Global Health

FOURTH EDITION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORHEALTH SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Diseases, Programs, Systems, and Policies © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Michael H. Merson, MD Wolfgang Joklik Professor of Global Health © Jones &Duke Bartlett Global Learning, Health LLC Institute © Jones & Bartlett Learning, LLC NOT FOR SALE ORDuke DISTRIBUTION University NOT FOR SALE OR DISTRIBUTION Durham, North Carolina

© Jones & Bartlett Learning,Robert LLC E. Black, MD,© Jones MPH & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Professor and Director Institute for International Programs Department of International Health © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONJohns Hopkins BloombergNOT SchoolFOR SALE of OR Public DISTRIBUTION Health Baltimore, Maryland

© Jones & BartlettAnne Learning, J. Mills, LLC PhD © Jones & Bartlett Learning, LLC ProfessorNOT FOR SALE and OR Deputy DISTRIBUTION Director and ProvostNOT FOR SALE OR DISTRIBUTION London School of Hygiene & Tropical Medicine London, UK © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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Library of Congress Cataloging-in-Publication© Jones & Bartlett Data Learning, LLC © Jones & Bartlett Learning, LLC Names: Merson, Michael H., NOTeditor. |FOR Black, RobertSALE E., OReditor. DISTRIBUTION | Mills, Anne, editor. NOT FOR SALE OR DISTRIBUTION Title: Global health: diseases, programs, systems, and policies / [edited] by Michael H. Merson, Robert E. Black, and Anne J. Mills. Other titles: Global health (Merson) Description: Fourth edition. | Burlington, Massachusetts: Jones & Bartlett Learning, [2020] | Includes bibliographical references and index. Identifiers:© JonesLCCN 2018023789 & Bartlett | ISBN Learning, 9781284122626 LLC (casebound) © Jones & Bartlett Learning, LLC Subjects:NOT | MESH: FOR Global SALE Health | ORPublic DISTRIBUTION Health | International Cooperation | Public HealthNOT Administration FOR SALE | Health OR Policy DISTRIBUTION Classification: LCC RA441 | NLM WA 530.1 | DDC 362.1—dc23 LC record available at https://lccn.loc.gov/2018023789 6048 © JonesPrinted & Bartlett in the United Learning, States of America LLC © Jones & Bartlett Learning, LLC 22 21 20 19 18 10 9 8 7 6 5 4 3 2 1 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONChapter 1 Measures ofNOT Health FOR and SALE Disease OR DISTRIBUTION in Populations...... 1 Chapter 2 Culture, Behavior, and Health ...... 43

C©hapter Jones 3& BartlettGlobal Learning, Health, LLC Human Rights, and Ethics© Jones. . . . &. .Bartlett . . . Learning,75 LLC ChapterNOT FOR 4 SALEUnderstanding OR DISTRIBUTION and Acting on Social DeterminantsNOT FOR SALE OR DISTRIBUTION of Health and Health Equity...... 95

© Jones & BartlettChapter Learning, 5 Reproductive LLC Health. . ©. .Jones . . . .& .Bartlett . . . . Learning,. . . . LLC131 NOT FOR SALEChapter OR DISTRIBUTION 6 Infectious Diseases . . .NOT . . . FOR . . . SALE . . . OR. . .DISTRIBUTION . . . 195 Chapter 7 Nutrition...... 259 © Jones & Bartlett Learning,Chapter LLC 8 Chronic Diseases© Jones and & RisksBartlett. . . Learning, ...... LLC ...... 335 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Chapter 9 Unintentional Injuries and Violence ...... 381 Chapter 10 Global Mental Health ...... 423 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC CNOThapter FOR 11 SALE Environmental OR DISTRIBUTION and Occupational HealthNOT. .FOR . . .SALE . . . . OR 477DISTRIBUTION Chapter 12 Complex Emergencies...... 537

© Jones & BartlettChapter Learning, 13 T LLChe Design of Health Systems© Jones. . &. Bartlett. . . . . Learning, . . . . . LLC597 NOT FOR SALEChapter OR DISTRIBUTION 14 Public Health InfrastructureNOT. FOR. . . SALE. . . . OR . . DISTRIBUTION. . . . 637 Chapter 15 Management and Planning for Global Health...... 679 © Jones & Bartlett Learning,Chapter LLC 16 Pharmaceuticals© Jones. . &. Bartlett. . . . . Learning, ...... LLC . . . . . 731 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© Jones & Bartlett Learning,Chapter 17LLC Innovation, Technology,© Jones and& Bartlett Design Learning,...... LLC. . . . . 769 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Chapter 18 Evaluations of Large-Scale Health Programs...... 793 Chapter 19 Health and “The Economy”...... 835 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ChapterNOT 20 FOR SALEInternational OR DISTRIBUTION Trade and Health ...... NOT . . .FOR . . . SALE857 OR DISTRIBUTION Chapter 21 Global Health Governance and Diplomacy...... 893 Acronyms 923 © JonesIndex & Bartlett Learning, LLC © Jones & Bartlett Learning,931 LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & BartlettChapter Learning,2 Culture, Behavior,LLC and Health. . . . ©43 JonesChapter & Bartlett 4 Understanding Learning, LLC and Acting NOT FOR SALEBasic ORConcepts DISTRIBUTION from Medical Anthropology. . . . NOT. 44 FOR SALE ORon Social DISTRIBUTION Determinants Theories of Health Behavior and Behavior Change. . . .55 of Health and Health Equity . . . . 