4

Global health
Babulal Sethia, Parveen Kumar

Introduction 43
Millennium development goals 43
Global burden of disease 44
Poverty 46
Water and sanitation 47
Organizations and the global health agenda 47
Education 47
Maternal health and child health 48
Mental health 48
Accidents and trauma 49
Conflict and catastrophe 49
Economics and politics in global health 49
Social determinants of health 49
Human rights and the value of engagement in global
health 50

Introduction
The discipline of ‘global health’ evolved from ‘international health’, which
focused historically on the study and management of infectious tropical diseases.
 There is no universally agreed definition of ‘global health’ (GH). It is ‘an area
of study, research and practice that places a priority on improving health and
achieving equity in health for all people worldwide’. It recognizes that health is
determined by problems, issues and concerns that transcend national boundaries,
and looks at the healthcare needs of people across the world as well as in
individual nations. Such needs are seen in high-, as well as low- and middle-
income countries (LMICs), but may be particularly acute, for example, during or
after conflicts of war, with the consequences of population displacement or of
direct trauma, including rape. Effective delivery of GH needs inevitably requires
multidisciplinary collaboration between healthcare workers, politicians,
economists and scientists in pursuit of both individual wellbeing and population-
based prevention and care. Examples of successful interventions include
campaigns for the provision of vaccines by the Global Alliance for Vaccines and
Immunization (GAVI), and initiatives to reduce the economic exploitation of
child labour. On the infection front, the African Programme for Onchocerciasis
control has used the safe drug, ivermectin, which, as a single dose given
annually, has transformed the lives of millions. Another example is the use of
praziquantel for the eradication of schistosomiasis (bilharzia), one of the most
common but neglected tropical diseases, initiated by the Schistosomiasis Control
Programme and funded by many organizations.

The scale of the problem worldwide

Data published by the World Health Organization (WHO) in 2012 show that
although life expectancy had increased by 6 years since 1990 (mean 70 years in
males, range 62–79 years), several unaccept​able facts remain true:
• Around 6.6 million children under the age of 5 years die each year.
• Preterm birth (before 37 weeks' gestation) accounts for >1 million deaths per
year.
• Each day, 800 women die due to complications of pregnancy and childbirth.
• Cardiovascular diseases are the leading cause of death globally.
• Some 70% of deaths from the human immunodeficiency virus/acquired
immunodeficiency syndrome (HIV/AIDS) occur in sub-Saharan Africa.
• Mental health disorders, such as depression, are amongst the 20 leading causes
of disability worldwide.
• Tobacco kills nearly 6 million people each year (and is predicted to kill 8 
million per year by 2030).
• Almost 1 in 10 people has diabetes.
• Nearly 1.24 million people die from road traffic accidents every year.

Further reading
HM Government. Health is Global: UK Government Strategy 2008-2013.
London: Department of Health; 2008
Koplan JP, Bond TC, Merson MH et al. Towards a common definition of
global health. Lancet 2009; 373:1993–1995.

Millennium Development Goals

At the Millennium Summit in September 2000, world leaders from 189 countries
adopted a series of time-bound goals, to be achieved by 2015. Twenty-one
targets were enshrined within the eight Millennium Development Goals
(MDGs). These goals are listed in Figure 4.1.

FIGURE 4.1 Millennium development goals.

The goals provided a focus for a major increase in GH investment from all
countries, particularly for disease-specific entities (MDG 6: HIV/AIDS,
malaria). However, critics have noted that much of the early financial investment
for these commitments was used to defray existing debt in low- and middle-
income countries (LMICs), whilst progress in the achievement of the targets by
2015 was very uneven. Furthermore, it has been suggested that failures in
achievement of MDG targets was inevitably promoted by a lack of local
participation in their original development (MDGs 1, 2 and 7). A significant
deficiency in the MDGs was a failure to mention agriculture specifically, an
essential component of the challenge to eradicate extreme hunger and poverty
posed in MDG 1.
Notwithstanding a variety of criticisms, much progress in achieving parts of
the MDGs was reported by 2014, as noted in the update issued by the WHO in
2014 (Box 4.1).

