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David Sanders was founding Director of School of Public Health at the University of the
Western Cape (UWC), South Africa (1993–2019), and an internationally recognized
academic. As one of the founding members of the global People’s Health Movement, and the
co-chair from 2013–2019, he was also well-known as a health activist who was not afraid to
speak truth to power.
He was a paediatric and public health specialist, who believed passionately in the Primary
Health Care approach as envisaged in the Alma Ata Declaration of 1978. He had over 40
years’ experience in health policy and programme development in Zimbabwe and South
Africa, with a particular interest in child health and nutrition, and in optimizing human
resources for health – and specifically advocating for greater recognition and investment in
the work of Community Health Workers.
He had published extensively in these fields, as well as on the political economy of health
and globalization. The first edition of The Struggle for Health: Medicine and the Politics of
Underdevelopment, published in 1985, inspired a generation of young health care workers to
see beyond curative care, to the social determinants of health.
David was remarkable for bridging the often-divided worlds of academia, socialist politics
and activism. He combined research and service development with grassroots and global
activism, for the pursuit of health justice. The second edition of this book, with inputs by
fellow travellers, is part of David’s legacy and will contribute to furthering the struggle for
Health for All.
The Struggle for Health
 The Struggle for Health
Medicine and the Politics of Underdevelopment

Second Edition

DAVID SANDERS
WITH WIM DE CEUKELAIRE
AND BARBARA HUTTON
 Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
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Editors
Ms Barbara Hutton (Research Consultant and Educational Writer/Specialist)
Dr Wim De Ceukelaire (Director, Belgian NGO Viva Salud)

Reviewers
Dr Richard Carver (Co-author of the first edition of The Struggle for Health; Visiting Research Fellow, Oxford Brookes
University; Co-editor, Journal of Human Rights Practice)
Emeritus Professor Sue Fawcus (Senior Research Scholar in the Department of Obstetrics and Gynaecology, University
Cape Town, and the wife of the late Emeritus Professor Sanders)
Ms Nikki Schaay (Senior Researcher, School of Public Health, University of the Western Cape)

Consultants
Professor Fran Baum (Director, Stretton Health Equity, University of Adelaide, Australia; Extraordinary Professor at the
School of Public Health, University of the Western Cape; and Member, People’s Health Movement, Advisory Council)
Dr Chiara Bodini (Researcher, Centre for International and Intercultural Health, University of Bologna; People’s Health
Movement)
Emeritus Professor David Legge (Emeritus Scholar, School of Public Health and Human Biosciences, La Trobe University,
Australia)

Contributors
Ms Jesse Breytenbach (Book cover designer, illustrator and artist)
Ms Colleen Crawford Cousins (Illustrator and artist)

Support from School of Public Health, University of the Western Cape

Professor Uta Lehmann (Director, School of Public Health, University of the Western Cape)
Ms Carnita Ernest (Project Manager, School of Public Health, University of the Western Cape)
This book is dedicated to the children and their mothers living in poverty in Zimbabwe, who made me learn something about
the struggle for health.
The untimely demise of David Sanders on 31st August 2019 was an irreparable loss to all of us personally, David’s family,
and the broader health movement globally and in South Africa. This second edition of his iconic book, The Struggle for
Health is part of his legacy and an inspiration to us all to carry forward his vision of strengthening the struggle for Health
for All.
 Foreword

Some books sit on shelves and gather dust. Few books start a movement. The Struggle for
Health was an example of the latter.
It wasn’t just a book. It became a slogan, the name of an international university on the
politics of health for young activists, and the battle cry of the People’s Health Movement.
It also became my life.
And I was not alone. You could sit in the breakfast room of a hotel with David Sanders
anywhere in the world preparing for an international health meeting and someone would
walk up to your table to introduce themselves. Invariably the person would explain how
much The Struggle for Health had meant for their personal development and choices in life.
Some of them had made a career in health ministries or in the World Health Organization
(WHO). Others were rural doctors, staff of non-governmental organisations or health
activists. All of them testified how important the book had been for them.
In his foreword to the book’s first edition, Professor David Morley wrote: “Perhaps books
such as this will awaken those, particularly in the less developed countries of the world, to
realize that improvement in the health of the vast majority of their patients in the shanty
towns and rural areas will come largely through political change rather than through pills
and injections.” And indeed, that came through. But Morley, a pioneering paediatrician in
colonial and post-colonial Africa, was a giant of another era. It was the era of ‘tropical
medicine’, a specialty that was taught in institutions that reeked of colonialism. Alternative
analyses were rare and hard to come by, in particular, those which located health and disease
in relation to the dynamics of colonialism, racism, capitalism, patriarchy and imperialism.
Even harder to find were books like The Struggle for Health, which brought together such
an analysis with a strong ethical position around injustice, and which offered accessible
pathways into activism for health and social justice. The Struggle for Health avoids a
simplistic dichotomy between health care versus political activism; rather it points toward
ways of approaching health care which also challenge the structures which reproduce
avoidable and inequitable burdens of disease and injury.
Today, almost every medical faculty has courses on ‘global health’ and even well-
established medical journals are publishing articles on the decolonisation of health and health
care. There is a vast amount of critical material available on the internet. Nonetheless there
remains an urgent need for the analysis presented in The Struggle for Health to be updated to
recognise the changing context. Many of the ideas in the first edition have found their way
into the thinking and writing of others. But there are very few books that present an
accessible, radical and comprehensive analysis of the political economy of health. The
Struggle for Health is accessible for anyone who wants to know more about the causes of the
inequities in global health and health care. It is an invitation, an inspiration, to an activist
engagement in the struggle for health.
As we are now entering the era of climate chaos and pandemics, the book needed an
update. Whereas the first edition recognised the double burden of infectious diseases and
non-communicable diseases, these burdens have multiplied. Changing geopolitics, the
fracturing of neoliberal globalisation, the urgency of climate change and the emerging threat
of a new fascism are changing the context in which the struggle for health is embedded.
The politics, the ethics and the activist orientation remain central to this second edition of
The Struggle for Health while adapting to changing circumstances.
We hope it will inspire even more people to join the struggle and the movement.

Wim De Ceukelaire
Director
Viva Salud
 Preface to Edition 1 (David Sanders, 1985)

Some time ago, a British volunteer agency published a recruiting poster which carried a
picture of the renowned German medical missionary Albert Schweitzer and the legend: “You
won’t be the first long-haired idealist to go into the jungle and teach his skills.” Unwittingly,
perhaps, this expressed a sentiment that has always underlain the relationship between
developed and underdeveloped countries—the notion of the West’s civilising mission.

Nobel Foundation, Public domain, via Wikimedia Commons

YOU WON’T BE THE FIRST LONG-HAIRED IDEALIST TO GO INTO

THE JUNGLE AND TEACH HIS SKILLS.
Tradesmen and craftsmen, graduates and teachers, engineers and technicians,
agriculturalists and foresters, medical auxiliaries, librarians and accountants, surveyors and
architects, urgently needed for voluntary service overseas.
If you would like more information please contact: Voluntary Service Overseas, 14 Bishops
Bridge Road, London W2. Tel. 01-262 2611
Hard work. Long hours. Low pay. The most memorable year of your life.

This book began life in the late 1970s as a manual for volunteer British health care
workers going to work in the underdeveloped world. Over the years, it has grown into
something rather broader, which I hope will be used by others as well—by health care
workers anywhere, exploring the roots of ill-health in their societies and questioning their
roles, indeed by anyone concerned with ‘development’.
 Many people can see that much ill-health is the result of widespread poverty, hunger or
unsanitary conditions. And of course, common sense tells us that ‘prevention is better than
cure’—an idea that has been enthusiastically taken up by the international health
bureaucracy. But there is still a firmly entrenched belief that the highly trained health
professional is important to the well-being of those who live in the tropical climates of the
underdeveloped world, with their ‘reservoir of diseases’.
This book offers a far more radical approach than simply the need for more preventive
medicine. It argues that medicine of any sort plays a very minor role in improving the health
of peoples—that their health is inextricably linked to the context in which they live and work.
Poverty and inequality impact on the patterns of ill-health within and across countries,
whether they are rich or poor. Improvements in health can only be made by combining more
appropriate health care with the struggle against inequality and underdevelopment. This
struggle must involve health care workers, among others.
For an overall improvement in the health of populations we need more than a heavily
doctor- and cure-oriented system of health care which only reaches a small and usually
privileged minority. The failure to radically improve nutrition, water supplies, sanitation,
living conditions and education, combined with the unequal distribution of resources and
political power within and across nations, leave many millions of people suffering and dying
from easily preventable conditions.
This book is no conventional health manual—though it has a similar starting point. It is
dedicated to the proposition that problems of health, development and underdevelopment are
intimately linked. It is for that reason that it might sometimes read like a lesson in history or
politics, rather than a book on health care. There is no reason to apologise for this. For too
long health has been widely looked upon as an issue apart from the real problems of society.
The time has come to redress the balance.

A NOTE ABOUT THE TERMS DEVELOPED AND

UNDERDEVELOPED
Some readers might object to the use of the word ‘underdeveloped’ to describe countries in
the Global South. This book takes the same approach as John Berger:
The term ‘underdeveloped’ has caused diplomatic embarrassment. The word ‘developing’ has been substituted.
‘Developing’ as distinct from ‘developed’. The only serious contribution to this semantic discussion has been made by
the Cubans, who have pointed out that there should be a transitive verb: to underdevelop. An economy is
underdeveloped because of what is being done around it, within it and to it (Berger & Mohr, 1975).
 Preface to Edition 2 (Sue Fawcus, 2022)