95 Common Features of Successful Health Introduction...... 95 Communication and Health Conceptual Frameworks for Understanding Promotion Programs© Jones ...... &. . . Bartlett ...... Learning, ...... 60 LLC Social Determinants of© Health Jones and & Bartlett Learning, LLC Methodologies forNOT Understanding FOR SALE OR DISTRIBUTIONHealth Equity...... NOT ...... FOR . . . . . SALE OR DISTRIBUTION . 96 Culture and Behavior...... 61 Addressing SDH Through Intersectoral Case Study: Use of a Focused Ethnographic Action and Health in All Policies ...... 104 Study to Assess the Acceptability of a Implications for Health Systems and Services . . . . 108 ©F ortifiedJones I nfant& Bartlett Cereal in Learning, Africa...... LLC ...... 64 Social Exclusion,© Jones Social & Bartlett Agency , Learning,and LLC CNOTase S tudyFOR: T heSALE Slim DORisease DISTRIBUTION—HIV/AIDS PowerNOT as a SDHFOR. . . SALE ...... OR . . . . DISTRIBUTION. . . 111 in Sub-Saharan Africa...... 65 Global SDH, Local Impact: Experiences of Ebola...... 68 Extractive Industries in East and Conclusion...... 69 Southern Africa...... 117 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Evaluating Action on the Social © Jones & Bartlett Learning, LLC © JonesChapter & 7 BartlettNutrition Learning,...... LLC . . . 259 Determinants of Health and Health Equity. . . . 120 NOT FOR SALE OR DISTRIBUTION NOTIntroduction FOR SALE...... OR . . . . DISTRIBUTION ...... 259 Conclusion...... 124 Spectrum of Malnutrition and Its Acknowledgments...... 125 Consequences Across the Life Course...... 259 Discussion Questions...... 125 Causes of Malnutrition...... 287 References ...... ©. . Jones ...... &. . Bartlett. . Learning,125 Policies LLC and Programs to Address© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONMalnutrition in All Its Forms. .NOT ...... FOR . . . . SALE297 OR DISTRIBUTION Chapter 5 Reproductive Health...... 131 Discussion Questions...... 314 Demographic Trends and Fertility References ...... 315 Determinants...... 132 Family P©lanning Jones Programs & Bartlett. . . . .Learning, ...... LLC147 Chapter 8 Chronic© Jones Diseases & Bartlett and Risks Learning,. . . . . 335 LLC ImpactNOT of Reproductive FOR SALE Patterns OR DISTRIBUTION Introduction. .NOT ...... FOR . . . . . SALE ...... OR DISTRIBUTION335 on the Health of Children...... 166 The Burden of Chronic Disease: Causes Impact of Reproductive Patterns and Impacts...... 335 on the Health of Women ...... 170 Categories of Chronic Disease...... 342 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Mechanisms to Reduce Maternal Global Costs and Consequences NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Morbidity and Mortality in Low- and of Chronic Diseases...... 351 Middle-Income Countries ...... 178 Impact on Sustainable Development Conclusion...... 185 and the Environment...... 353 Discussion Questions...... 185 Stakeholder Responses to the Growing © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC References ...... 186 Burden of Chronic Disease...... 353 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Future Drivers for Prevention and Chapter 6 Infectious Diseases...... 195 Management of Chronic Diseases ...... 361 Overview...... 195 Summary...... 372 Control© of Jones Infectious & DBartlettiseases. . .Learning, ...... LLC196 Discussion Questions© Jones. . . &. . .Bartlett ...... Learning,. . . 372 LLC ChildhoodNOT Vaccine FOR-P SALEreventable OR D DISTRIBUTIONiseases: References . .NOT . . . . .FOR . . . . SALE...... OR . . . .DISTRIBUTION373 The Expanded Program on Immunization. . . . . 198 Chapter 9 Unintentional Injuries Enteric Infections and Acute Respiratory Infections...... 207 and Violence ...... 381 © JonesB acterial& Bartlett Meningitis Learning,...... LLC ...... 214 © JonesIntroduction & Bartlett...... Learning, ...... LLC 381 NOT FORMycobacterial SALE OR Infections DISTRIBUTION...... 217 NOTThe FOR Global SALE Burden OR of Unintentional DISTRIBUTION Sexually Transmitted Infections and AIDS...... 223 Injuries and Violence...... 382 Viral Hepatitis...... 229 Risk Factors for Unintentional Injuries and Violence...... 393 Malaria and Other Arthropod-Borne Diseases© Jones...... & . . Bartlett . . . Learning,232 Interventions LLC to Prevent Unintentional© Jones & Bartlett Learning, LLC Injuries and Violence...... 399 Helminthiasis...... NOT . . . . . FOR...... SALE OR DISTRIBUTION236 NOT FOR SALE OR DISTRIBUTION Advancing the Injury and Violence Prevention Zoonoses...... 239 Agenda: Opportunities and Challenges...... 410 Viral Hemorrhagic Fevers...... 241 Conclusion...... 414 Infectious Causes of Blindness...... 246 © Jones & Bartlett Learning, LLC Discussion Questions© Jones. . . &. . Bartlett...... Learning, . . . 414 LLC Antimicrobial Resistance...... 248 NOT FOR SALE OR DISTRIBUTION AcknowledgmentsNOT .FOR . . . . .SALE . . . . . OR. . . .DISTRIBUTION . . 414 Emergence of New Infectious Disease Threats . . . . 249 Disclaimer...... 414 Global Health Security Agenda ...... 251 References ...... 414 Conclusion...... 251 © JonesA cknowledgments& Bartlett Learning,...... LLC ...... 252 © JonesChapter & 10 Bartlett Global MentalLearning, Health LLC...... 423 NOT FORDiscussion SALE QORuestions DISTRIBUTION...... 252 NOTIntroduction FOR SALE...... OR . . . . DISTRIBUTION ...... 423 References ...... 252 Historical Development of Global Mental Health. . . . 425