 Box 4.1
Achievement of millennium development goals
(MDGs)
key facts
• Globally, the number of deaths of children under 5 years of age fell from
12.6 million in 1990 to 6.6 million in 2012
• In developing countries, the percentage of underweight children under 5 
years old dropped from 25% in 1990 to 15% in 2012
• Births attended by a skilled health worker have increased globally, but still
fewer than 50% of births are attended in the WHO African region
• Globally, new HIV infections declined by 33% between 2001 and 2012
• Existing cases of tuberculosis are declining, along with deaths among HIV-
negative tuberculosis cases
• In 2010, the world met the United Nations MDG target on access to safe
drinking water, as measured by the proxy indicator of access to improved
drinking-water sources, but more needs to be done to achieve the sanitation
target
(Adapted from WHO Factsheet No. 290, updated May 2015.)

The new set of goals, targets and indicators issued by the UN states are called
Sustainable Development Goals (SDGs), to be achieved by 2030. These
demonstrate a wide-ranging and more integrated approach between the agreed
goals, especially with regard to those that succeed MDGs 1, 2 and 7. There are
17 proposed goals incorporating 169 targets. They are worthy aims but may turn
out to be unrealistic, as they cover a vast area for improvement (Box 4.2). Health
is only explicitly mentioned in one target (Goal 3) and this emphasizes the fact
that the concept of health is inextricably linked to the other major players like
politics, economics and agriculture. Goal 3 has been expanded to be more
explicit and includes nine targets and four additional targets that were missing
from the MDGs. They now include non-communicable diseases, mental ill
health, road accident injuries and universal health coverage (Box 4.3). The UN
Secretary General, Ban Ki-moon, has offered conceptual guidance, suggesting
six essential overarching SDG elements: ‘dignity, prosperity, justice, partnership,
planet, people’.

 Box 4.2
Sustainable Development Goals: the 17 proposed
aims
1. End poverty in all its forms everywhere
2. End hunger, achieve food security and improved nutrition, and promote
sustainable agriculture
3. Ensure healthy lives and promote wellbeing for all at all ages
4. Ensure inclusive and equitable quality education and promote life-long
learning opportunities for all
5. Achieve gender equality and empower all women and girls. A target
example: eliminating violence against women
6. Ensure availability and sustainable management of water and sanitation
for all
7. Ensure access to affordable, reliable, sustainable and modern energy for
all
8. Promote sustained, inclusive and sustainable economic growth, full and
productive employment, and decent work for all
9. Build resilient infrastructure, promote inclusive and sustainable
industrialization, and foster innovation
10. Reduce inequality within and amongst countries
11. Make cities and human settlements inclusive, safe, resilient and
sustainable
12. Ensure sustainable consumption and production patterns
13. Take urgent action to combat climate change and its impacts
14. Conserve and sustainably use the oceans, seas and marine resources for
sustainable development
 15. Protect, restore and promote sustainable use of terrestrial ecosystems,
sustainably manage forests, combat desertification and halt and reverse
land degradation, and halt biodiversity loss
16. Promote peaceful and inclusive societies for sustainable development,
provide access to justice for all and build effective, accountable and
inclusive institutions at all levels
17. Strengthen the means of implementation and revitalize the global
partnership for sustainable development
For the 169 targets enshrined within the goals, see http://www.un.org/sustainabledevelopment/.