The first edition of The Struggle for Health was published in 1985 and has been widely read
and endorsed by those who seek a broader and more political understanding of ill-health that
went beyond the medical and commercial model. This revolutionary book charted new ways
of understanding and tackling the causes of ill-health, and suggested strategies to enable
Health for All. The book appealed to diverse audiences, including health care workers in both
developed and underdeveloped countries, health care workers in training, academics in health
science, sociology and health economics faculties, as well as activists for social change and
community-based workers. Many said the book was for them a ‘game changer’, ‘eye
opener’, ‘career changer’, to mention but a few of the comments received.
Since the book was written, the world has seen many changes in health and disease
burdens, and their social, economic and political determinants. Developments and challenges
related to health include, but are not limited to the HIV/AIDS epidemic; the COVID-19
pandemic; the increasing burden of non-communicable diseases; the dual burden of
malnutrition (undernutrition and overnutrition); and the increasing burden of mental health
disorders; whilst the plight of children which prompted the first edition has continued in
many parts of the world.
In relation to social determinants, poverty remains a major driver of poor health, with the
income gap between people who are rich and those who are poor increasing and lack of
access to housing, land, water and sanitation persisting for many, despite some progress.
Serious and urgent problems which have been more widely recognised in the twenty-first
century include the climate change crisis and its influence on health outcomes, armed
conflicts within and between countries that drive migration, and gender-based violence.
In the broader political and global context, we have seen globalisation with the
consolidation of multinational corporations and the predominance of neoliberal politics, the
fading of the welfare state and socially driven policies, and the emergence of new global
power alliances. Developments in Information and Communication Technology (fourth and
fifth industrial revolutions) have changed the nature of local, personal and global
communications, with mixed implications, often reinforcing existing inequities.
To counter the adverse effects of the above developments, new forms of social movements
have emerged to supplement that of organised labour, and include campaigns around social
justice issues, homelessness, the right to health, equality in education, elimination of gender-
based violence and combating climate change and its impacts.
In view of the major impacts on health from the 1980s due to the above factors, David
Sanders was in the process of updating The Struggle for Health to incorporate these issues.
He was assisted by Barbara Hutton and Wim De Ceukelaire. He was 75% through this task
when his sudden death sadly prevented him from completing the process. This project was
too important to be allowed to lapse, so a group of fellow travellers in health and politics
from the University of the Western Cape, the People’s Health Movement and others have
collectively helped to finish the book. This was done out of respect for David’s enduring
legacy, but also because we all know how important the messages and analyses in the book
are—continuing the urgent work of the struggle for health and equity.
When I first met David, I was a medical student considering giving up my studies due to
disillusionment with the narrow focus of a London teaching hospital and having been
exposed to the importance of the social determinants of health in a rural village in North
India. David encouraged me to ‘not give up’, suggesting that as a doctor there would be the
choice to be a kind, compassionate clinical doctor making individuals’ lives better, or to go
into public health and tackle the social determinants of ill-health, or to become a
revolutionary and fight to change the political system that perpetuates inequality. For David it
was not ‘either/or’; remarkably he did all three in his life’s work. All three archetypes can
become activists for social justice in health; and all three archetypes require awareness of
both the individual’s needs and the broader context.
The second edition of The Struggle for Health, therefore, has not departed from the core
message of the first edition: Health for All cannot be achieved without a change in the global
economic order, community involvement and mobilisation, social justice and a
Comprehensive Primary Health Care Approach—as enshrined in the 1978 Alma-Ata
Declaration, but watered down considerably in the 2018 Astana Declaration. This second
edition utilises the same approach as the first, with a narrative that starts with diseases, then
describes historical trends and the limitation of the medical (and commercial) model of care,
focuses on the social determinants of health, and examines the economic and political
determinants which influence both health and health care systems. It asks the question
‘WHY’ at each juncture and has used a similar analysis as in the original book to understand
and interpret all the changes since 1985. Most importantly, this second edition presents a
strengthened call to action, building upon the original work and advocating for systemic
changes to ensure justice and equity in Health for All.
Chapter 1 gives an overall impression of the conditions and diseases that most commonly
affect people globally, especially those who live in poverty within and across countries.
Chapter 2 provides a deeper description of global disease patterns. It compares the
disease pattern of European countries before they were industrialised, with diseases in
underdeveloped countries today; and finds that many diseases we now regard as ‘diseases of
poverty or underdevelopment’ were once prevalent in the northern hemisphere. However,
instead of poorer countries following the same epidemiological transition as industrialised
countries, another type of transition has evolved in which countries are struggling with more
than one dominant disease pattern at the same time. Importantly, this is increasingly polarised
across income groups, both across and within rich and poor countries.
Chapter 3 asks why this is so. How were the countries of the West able to eradicate those
illnesses which were still prevalent in the early nineteenth century? Why are their former
colonies—the underdeveloped countries—not able to? Why indeed are they still
underdeveloped? Is there a connection between development in some countries and
underdevelopment in others? In any given country, are health standards roughly equal for the
whole population? Finally, this chapter discusses the question of population—so often seen
as the crucial factor for explaining underdevelopment and poverty. Again, it compares the
population structure of industrialised countries in the eighteenth and nineteenth centuries
with that of underdeveloped countries today and asks: Is there a lesson to learn?
Chapter 4 looks at the history of medical services in those societies dominated by
imperialism, which are the foundations of the present-day health care services in both
developed and underdeveloped countries. It asks, what about the medical contribution? What
about disease prevention, treatment and cure? Does the medical contribution significantly
counteract the imbalance in the spread of health-promoting resources?
Chapter 5 examines what has happened within the context of neoliberal globalisation in
the struggle for accessible and affordable health care for all. It explores some of the forces
that have led to and shaped the privatisation and commercialisation of health care.
Chapter 6 isolates the various influences that have shaped the dominant medical model.
It explores the role of doctors, of big business interests and of the State, looking at the areas
where the three interact. Is it possible to make the necessary changes in this model, in either
developed or underdeveloped countries, while the commercial determinants of health are still
at work?
Chapter 7 asks, what are some alternatives to the medical model? To answer this
challenge, the examples of China and Cuba in the twentieth century are given, where
victorious popular struggles resulted in a change of economic and political systems, enabling
underdevelopment to be successfully tackled and great improvements in peoples’ health to be
made. Significant changes and sometimes reversals in the last few decades for these two
countries are discussed. State-led community health worker programmes in Ethiopia, Iran
and India are examined as more recent examples of alternative approaches to health care and
promotion. Finally, the chapter describes the global movement for the right to health, the
People’s Health Movement, which grew out of these alternative models.
Throughout his life David directed his energies to working with communities in struggle,
whilst also challenging power and inequality in global forums, and performing rigorous
academic research to provide evidence for the strategies he (and others) advocated for. These
features are all central aims of the People’s Health Movement which he helped to found and
which he was a part of for many years. David never gave up on the struggle for health,
against all the odds, and this second edition is part of his legacy.
 Acknowledgements

The preface to the second edition would be incomplete without acknowledging all those who
enabled its production.
Barbara Hutton and Wim De Ceukelaire worked with David on it. Wim’s collaboration
began in 2006 and together with David, he developed the concept of the second edition and
updated the analysis and the data. Barbara joined the team in 2017 to help with writing and
editing the actual chapters. She was also responsible for ‘holding’ the book after David’s
death and drawing the team and content together in preparation for publishing.
The University of the Western Cape permitted the funds from David’s Author Fund to be
used for completion of the book. Uta Lehmann, Nikki Schaay and Carnita Ernest were key in
enabling this.
Fran Baum, Chiara Bodini and David Legge, all from the People’s Health Movement,
assisted Wim in writing sections and the last chapter.
Richard Carver, who co-authored the first edition and whom we tracked down, did the
final edit of the second edition.
Jesse Breytenbach designed the front cover illustration, and was assisted by Colleen
Crawford Cousins who also provided illustrations for the first edition.
Oxford University Press, who believed in the project and agreed to publish.
The plight of the world’s children which inspired the first edition; and David’s joy of
having his own children, Ben, Lisa and Oscar whom he loved dearly.
And lastly, David Sanders, for his inspiration, clear analysis, compassion, courage and
commitment, and of course his unique sense of humour.
 Contents

1. Snapshots of (Ill)Health Around the World

2. Global Disease Patterns
3. Health, Population and Inequality
4. The Medical Contribution
5. Health Policies and Health Care in the Context of Neoliberal Globalisation
6. The Commercialisation of Health Care: Medicine, Business and the State
7. Changing Medicine, Changing Society
Postscript: The Role of the Concerned Health Worker
Glossary
Index
 1
Snapshots of (Ill)Health Around the World

The Child’s Name Is Today

We are guilty of many errors and faults,
But our worst crime is abandoning the children,
Neglecting the fountain of life.

Many of the things we need can wait.

The child cannot.

Right now is the time his bones are being formed,

his blood is being made and his senses are being developed.
To him we cannot answer, ‘Tomorrow’.
His name is ‘Today’.
Gabriela Mistral (Chilean Nobel Prize in Literature winner, 1945)

What are the world’s main public health challenges? What are the most prevalent conditions
and diseases that transcend national and international borders? Mainly through visual images
and short scenarios, this chapter gives a broad impression of the health conditions and
diseases that most commonly affect people around the world, especially those who are poor,
both within and across countries (see Figure 1.1).
Fig. 1.1 To a child we cannot answer ‘Tomorrow’. Their name is ‘Today’.
Source: Wim De Ceukelaire—Viva Salud.

The scenarios include global hunger, which in 2019, impacted 8.9% of the global
population; non-communicable diseases (NCDs), which in 2019 accounted for 74% of all
deaths worldwide; communicable, maternal, neonatal and nutritional diseases (CMNN),
which in 2019 accounted for 10.2 million deaths globally; and human-caused global
warming, which has had a significant impact on the lives, health and livelihoods of the
poorest and most vulnerable populations globally.

NOTE: Common health conditions and diseases mentioned in this chapter are explored in
greater detail in the chapters that follow.

Scenario 1: global hunger

The child in the image in Figure 1.2 is receiving fluid replacement for dehydration caused by
severe diarrhoea. Both an intravenous and a nasogastric route are being used as the child is
critically ill and too weak to drink. The intravenous route entails inserting a needle into a
vein in the forearm and requires sterile, accurately prepared solutions of glucose, salt and
water. The nasogastric route requires the insertion of a polyvinyl tube into the nostril and
down into the stomach. Both routes require trained personnel. The child is obviously
extremely undernourished and has a form of protein-energy malnutrition (PEM) called
marasmus.

Fig. 1.2 A child receives fluid replacement for dehydration.

Source: UN Photo/Mark Garten. http://www.unmultimedia.org/photo/detail.jsp?
id=494/494704&key=0&query=494704&lang=en&sf=.

Another form of PEM is kwashiorkor (see Figure 1.3). Marasmus and kwashiorkor are
two forms of essentially the same disease, with the main difference being age distribution,
although this varies somewhat from country to country. Marasmus typically occurs in
children who are under the age of one year, whereas kwashiorkor generally occurs in children
in the one- to five-year age group.
Fig. 1.3 A child with kwashiorkor, with the typical symptoms of oedema or swelling of the hands and feet, and bulging
stomach.
Source: Dr Lyle Conrad (Public domain), via Wikimedia Commons.
https://commons.wikimedia.org/wiki/file%3astarved_girl.jpg.

GLOSSARY
Undernourished (hunger): a chronic condition that occurs when a person does not eat or
absorb enough nutrients to grow (UNICEF, 2019).
Protein-energy malnutrition (PEM) or protein-energy undernutrition (PEU): a form of
malnutrition that occurs due to a deficiency of protein and/or calories. It is likely to be due
to malnutrition over a long period. It includes:
• Wasting: the child is too thin for their height. This is the result of sudden and quick weight loss or failure to gain
weight. The child does not get enough calories from food and faces increased risk of death.
• Stunting: the child is too short for their age. This is the result of chronic or repeated undernutrition. The physical
and cognitive effects can last a lifetime.
• Underweight: the child has low-weight-for-age. The child may be wasted, stunted or both.

Marasmus: a form of malnutrition that typically occurs in children who are under one year.
It leads to dehydration and weight loss, and may include chronic diarrhoea and stomach
shrinkage.
Kwashiorkor: a form of malnutrition that typically occurs in children in the one- to five-
year age group.

From the early 1990s until 2014, global hunger gradually declined, despite a significant
growth in world population (FAO et al., 2020). By 2019, more than 690 million people, or
8.9% of the global population, suffered from undernourishment, most of whom were in the
underdeveloped regions of the world. This was 60 million more than in 2014. The COVID-
19 pandemic has exacerbated global hunger, with undernutrition being experienced by a
further estimated 132 million people in 2020 (FAO et al., 2020). It is expected that the
pandemic will affect food systems, food security and hunger in multiple ways, so that by
2030, there will be approximately 909 million undernourished people globally (FAO et al.,
2020).

GLOSSARY
Food security: relies on food being physically available; people having economic and
physical access to the food; using the food in a way that satisfies energy and nutrient intake;
and food stability over time (FAO et al., 2020).

Hunger and undernutrition are unevenly distributed throughout the world. There are
marked differences across regions and sub-regions, as well as within individual countries. In
almost every sub-region of Africa hunger is rising, with 19.1% of the African population
(250 million people) being undernourished—more than double the world average of 8.9%
(FAO et al., 2020). A detailed breakdown is presented in Table 1.1.

Table 1.1 Prevalence of undernourishment (PoU) in the world, 2005–2019 and projections
up to 2030

Prevalence of undernourishment (%)

2005 2010 2015 2016 2017 2018 20191 20302
WORLD 12.6 9.6 8.9 8.8 8.7 8.9 8.9 9.8
AFRICA 21.0 18.9 18.3 18.5 18.6 18.6 19.1 25.7
Northern Africa 9.8 8.8 6.2 6.3 6.6 6.3 6.5 7.4
Sub-Saharan Africa 23.9 21.3 21.2 21.4 21.4 21.4 22.0 29.4
Eastern Africa 32.2 28.9 26.9 27.1 26.8 26.7 27.2 33.6
Middle Africa 35.5 30.4 28.2 28.8 28.7 29.0 29.8 38.0
Southern Africa 4.9 5.4 7.0 8.0 7.0 7.9 8.4 14.6
Western Africa 13.8 12.1 14.3 14.2 14.6 14.3 15.2 23.0
ASIA 14.4 10.1 8.8 8.5 8.2 8.4 8.3 6.6
Central Asia 11.0 7.7 3.0 3.0 3.0 3.0 2.7 <2.5
Eastern Asia 7.6 3.8 <2.5 <2.5 <2.5 <2.5 <2.5 <2.5
South-Eastern Asia 17.3 11.7 10.5 10.0 9.8 9.8 9.8 8.7
Southern Asia 20.6 15.4 14.4 13.8 13.1 13.8 13.4 9.5
Western Asia 11.8 10.4 10.7 11.1 11.1 11.2 11.2 13.1
Western Asia and Northern Africa 10.9 9.7 8.6 8.9 9.0 8.9 9.0 10.4
LATIN AMERICA AND THE CARIBBEAN 8.7 6.7 6.2 6.7 6.8 7.3 7.4 9.5
Caribbean 21.3 17.5 17.3 17.0 16.6 17.0 16.6 14.4
Latin America 7.8 5.9 5.4 6.0 6.1 6.6 6.7 9.1
Central America 8.1 7.9 7.9 8.6 8.3 8.4 9.3 12.4
South America 7.6 5.1 4.4 4.9 5.2 5.8 5.6 7.7
OCEANIA 5.6 5.4 5.5 5.9 6.0 5.7 5.8 7.0
NORTH AMERICA AND EUROPE <2.5 <2.5 <2.5 <2.5 <2.5 <2.5 <2.5 <2.5
1
Projected values.
2
Projections up to 2030 do not reflect the potential impact of the COVID-19 pandemic.
Source: FAO et al. (2020), p. 9.