Culture and Mental Disorders...... 428 Communicable Disease Control ...... 578 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEThe Determinants OR DISTRIBUTION of Mental Disorders...... 434NOT FORNoncommunicable SALE OR DISTRIBUTION Diseases...... 584 The Burden of Mental Disorders...... 437 Role of International, National, and Interventions...... 445 Nongovernmental Organizations...... 584 Global Mental Health: Looking Ahead...... 461 Conclusion...... 590 Discussion Questions© Jones...... &. . .Bartlett ...... Learning,465 LLCDiscussion Questions. . .© . .Jones ...... & . . Bartlett. . . Learning,591 LLC References . . . . .NOT . . . . FOR. . . . . SALE ...... OR . DISTRIBUTION466 References ...... NOT. . . . .FOR . . . . .SALE . . OR DISTRIBUTION591

Chapter 11 Environmental and Chapter 13 The Design of Occupational Health...... 477 Health Systems...... 597 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Understanding the Health System...... 598 IntroductionNOT FOR. . SALE ...... OR. . . . .DISTRIBUTION ...... 477 NOT FOR SALE OR DISTRIBUTION The Burden and Distribution of Disease from Historical Development of Health Systems. . . . . 603 Environmental and Occupational Hazards . . . . 478 The Role of the State...... 605 Methods for Environmental Health Governance and Regulation...... 608 © Jones & BartlettResearch Learning, and Practice LLC...... 488© JonesFinancing & Bartlett...... Learning,...... LLC . 613 NOT FOR SALEAssessment OR DISTRIBUTION of Environmental Health NOT FORResource SALE A llocationOR DISTRIBUTION...... 620 Impacts and Risks ...... 495 Provision of Services...... 625 Occupational Health...... 498 Performance of Different Types of Systems. . . . . 628 Major Issues in Environmental Health...... 505 Universal Health Coverage and The Future of Environmental© Jones &Health Bartlett Learning, LLC Global Health Security©. . .Jones ...... &. . .Bartlett . . Learning,630 LLC in an Unequal WorldNOT. . FOR ...... SALE ...... OR DISTRIBUTION525 NOT FOR SALE OR DISTRIBUTION Conclusion...... 631 Conclusion...... 527 Discussion Questions...... 632 Discussion Questions...... 528 References ...... 632 Acknowledgments...... 528 References© Jones. &. . Bartlett...... Learning, ...... LLC . 528 © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION ChapterNOT 14 FORPublic SALE Health OR Infrastructure DISTRIBUTION. . . 637 Chapter 12 Complex Emergencies ...... 537 Introduction...... 637 Essential Public Health Functions...... 639 Introduction...... 537 Strengthening Public Health Systems ...... 640 Direct Public Health Impact of War...... 541 © Jones & Bartlett Learning, LLC © JonesH ealth& Bartlett Security .Learning, ...... LLC ...... 657 Indirect Public Health Impact of Civil Conflict. . . . 544 NOT FOR SALE OR DISTRIBUTION NOT FORConclusion SALE . OR. . . .DISTRIBUTION ...... 671 The Effects of Armed Conflict and Political Violence on Health Services ...... 547 Acknowledgments...... 671 Specific Health Outcomes...... 549 Discussion Questions...... 672 Prevention and Mitigation© Jones of &Complex Bartlett Learning, LLCReferences ...... © . Jones...... & . Bartlett. . Learning,672 LLC Emergencies. . NOT. . . . .FOR . . . . SALE...... OR . . DISTRIBUTION558 NOT FOR SALE OR DISTRIBUTION Responses to Complex Emergencies...... 560 Chapter 15 Management and Planning Rapid Assessment...... 561 for Global Health...... 679 Health Information Systems ...... 563 What is Management and Planning?...... 679 Shelter© Jones and &Environment Bartlett Learning,...... LLC . . . . 565 The Context© Jones of Management & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Water and Sanitation...... 566 and Planning...... 682 Food Rations and Distribution...... 567 Organizing...... 686 Nutritional Rehabilitation...... 570 Planning...... 689 Management of Resources...... 699 © Jones & BartlettHealth Services: Learning, Response LLC to Complex © Jones & Bartlett Learning, LLC NOT FOR SALEEmergencies OR DISTRIBUTION...... 572NOT FORTransport SALE Management OR DISTRIBUTION...... 712 Reproductive Health...... 576 Key Themes in Management and Planning. . . . 715

