobalhealthhasbeenexploding.AninformalsurveyatHarvardMedicalSchoolin2006
revealedthatnearlyonequarterofthe160enteringstudentseitherhadsignificantglobalhealth
experienceorwereplanningacareeringlobalhealth.Asimilarseachangeamongtraineeshasbeen
reportedatothermedicalschools.Halfacenturyorevenadecadeago,suchhighlevelsofinterestwould
havebeenunimaginable.
Persistentepidemics,improvedmetrics,andgrowinginteresthaveonlyrecentlybeenmatchedbyan
unprecedentedinvestmentinaddressingthehealthproblemsofpoorpeopleinthedevelopingworld.Ours
isamomentofopportunity.Toensurethattheopportunityisnotwasted,thebasicfactsneedtobelaid
outforspecialistsandlaypeoplealike.Morethan12millionpeopledieeachyearsimplybecausetheylive
inpoverty.AnabsolutemajorityoftheseprematuredeathsoccurinAfrica,withthepoorerregionsofAsia
notfarbehind.Mostofthesedeathsoccurbecausetheworld'spoorestdonothaveaccesstothefruitsof
science.Theyincludedeathsfromvaccinepreventableillnessdeathsduringchildbirthdeathsfrom
infectiousdiseasesthatmightbecuredwithaccesstoantibioticsandotheressentialmedicinesdeaths
frommalariathatwouldhavebeenpreventedbybednetsandaccesstotherapyanddeathsfromwater
borneillnesses.Otherexcessmortalityisattributabletotheinadequacyofeffortstodevelopnewtools.
Thosefundingthediscoveryanddevelopmentofnewtoolstypicallyneglecttheconcurrentneedfor
strategiestomakethemavailabletothepoor.Indeed,somewouldarguethatthebiggestchallengefacing
thosewhoseektoaddressthisoutcomegapisthelackofpracticalmeansofdistributionintheregions
mostheavilyaffected.
Thedevelopmentoftoolsmustbefollowedinshortorderbytheirequitabledistribution.Whennew
preventiveandtherapeutictoolsaredevelopedwithoutconcurrentattentiontodeliveryorimplementation,
wefacewhataresometimestermedperverseeffects:evenasnewtoolsaredeveloped,inequalitiesof
outcomelessmorbidityandmortalityamongthosewhocanaffordaccess,withsustainedhighmorbidity
andmortalityamongthosewhocannotwillgrowintheabsenceofanequityplantodeliverthetoolsto
thosemostatrisk.Preventingsuchafutureisthemostimportantgoalofglobalhealth.

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FarmerPE:InfectionsandInequalities:TheModernPlagues,2ded.Berkeley,UniversityofCalifornia

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Press,2001
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health.ForeignAffairs86:155,2007
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