Figure 1.4 shows that by 2030, it is estimated that the African region will overtake the
Asian region as having the highest number of undernourished people—433.2 million, i.e.
51.5% of the global undernourished (FAO et al., 2020).
Fig. 1.4 Number of undernourished people in millions globally in 2019; and projections for 2030, without taking the
COVID-19 pandemic into account.
Source: FAO et al. (2020), p. 16.

In 2019, 2 billion people, a quarter of the world’s population, experienced food insecurity
—746 million faced severe food insecurity and an additional 1.25 billion experienced
moderate food insecurity (FAO et al., 2020). Over half the population in Africa (51.6%),
almost one-third in Latin America and the Caribbean (31.7%), and more than one-fifth in
Asia (22.3%) were food insecure.

GLOSSARY
Food insecurity: people do not have access to sufficient, safe and nutritious food necessary
to live a healthy and active life (FAO et al., 2020).
• Severe food insecurity: people have run out of food and have gone a day or a few days without eating (FAO et al.,
2020).
• Moderate food insecurity: people are unsure about their ability to access food and are forced to compromise on the
quality and/or quantity of food they consume (FAO et al., 2020).

Globally in 2019, of the children under five years old, an estimated:

 • 144 million (21.3%) were stunted (see Figure 1.5).
• 47 million (6.9%) suffered from wasting.
• 38 million (5.6%) were overweight (UNICEF et al., 2020).

Fig. 1.5 Percentage of stunted children under five years, by UN sub-regions, 2019.
Source: UNICEF et al. (2020).

The global health community recognises that many countries are now facing a double or
triple burden of malnutrition. This is defined as the coexistence of undernutrition, hidden
hunger and overweight and obesity (UNICEF et al., 2020). Although in the 1990s, the triple
burden was typically seen in middle-income countries, today it predominates in the poorest
countries, particularly in south and east Asia and Sub-Saharan Africa (Popkin et al., 2019).

GLOSSARY
Triple burden of malnutrition (TBM): the simultaneous occurrence of undernutrition,
hidden hunger and overweight and obesity in the same country, community, household or
individual.
Hidden hunger: not getting enough essential vitamins and minerals (UNICEF et al., 2020).
Overweight: a person’s weight is too high for their height (UNICEF et al., 2020).
Obesity: a severe form of overweight (UNICEF et al., 2020).
 Scenario 2: non-communicable diseases (NCDs)
I know that the food I buy from fast food outlets is unhealthy, but it’s cheaper to feed a family of four at McDonald’s
than it is to cook a meal for them at home. But there is no such thing as cheap food because the real cost of this food
is my health. I know I should get more physical exercise, but there are two factors which prevent this. Firstly, my
weight and secondly, because I smoke tobacco, I suffer from shortness of breath. It is an effort to get out of bed in the
morning, and generally, I just feel helpless, hopeless and very depressed (Paige Bagley [not her real name],
Baltimore, USA).

The convergence of a sedentary lifestyle, the use of tobacco and a diet high in sugars, salt and
fat has led to approximately 42% of American adults having obesity and the associated health
issues (CDC, 2020).
Forty-two-year-old Paige Bagley represents just one of the 40 million people in the USA
who in 2019 relied on the Supplemental Nutrition Assistance Program (SNAP—previously
called the Food Stamp Program) for food aid. Against the backdrop of COVID-19, this
number is expected to rise to more than 50 million (including 17 million children), with the
most vulnerable being ethnic and racial minorities, and those with non-communicable
diseases (Feeding America, 2020).

GLOSSARY
Non-communicable diseases (NCDs): non-infectious and non-transmissible conditions or
diseases, such as heart attacks, stroke, cancer, chronic respiratory diseases, diabetes or a
mental health condition (WHO, 2020b). NCDs may be chronic, i.e. of long duration and
slow progression, or they may result in more rapid deaths.

NCDs affect people of all ages, in all regions and countries of the world. Globally, NCDs
accounted for 74% of all deaths in 2019, with seven NCDs making up the ten leading causes
of death: ischaemic heart disease; stroke; chronic obstructive pulmonary disease; tracheal,
bronchus and lung cancers; Alzheimer’s disease and other dementias; diabetes mellitus; and
kidney disease (WHO, 2020a).
Approximately 36% (15 million) of all NCD deaths were in people under 70 years, and
85% occurred in low- and middle-income countries (WHO, 2014a; 2018a). People living in
poverty are disproportionately affected by NCDs. For example, the probability of dying from
one of these diseases before the age of 70 years varies across regions (see Figure 1.6), from
25% in South-East Asia to 15% in the Americas. This probability also varies between
countries, from over 30% in low- and middle-income countries to less than 10% in high-
income countries.
Fig. 1.6 Probability of dying from one of the four main NCDs between the ages of 30 and 70 years, by WHO region, 2012.
Source: WHO. (2014a), p. 11.

Mental health disorders and NCDs

Mental health disorders, including depression, anxiety disorders, bipolar disorder, eating
disorders, schizophrenia, mental or substance use disorder and Alzheimer’s disease
(particularly dementia), can be experienced in isolation or co-morbid with other NCDs (NCD
Alliance, 2017). Mental health disorders are experienced worldwide but are widely
underreported, particularly in lower-income countries. In 2017, substance use and mental
health disorders accounted for about 5% of the global disease burden, although this was as
high as 10% in certain countries, with the highest contribution to the overall health burden
being in Australia, Saudi Arabia and Iran (Ritchie & Roser, 2018).

GLOSSARY
Disease burden/burden of diseases: a comprehensive measure of the health status of a
nation, attained by assessing the diseases, injuries and impairments, and death rate in a
population in a certain period of time.

The COVID-19 pandemic has had major implications for mental health, and has
highlighted how people living with NCDs and mental health disorders are at increased risk of
becoming severely ill from the virus. This is due to, among other things, the disruption of
critical health services, despite an increased demand for these services (WHO, 2020b).
Bereavement, isolation, loss of income and fear are triggering mental health conditions or exacerbating existing ones.
Many people may be facing increased levels of alcohol and drug use, insomnia, and anxiety. Meanwhile, COVID-19
itself can lead to neurological and mental complications, such as delirium, agitation, and stroke. People with pre-
existing mental, neurological or substance use disorders are also more vulnerable to SARS-CoV-2 infection—they may
stand a higher risk of severe outcomes and even death (WHO, 2020c).

Following the outbreak of the COVID-19 pandemic, the pre-existing crisis of gender-
based violence (GBV) intensified globally, as pressure and tension built up in the home,
heightened by the cramped and confined living conditions of lockdown (UN Women, 2020).
UN Women has declared GBV a ‘shadow pandemic’, which typically escalates in crisis
contexts:
The Ebola pandemic demonstrated that multiple forms of violence are exacerbated within crisis contexts, including
trafficking, child marriage, and sexual exploitation and abuse. COVID-19 is likely driving similar trends … (UN
Women, 2020, p. 4).

GLOSSARY
Gender-based violence (GBV)/violence against women and girls: any form of violence—
physical, sexual, psychological harm and controlling behaviour—that is perpetrated against
an individual because of their gender. Prior to the outbreak of COVID-19, “globally 243
million women and girls aged 15–49 [had] been subjected to sexual and/or physical
violence perpetrated by an intimate partner in the previous 12 months” (UN Women, 2020).

Scenario 3: communicable, maternal, neonatal and nutritional

(CMNN) diseases
CMNN disorders include HIV/AIDS and sexually transmitted infections; respiratory
infections and tuberculosis; diarrhoeal diseases; neglected tropical diseases and malaria;
maternal and preterm birth complications; and nutritional deficiencies (The Lancet, 2020). In
2019, these diseases caused 10.2 million deaths globally—which represents a 36.3% decrease
since 2010 (The Lancet, 2020). Despite this rather substantial decline, there are still
important challenges around certain diseases, especially in certain regions of the world. In
the African region, for example, the convergence of NCDs and communicable diseases like
HIV/AIDS and malaria present ongoing health difficulties to the poorest and most
marginalised populations.

Global HIV/AIDS statistics

According to UNAIDS (2020a), in 2019, 690 000 people died from AIDS-related illnesses,
globally. However, in this same year:
• Approximately 38 million people were living with HIV—36.2 million adults and 1.8 million children under 15 years
(see Figure 1.7). This number continues to rise for two main reasons:

• With antiretroviral treatment (ART), more people are living longer (26 million on ART by mid-2020).
• The number of new infections is still high—1.7 million (although there has been a 23% decline in new HIV
infections since 2010).
• Outside Sub-Saharan Africa, women and girls accounted for about 48% of all new HIV infections worldwide. In Sub-
Saharan Africa, women and girls accounted for 59% of all new HIV infections. Structural gender inequalities
(perpetuated by patriarchal institutions and norms), discrimination and GBV undermine women’s efforts to prevent
HIV (UNAIDS, 2020b).
• Thirty-five percent of women worldwide experienced GBV and inequalities, making them 1.5 times more likely to
become HIV-infected than those who have not experienced such violence. Female sex workers are 30 times more
likely to acquire HIV than the general population.
• Tuberculosis remained the leading cause of death among people living with HIV. It accounted for about one in three
AIDS-related deaths.
• It was spectulated that the COVID-19 pandemic could disrupt the rate of increase in HIV treatment and services to
prevent transmission. These disruptions could result in up to 293 000 new HIV infections and up to 148 000
additional AIDS-related deaths globally (UNAIDS, 2020c).
Fig. 1.7 People living with HIV globally, 2020: 38 million—36.2 million adults and 1.8 million children under 15 years.
Source: UNAIDS. (2020d). Estimates. https://www.unaids.org/en/resources/infographics/people-living-with-hiv-around-the-
world.

Scenario 4: climate change and related health hazards

Human-caused global warming has increased the likelihood of more frequent and extreme
weather events, such as unprecedented heatwaves, droughts, heavy rainfall and floods
(Diffenbaugh, 2020). The rising incidence of these events is having a significant impact on
the lives, health and livelihoods of the poorest and most vulnerable populations globally.
Hardest hit are low- and middle-income countries and populations, especially in Sub-Saharan
Africa, South Asia and Small Island Developing States (SIDS) (see Figure 1.8).
Fig. 1.8 The 18 countries needing emergency assistance due to the destructive effects of climate-induced disasters, conflict,
economic crises and political instability.
Source: WFP. (2020).

GLOSSARY
Global warming: the effect of human activities, particularly the burning of fossil fuels
(coal), that release heat-trapping greenhouse gases that profoundly affect our global climate
system and cause the average temperature of the Earth to rise.

Climate change impacts on crop yields and food production, water availability, land
degradation, food security and rural livelihoods. Together with armed conflict, political
instability and economic collapse, it forces people to flee their homes and places of work,
and pushes a significant number of people worldwide into poverty and hunger (WFP, 2020).
It affects population health, putting additional strain on already stressed health systems and
social structures, and exacerbates social inequalities (WHO, 2015).
Climate change has an especially disproportionate effect on children’s health and
nutrition. After a flood or typhoon, for example, children are at the highest risk for
waterborne diseases, such as diarrhoea, which also increases their risk of malnutrition and
death (UNICEF, 2019). The impact falls most heavily on children from the poorest families
who are the least able to cope. From 2030 onwards, climate change is expected to cause
approximately 250 000 additional deaths per year, from malnutrition, malaria, diarrhoea and
heat stress (WHO, 2018b).

Free riders and forced riders

Greenhouse gas emissions are felt beyond a country’s own borders, and the effects of the
resulting climate change in different countries are highly variable. Although some countries
emit more greenhouse gas than others, they may be less vulnerable to the effects of the
resulting climate change. Researchers have identified ‘free rider’ countries which contribute
disproportionately to global greenhouse gas emissions but are the least vulnerable to the
effects of the resulting climate change. The largest three contributors are China, the USA and
India (Althor et al., 2016). ‘Forced rider’ countries are those that are most vulnerable to
climate change but have contributed little to its actual emission, such as SIDS and some
African countries (Althor et al., 2016). This inequity is increasing. In other words: those who
will bear the burden of the climate chaos are not those who are responsible for it.
The two maps in Figure 1.9 show the global inequity in greenhouse gas emissions and
those who bear the burden of its impacts for 2010 and predicted for 2030. Free riders, who
are predominantly found in the industrialised world, are shown in black, while forced riders,
who are mainly in less-industrialised and poorer countries, are in dark grey. Countries with
intermediate levels of equity are shown in shades of grey, and countries that produce
greenhouse gas emissions concomitant with their vulnerability are shown in the lightest grey.
Fig. 1.9 Global inequity in the responsibility for climate change and the burden of its impacts.
Source: Althor et al. (2016).