Conclusion and Challenges for Managers Disseminating Evaluation Findings and © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC and Planners...... 723 Promoting their Uptake...... 829 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Discussion Questions...... 725 Working in Large-Scale Evaluations...... 829 References ...... 726 Acknowledgments...... 831 Discussion Questions...... 831 Chapter 16 Pharmaceuticals© Jones. . &. .Bartlett . . . . Learning,731 References LLC ...... © . .Jones . . . . . & Bartlett831 Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Introduction...... 731 Chapter 19 Health and “The Economy”. . . . 835 Pharmaceutical Availability: Upstream Issues. . . . 732 Availability: Country-Level Distribution Systems Introduction...... 835 and Pharmaceutical Management...... 738 A Macroeconomic Focus ...... 836 Affordability© Jones. . . . . & . . Bartlett ...... Learning,...... LLC746 The Household© asJones the Nexus & Bartlett of the Learning, LLC Safe andNOT Effective FOR UseSALE of Medicines OR DISTRIBUTION...... 749 Health–WealthNOT Relationship FOR SALE. . . .OR . . . DISTRIBUTION. . . . 838 Antimicrobials and Antimicrobial Resistance. . . . 755 Macroeconomics and Risk Factors for Disease...... 843 Pharmaceuticals for Noncommunicable Diseases...... 759 The Macroeconomy and the © Jones & Bartlett Learning, LLC © JonesHealthcare & Bartlett Sector . .Learning, ...... LLC . . . . . 847 Conclusion...... 762 NOT FOR SALE OR DISTRIBUTION NOTConclusion FOR SALE...... OR . . .DISTRIBUTION ...... 850 Discussion Questions...... 762 Acknowledgments...... 852 References ...... 763 Discussion Questions...... 852 References ...... 853 Chapter 17 Innovation,© Jones Technology, & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC and DesignNOT. . . FOR . . . .SALE . . . . OR 769DISTRIBUTIONChapter 20 International TradeNOT FOR SALE OR DISTRIBUTION Introduction...... 769 and Health...... 857 Innovation: A Catalyst for Change Introduction...... 857 in Global Health...... 769 Relationship Between Trade and Health...... 858 Technology© Jones Platforms & Bartlett Impacting Learning, the LLC © Jones & Bartlett Learning, LLC The Impact of Trade on Health: GlobalNOT Health FOR Landscape SALE. OR. . . .DISTRIBUTION ...... 771 NOT FOR SALE OR DISTRIBUTION Different Pathways ...... 861 Global Health Innovation Processes...... 777 Trade and Its Effects on Health Systems...... 870 Technological Opportunities: Filling the Conclusion: From Conflict Between Gaps in Global Health ...... 785 Trade and Health to Coherence...... 885 © JonesConclusion & Bartlett. . . Learning,...... LLC ...... 789 © Jones & Bartlett Learning, LLC Discussion Questions...... 887 NOT FORDiscussion SALE QuestionsOR DISTRIBUTION...... 790 NOT FOR SALE OR DISTRIBUTION References ...... 887 References ...... 790 Chapter 21 Global Health Governance Chapter 18 Evaluations of Large-Scale © Jones & Bartlett Learning, LLC and Diplomacy© . . Jones...... & . . Bartlett. . . . 893 Learning, LLC Health Programs...... 793 NOT FOR SALE OR DISTRIBUTIONIntroduction...... NOT. . . . FOR SALE893 OR DISTRIBUTION Why We Need Large-Scale Impact Evaluations. . . 793 Globalization and Global Health Needs...... 894 Planning the Evaluation ...... 796 What Is Global Health Governance?...... 897 Developing an Impact Model...... 800 Mapping Existing Institutional Arrangements Stepwise© JonesApproach & to Bartlett Impact Evaluations Learning,. . LLC. . . 801 Governing ©Global Jones Health & .Bartlett ...... Learning, . . . . . 904 LLC Types ofNOT Inference FOR and SALE Choice OR of DISTRIBUTION Design...... 803 Conclusion. .NOT . . . . .FOR . . . . SALE ...... OR . . . .DISTRIBUTION919 Defining the Indicators and Discussion Questions...... 919 Obtaining the Data...... 810 References ...... 919 Incorporating Equity © Jones &in theBartlett Evaluation Learning,...... LLC ...... 822 © JonesAcronyms &. .Bartlett . . . . . Learning,...... LLC . . . . 923 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Carrying Out the Evaluation ...... 822 Index ...... 931

Nancy Kass, ScD © JonesLondon & Bartlett School Learning, of Hygiene and LLC Tropical Medicine © Jones & Bartlett Learning, LLC London, United Kingdom Vice Provost for Graduate and Professional NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Education Kara Hanson, MPhil, SD Phoebe R. Berman Professor of Bioethics and Public Professor of Health System Economics Health Faculty of Public Health and Policy Deputy Director of Public Health in the Berman London School of Hygiene and © Jones & Bartlett Learning, LLCInstitute of Bioethics © Jones & Bartlett Learning, LLC Tropical Medicine NOT FOR SALE OR DISTRIBUTIONJohns Hopkins University NOT FOR SALE OR DISTRIBUTION London, United Kingdom Baltimore, Maryland David J . Heller, MD, MPH Berit Kieselbach, MSc, MPH Assistant Professor Arnhold Institute for Global Health Technical Officer, Violence Prevention © Jones & Bartlett Learning, LLC Department for© JonesManagement & Bartlett of Noncommunicable Learning, LLC Icahn SchoolNOT FORof Medicine SALE at ORMount DISTRIBUTION Sinai NOT FOR SALE OR DISTRIBUTION New York, New York Diseases, Disability, Violence and Injury Prevention David L . Heymann, MD World Health Organization Professor of Infectious Disease Epidemiology Geneva, Switzerland © JonesLondon & Bartlett School Learning, of Hygiene & LLC Tropical Medicine © Jones & Bartlett Learning, LLC London, United Kingdom Tord Kjellstrom, MEng, PhD (Med) NOT FOR SALE OR DISTRIBUTION NOTVisiting FOR Fellow SALE OR DISTRIBUTION Adnan A . Hyder, MD, MPH, PhD Australian National University Professor & Associate Chair, International Health Canberra, Australia Director, Health Systems Program, International Health © Jones & Bartlett Learning,Brandon LLC A . Kohrt, MD, PhD © Jones & Bartlett Learning, LLC Director, Johns HopkinsNOT International FOR SALE Injury OR DISTRIBUTIONCharles and Sonia Akman AssociateNOT FOR Professor SALE in OR DISTRIBUTION Research Unit Global Psychiatry Department of Psychiatry and Associate Director, Johns Hopkins Berman Institute Behavioral Sciences of Bioethics The George Washington University Johns Hopkins Bloomberg School of Public Health Washington, DC © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Baltimore, Maryland Sandra D . Lane, PhD, MPH NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Brady Hunt Laura J. and L. Douglas Meredith Professor PhD Candidate Professor of Public Health and Anthropology Richards-Kortum Laboratory Syracuse University Department of Bioengineering & © JonesRice & BartlettUniversity Learning, LLC © JonesResearch & Professor Bartlett Learning, LLC NOT FORHouston, SALE Texas OR DISTRIBUTION NOTObstetrics FOR SALE and Gynecology OR DISTRIBUTION Upstate Medical University Dean T . Jamison, MS, PhD Syracuse, New York Professor, Global Health Adjunct Professor, Health Services Kelley Lee, BA MPA, MA, DPhil, FFPH, FCAHS Institute for Health Metrics© Jones and Evaluation & Bartlett Learning,Professor LLC © Jones & Bartlett Learning, LLC Department of Global HealthNOT FOR SALE OR DISTRIBUTIONFaculty of Health Sciences NOT FOR SALE OR DISTRIBUTION University of Washington Simon Fraser University Seattle, Washington Burnaby, British Columbia, Canada Benjamin Johns, PhD Siobhan Leir, MSc Senior ©Associate Jones / &Scientist Bartlett Learning, LLC Research Assistant© Jones in Global & Bartlett Public Health Learning, LLC InternationalNOT FORDevelopment SALE ORDivision DISTRIBUTION London SchoolNOT of Hygiene FOR SALE & Tropical OR MedicineDISTRIBUTION Abt Associates, Inc. London, United Kingdom Rockville, Maryland Henry Lishi Li, MA, MSc Sandeep P . Kishore, MD, PhD, MSc PhD Candidate © JonesAssociate & Bartlett Director Learning, LLC © JonesDepartment & Bartlett of Health Learning, Services Research LLC and Policy NOT FORArnhold SALE Institute OR DISTRIBUTION for Global Health NOTLondon FOR School SALE of ORHygiene DISTRIBUTION & Icahn School of Medicine at Mount Sinai Tropical Medicine New York, New York London, United Kingdom

Tonya Littlejohn, MBBS, MA Melinda K . Munos, PhD © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Affiliated Scholar Assistant Professor NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Center for Public Health and Human Rights Department of International Health Johns Hopkins Bloomberg School of Public Health Bloomberg School of Public Health Baltimore, Maryland Johns Hopkins University Rene Loewenson, PhD, FRSPH Baltimore, Maryland © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Director Mary Natoli Training and ResearchNOT SupportFOR SALE Centre OR DISTRIBUTIONPhD Candidate NOT FOR SALE OR DISTRIBUTION Harare, Zimbabwe Richards-Kortum Laboratory Crick Lund, PhD Department of Bioengineering Rice University Professor of Global Mental Health and Development Houston, Texas Centre© Jones for Global & Bartlett Mental Learning,Health LLC © Jones & Bartlett Learning, LLC InstituteNOT FOR of Psychiatry, SALE OR Psychology, DISTRIBUTION and Neuroscience Maria OdenNOT FOR SALE OR DISTRIBUTION King’s College London Teaching Professor London, United Kingdom Department of Bioengineering & Rice University © Jones & BartlettProfessor Learning, of Public Mental LLC Health © JonesHouston, & Bartlett Texas Learning, LLC NOT FOR SALEAlan J.OR Flisher DISTRIBUTION Centre for Public Mental Health NOT FORMarsha SALE Orgill, OR BAdmin DISTRIBUTION (Hons), MPhil Department of Psychiatry and Mental Health Senior Researcher University of Cape Town Health Policy and Systems Division, School of Public Cape Town, South Africa Health and Family Medicine Alexandra Macmillan,© MBChB,Jones MPH, & BartlettPhD, FNZCPHM Learning, LLCUniversity of Cape Town© Jones & Bartlett Learning, LLC Senior Lecturer EnvironmentalNOT FOR SALE Health OR DISTRIBUTIONCape Town, South AfricaNOT FOR SALE OR DISTRIBUTION University of Otago Benjamin Palafox, MSc Dunedin, New Zealand Research Fellow, Pharmaceutical Policy and Melisa Martinez-Alvarez, BSc, MSc, PhD Economics Senior© Jones Scientist & Bartlett Learning, LLC Department© Jones of Global & Bartlett Health and Learning, Development LLC London School of Hygiene & Tropical Medicine MRCNOT Unit FOR at TheSALE Gambia OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION London School of Hygiene & Tropical Medicine London, United Kingdom Barbara McPake, PhD Vikram Patel, MSc, MRCPsych, PhD, FMedSci Professor of Health Economics and The Pershing Square Professor of Global Health and Director, Nossal Institute for Global Health Wellcome Trust Principal Research Fellow © Jones & BartlettMelbourne Learning, School of PopulationLLC and Global Health© JonesHarvard & Bartlett University Learning, LLC NOT FOR SALEUniversity OR DISTRIBUTIONof Melbourne NOT FORBoston, SALE Massachusetts OR DISTRIBUTION Melbourne, Australia