 Box 4.3
The nine main targets and four additional targets
(3.a–d) of the Sustainable Development Goal for
health (GOAL 3)
3.1. By 2030, reduce the global maternal mortality ratio to less than 70 per
100 000 live births
3.2. By 2030, end preventable deaths of newborns and children under 5 years
of age, with all countries aiming to reduce neonatal mortality to at least as
low as 12 per 1000 live births and under-5 mortality to at least as low as 25
per 1000 live births
3.3. By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected
tropical diseases, and combat hepatitis, water-borne diseases and other
communicable diseases
3.4. By 2030, reduce by a third premature mortality from non-communicable
diseases through prevention and treatment, and promote mental health and
wellbeing
3.5. Strengthen the prevention and treatment of substance abuse, including
narcotic drug abuse and harmful use of alcohol
3.6. By 2020, halve the number of global deaths and injuries from road traffic
accidents
3.7. By 2030, ensure universal access to sexual and reproductive healthcare
services, including family planning, information, and education, and the
integration of reproductive health into national strategies and programmes
 3.8. Achieve universal health coverage, including financial risk protection,
access to quality essential healthcare services, and access to safe, effective,
quality and affordable essential medicines and vaccines for all
3.9. By 2030, substantially reduce the number of deaths and illnesses from
hazardous chemicals and air, water, and soil pollution and contamination
3.a. Strengthen the implementation of the WHO Framework Convention on
Tobacco Control in all countries, as appropriate
3.b. Support the research and development of vaccines and medicines for the
communicable and non-communicable diseases that primarily affect
developing countries, provide access to affordable essential medicines and
vaccines in accordance with the Doha Declaration on the TRIPS Agreement
and Public Health, which affirms the right of developing countries to use to
the full the provisions in the TRIPS Agreement regarding flexibilities to
protect public health, and, in particular, provide access to medicines for all
3.c. Substantially increase health financing and the recruitment, development,
training and retention of the health workforce in developing countries,
especially in the least developed countries and small island developing states
3.d. Strengthen the capacity of all countries, in particular developing
countries, for early warning, risk reduction and management of national and
global health risks
TRIPS, Trade-Related Aspects of Intellectual Property Rights.
(From Maurice J. Special report: UN set to change the world with new development goals. Lancet 2015;
386:1121–1124, with permission.)

Global Burden of Disease

In 2006, 90% of GH funds were spent in high-income countries that carried only
10% of the disease burden (Fig. 4.2). Clearly, the world faces many health
challenges that are difficult to prioritize.
 FIGURE 4.2 Mismatch between health spending and resources. (From Gottet P, Schieber G.
Health Financing Revisited: A Practitioner's Guide. Washington: World Bank; 2006.)

The Global Burden of Disease (GBD) Study 2010 provides critical data for
guiding prevention and other interventions. This study is a worldwide
collaboration across 302 institutions and has retrospectively reassessed the data
from 1990, 2005 and 2010 using the same methodology, thus enabling accurate
comparisons of health trends. This gives an understanding of the present and
future health priorities for the global community and for individual countries. It
was made possible by the introduction of a new metric in 2010, which gave a
single measure to quantify the burden of diseases, injuries and risk factors. This
disability-adjusted life year (DALY) metric allowed the comparison of burden
across diseases, both untreated and treated, mortality, morbidity, disability,
injuries and risk factors. DALYs measure health gaps, as opposed to health
expectancies. They are derived from the calculation of the years of life lost due
to early death (YLL) and years lived with disability (YLD).

Unfortunately, this GBD equation has some deficiencies and limitations. It

does not, for example, address rapid transitions in GH, such as demographic
changes, changes in causes of death, and changes in causes of disability. DALYs
do not identify the transitional demographic changes of increases in population
number, and of population age. A change in DALYs, whilst a potentially useful
indicator of health outcomes, must therefore be interpreted with care. Both a
decrease and an increase in DALYs may reflect improved outcomes. A decrease
in DALYs for maternal and neo​natal deaths can be accounted for by better
education, nutrition or obstetric facilities. However, an increase in DALYs is
seen when an ageing population requires treatment for chronic ill health, despite
a reduction in mortality.

Further reading
Murray CJL, Lopez AD. Measuring the global burden of disease. N Engl J
Med 2013; 369:448–457.

Poverty
More than 3 billion people, nearly half of the world population, live in poverty
(defined as living on less than US$2.50 per day), and more than 1.3 billion
individuals receive less than US$1.25 per day (extreme poverty). Some 1 billion
children worldwide live in poverty.
In ‘The Future We Want’, the outcome document of the 2012 Rio + 20
Conference on the Sustainable Development Agenda, the need to accord the
highest priority to poverty eradication was agreed. The 2016 SDGs (see Box
4.2 ) include five goals (SDGs 1, 2, 12, 13 and 15) relating to this ambition.