GLOSSARY
Equity: different treatment and access to resources and opportunities, recognising that
disadvantaged groups might need more support or resources in order to achieve equal
outcomes; based on fairness.

In 2017/2018, 101 countries participated in a WHO Health and Climate Change Survey
(WHO, 2018b), outlining climate hazards and their expected health impacts. Forty-eight of
these countries had conducted vulnerability and adaptation assessments for health in relation
to climate change. The following were some of the main climate-sensitive diseases identified:
• Vector-borne diseases, such as malaria and dengue, where the risk increases as a result of factors such as the rapid
growth of parasites and pests, their spread into new areas, and the reduced effectiveness of control measures.
• Water- and food-borne diseases, such as diarrhoeal diseases in children, where the risk increases as a result of the
rapid growth of pathogens and contaminated water sources due to flood damage to water and sanitation
infrastructure.
• Heat-related illnesses, which may contribute directly to deaths from cardiovascular and respiratory diseases
especially in older people.

A NOTE ABOUT OTHER HEALTH ISSUES

There are other significant health issues which have not been explored in depth in this
chapter or this book, for example:
• The 2 billion people who live in conditions that are affected by warfare and conflict, which result in displacement,
loss of livelihoods and food insecurity, all of which have ongoing physical and mental health implications for those
affected, especially women and children (Garry & Checchi, 2019).
• The more than 5 million people who die each year due to injuries, violence against self or others, road traffic
accidents, burns, drownings, falls and poisoning (WHO, 2014b). Road traffic accidents alone account for 1.35
million deaths globally, involving pedestrians, cyclists and motorcyclists. Ninety percent of these deaths occur in
low- and middle-income countries, with the highest death rates being in the African region (WHO, 2020c).

Inequalities in health outcomes

There is no single indicator of health in a community. However, a number of statistics taken
together can give us a broad view of the level of human development, equality/inequality
(see Figure 1.10), well-being and the burden of disease.
Fig. 1.10 Equality and equity.
Source: Figure reproduced with permission from the Interaction Institute for Social Change. Artist: Angus Maguire.

GLOSSARY
Equality: equal treatment and access to resources and opportunities, regardless of need or
outcomes; based on sameness.
Inequality: unequal treatment or access to resources and opportunities.

Pregnant women, children and adolescents account for more than one-third of the global
burden of premature mortality (death), with most of their deaths being preventable or their
conditions being treatable. In most cases these deaths reflect the huge disparities in access to
health care between those who are rich and people who are poor, and between urban and
rural dwellers within and between countries (WHO, 2015).
An important indicator of the most at-risk populations is the mortality rate of children
under five years. Despite substantial progress being made over the past few decades to
reduce under-five-year-old mortality from 12.6 million in 1990 to 5.4 million in 2017, the
global burden of child deaths remains extremely high (Roser et al., 2019).
Of course, the death of every child is an enormous tragedy, and in many countries far too many children die because of
causes we know how to prevent and treat … today the highest child mortality rates are in Sub-Saharan Africa, where
we still have countries with child mortality rates greater than 10%—this means that one out of 10 children born never
reach their 5th birthday (Roser et al., 2019).
 The gap between child mortality in underdeveloped and developed countries is
particularly significant. In developed countries, the majority of people who die are old, while
in underdeveloped countries the reverse is true—almost one in three deaths is in children
under five years (WHO, 2019).
The problems of health, development and poverty or underdevelopment are intimately
linked. In 2019, two regions alone accounted for 80% of the 5.2 million deaths of children
under five years globally, despite these regions only accounting for 52% of the global under-
five population—53% in Sub-Saharan Africa and 26% in Central and Southern Asia
(UNICEF, 2020). Nutrition-related factors contributed to about 45% of these deaths
(UNICEF, 2020).
Inequalities in health outcomes are not only between underdeveloped and developed
countries, but also exist within communities of both underdeveloped and developed
countries. In other words, the poorest areas within the poorest underdeveloped regions and
countries have the highest levels of child mortality (UNICEF, 2019). Even among developed
countries the mortality rate for children under five years differs. For example, in 2013, in the
UK this rate was double that of Iceland (2.4 per 1000)—the country with the lowest rate
globally (WHO, 2015). The reasons for these inequalities will be explored in more detail in
Chapter 2.

Conclusion
This chapter has provided a broad overview of a few major public health challenges that
transcend national and international borders—global hunger, non-communicable diseases,
communicable diseases and some health risks associated with climate change. These illnesses
and diseases interact within specific populations according to patterns of inequality deeply
entrenched in our societies. In future chapters, this will be analysed historically for social and
political determinants and solutions.

NOTE: The word ‘underdeveloped’ in this book is used to describe how economies in the
Global South have been, and continue to be, underdeveloped by what is done around them,
within them and to them (see the Note in the Preface to Edition 1).

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de Onis, M., Borghi, E., Arimond, M., et al. (2019). Prevalence thresholds for wasting, overweight and stunting in children
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probabilities of unprecedented events. Science Advances, 6(12):eaay2368.
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FAO, IFAD & WFP. (2020). The State of Food Security and Nutrition in the World 2020. Transforming Food Systems for
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Popkin, B.M., Corvalan, C. & Grummer-Strawn, L.M. (2019). Dynamics of the double burden of malnutrition and the
changing nutrition reality. The Lancet, 395(10217):65–74.
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UNAIDS. (2020c). New modelling shows COVID-19 should not be a reason for delaying the 2030 deadline for ending
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 2
Global Disease Patterns

In all probability it is the local conditions of society that determine the form of the disease, and we can so far state as
a fairly general rule that the simple form is the more common, the poorer and one-sided the food and the worse the
housing (Virchow & Reinhardt, 1848, p. 248).

Why do more children die in underdeveloped countries than in developed countries? Why is
this excess mortality especially seen in communities that are poor, in both rich and poor
countries?
This chapter focuses on the changing pattern of health and disease worldwide. It first
presents the 10 leading causes of death globally, before narrowing the focus to the leading
causes of death among children under five years old as an indicator of the most at-risk
populations. Disease patterns in underdeveloped countries are compared with those of
European countries in the nineteenth century and we see that many diseases we now regard
as ‘diseases of poverty’ were once prevalent in the northern hemisphere. Why is this so?
Different theories have been put forward to explain the change in disease patterns that
countries follow as they urbanise and modernise. Instead of poorer countries following the
same epidemiological transition as rich countries, another type of transition is evolving. In
this new transition, countries are struggling with more than one dominant disease pattern at
the same time—there is often a double, triple and sometimes even a quadruple burden of
disease. Importantly, this is increasingly polarised across income groups, occurring not only
between rich and poor countries, but also across social class within poor and rich countries.
Fig. 2.1 Climate-controlled luxury towers of people who are rich contrasted by the improvised shacks of people who are
poor, who are exposed to varying climatic conditions in Mumbai.
Source: Nicolas Vigier, Flickr.

Facts and figures

Of the world’s 7.5 billion people:
• More than 820 million are suffering from chronic undernourishment. Almost all live in underdeveloped countries,
with most being in Africa (representing, for example, 20% of the population of Africa) (FAO et al., 2019).
• 2.2 billion people around the world do not have safely managed drinking water services (UNICEF & WHO, 2019).
• 2.4 billion people do not have access to any type of improved sanitation facility (UNICEF & WHO, 2019).
• Approximately 100 million people are homeless worldwide and one in four people live in inadequate housing or
overcrowded conditions which are harmful to their health and safety (see Figure 2.1). It is estimated that by 2030, 3
billion people (about 40%) globally will lack affordable and accessible housing (UN-Habitat, 2021).

The global burden of disease

 Everyone, all over the world, deserves to live a long life in full health. In order to achieve this goal, we need a
comprehensive picture of what disables and kills people across countries, time, age, and sex. The Global Burden of
Disease (GBD) provides a tool to quantify health loss from hundreds of diseases, injuries, and risk factors, so that
health systems can be improved and disparities can be eliminated (Institute for Health Metrics and Evaluation
[IHME], 2019).

In the early 1990s, the World Bank, World Health Organization (WHO) and Harvard School
of Public Health commissioned the first Global Burden of Disease (GBD) study to
systematically measure the world’s health problems and disease patterns. The aim was to
assist health policy-makers to determine the focus of their public health policies and actions.
Since this first GBD study, researchers from various international organisations, led by the
WHO, have continued to update the findings. The latest GBD report, GBD 2017, was
published in November 2018. From such reports, GBD can be measured for different
countries and social classes and the disease patterns can be compared. In addition, the
magnitude of emerging problems can be monitored, for example the increasing burden of
mental health conditions in the NCD group; and most notably the occurrence of new
epidemics (HIV/AIDS) and pandemics (COVID-19), both communicable diseases that have
had profound impacts on morbidity and mortality.

GLOSSARY
Morbidity: illness, a diseased state, disability or poor health.
Mortality: death.

The GBD study combines health conditions into three broad categories (see Table 2.1).
Drawing on these categories, countries are described as suffering from a double, triple or
quadruple burden of disease, depending on which category or categories are dominant.
Trends in each category can be monitored over time for different settings.

Table 2.1 The GBD study’s classification of health conditions

Group Type Examples

1 Communicable Malaria, tuberculosis (TB), lower respiratory diseases, severe malnutrition, diarrhoeal
diseases, maternal, diseases, conditions arising during pregnancy and childbirth, HIV/AIDS, COVID-19
perinatal,
nutritional
2 NCDs Heart attack, stroke, diabetes, dementia/Alzheimer’s disease, chronic obstructive pulmonary
disease (COPD) (e.g. chronic bronchitis, refractory [non-reversible] asthma and some forms
of bronchiectasis), lung cancer (including trachea and bronchus cancers)
3 Violence and Injuries from road accidents
injuries
 The global picture
In 2019 (pre COVID-19), 55% of the 55.4 million global deaths—in terms of total number of
lives lost globally—were due to 10 main causes, as shown in Figure 2.2 (WHO, 2020a).
Fig. 2.2 Global health estimates: Leading causes of death. Cause-specific mortality, 2000–2019.
Source: WHO. (2020a). The Global Health Observatory. Global health estimates: Leading causes of death, Cause-specific
mortality, 2000–2019.

NOTE: By 3 May 2021, COVID-19 had claimed over 3.1 million lives globally, making it
one of the leading causes of death worldwide (WHO, 2021).
 In 2019, 7 of the top 10 causes of death globally (80%) were NCDs, which are all on the
rise (WHO, 2020a):
• Ischaemic heart disease was responsible for 16% of all deaths—rising from 2 million deaths in 2000 to 8.9 million in
2019. This was followed by stroke (11% of all deaths) and obstructive pulmonary disease (6% of all deaths).
• Trachea, bronchus and lung cancers claimed 1.8 million lives (up from 1.2 million in 2000).
• Alzheimer’s disease and other forms of dementia ranked seventh, with 65% of these deaths occurring in women.
• Deaths caused by diabetes have increased by 70% since 2000, with the largest increase being in male deaths.
• Kidney disease caused 1.3 million deaths (up from 813 000 in 2000).

In 2019, in the communicable disease category (WHO, 2020a):

• Lower respiratory infections ranked fourth in the top 10, claiming 2.6 million lives (down from 3 million in 2000).
• Neonatal conditions claimed 2 million lives (down from 3.2 million in 2000).
• Less than 295 000 women died in pregnancy or childbirth in 2017 (down from 451 000 in 2000) (WHO, 2019).
• Diarrhoeal diseases claimed 1.5 million lives (down from 2.6 million in 2000).

By the fourth quarter of 2020 there was an increase in deaths directly related to COVID-
19, as well as excess deaths from other categories due indirectly to the effect of the
pandemic on the health system and on underlying factors, such as increasing poverty and
hunger. As an example, from the end of January 2020 to early October 2020, the USA had
299 000 more deaths than the normal number during the same period in previous years. Two-
thirds were attributed to COVID-19, and the largest percentage increases were among
Hispanic and Latino people and among adults aged 25–44 years (Rossen et al., 2020).