Margaret Peden, BSc Nurs, BSc Med Hons, PhD Jane Menken, MS, PhD Senior Research Fellow & Head of Distinguished Professor of Sociology Injury Programme Research Professor,© InstituteJones &of BehavioralBartlett Learning, Science LLCThe George Institute for© GlobalJones Health & Bartlett Learning, LLC University of Colorado,NOT FORBoulder SALE OR DISTRIBUTIONOxford University NOT FOR SALE OR DISTRIBUTION Boulder, Colorado Oxford, United Kingdom Dipak Kumar Mitra, MBBS, MPH, PhD Ajay Pillarisetti, MPH, PhD Associate Professor of Epidemiology Lecturer and Postdoctoral Scholar School© Jones of Public & Bartlett Health Learning, LLC Environmental© Jones Health & Bartlett Sciences Learning, LLC IndependentNOT FOR University,SALE OR Bangladesh DISTRIBUTION (IUB) UniversityNOT of FORCalifornia, SALE Berkeley OR DISTRIBUTION Dhaka, Bangladesh Berkeley, California Tolib Mirzoev, MD, MA, PGCertLTHE, PhD Jennifer Prah Ruger, BA, MA, MSc, PhD, MSL Associate Professor Amartya Sen Professor of Health Equity, Economics, © Jones & BartlettNuffield Learning, Centre for InternationalLLC Health and © Jones and& Bartlett Policy Learning, LLC NOT FOR SALEDevelopment, OR DISTRIBUTION Leeds Institute of Health SciencesNOT FORSchool SALE of Social OR PolicyDISTRIBUTION & Practice University of Leeds University of Pennsylvania Leeds, United Kingdom Philadelphia, Pennsylvania

M . Omar Rahman, MD, MPH, DSc Sarah Simpson © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Vice Chancellor and Dean Conjoint Lecturer NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION School of Public Health UNSW Sydney Independent University, Bangladesh (IUB) Sydney, Australia Dhaka, Bangladesh Director Michael Kent Ranson, MD, MPH,© Jones PhD & Bartlett Learning,EquiACT LLC © Jones & Bartlett Learning, LLC Senior Economist (Health)NOT FOR SALE OR DISTRIBUTIONMontluel, France NOT FOR SALE OR DISTRIBUTION The World Bank Washington, DC Kirk R . Smith, MPH, PhD Professor Global Environmental Health Arthur Reingold, MD University of California, Berkeley Professor© Jonesand Division & Bartlett Head, Epidemiology Learning, andLLC Berkeley, California© Jones & Bartlett Learning, LLC BiostatisticsNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION School of Public Health Richard Smith, BA, MSc, PhD, HonMFPH University of California, Berkeley Professor of Health System Economics Berkeley, California Dean of Faculty of Public Health and Policy © JonesEric & Richardson Bartlett Learning, LLC © JonesLondon &School Bartlett of Hygiene Learning, and LLC NOT FORAssociate SALE Professor OR DISTRIBUTION of Practice NOTTropical FOR SALE Medicine OR DISTRIBUTION Department of Biomedical Engineering London, United Kingdom Duke University Durham, North Carolina Christine P . Stewart, MPH, PhD Associate Professor Rebecca Richards-Kortum, PhD© Jones & Bartlett Learning,Department LLC of Nutrition © Jones & Bartlett Learning, LLC Malcom Gillis UniversityNOT Professor FOR SALE OR DISTRIBUTIONProgram in International and NOTCommunity FOR SALENutrition OR DISTRIBUTION Department of Bioengineering University of California, Davis Rice University Davis, California Houston, Texas Michael J . Toole, BMedSc, MBBS, DTM&H Sakib Rokadiya, MRCP, DTMH © Jones & Bartlett Learning, LLC Principal Research© Jones Fellow & Bartlett Learning, LLC Specialist Registrar in Infectious Diseases & General NOT FOR SALE OR DISTRIBUTION Burnet InstituteNOT FOR SALE OR DISTRIBUTION Medicine Professor, School of Public Health Barts Health NHS Trust Monash University London, United Kingdom Melbourne, Australia Giuliano Russo © Jones & Bartlett Learning, LLC © JonesCesar G . Victora, & Bartlett MD, PhD Learning, LLC Lecturer in Global Health NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Centre for Global Public Health Emeritus Professor of Epidemiology Queen Mary University of London Federal University of Pelotas in Brazil London, United Kingdom Pelotas, Brazil Susan C . Scrimshaw, PhD Ronald J . Waldman, MD, MPH © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Nevin Scrimshaw International Nutrition Professor of Global Health Foundation, Tufts University,NOT FOR & Former SALE OR DISTRIBUTIONMilken Institute School of PublicNOT Health FOR SALE OR DISTRIBUTION President of The Sage Colleges and The George Washington University of Simmons College Washington, DC Thornton, New Hampshire Keith P . West, Jr ., DrPH, MPH © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Rima Shretta, MSc, PhD George G. Graham Professor, Infant and Child AssociateNOT Director FOR SALE OR DISTRIBUTION Nutrition NOT FOR SALE OR DISTRIBUTION Malaria Elimination Initiative Department of International Health Global Health Group Bloomberg School of Public Health University of California, San Francisco Johns Hopkins University © JonesSan & Francisco,Bartlett CaliforniaLearning, LLC © JonesBaltimore, & MarylandBartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Harvey Whiteford, MBBS, MPH, PhD Alistair Woodward, MB BS, MMedSci, PhD, FNZCPHM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Professor of Population Mental Health Professor Epidemiology and Biostatistics NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION School of Public Health, The University of University of Auckland Queensland Auckland, New Zealand Brisbane, Australia Derek Yach, MBChB, MPH James Whitworth, MD, FMedSci © Jones & Bartlett Learning, LLCChief Health Officer © Jones & Bartlett Learning, LLC Professor of International Public Health The Vitality Group NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION London School of Hygiene & Tropical Medicine New York, New York London, United Kingdom

© Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Anton Balazh/Shutterstock © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALEAbout OR DISTRIBUTION the Authors © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Michael H. Merson, MD, is the Wolfgang Joklik benefits of zinc supplements in prevention and treat- Professor of Global Health at Duke University. He ment of childhood diarrhea and pneumonia. His joined the Duke faculty in November 2006 as the other interests are related to the use of evidence in pol- founding© Jones director & Bartlett of the Learning,Duke Global LLC Health Insti- icy and© programs, Jones including& Bartlett estimates Learning, of the causesLLC of tuteNOT and FOR served SALE in that OR role DISTRIBUTIONthrough 2017. In addition, child mortality,NOT FOR the developmentSALE OR DISTRIBUTIONof research capacity, Dr. Merson was Vice President and Vice Provost for and the strengthening of public health training. Global Affairs from 2011 until 2018, and Vice Chan- As a member of the U.S. National Academy of cellor for Duke-National University of Singapore Medicine and advisory bodies of the World Health Affairs from 2010 until 2016. Organization, the International Center for Diarrheal © Jones & BartlettDr. MersonLearning, has held LLC leadership positions at ©the Jones Diseases & Bartlett Research, Learning, Bangladesh, LLC and other interna- NOT FOR SALECenters OR for DISTRIBUTION Disease Control and Prevention and NOTthe FORtional SALE organizations, OR DISTRIBUTION Dr. Black assists with the devel- International Center for Diarrheal Diseases Research, opment of research and policies intended to improve Bangladesh; served as Director of the World Health child health. He chaired the Child Health and Nutri- Organization’s Diarrheal and Acute Respiratory Con- tion Research Initiative and serves on the governing trol Programs and© JonesGlobal &Program Bartlett on Learning,AIDS; and LLCboards of Nutrition International© Jones and & VitaminBartlett Angels. Learning, LLC was the first DeanNOT of Public FOR HealthSALE at ORYale DISTRIBUTIONUniversity. He has more than 700 scientificNOT FOR journal SALE publications. OR DISTRIBUTION Dr. Merson’s research and writings have been primar- Dr. Black is the recipient of the Programme for Global ily on the etiology of diarrheal diseases in low- and Paediatric Research Award for Outstanding Contri- middle-income countries, AIDS prevention and pol- butions to Global Child Health in 2010, the Prince icy, and academic global health. He has served as an Mahidol Award for Public Health in 2010, the Canada advisor© Jones to a number& Bartlett of international Learning, organizations LLC and Gairdner© GlobalJones Health & Bartlett Award Learning,in 2011, the NutritionLLC advisoryNOT FOR bodies; SALE is an ORelected DISTRIBUTION member of the National LeadershipNOT Award FOR fromSALE Sight OR and DISTRIBUTION Life in 2013, and Academy of Medicine; and has received two honor- the Jimmy and Rosalynn Carter Humanitarian Award ary degrees and the U.S. Surgeon General’s Exemplary in 2016. Service Medal. Anne J. Mills, PhD, is Deputy Director and Provost © Jones & BartlettRobert E. Learning, Black, MD, LLC MPH, is Professor and Direc© Jones- of &the Bartlett London Learning,School of Hygiene LLC & Tropical Medi- NOT FOR SALEtor of OR the DISTRIBUTIONInstitute for International Programs of NOTthe FORcine SALE (LSHTM), OR andDISTRIBUTION Professor of Health Economics Johns Hopkins Bloomberg School of Public Health in and Policy. She has degrees from Oxford University Baltimore, Maryland. Dr. Black is trained in medicine, (MA), Leeds University (Diploma), and London Uni- infectious diseases, and epidemiology. He has served versity (PhD). After two years as Overseas Develop- as a medical epidemiologist© Jones at& the Bartlett Centers Learning, for Disease LLCment Institute Fellow and© JonesEconomist & Bartlettin the Ministry Learning, LLC Control and PreventionNOT FOR and worked SALE at OR institutions DISTRIBUTION in of Health in Malawi, sheNOT spent FOR three SALE years OR at DISTRIBUTIONthe Bangladesh and Peru on research related to childhood University of Leeds studying health planning in the infectious diseases and nutritional problems. He was National Health Service; she moved to the LSHTM Chair of the Department of International Health of in 1979. the Bloomberg School of Public Health from 1985 to Dr. Mills has researched and published widely 2013.