Poverty, hunger, agriculture and climate change

These issues are inextricably interdependent. Food production is compromised
when agricultural land is directed towards alternative uses, such as industrial
development. On the other hand, 25% of food is wasted in LMICs by crop
deterioration due to deficiencies in transport and storage. The UK and US
together waste approximately US$81 billion of food each year.
In 2009, the UCL–Lancet Commission on ‘Managing the Health Effects of
Climate Change’ called climate change ‘the biggest global health threat of the
21st century’. Changes in climate pose major threats to human health, either
directly (heatwaves, floods, droughts), or indirectly (agricultural losses, mass
migration). For example, a 1° rise in mean temperature in India would result in
the loss of 7 million tons of wheat (Fig. 4.3). By limiting the use of fossil fuels
and reducing carbon emissions, it is possible to avoid a potentially catastrophic
rise in global temperature (Fig. 4.4). Urgent action is essential if the gains in GH
and development of the last 50 years are to be maintained.

FIGURE 4.3 Climate change and modelled cereal grain yields to 2050. A rise in global
temperature will make currently ‘hot’ countries (red) hotter, decreasing their grain yield.
Alternatively, current cold countries (green) will get warmer with an increased yield of
grain. (From UN Development Programme 2009.)

FIGURE 4.4 Rise in average global temperatures 1880–2012.

Pain and suffering, especially in LMICs, is often caused by the catastrophic

expenditure associated with chronic illness and disease. Every year, as many as
150 million people face financial catastrophe as a result of having to pay for
health care.

Further reading
Watts N, Adger WN, Agnolucci P et al. Health and climate change: policy
responses to protect public health. Lancet 2015; 386:1861–1914.
Xu K, Evans DB, Carrin G et al. Designing Health Financing Systems to
Reduce Catastrophic Health Expenditure. WHO 2005;
http://www.who.int/health_financing/.
http://www.grida.no/publications/ The Environmental Food Crisis.

Water and Sanitation

Poor water, sanitation and hygiene are major causes of early mortality,
particularly in children. In 2010, 11% of the world population lacked access to
clean water supplies. WHO/UNICEF defined an improved water supply as ‘one
that, by nature of its construction or through active intervention, is protected
from outside contamination, in particular from contamination with faecal
matter’. The statement also stipulated that each person should have access to at
least 20 L of water per day from a source within 1 km of the user's dwelling.
The target to halve the proportion of people without sustainable access to safe
drinking water and basic sanitation by 2015 (MDG 7) was not met.
One in five people still defecates in the open, and 13% live where water is
collected from unprotected sources. Some of the other consequences of
inadequate sanitation are listed in Box 4.4. It is clear that most of the mortality
resulting from poor sanitation and unsafe drinking water is preventable.

 Box 4.4
Sanitation
• 2.5 billion people lack adequate sanitation
• Open defecation results in the death of >750 000 children under 5 years of
age annually
• 80% of diseases in LMICs are caused by poor sanitation/unsafe water
• More than 7 out of 10 people without improved sanitation were rural
 inhabitants (2006)
• Every $1 spent on sanitation brings a $5.5 return by keeping people healthy
and productive
• Improvement in sanitation could save 1.5 million children each year.
LMICs, low- and middle-income countries.
(Data from: 1. United Nations Department of Public Information. The Future We Want: Water and
Sanitation. Rio +20 United Nations Conference on Sustainable Development; 2012. 2. UN-Water.
Sanitation. Factsheet; 2014. From http://www.unwater.org. 3. Sanitation Drive Factsheet 1, Sanitation
for All: Making the right a reality; 2015. From http://www.sanitationdrive2015.org.)

Water is usually collected by women, often from distant sources; this can be a
hazardous journey, as the women are unprotected and open to abuse. A
secondary effect of improved access to water is that the time saved in collecting
water can now be spent on income generation, food production, education and
activities that can lead to social and health benefits.

Organizations and the Global Health Agenda

International support for GH initiatives may be directed at disease-specific
projects (vertical care models) or allied to national health system development.
Some of the vast number of organizations active in these areas are listed in Box
4.5. The contributions of these bodies overlap considerably but cover the key
areas for health development and infrastructural support, including the response
to emergency situations (war and natural disasters). The areas encompass service
delivery, patient care, education and training, research, equipment, medicines
and human resources. Investment in healthcare systems promotes public health
benefit by the provision of vaccination, hygiene and sanitation, as well as major
infrastructural projects including technology and communications, such as
building roads.