GLOSSARY
Excess deaths: the number of deaths from all causes, in excess of what is normal for a
country and time period, based on historic averages.

The picture according to income group

The World Bank classifies countries into four main income groupings according to their
gross national income (GNI) per capita. In July 2020:
• Low-income economies were those with a GNI per capita of US$1036 or less.
• Lower middle-income economies were those with a GNI per capita between US$1036 and US$4045.
• Upper middle-income economies were those with a GNI per capita between US$4046 and US$12 535.
• High-income economies were those with a GNI per capita of US$12 535 or more.

GLOSSARY
Gross national income (GNI) per capita: a country’s final income in a year (before tax),
divided by its population, reflected in US dollars. GNI is said to be a good reflection of the
general standard of living enjoyed by the average citizen in a country.

The breakdown of the top leading causes of death in low- and high-income countries is
shown in Table 2.2.

Fig. 2.3 Deaths due to road traffic accidents.

Source: WHO. (2017).

Despite the global decline in death from communicable diseases up to 2019 (before the
COVID-19 pandemic in the 2020s), they remain the leading cause of death in low- and
middle-income countries. However, at the same time there was a rapid increase in deaths
caused by NCDs and violence and injury. For this reason, many countries are described as
struggling with a triple burden of disease, and some in Sub-Saharan Africa, where HIV/AIDS
is still prevalent, with a quadruple burden of disease.
Table 2.2 Main differences between low- and high-income countries in terms of causes of
death, 2015/2016

Low-income countries High-income countries

• Nearly 4 in every 100 deaths are among children under 15 years • 7 in every 10 deaths are among people
• 2 in every 10 deaths are among people aged 70 years and older aged 70 years and older
• 1 in every 100 deaths is among children
under 15 years
Group 1 conditions (communicable diseases) accounted for 52% of all Group 1 (lower respiratory infections)
deaths (lower respiratory infections; HIV/AIDS; diarrhoeal diseases; accounted for 7% of all deaths
malaria; TB; complications of childbirth due to prematurity, birth asphyxia
and birth trauma, and maternal deaths)
Group 2 conditions (NCDs) accounted for 37% of all deaths (up from 23% Group 2 conditions accounted for 88% of all
in 2000) deaths (including cardiovascular diseases;
cancers; dementia; chronic obstructive lung
disease; and diabetes)
Group 3 (injuries and violence) accounted for 28.5 deaths per 100 000 Group 3 (mainly suicide and homicide)
people. About 90% of injury-related deaths occur in low- and middle-
income countries (WHO, 2014a)

A NOTE ABOUT GROUP 3 CONDITIONS

In 2017, violence and injuries resulted in nearly 5 million deaths worldwide:
• Road accidents claimed 1.4 million lives, with 90% occurring in low- and middle-income countries, and the majority
happening in Africa (see Figure 2.3).
• Another approximately 1.3 million deaths were due to suicide and homicide.
• Other main causes of death from injuries were burns, falls, drowning, poisoning and violent conflict.

Disease in underdeveloped countries

It is important to give priority to maternal and child health and well-being when studying
differences in diseases and death in poor and rich countries. Not only are children the most
vulnerable age group, but also their health is important for the rest of their lives, as well as in
the lives of the generation to come. Childhood mortality provides us with a good picture of
child health and well-being (UNICEF, 2015b).
In low-income countries, nearly 4 in every 10 deaths are among children under 15 years, and only 2 in every 10 deaths
are among people aged 70 years and older . . . Complications of childbirth due to prematurity, and birth asphyxia and
birth trauma are among the leading causes of death, claiming the lives of many newborns and infants (WHO, 2014b).
Another random document with
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 The apparatus is first set by using pure potassium or sodium
nitrate. Since the temperature and pressure do not vary much within
an hour or two the volume of water obtained with a sample of white
saltpeter can be compared directly with that given off by the same
weight of a pure potassium or sodium nitrate without correction.
Example.—Two hundred and fifty milligrams of potassium nitrate,
containing 34.625 milligrams of nitrogen, displaced in a given case
sixty cubic centimeters of water; therefore one cubic centimeter of
water equals 0.578 milligram of nitrogen. If 289 instead of 250
milligrams be taken then the number of cubic centimeters of water
displaced divided by five will give the per cent of nitrogen.
217. Method of Difference.—In the analysis of Chile saltpeter by
the direct method a variation of 0.25 per cent in the content of
nitrogen is allowed from the dealers’ guaranty. This would allow a
total variation in the content of sodium nitrate of 1.52 per cent.
Dealers and shippers have always been accustomed to estimate the
quantity of sodium nitrate in a sample by difference; i. e., by
estimating the constituents not sodium nitrate and subtracting the
sum of the results from 100. Chile saltpeter usually contains sodium
nitrate, water, insoluble ferruginous matters, sodium chlorid, sodium
sulfate, magnesium chlorid, sodium iodate, calcium sulfate and
sometimes small quantities of potassium nitrate.
When the total sodium nitrate is to be estimated by difference the
following procedure, arranged by Crispo,[182] may be followed:
Water.—Dry ten grams of the finely powdered sample to constant
weight at 150°-160°.
Chlorin.—The residue, after drying, is dissolved and the volume
made up to one-fourth liter with water and the chlorin determined in
one-fifth thereof and calculated as sodium chlorid.
Insoluble.—Twenty grams are treated with water until all soluble
matter has disappeared, filtered on a tared gooch, and the filtrate
dried to constant weight.
Sulfuric Acid.—The sulfuric acid is precipitated by barium chlorid
in the slightly acid filtrate from the insoluble matter. The acidity is
produced by a few drops of nitric acid. The rest of the process is
conducted in the usual way.
Magnesia.—This is precipitated by ammonium sodium
phosphate, filtered, ignited, and weighed as pyrophosphate. The
magnesium is then calculated as chlorid. Magnesia is rarely found in
excess of one-fourth per cent. When this amount is not exceeded the
estimation of it may be neglected without any great error. As has
already been said the chlorin is all calculated as sodium chlorid. If a
part of it be combined with one-fourth per cent of magnesia it would
represent 0.59 per cent of magnesium chlorid instead of 0.73 per
cent sodium chlorid. In omitting the estimation of the magnesia
therefore the importer is only damaged to the extent of 0.14 per cent
of sodium nitrate.
Sodium Iodate.—This body, present only in small quantities, may
also be neglected. In case the content of this body should reach one-
fourth per cent the estimation of chlorin by titration using potassium
chromate as indicator is impracticable. Such an instance, however, is
rarely known.
Approximate Results.—When the determinations outlined above
have been carefully made it is claimed that the result obtained by
subtraction from 100 will not vary more than from two-tenths to
three-tenths per cent from the true content of sodium nitrate. The
method, however, cannot be considered strictly scientific and is
much more tedious and chronophagous than the direct
determination. In the direct determination, however, the analyst must
assure himself that potassium is present in only appreciable
quantities otherwise the per cent of sodium nitrate will be too low.
The presence of potassium nitrate is a detriment in this respect
only; viz., that it contains a less percentage of nitrogen than the
corresponding sodium salt. As a fertilizer, the value of Chile saltpeter
may be increased by its content of potassium.
218. The Application of Chile Saltpeter to the Soil.—The
analyst is often asked to determine the desirability of the use of
sodium nitrate as a fertilizer and the methods and times of applying
it. These are questions which are scarcely germane to the purpose
of this work but which, nevertheless, for the sake of convenience
may be briefly discussed. In the first place it may be said that the
data of a chance chemical analysis will not afford a sufficiently broad
basis for an answer. A given soil may be very rich in nitrogen as
revealed by chemical analysis, and yet poor in an available supply.
This is frequently the case with vegetable soils, containing, as they
do, large quantities of nitrogen but holding it in practically an inert
state. I have found such soils very rich in nitrogen, yet almost entirely
devoid of nitrifying organisms. It is necessary therefore in reaching a
judgment on this subject from analytical data to consider the different
states in which the nitrogen may exist in a soil and above all the
nitrifying power of the soil if the nitrogen be chiefly present in an
organic state. Culture solutions should therefore be seeded with
samples of the soil under examination and the beginning and rapidity
of the nitrification carefully noted. In conjunction with this the nitrogen
present in the soil in a nitric or ammoniacal form should be
accurately determined. These determinations should be made
according to the directions given in the first volume, pp. 448-548.
For the determination of nitrifying power we prefer the following
method:
219. Taking Samples of Soil in Sterilized Tubes.—Brass tubes
are prepared twenty centimeters in length and one and a half in
diameter. One end is ground to a beveled edge and compressed in a
mold so as to make the cutting edge slightly smaller in diameter than
the internal diameter of the tube. It is then ground or filed until
smooth and sharp. The blunt end of the tube is stoppered loosely
with cotton and it is then sterilized by heating for an hour to 150°.
Rubber caps are provided and each one has placed at the bottom a
rubber ball to prevent the rubber from being cut by the edges of the
brass tube. The caps should be of two distinct colors. Half of the
rubber caps are sterilized by being boiled for an hour in water for
three successive days. The caps cannot be heated to 150° dry heat
with safety. On removing the brass tube from the sterilizing oven as
soon as it is cool enough to handle, a sterilized rubber cap is slipped
over its cutting end. An unsterilized cap is then slipped over the other
end containing the cotton plug. Inasmuch as the cotton plug is never
removed it is not necessary to sterilize the cap covering it. Large
numbers of the tubes can thus be prepared for use and they can be
safely transmitted to a distance by express or mail. For convenience,
each tube is encased in a small cloth bag, which is tied with a cord
carrying a tag on which the necessary data can be recorded at the
time of taking the sample.
The tubes and their rubber caps thus carefully sterilized should
not be removed from their cloth envelopes until the moment of taking
each sample. After the sample has been taken and the cap replaced
on the tube the latter should be immediately enclosed in the cloth
sack and labeled with one of the tags therewith enclosed. The
sample should be taken in two kinds of soil, in one instance in a
cultivated soil, which is most characteristic of the locality, and in the
second place a virgin soil of the same type. The virgin soil may be
either soil which has been covered with grass or in forest. The spots
at which the samples are to be taken having been previously
selected, the tags for each tube should be prepared beforehand so
as to avoid delay at the time of sampling. A pit with straight walls
should be dug, the sides of which are at least two feet wide and even
three feet would be better. The pit should be about forty-two inches
deep. One of the sides having been made perfectly smooth and
without allowing the loose fragments from the top to fall down and
adhere to the walls below, the spots at which the samples are to be
taken should be marked with a tape line at the following points; viz.,
three, fifteen, twenty-seven, and thirty-nine inches, respectively,
below the surface. Beginning at the bottom point, carefully scrape off
the surface of the wall over an area slightly larger than that of the
end of the sample tube by means of a spatula, which, just previous
to use, has been held for a moment or two in the flame of an alcohol
or other convenient lamp. The sample tube having been removed
from its sack, it will be noted that the end covered with black rubber
is the one which is to be held in the hand, and this black rubber cap
should be first removed being careful not to extract the plug of
sterilized cotton which closes the end of the tube. Holding the tube
firmly by the end, the fingers extending only about two inches from
the end, remove the light-colored cap and push the tube with a
turning motion into the side of the pit at the point where the surface
has been removed with the sterilized spatula. When this is properly
done the tube will be filled with a cylinder of soil equal to the length
of the part of the tube penetrating the wall of the pit. The tube is then
withdrawn, the light rubber cap first replaced, and then the black
one. The light rubber cap should be held in the hand during the
process in such a way that no dust or particles of soil are permitted
to contaminate its inner walls. For this purpose the open end of the
cap should be held downward. For the same reason after the
removal of the light rubber cap the brass tube should be carefully
preserved from dust or fragments, the open end, that is the cutting
end, being held downward until ready for use. After one tube has
been filled, capped, replaced in the sack and labeled, the spatula
should be again sterilized and samples taken in regular order until
the top one is finished.
220. Directions for Taking Bulk Samples.—From the sides of
the pit described above, bulk samples should be taken as follows:
By means of a spade the soil should be removed from the four
sides to the depth of six or nine inches or until the change of color
between the soil and subsoil is noted; in all enough to make about
150 pounds of the air-dried soil. In the same way take a sample of
the subsoil to the depth of nine additional inches. Remove all stones,
large pebbles, sticks, roots, etc., and spread the samples in a
sheltered place where they can be air-dried as rapidly as possible.
The bulk samples should be taken both from the cultivated and virgin
soils. In selecting the cultivated soil, preference should be given to
those soils which have not been fertilized within a few years. If
recent fertilization have been practiced the character and amount of
it should be noted.
221. The Nitrifiable Solution.—The solution to test the nitrifying
power of the samples collected as above described is conveniently
made as follows:

Potassium phosphate, one gram per liter.

Magnesium sulfate, half a gram per liter.
Calcium chlorid, a trace.
Ammonium sulfate, 200 milligrams of nitrogen per liter.
 Calcium carbonate, in excess.

One liter of the above solution is enough for ten samples, each of
100 cubic centimeters. This quantity is placed in an erlenmeyer,
which is stoppered with cotton and sterilized by being kept at 100°
for an hour on three successive days. The erlenmeyer should be
sterilized beforehand by heating for an hour at 150°. The freshly
precipitated and washed calcium carbonate should be sterilized
separately and added to each erlenmeyer at the time of seeding.
Enough should always be used to be in excess of the nitrous and
nitric acids found. The seeding is accomplished by filling a sterilized
spoon which holds approximately half a gram of the soil, from the
contents of one of the brass tubes, lifting the plug in the erlenmeyer
and transferring quickly to the flask. This should be done in a
perfectly still room, preferably as high above the ground as possible
and in a place free from dust and under cover. The cotton plug being
replaced the erlenmeyer is shaken until the sample of soil added is
thoroughly disintegrated and intimately mixed with its contents. With
care and experience the seeding is easily accomplished without
danger of accidental contamination.
At the end of each period of five days the beginning and progress
of nitrification should be determined by some of the methods
described in volume first. Either the ammonia can be determined by
nesslerizing or the nitrous and nitric acids estimated. For nitrous acid
we prefer the method described in volume first, paragraph 504, and
for nitric the one in same volume paragraphs 497 and 498.
By supplementing the analysis of a soil by the above described
experiments in nitrification the analyst will be able to judge with
sufficient accuracy of its needs for nitric nitrogen.
222. Quantity of Chile Saltpeter to be Applied.—The quantities
of Chile saltpeter which should be applied per acre vary with so
many conditions as to make any definite statement impossible. On
account of the great solubility of this salt no more should be used
than is necessary for the nutrition of the crop. For each 100 pounds
used, from fourteen to fifteen pounds of nitrogen will be added to the
soil. Field crops, as a rule, will require less of the salt than garden
crops. There is an economic limit to the application which should not
be passed. As a rule 250 pounds per acre will prove to be a
maximum dressing. The character of the crop must also be
considered. Different amounts are required for sugar beets, tobacco,
wheat, and other standard crops. It is rarely the case that a crop
demands a dressing of Chile saltpeter alone. It will give the best
effects, as a rule, when applied with phosphoric acid or potash. But
this is a branch of the subject which cannot be entered into at
greater length in this manual. The reader is referred to Stutzer’s work
on Chile saltpeter for further information.[183]
223. Consumption of Chile Saltpeter.—The entire consumption
of sodium nitrate for manurial purposes in the whole world for 1894
was 992,150 metric tons, valued at $41,000,000. For the several
countries using it the consumption was distributed as follows:
Germany 397,200 tons.
France 187,100 “
England 117,000 “
Belgium 123,000 “
United States 100,000 “
Holland 56,700 “
Italy and Spain 5,200 “
Other countries 5,950 “
Total 992,150 “
The above figures represent the actual commerce of each
country in Chile saltpeter, and may not give the exact consumption.
[184] For instance, Germany exports sodium nitrate to Russia and
Austria, but it imports this salt from Holland and Belgium. Belgium
imports from France, but its exportation is greater than its
importations from that country, so that its actual consumption on the
farm probably falls considerably below that given on the table.
Holland also exports larger quantities than are imported from
neighboring states. The exports from England are inconsiderable
compared with the quantities received, amounting only to about
5,000 tons a year, while the exportations from France reach nearly
10,000 tons.
 Sodium nitrate has a moderate value at the factories where it is
prepared for shipment in Chile. Its chief value at the ports where it is
delivered for consumption comes from freights and profits of the
syndicate. The factories, where it is prepared for the market, are at
or near the deposits, and the freights thence to the sea coast are
very high. The rail roads which have been constructed to the high
plateaux which contain the deposits, have been built at a very great
cost, and the freights charged are correspondingly high. There is
also a tax of $1.20 levied on each ton exported. Deducting all costs
of transportation and export duties the actual value of sodium nitrate
at the factory, ready for shipment, is about sixteen dollars in gold a
ton.

AUTHORITIES CITED IN
PART SECOND.

[125] American Chemical Journal, Vol. 13, No. 7.

[126] Atwater: Report of the U. S. Commissioner of Fish and
Fisheries, 1888, pp. 679-868.
[127] American Naturalist, Vol. 14, p. 473.
[128] Wiley: Retiring Address as President of American Chemical
Society, Baltimore Meeting, Dec. 1893, Journal of the American
Chemical Society, Vol. 16, pp. 17-20.
[129] Vid. op. et. loc. cit. supra.
[130] Vid. op. et. loc. cit. 4.
[131] Vid. op. et. loc. cit. 4.
[132] Vid. op. et. loc. cit. 4.
[133] Bulletin No. 43, p. 343 (to paragraph 156).
[134] American Chemical Journal, Vol. 2, pp. 27, et seq.
[135] Vid. op. et. loc. cit. supra.
[136] Weather Bureau: Barometers and Measurements of
Atmospheric Pressures.
[137] Physikalisch-Chemische Tabellen Landolt und Börnstein, S.
32.
[138] Battle and Dancy: Conversion Tables, p. 34.
[139] Bulletin No. 43, p. 348 (to paragraph 169).
[140] Guide pour le dosage de l’Azote No. 3, p. 8.
[141] Zeitschrift für analytische Chemie, Band 23, S. 557.
[142] Chemiker Zeitung, Band 8, S. 1747.
[143] Journal of the Chemical Society, Transactions, 1881, p. 87.
[144] Bulletin No. 16, p. 51.
[145] Bulletin No. 28, p. 193 (to paragraph 175).
[146] Journal Society of Chemical Industry, Vol. 2, p. 21.
[147] Bulletin de l’Association des Chimistes de Sucrèrie, Tome 9,
p. 598.
(bis p. 192) Journal Chemical Society; Transactions, Vol. 21, p.
161.
[148] Zeitschrift für analytische Chemie, Band 22, S. 366.
[149] Vid. op. cit. supra, pp. 370, et seq.
[150] Vid. op. cit., 24. Band 24, S. 455.
[151] Chemisches Centralblatt, 1886, S. 165.
[152] Nederlandsche Staatscourant, Jan. 11, 1893.
[153] Die Agricultur-Chemische Versuchs-Station, Halle a/S., S.
34.
(bis. p. 204) Bulletin No. 43, p. 345.
[154] Bulletin No. 31, 142.
[155] Fresenius, quantitative Analyse, 6th Auflage, S. 731.
[156] Zeitschrift für Analytische Chemie, Band 24, S. 455.
[157] Vid. op. cit. supra, Band 25, S. 149.
[158] Archive der Pharmacie {3}, Band 23, S. 177.
[159] Chemisches Centralblatt, 1886, S. 375.
[160] Vid. op. cit. supra, S. 161.
[161] Vid. op. cit. 35, S. 433.
[162] Vid. op. et. loc. cit. 28.
[163] Vid. op. cit. 29, S. 44.
[164] Bulletin No. 16, p. 51.
[165] Zeitschrift für analytische Chemie, Band 28, S. 188.
[166] Bulletin No. 35, p. 68.
[167] Bulletin No. 35, p. 202.
[168] Bulletin No. 112, Connecticut Agricultural Experiment
Station, and Bulletin No. 35, p. 96.
[169] Guide pour le dosage de l’Azote, p. 14.
[170] Revue de Chimie Analytique Appliquée, Tome 1, p. 51.
[171] Chemiker Zeitung, Band 4, S. 360.
[172] Bulletin No. 43, p. 361.
[173] Bulletin de la Société Chimique, 1890, p. 324.
[174] Bulletin No. 35, p. 88.
[175] Die Agricultur-Chemische Versuchs-Station, Halle a/S., S.
50.
[176] Vid., Vol. 1, p. 539.
[177] Berichte der deutschen chemischen Gesellschaft, Band
27,S. 1633.
[178] Vid. op. et. loc. cit. supra.
[179] Vid. op. cit. 51, S. 48.
[180] Zeitschrift für analytische Chemie, Band 34, S. 26.
[181] Vid. op. cit. supra, Band 32, S. 553.
[182] L’Engrais, Tome 9, p. 877.
[183] Der Chile Saltpeter; Seine Bedeutung und Anwendung als
Düngemittel.
[184] L’Engrais, 5 Avril, 1895, p. 324.
 PART THIRD.
POTASH IN FERTILIZING MATERIALS
AND FERTILIZERS.

224. Introduction.—The potash present in unfertilized soils has been derived from the decay of
rocks containing potash minerals. Among these potash producers feldspars are perhaps the most
important. For a discussion of the nature of their decomposition and the causes producing it the first part
of volume first may be consulted. Potash is quite as extensively distributed as phosphoric acid and no
true soils are without it in some proportion. Its presence is necessary to plant growth and it forms, in
combination with organic and mineral acids, an essential part of the vegetable organism, existing in
exceptionally rich quantities in the seeds. It is possible that potash salts, such as the chlorid, sulfate,
and phosphate may be assimilated as such, but, as with other compounds, we must not deny to the
plant the remarkable faculty of being able to decompose its most stable salts and to form from the
fragments thus produced entirely new compounds. This is certainly true of the potash compounds
existing in plants in combination with organic acids. The potash which is assimilated by plants exists in
the soil chiefly in a mineral state, and that added as fertilizer is chiefly in the same condition. That part of
the potash in a soil arising directly from the decomposition of vegetable matters may exist partly in
organic combination, but this portion, in comparison with the total quantity absorbed by the plant, is
insignificant.
It is then safe to assume that at least a considerable part of the potash absorbed by the plant is
decomposed from its original form of combination by the vegetable biochemical forces, and is finally
incorporated in the plant tissues in forms determined by the same powerful forces of vegetable
metabolism.
The analyst is not often called upon to investigate the forms in which the potash exists in plants,
when engaged in investigation of fertilizers. It is chiefly found in combination with organic and
phosphoric acids, and on ignition will appear as phosphate or carbonate in the ash.
225. Forms in which Potash is Found in Fertilizers.—The chief natural sources of potash used in
fertilizer fabrication are: First, organic compounds, such as desiccated mineral matters, tobacco waste,
cottonseed hulls, etc.; second, the ash derived from burning terrestrial plants of all kinds; third, the
natural mineral deposits, such as Stassfurt salts.
All of these forms of potash may be found in mixed fertilizers. While the final methods of analyses
are the same in all cases the preliminary treatment is very different, being adapted to the nature of the
sample. For analytical purposes, it is highly important that the potash be brought into a soluble mineral
form, and that any organic matters which the sample contains be destroyed. If the sample be already of
a mineral nature, it may still be mixed with other organic matter and then it requires treatment as above,
for it is not safe always to rely solely on the solubility of the potash mineral, and the solution, moreover,
in such cases, is likely to contain organic matter. In some States, only that portion of the potash soluble
in water is allowed to be considered in official fertilizer work. In these cases it is evident that the organic
matter present should not be destroyed in the original sample, but only in the aqueous solution. Since,
however, the potash occluded in organic matter becomes constantly available as the process of decay
goes on, it is not just to exclude it from the available supply. It may not be so immediately available as
when in a soluble mineral state, but it is not long before it becomes valuable. Experience has shown,
moreover, that phosphorus, nitrogen, and potash are all more valuable finally when applied to the soil in
an organic form. This fact is a corroboration of the theory already advanced that all mineral compound
bodies are probably decomposed before they enter as component parts into the tissues of the vegetable
organism.
It is highly probable, therefore, that the potash existing in organic compounds, finely divided and
easily decomposed, is of equal, if not greater value to plant life than that already in a soluble mineral
state. The organic matter, when present, is destroyed, either by ignition at a low temperature, or by
moist combustion with an oxidizing agent before the potash is precipitated.

ORGANIC SOURCES OF POTASH.