 Box 4.5
Some organizations involved in global aid
International organizations
• World Health Organization (WHO)
• Global Fund to fight AIDS, Tuberculosis and Malaria
• Joint United Nations Programme on HIV/AIDS (UNAIDS)
• World Bank
• Department for International Development (DFID; UK)
• President's Emergency Plan for AIDS Relief (PEPFAR; USA)
• Global Alliance for Vaccines and Immunization (GAVI)
Scientific and educational organizations
• Mainly disease-specific, e.g. microbiology, diabetes, infectious diseases
• Consortium of Universities for Global Health (CUGH)
• Global Health through Education, Training and Service (GHETS)
Advocacy and policy organizations
• Centre for Strategic and International Studies (CSIS)
• Global Health Policy Centre
• Global Alliance for Chronic Diseases (GACD)
• Global Health Council
• Global Health Technologies Coalition (GHTC)
• The Earth Institute (Columbia University)
• Kaiser Family Foundation (KFF)
• US Global Health Policy
• Tropical Health and Education Trust (THET)
Foundations
• Bill and Melinda Gates Foundation
• Wellcome Trust
• UN Foundation (UNF)
• Accordia Global Health Foundation
Other non-governmental organizations
• Save the Children
• United Nations International Children's Emergency Fund (UNICEF)
• Red Cross
• Oxfam
 • International Rescue Committee (IRC)
• Médecins sans Frontières (MSF)

Empowering the local population to help themselves by delivering local

appropriate education is of paramount importance. Global Health through
Education Training and Service (GHETS) is an American non-governmental,
non-profit organization that works with a network of medical and nursing
schools to increase the number of locally trained, primary healthcare workers.
These schools build community-based clinics in rural and urban areas.

Further reading
http://gapminder.org Gapminder: global trends, and health and wealth of
nations.
http://www.ghets.org Global Health through Education, Training and
Service.
http://www.globalfamilydoctor.com Rural Medical Education Guidebook
(WONCA): free online book for family doctors.
http://www.thet.org Tropical Health and Education Trust.
http://worldmapper.org Worldmapper: countries resized according to topic.

Education
Education has a major impact on the health of a nation. There is evidence to
suggest that the more years spent in schooling, the better the health outcomes.
Literacy and, in particular, health literacy can have a major impact on nutrition
and the control of disease: for example, by the simple process of hand washing.
Education helps to promote healthier lifestyles, both by improving nutrition and
development, and by reducing the risks associated with infectious diseases. As a
result, unemployment falls whilst family and community wellbeing is improved.
Women have a crucial role in the welfare of their families and the
development of a country's good health. Traditionally, women have a lower
social status in societies where they are suppressed. Nevertheless, it is they who
have the dominant impact on the health of the family and the wellbeing of
children. They shoulder all the demands of child care, and of care of the elderly
and the sick, as well as all household responsibilities.
Approximately 25% of girls in ‘developing countries’ become mothers before
the age of 18. These pregnancies have a high rate of deaths from complications
of pregnancy and childbirth. The cost to a country's economy of adolescent
pregnancy, as a share of gross domestic product, can be as high as 30%. The
education and welfare of women should be major issues in any developing
society, as they reduce poverty and aid a country's development.

Further reading
Chaaban J, Cunningham W. World Bank Policy Research Working Paper
5753: Measuring the Economic Gain of Investing in Girls: the Girls Effect
Dividend. World Bank 2011; http://papers.ssrn.com/.
United Nations Population Fund. State of World Population 2014. New
York: UN; 2014.