226. Tobacco Stems and Waste.—Until within a few years tobacco stems and other waste from
factories, were treated as a nuisance in this country, and burned or dumped into streams. By burning
and saving the ash the potash contained in the stems and waste would be recovered in a form suitable
for field use. The nitrogen, however, contained in these waste materials, both in the form of nicotin and
of albuminoids would be lost. Ignition of this waste, therefore, should not be practiced. It should be
prepared for use by grinding to a fine powder. Applied to the soil in this condition the powder may be
useful as an insecticide as well as a fertilizer. Tobacco stems contain from twelve to twenty-seven per
cent of moisture, and from twelve to twenty per cent of ash. The composition of the stems from two
celebrated tobacco growing regions is subjoined:[185]
Kentucky stems. Connecticut stems.
Moisture 26.70 per cent. 13.47 per cent.
Organic and volatile 60.18 “ “ 70.85 “ “
Ash 13.12 “ “ 15.68 “ “
The ash calculated to the original substance had the following composition:
Kentucky stems. Connecticut stems.
Phosphoric acid 0.67 per cent. 0.53 per cent.
Potash 8.03 “ “ 6.41 “ “
It is thus seen that about half the ash of tobacco stems is composed of potash. The stalks of the
tobacco have almost the same composition as the stems, but the percentage of ash is not quite so
great. In three samples analyzed at the Connecticut station the percentages of ash found in the water-
free substance were 6.64, 7.00, and 7.46 respectively. The pure ash of the stalks was found to have the
following composition:[186]
Description of samples.
Constituents Cut Aug. 22. Cut Sept. 17.
Silica 0.82 per cent. 0.57percent.
Iron and aluminum oxids 1.38 “ “ 1.38 “ “
Lime 14.01 “ “ 16.58 “ “
Magnesia 6.64 “ “ 7.36 “ “
Potash 56.34 “ “ 54.46 “ “
Soda 1.28 “ “ 1.16 “ “
Sulfuric acid 8.06 “ “ 6.75 “ “
Phosphoric acid 6.37 “ “ 6.27 “ “
Chlorin 6.55 “ “ 7.05 “ “
101.45 “ “ 101.58 “ “
Deduct oxygen = chlorin 1.45 “ “ 1.58 “ “
100.00 “ “ 100.00 “ “
The leaves of the tobacco contain more ash than the stalks or stems, but the percentage of potash
therein is less. In eighteen samples analyzed at the Colorado station the percentages of moisture in the
leaf varied from 6.08 to 28.00, and those of ash from 22.60 to 28.00.[187] The percentages of potash in
the ash varied from 15.20 to 26.30. In these data the carbon dioxid, sand, etc., are included, while in
those quoted from the Connecticut station they were excluded.
227. Cottonseed Hulls and Meal.—A considerable quantity of potash is added to the soil in
cottonseed meal and hulls. The practice of burning the hulls cannot be recommended, although it is
frequently practiced, for the incineration does not increase the quantities of phosphoric acid and potash,
while it destroys the availability of the nitrogen. Nevertheless the analyst will often have to deal with
samples of the raw materials above mentioned, as well as with the ash of the hulls, in which the potash
can be determined by some one of the standard methods to be described. In general it is found that the
hulls of seeds and the bark and leaves of plants have a greater percentage of ash than the interior
portions. In the case of cottonseed however, an exception is to be noted. The cottonseed meal in the
air-dried state has about seven per cent of ash, while the hulls have only about three. When it is
remembered, however, that the greater part of the oil has been removed from the meal it will be seen
that in the whole seed in the fresh state the discrepancy is not so marked.
In the crude ash of the hulls the percentage of potash varies generally from twenty to twenty-five per
cent, but in numerous cases these limits are exceeded. In twelve samples of cottonseed hull ashes
examined by the Connecticut station the mean percentage of potash in the crude sample was 22.47,
and the extremes 15.57 and 30.24 per cent respectively.[188] In determining the value of the ash per ton
the content of phosphoric acid must also be taken into account.
Cottonseed meal contains about 1.75 per cent of potash. Since the mean percentage of ash in the
meal is seven, the mean content of potash in the crude ash is about twenty-five.
228. Wood Ashes.—Unleached wood ashes furnish an important quantity of potash fertilizer. The
composition of the ash of woods is extremely variable. Not only do different varieties of trees have
varying quantities of ash, but in the same variety the bark and twigs will give an ash quite different in
quantity and composition from that furnished by the wood itself. In general the hard woods, such as
hickory, oak, and maple, furnish a quality of ash superior for fertilizing purposes to that afforded by the
soft woods, such as the pine and tulip trees.
The character of the unleached wood ashes found in the trade is indicated by the subjoined
analyses. The first table contains the mean, maximum and minimum results of the analyses of ninety-
seven samples by Goessmann.[189]
Mean composition of wood ashes.
Means. Maxima. Minima.
Potash 5.5 10.2 2.5
Phosphoric acid 1.9 4.0 0.3
Lime 34.3 50.9 18.0
Magnesia 3.5 7.5 2.3
Insoluble 12.9 27.9 2.1
Moisture 12.0 28.6 0.7
Carbon dioxid and undetermined 29.9
In sixteen analyses made at the Connecticut station the data obtained are given below:[190]
Means. Maxima. Minima.
Potash 5.3 7.7 4.0
Phosphoric acid 1.4 1.8 0.9
In fifteen analyses of ashes from domestic wood-fires in New England stoves, the following mean
percentages of potash and phosphoric acid were found:
Potash 9.63
Phosphoric acid 2.32
 In leaching, ashes lose chiefly the potassium carbonate and phosphate which they contain. Leached
and unleached Canada ashes have the following composition:
Unleached. Leached.
Insoluble 13.0 per cent. 13.0percent.
Moisture 12.0 “ “ 30.0 “ “
Calcium carbonate and hydroxid 61.0 “ “ 51.0 “ “
Potassium carbonate 5.5 “ “ 1.1 “ “
Phosphoric acid 1.9 “ “ 1.4 “ “
Undetermined 6.6 “ “ 3.5 “ “
In the wood ashes of commerce therefore, it is evident that the proportion of the potash to the lime is
relatively low.
The number of parts by weight of the chief ingredients of the ash in ten thousand pounds of woods of
different kinds is given in the table below together with the percentage composition of the pure ash, that
is the crude ash deprived of carbon and carbon dioxid.

Pounds of the Ingredients Named

in Ten Thousand Pounds of Wood.
Dogwood. Sycamore. Post oak. Ash. Red Oak. Hickory.
Cornus Platanus Carya
Q. obtusiloba. F. Americana. Q. rubra.
florida. occidentalis. tomentosa.
Potash 9.02 18.06 16.85 14.94 13.95 13.80
Phosphoric acid 5.72 9.55 6.96 1.15 5.98 5.83
Lime 6.41 24.73 35.61 7.60 27.40 18.40
Magnesia 14.67 .49 5.28 .10 3.05 4.86

Old
White oak. Magnolia. Georgia pine. Yellow pine. Black pine. Chestnut.
p
Castanea
Q. alba. M. grandiflora. P. palustris. P. mitis. Picea nigra. vesca or P. m
sativa.
Potash 10.60 7.13 5.01 4.54 3.02 2.90
Phosphoric acid 2.49 3.19 1.24 .96 .92 1.09
Lime 7.85 14.21 18.04 15.16 12.46 7.93 12
Magnesia .90 2.94 2.03 .74 .10 .34 1

The Pure Ashes of the Woods

Contain the Following Per Cents
of the Ingredient Named.
Dogwood. Sycamore. Post oak. Ash. Red Oak. Hickory.
Cornus Platanus Carya
Q. obtusiloba. F. Americana. Q. rubra.
florida. occidentalis. tomentosa.
Potash 28.04 23.17 21.92 46.04 24.66 28.60
Phosphoric acid 8.51 12.23 9.00 3.58 10.55 11.97
Lime 38.93 31.62 46.39 23.57 48.26 37.94
Magnesia 6.80 .62 6.88 .60 5.38 10.04

Old
White oak. Magnolia. Georgia pine. Yellow pine. Black pine. Chestnut.
p
 Old
White oak. Magnolia. Georgia pine. Yellow pine. Black pine. Chestnut.
p
Castanea
Q. alba. M. grandiflora. P. palustris. P. mitis. Picea nigra. vesca or P. m
sativa.
Potash 42.16 19.54 15.35 19.70 14.30 18.10 3
Phosphoric acid 9.48 8.75 3.82 4.18 4.33 6.76 4
Lime 29.85 38.94 55.24 65.53 58.98 49.18 67
Magnesia 3.43 8.05 6.25 3.20 .50 2.11 6

229. Fertilizing Value of Ashes.—Primarily, the fertilizing value of wood-ashes depends on the
quantity of plant food which they contain. With the exception of potash and phosphoric acid, however,
the constituents of wood-ashes have little, if any, commercial value. The beneficial effects following the
application of ashes, however, are greater than would be produced by the same quantities of matter
added in a purely manurial state. The organic origin of these materials in the ash has caused them to be
presented to the plant in a form peculiarly suited for absorption. Land treated generally with wood-ashes
becomes more amenable to culture, is readily kept in good tilth, and thus retains moisture in dry
seasons and permits of easy drainage in wet. These effects are probably due to the lime content of the
ash, a property moreover favorable to nitrification and adapted to correcting acidity. Injurious iron salts,
which are sometimes found in wet and sour lands, are precipitated by the ash and rendered innocuous
or even beneficial. A good wood-ash fertilizer therefore is worth more than would be indicated by its
commercial value calculated in the usual way.
230. Molasses from Sugar-Beets.—The residual molasses resulting after the extraction of all the
crystallizable sugar in beet-sugar manufacture is very rich in potash. The molasses contains from ten to
fifteen per cent of ash.
The composition of the ash varies greatly in the content of potash as well as of the other
constituents.[191] The content of potassium carbonate varies from twenty-two to fifty-five per cent and, in
addition to this, some potassium sulfate and chlorid are usually present.
The following figures give the composition of a good quality of beet-molasses ash:

Potassium carbonate 45.30 per cent

Sodium “ 13.86 “
Potassium chlorid 22.40 “
“ sulfate 8.00 “
Silica, lime, alumina, water, phosphoric
acid, and undetermined 15.82 “

Thus, in 100 parts of such an ash over three-quarters are potash salts. The molasses may be
applied directly to the soil or diluted and sprayed over the fields.
231. Residue of Wineries.—The pomace of grapes after being pressed or fermented for wine
production contains considerable quantities of potash as crude argol or acid potassium tartrate. This
material can be applied directly to the soil or first burned, when its potash will be secured in the form of
carbonate.
The use of the winery refuse for fertilizing purposes has not assumed any commercial importance in
this country.
232. Destruction of Organic Matter by Direct Ignition.—The simplest and most direct method for
destroying organic matter is by direct ignition. The incineration may be conducted in the open air or in a
muffle and the temperature should be as low as possible. In no case should a low red heat be
exceeded. By reason of the moderate draft produced in a muffle and the more even heat which can be
maintained this method of burning is to be preferred. With the exercise of due care, however, excellent
results can be obtained in an open dish or one partly closed with a lid. At first, with many samples, the
organic matter will burn of its own accord after it is once ignited, and during this combustion the lamp
should be withdrawn. The ignition in most cases should be continued in a platinum dish but should the
sample contain any reducible metal capable of injuring the platinum a porcelain vessel should be used.
The lamp should give a diffused flame to avoid overheating of any portions of the dish and to secure
more uniform combustion. In using a muffle the heat employed should be only great enough to secure
combustion and the draft should be so regulated as to avoid loss due to the mechanical deportation of
the ash particles.
233. Ignition with Sulfuric Acid.—The favorable action of sulfuric acid in securing a perfect
incineration may also be utilized in the preparation of samples containing organic matter for potash
determinations. In this case the bases which by direct ignition would be secured as carbonates are
obtained as sulfates. In the method adopted by the official chemists it is directed to saturate the sample
with sulfuric acid and to ignite in a muffle until all organic matter is destroyed.[192] Afterwards, when cool
the ash is moistened with a little hydrochloric acid and warmed, whereby it is the more easily detached
from the dish. The potash is then determined by any one of the standard methods. This method has
several advantages over the direct ignition. Where any chlorids of the alkalies are present in the ash
there is danger of loss of potash from volatilization. This is avoided by the sulfate process. Moreover,
there is not so much danger in this method of occluding particles of carbon in the ash.
234. The Destruction of Organic Matter by Moist Combustion.—In the process of ignition to
destroy organic matter or remove ammonium salts in the determination of potash, there are often
sources of error which may cause considerable loss. This loss, as has already been mentioned, may
arise from the volatilization of the potash salts or mechanically from spattering. In order to avoid these
causes of error de Roode has used aqua regia both for the destruction of the ammonium salts and for
the oxidation of the organic matter at least sufficiently to prevent any subsequent reduction of the
platinum chlorid.[193] His method consists in boiling a sample of the fertilizer, or an aliquot portion of a
solution thereof with aqua regia. The proposed method has not yet had a sufficient experimental
demonstration to warrant its use, but analysts may find it profitable to compare this process with the
standard methods. The organic matter may also be destroyed by combustion with sulfuric acid, as in the
kjeldahl method for nitrogen. The residue, however, contains ammonium sulfate and a large excess of
sulfuric acid, and for both reasons would not be in a fit condition for the estimation of potash.
It is suggested that the organic matter might also be destroyed by boiling with strong hydrochloric
acid, to which from time to time, small quantities of sodium chlorate free of potash is added.
Subsequently the solution could be boiled with addition of a little nitric acid and the ammonium salts be
removed.

POTASH IN MINERAL DEPOSITS.

235. Occurrence and History.—The generally accepted theory of the manner in which potash has
been collected into deposits suited to use as a fertilizer has already been described.[194] The Stassfurt
deposits, which have for many years been almost the sole source of potash in fertilizers, were first
known as mines of rock salt. In 1839, having previously been acquired by the Prussian treasury, they
were abandoned by reason of the more economical working of rock salt quarries in other localities.[195]
It was determined thereafter to explore the extent of these mines by boring, and a well was sunk to the
depth of 246 meters, when the upper layer of the salt deposit was reached. The boring was continued
into the salt to a total depth of 581 meters without reaching the bottom. The results of these experiments
were totally unexpected. Instead of getting a brine saturated with common salt, one was obtained
containing large quantities of potassium and magnesium chlorids.[196] Shafts were sunk in other places,
and with such favorable results, that in 1862 potash salts became a regular article of commerce from
that locality. At first these salts were regarded as troublesome impurities in the brine from which
common salt was to be made, but at this time the common salt has come to be regarded as the
disturbing factor. At the present time the entire product is controlled by a syndicate of nine large firms
located at Stassfurt and vicinity. Outside of the syndicate properties a shaft has been sunk at
Anderbeck, (Halberstadt,) which, however, has produced only carnallit, since kainit has not been found
there. Also at Sondershausen, potash salts have been discovered and a shaft is now sinking there.
It is thus seen that the potash deposits extend over a wide area in Germany, and there is little fear of
the deposits becoming exhausted in many centuries. In this country no potash deposits of any
commercial importance have been discovered; but the geological conditions requisite to these
formations have not been wanting, and their future discovery is not improbable.

Figure. 17.
Geological Relations of the Potash
Deposits near Stassfurt.

236. Changes in Potash Salts in Situ.—The deposits of potash salts are not all found at the
present in the same condition in which they were first deposited from the natural brines. The layers of
salt have been subjected to the usual upheavals and subsidences peculiar to geological history. The
layers of salt were thus tilted and the edges often brought to the surface. Here they were exposed to
solution, and the dissolved brine afterward separated its crystallizable salts in new combinations. For
instance, kieserit and the potassium chlorid of the carnallit were first dissolved and there was left a salt
compound chiefly of potassium and sodium chlorids, sylvinit. In some cases there was a mutual reaction
between the magnesium sulfate and the potassium chlorid and the magnesium potassium sulfate,
schönit, was thus produced. This salt is also prepared at the mines artificially. The most important of
these secondary products however, from the agricultural standpoint, is kainit. This salt arose by the
bringing together of potassium sulfate, magnesium sulfate, and magnesium chlorid, and was formed
everywhere about the borders of the layers of carnallit wherever water could work upon them. In
quantity the kainit, as might be supposed, is far less than the carnallit, the latter existing in immense
deposits. There is however quite enough of it to satisfy all the demands of agriculture for an indefinite
time. In fact for many purposes the carnallit can take the place of kainit without detriment to the growing
crops. The relative positions and quantities of the layers of mineral matters in the potash mines, and the
depth in meters at which they are found is shown in Fig. 17.[197]
237. Kainit.—The most important of the natural salts of potash for fertilizing purposes is the mixture
known as kainit. It is composed in a pure state of a molecule each of potassium sulfate, magnesium
sulfate, magnesium chlorid, and water. Chemically it is represented by the symbols:
K₂SO₄·MgSO₄·MgCl₂·H₂O. Its theoretical percentage of potash (K₂O), oxygen = 16, is 23.2.
Pure kainit, however, is never found in commerce. It is mixed naturally as it comes from the mines
with common salt, potassium chlorid, gypsum, and other bodies. The content of potash in the
commercial salt is therefore only a little more than half that of the pure mineral. In general it may be
taken at 12.5 per cent, of which more than one per cent is derived from the potassium chlorid present.
The following analysis given by Maercker may be regarded as typical:[198]

Potassium sulfate 21.3 per cent

Magnesium “ 14.5 “
Magnesium chlorid 12.4 “
Potassium “ 2.0 “
Sodium “ 34.6 “
Calcium sulfate (gypsum) 1.7 “
Water 12.7 “
Alumina 0.8 “

Kainit occurs as a crystalline, partly colorless, partly yellow-red mass. When ground, in which state it
is sent into commerce, it forms a fine, gray-colored mass containing many small yellow and red
fragments. It is not hygroscopic and if it become moist it is due to the excess of common salt which it
contains.
According to Maercker kainit was formerly regarded as a potassium magnesium sulfate. But this
conception does not even apply to the pure salt much less to that which comes from the mines. If,
therefore, the agronomist desire a fertilizer free from chlorin he would be deceived in choosing kainit
which may sometimes contain nearly fifty per cent of its weight of chlorids.
Where a fertilizer free of chlorin is desired, as for instance, in the culture of tobacco, kainit cannot be
considered. In many other cases, however, the chlorin content of this body instead of being a detriment
may prove positively advantageous, the chlorids on account of their easy diffusibility through the soil
serving to distribute the other ingredients.
By reason of the presence of common salt and magnesium chlorid the ground kainit delivered to
commerce tends to harden into compact masses. To prevent this in Germany it is recommended to mix
it with about two and a half per cent of fine-ground dry peat.
Such a mixture is recommended in all cases where the freshly ground kainit is not to be immediately
applied to the soil.
238. Carnallit.—This mineral is a mixture of even molecules of potassium and magnesium chlorids
crystallized with six molecules of water. It is represented by the symbols KCl·MgCl₂·6H₂O. As it comes
from the mines it contains small quantities of potassium and magnesium sulfates and small quantities of
other accidental impurities. Existing as it does in immense quantities it has been extensively used for the
manufacture of the commercial potassium chlorid (muriate of potash). For many purposes in agriculture,
for instance, fertilizing tobacco fields, it is not suited, and it is less widely used as a fertilizer in general
than its alteration product kainit. Its direct use as a fertilizer however is rapidly increasing since later
experience has shown that chlorin compounds are capable of a far wider application in agriculture
without danger of injury than was formerly supposed. As it comes from the mines, the Stassfurt carnallit
has the following composition:[199]

Potassium chlorid 15.5 per cent.

Magnesium “ 21.5 “ “
Magnesium sulfate 12.1 “ “
Sodium chlorid 22.4 “ “
Calcium sulfate 1.9 “ “
Water 26.1 “ “
Undetermined 0.5 “ “
 Pure carnallit would have the following composition:
Chlorin 38.3 per cent.
Potassium 14.0 “ “
Magnesium 8.7 “ “
Water 39.0 “ “
Equivalent to
Potassium chlorid 26.8 “ “
Magnesium “ 34.2 “ “
Water 39.0 “ “

The commercial article as taken from the mines, as is seen above, has less potash (K₂O) than kainit,
the mean content being about nine and nine-tenths per cent. Those proposing to use this body for
fertilizing purposes should bear in mind that it contains less potash and more chlorin than kainit.
Carnallit occurs in characteristic brown-red masses. On account of its highly hygroscopic nature it
should be kept as much as possible out of contact with moist air and should not be ground until
immediately before using.
By reason of the greater bulk in proportion to its content of potash and its hygroscopic nature and
consequent increased difficulty in handling, the price per unit of potash in carnallit is less than in kainit.
In some localities small quantities of ammonium chlorid have been found with carnallit but not to
exceed one-tenth per cent. It has therefore no practical significance to the farmer but may be of interest
to the analyst.
239. Polyhalit.—Polyhalit is a mineral occurring in Stassfurt deposits and consisting of a mixture of
potassium, magnesium, and calcium sulfates, with a small proportion of crystal water. This mineral, on
account of its being practically free of chlorin, would be one especially desirable for use in those cases,
as in the culture of tobacco, where chlorids are injurious. Unfortunately, it does not occur in sufficient
quantities to warrant the expectation of its ever being found in masses large enough to become a
general article of commerce. It is found only in pockets or seams among the other Stassfurt deposits,
and there is no assurance given on finding one of these deposits of polyhalit that it will extend to any
great distance. The composition of the mineral is shown by the following formula:
K₂SO₄·MgSO₄·(CaSO₄)₂·H₂O. Its percentage composition is shown by the following numbers:

Potassium sulfate 28.90 per cent.

Magnesium sulfate 19.93 “ “
Calcium sulfate 45.18 “ “
Water 5.99 “ “
The percentage of potash corresponding to the above formula is 15.62. It therefore contains a
considerable excess of potash over kainit, and on account of its freedom from chlorids, would be
preferred for many purposes.
240. Krugit.—This mineral occurs associated with polyhalit and differs from it only in containing four
molecules of calcium sulfate instead of two. Its formula is: K₂SO₄·MgSO₄·(CaSO₄)₄·H₂O. As it comes
from the mines it is frequently mixed with a little common salt. Its mean percentage composition as it
comes from the mines is given in the following numbers:
Potassium sulfate 18.60 per cent.
Magnesium sulfate 14.70 “ “
Calcium sulfate 61.00 “ “
Sodium chlorid 1.50 “ “
Water 4.20 “ “
 The percentage of potash corresponding to the above formula is 10.05. It is therefore less valuable
than kainit in so far as its content of potash is concerned. This salt also exists in limited quantities and is
not likely to become an important article of commerce.
241. Sylvin.—One of the alteration products of carnallit is a practically pure potassium chlorid which,
as it occurs in the Stassfurt mines is known as sylvin. The alteration of the carnallit arises from its
solution in water from which, on subsequent evaporation, the potassium chlorid is deposited alone. This
mineral is found in only limited quantities in the Stassfurt deposits and it therefore does not have any
great commercial importance.
242. Sylvinit.—This mineral has been mined in recent years in considerable quantities. It is, in fact,
only common salt carrying large quantities of potassium chlorid together with certain other accidental
impurities. It was probably formed by the drying up of a saline mass in such a way as not to permit the
complete separation of its mineral constituents. The average composition of sylvinit as it comes from the
mines is given in the following table:
Potassium chlorid 30.55 per cent.
Sodium chlorid 46.05 “
Potassium sulfate 6.95 “
Magnesium sulfate 4.80 “
Magnesium chlorid 2.54 “
Calcium sulfate 1.80 “
Water and insoluble 7.29 “
This salt is richer in chlorin than any other of the Stassfurt potash minerals, containing altogether
79.14 per cent of chlorids. Its potash content amounts to 23.04 per cent, but in proportion to the potash
which it contains, it is relatively poorer in chlorin than kainit and carnallit. On account of its high content
of potash the freights on a given weight thereof as contained in sylvanit are lower than for kainit and
carnallit.
243. Kieserit.—The mineral kieserit is essentially magnesium sulfate and it does not necessarily
contain any potash salts. Under the name of kieserit, however, or bergkieserit, there is mined a mixture
of carnallit and kieserit, which is a commercial source of potash. The mixture contains the following
average content of the bodies named:
Potassium chlorid 11.80 per cent.
Magnesium sulfate 21.50 “
Magnesium chlorid 17.20 “
Sodium chlorid 26.70 “
Calcium sulfate 0.80 “
Water 20.70 “
Insoluble 1.30 “
This mixture contains only about seven per cent of potash and would not prove profitable when used
at a distance from the mines on account of the cost of freights. It has proved valuable, however, for a
top dressing for meadow lands in the vicinity of Stassfurt.
244. Schönit.—Among the Stassfurt deposits there occurs in small quantities a mineral, schönit,
which is composed of the sulfates of potassium and magnesium. The quantity of the mineral occurring
naturally is very small and therefore it has no commercial importance. When, however, kainit is washed
with water the common salt and magnesium chlorid which it contains being more soluble are the first
leached out, and the residue has approximately the composition of the pure mineral. This mixture, as
prepared in the way mentioned above, has the following average composition:
Potassium sulfate 50.40 per cent.