Maternal Health and Child Health

Maternal health (see also Ch. 29)
Women remain disadvantaged in many parts of the world. Every second, 380
women become pregnant, 190 women face unplanned or unwanted pregnancy
(e.g. from rape), 110 women experience a pregnancy-related complication, 40
women have an unsafe abortion, and 1 woman dies from a pregnancy-related
complication. These stark data support the arguments for women to control their
own health and fertility.
Of major concern, 303 000 women die in childbirth every year and 80% of
these deaths are avoidable (WHO). Maternal mortality figures are more than 100
times greater in low-income countries (LICs) compared to higher-income
countries (HICs). The risk of dying in pregnancy varies from 1 : 8 in Mali,
compared to 1 : 17 400 in Sweden. The major medical causes of death are
haemorrhage, hypertensive disease of pregnancy and infections. Haemorrhage
can be intra- or pre-partum, when the most common cause is placental abruption,
or postpartum, when the uterus fails to contract, causing fatal haemorrhage.
Hypertensive disease can be complicated by pre-eclampsia (see p. 1303).
Infections can be caused, for example, by bacteria, HIV, malaria and syphilis.
Obstructed labour is another potentially fatal complication and can be due to the
fibrosis caused by female genital mutilation (FGM), traditionally practised in
some countries.
As most maternal and neonatal deaths occur around delivery, the need for
basic and emergency care around the time of labour and delivery is paramount.
The presence of a skilled birth attendant has been shown to reduce both maternal
and neonatal mortality in many LMICs.

Child health
Globally, the under 5 years mortality rate has fallen mainly due to the prevention
of pneumonia, diarrhoea and malaria by organizations and governments working
together. Nevertheless, over 50% of these deaths could have been prevented by
access to simple and affordable interventions. Most of these deaths are caused by
pre-term complications, birth asphyxia, diarrhoea, pneumonia and malaria.
Almost half are linked to malnutrition. These children die from common,
otherwise non-fatal, childhood ailments. Deaths in children under 5 years of age
are mainly concentrated in Southern Asia and in sub-Saharan Africa, where
children are 15 times more likely to die compared with children in developed
regions. In the rest of the world, mortality figures dropped from 32% (1990) to
18% (2013; WHO).

Vaccination
The World Health Assembly produced a framework to prevent millions of deaths
by more equitable access to vaccines, and adopted a ‘Decade of Vaccines Global
Vaccine Action Plan 2011–2020’. GAVI plays a critical role in this area by
financing and facilitating delivery of vaccine platforms. By 2013, it had
immunized 440 million additional children and prevented 6 million future
deaths.

Child labour
The global number of children engaged in child labour declined by one-third
between 2000 and 2012 (246 million dropping to 168 million). More than half
(85 million) are engaged in hazardous work. Agriculture remains the most
important sector utilizing child labour (98 million).

Child nutrition
Improving child nutrition remains a global imperative. According to data from
UNICEF (2013), stunting affects 165 million children under 5 years of age. This
problem can be mitigated by interventions during maternal pregnancy and before
the child is 2 years old.
 Further reading
Bustreo F, Okwo-Bele JM, Kamara L. World Health Organization
perspectives on the contribution of the Global Alliance for Vaccines and
Immunization on reducing child mortality. Arch Dis Child 2015; 100:S34–
S37.
Diallo Y, Etienne A, Mehran F and International Programme on the
Elimination of Child Labour. Global Child Labour Trends 2008 to 2012.
Geneva: International Labour Organization; 2013.
International Programme on the Elimination of Child Labour. Marking
Progress Against Child Labour: Global Estimates and Trends 2000–2012.
Geneva: International Labour Organization; 2013.
United Nations Children's Fund (UNICEF). Improving Child Nutrition: the
Achievable Imperative for Global Progress. New York: UNICEF; 2013.

Mental Health
Mental health (including psychological and neurological problems) constitutes
13% of the Global Burden of Disease (GBD). This exceeds the figures for
cardiovascular disease and cancer.
Depression represents a major clinical challenge with 350 million patients
worldwide. It is the third commonest contributor to GBD. Alcohol and illicit
drug misuse account for >5% of the global mental health burden. Additionally, it
is estimated that suicide will account for 1.5 million deaths each year by 2020,
with a further 15–30 million people attempting suicide.
Globally, the incidence of dementia is accelerating and 7.7 million new cases
occur each year. This increased burden disproportionately affects low- and
middle-income countries, where resources are few. All of this represents a major
worldwide financial burden.

Further reading
Collins PY, Patel V, Joestl SS et al. Grand challenges in global mental health.
Nature 2011; 475:27–30.
Saxena S, Wortmann M, Prince M et al. Dementia: a Public Health
Priority. Geneva: WHO; 2012.

Accidents and Trauma

We are currently in the midst of a global trauma epidemic. It is estimated that
5.8 million people die each year as a result of injury and trauma. At least 2 
million of these deaths are potentially avoidable.
Injuries are a significant and increasing cause of mortality and morbidity;
more than 90% of injury-related deaths occur in LMICs.
Around 5 billion people do not have access to safe, affordable surgical and
anaesthesia care when needed, particularly in LMICs. Many of those who do
access care risk personal financial ruin. The WHO estimates that, by 2030,
trauma from road traffic accidents will be the third most common cause
worldwide of both mortality and disability (as measured in DALYs).
The Guidelines for Essential Trauma Care (WHO 2004) have established a
core list of 11 essential trauma care services (Box 4.6). The implementation of
these recommendations has been hampered by deficiencies in planning and
infrastructure that need to be addressed by national governments.

Further reading
Mock C, Joshipura M, Lormand J et al. Strengthening trauma systems
globally: the Essential Trauma Care Project. J Trauma 2005; 59:1243–1246.
Sakran J, Greer SE, Werlin E et al. Care of the injured worldwide: trauma
still the neglected disease of modern society. Scand J Trauma Resusc Emerg
Med 2012; 20:64.

 Box 4.6
International guidelines for essential trauma care
(‘rights of the injured’)
• Obstructed airways cleared and maintained
• Impaired breathing supported until the injured person is self-ventilating
• Pneumothorax and haemothorax promptly relieved
• Bleeding stopped promptly
• Shock recognized and treated with intravenous fluid replacement
• Traumatic brain injury treated with timely decompression of space-
occupying lesions
• Intestinal and other abdominal injuries promptly addressed
• Disabling extremity injuries corrected
 • Unstable spinal cord injuries managed appropriately with early
immobilization
• Appropriate rehabilitative services available
• Medications for the above and for pain control readily available
(Adapted from Mock C, Joshipura M, Goosen J, Maier R. Overview of the Essential Trauma Care
Project. World J Surg 2006; 30:919–929.)

Conflict and Catastrophe

Recent years have seen a number of natural disasters; examples include
earthquakes in Haiti (2010) and Nepal (2015), the Sri Lanka tsunami (2004), and
typhoon Haiyan in the Philippines (2013). Conflicts also persist in Syria, South
Sudan, the Ukraine and numerous other parts of the world. Effective global
action following these unexpected events is frequently compromised by
deficiencies in the disaster response, including the provision of inappropriate
resources and inexperienced personnel. Many such deficiencies can be rectified
by appropriate training in disaster response. Other elements of an effective
international response must address long-term restructuring issues. Following
conflict, regulation of the trade in armaments is critical.
Conflicts and catastrophes severely disrupt healthcare provision, especially for
women and children. The use of rape as a weapon of war magnifies this tragedy.
Furthermore, disruption to education, together with the physical sequelae of
conflict, leads to increased long-term societal healthcare burdens, especially in
the field of mental health.

Economics and Politics in Global Health

Funding for initiatives in the GH development of LMICs (also known as
Development Assistance for Health, DAH) has, historically, originated from
multiple sources (see Box 4.5). Whilst these initiatives may have been beneficial
for some specific diseases like malaria (see pp. 297–301), tuberculosis (pp.
1106–1113) and HIV/AIDs (pp. 331–355), health systems development has
frequently lagged behind such high-profile schemes. The consequences of this
were seen in the slow response of the WHO and others to the 2014 outbreak of
Ebola in Africa.
Improvements in healthcare result in economic growth. For example, a 10%
reduction of malaria in endemic areas is associated with a 0.3% increase in GDP.
Treatment of HIV-positive patients with anti-retroviral drugs results in net
economic benefit through increased productivity and a reduction in medical care
treatment costs. A failure to invest in health and health systems is a threat to
future global prosperity, particularly in poor countries. As an example, surgery is
currently a neglected component of health systems and it is estimated that 5 
billion people currently lack access to safe, affordable surgical and anaesthesia
care when needed. The cumulative loss of economic productivity between 2015
and 2030, in the absence of a significant scaling up of global surgical services, is
estimated at US$12.3 trillion.
Political decisions regarding investment in healthcare and health systems also
need to focus on infrastructure, including food and agriculture, the environment
and human rights issues, especially the rights of women. In essence, the pursuit
of ‘pro-poor’ policies that place the poor at the centre of development policy is
essential for future global prosperity.

Further reading
Figuera J, McKee M. Health Systems, Health, Wealth and Societal Well-being.
Maidenhead: McGraw Hill/Open University Press; 2012.
Meara JG, Leather AJM, Hagander L et al. and the Lancet Commission on
Global Surgery. Global surgery 2030; evidence and solutions for achieving
health, welfare, and economic development. Lancet 2015; 386:569–624.
Resch S, Korenromp E, Stover J et al. Economic returns to investment in
AIDS treatment in low and middle income countries. PLoS ONE 2011;
6:e25310.

Social Determinants of Health

The drivers of health inequities reside in the social, economic and political
environments. The WHO (2008) defined the social determinants of health as ‘the
conditions in which people are born, grow, live, work, and age. These
circumstances are shaped by the distribution of money, power and resources at
global, national and local levels.’ The social gradient of health follows the
socioeconomic pattern from the top to the bottom. In general, the lower the
individual is within their socioeconomic position, the worse their health; this is
seen globally in HICs, as well as LMICs. The socioeconomic status of a person
is their social position in society and this is determined by their education,
income and occupation.
There is now clear evidence to justify national policies that aim to reduce
health inequity and the health divide across all countries. It has also been
suggested that reduction in health inequities should become one of the main
criteria used to assess the effectiveness of health systems and governments as a
whole.

Further reading
Marmot M, Allen J, Bell R et al and World Health Organization. European
review of social determinants of health and health divide. Lancet 2012;
38:1011–1029.

Human Rights and the Value of Engagement in

Global Health
The Universal Declaration of Human Rights (1948), whilst not legally binding,
serves as a ‘common standard for all peoples and all nations’. It has given rise to
two new legally binding covenants: the International Covenant on Civil and
Political Rights and the International Covenant on Economic, Social and
Cultural Rights.
The WHO is a specialized agency of the United Nations with a remit for
international public health. Its constitution enshrines ‘the highest attainable
standard of health’ as a fundamental right of every human being. The right to
health contains four elements: availability (of programmes of public health),
accessibility (of health facilities and services in a non-discriminating fashion),
acceptability (ethical and cultural requirements), and good-quality care.
There is a worldwide shortage of healthcare workers from all disciplines (Fig.
4.5). Engagement in GH challenges helps to promote patterns of behaviour that
benefit healthcare workers, as well as the recipients of their endeavours.
Altruistic behaviours, team-working and appreciation of cultural diversity are
but a few benefits of participation in GH challenges.
 FIGURE 4.5 Worldwide shortage of healthcare workers. There are 57 countries with a
critical shortage of 2.4 million health service providers (doctors, nurses and midwives).
Africa has 25% of the world's healthcare burden and 1.3% of the providers. (From Crisp N,
Cheng L. Global supply of health professionals. N Engl J Med 2014; 370:950–957 [Figure 1], with permission.)

Medical electives
Both medical students and doctors may undertake periods of time visiting and
working in unfamiliar environments, often in other countries. This is mutually
beneficial to all participants, provided that a culture of shared learning is
embraced. All such visits should have clear objectives and measurable
educational outcomes. Pre-departure preparation should include consideration of
culture, ethical challenges and security issues. All visitors must work within
their approved competencies and comply with national guidance on good
medical practice. It is essential for the appropriate pro​cesses for bipartite support
and supervision to be secure.
Maximum benefit is achieved when there is a mutual commitment to long-
term partnership. This type of experience promotes personal altruistic
behaviours.

Further reading
http://www.ohchr.org/ International Bill of Human Rights.
http://www.un.org/ Universal Declaration of Human Rights.
Bibliography
Crisp N. Turning the World Upside Down. The Search for Global Health
in the 21st Century. Royal Society of Medicine Press: London; 2010.
Global Burden of Disease Study 2013 Collaboration. Global, regional, and
national incidence, prevalence, and years lived with disability for 301
acute and chronic diseases and injuries in 188 countries, 1990–2013: a
systematic analysis for the Global Burden of Disease Study 2013.
Lancet. 2015;386:743–800.
Marmot M. The Health Gap. The Challenge of an Unequal World.
Bloomsbury Publishing: London; 2015.