© Jones & Bartlett Learning, LLC in the ©fields Jones of health & Bartlett economics Learning, and health LLC systems NOTDr. FOR Black’s SALE current OR research DISTRIBUTION includes field trials in low-NOT and middle-incomeFOR SALE OR countries DISTRIBUTION and continues of vaccines, micronutrients, and other interventions; to be involved in research on financial protection in effectiveness studies of health programs; and evalu- South Africa, Tanzania, India, and Thailand. She has ation of preventive and curative health service pro- had continuing involvement in supporting capac- © Jones & Bartlettgrams in Learning, low- and middle-income LLC countries. In ©the Jones ity & development Bartlett Learning, in health economics LLC in universities, last 20 years, he has led work that demonstrated the research institutes, and governments. She has been NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© Jonesinvolved & Bartlett in numerous Learning, policy LLC initiatives, including © JonesDr. Mills & received Bartlett the Learning, Prince Mahidol LLC Award in the the World Health Organization’s Commission on field of medicine. In 2013, she was elected a Fellow of NOT FOR SALE OR DISTRIBUTION NOT FORMacroeconomics SALE OR DISTRIBUTION and Health. She is a Foreign Asso- the Royal Society; and in 2015, she was made a Dame ciate of the U.S. Institute of Medicine and a Fellow in the Queen’s New Year’s Honours, for services to of the U.K. Academy of Medical Sciences. In 2009, international health.

© Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Anton Balazh/Shutterstock © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALEForew OR DISTRIBUTIONord © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION he philosophy, skills, and knowledge essential of the environment. Evolution is evident in humanity’s for global health practice continue to improve responses to its global health problems. with experience. The objective, of course, is the No global health decision stands alone. Instead, Timprovement© Jones & ofBartlett health for Learning, everyone in LLC the world, or such decisions© Jones are & alwaysBartlett dependent Learning, on LLCpolitical globalNOT healthFOR equity.SALE The OR DISTRIBUTIONmeans to achieve that objec- decisionsNOT and FOR compromises. SALE OR It is DISTRIBUTION difficult enough to tive require harnessing every resource and skill pos- gain agreement on a local level, where groups are sible in every country. When it comes to health, no acquainted and share many experiences. It is many country is more important than any other. times more difficult to achieve agreement across polit- The United States has direct experience with the ical and cultural divides. Global health workers are © Jones & Bartlettreturns ofLearning, global investment LLC in health. When Pres© Jones- forced & Bartlett to learn Learning, diplomatic LLCskills and to understand NOT FOR SALEident ORLyndon DISTRIBUTION Johnson provided funds for globalNOT FORthe SALEart of cross-culturalOR DISTRIBUTION transactions. Despite such smallpox eradication in 1966, the United States had difficulties, some of my best professional memories not had a case of smallpox for 17 years. It would have involve meetings, discussions, and field activities been easy to say this was not an American problem. involving people of various cultures and languages. Yet the investment© Jonesto eliminate & Bartlett smallpox Learning, in the rest LLCSuccessful approaches thrive© Jones on the & shared Bartlett knowledge Learning, LLC of the world had immediateNOT FOR financial SALE ORbenefits DISTRIBUTION because of people with differentNOT life experiences. FOR SALE OR DISTRIBUTION treating Americans with adverse effects caused by the For all of the improvements, there are, neverthe- vaccine was no longer necessary. We did not have to less, areas of concern. The rapid expansion of academic tolerate 6 to 8 deaths each year due to the vaccine. programs in global health presents practical problems And savings were realized in foreign quarantine pro- for students. We need more teachers who have actu- cedures© Jones as well.& Bartlett This country Learning, recoups LLC its investment ally worked© Jones in resource-poor & Bartlett situations. Learning, I attended LLC a inNOT smallpox FOR eradication SALE OR every DISTRIBUTION 3 months—more than superb NOTtropical FOR public SALE health OR program DISTRIBUTION 50 years ago, 150-fold, to date, and it will continue forever, an but not a single faculty member had actually lived in infinitebenefit–cost ratio. tropical areas, although they were frequent consul- Because of the increasing number of global health tants to field programs. The training of pediatricians, © Jones & Bartlettprograms, Learning, health benefits LLC continue to accrue for every© Jones surgeons, & Bartlett or internists Learning, involves LLC hands-on experiences. NOT FOR SALEcountry. OR More DISTRIBUTION than 35,000 deaths are averted each NOTday FORLikewise, SALE we OR need DISTRIBUTION to increase the ability of students to in children younger than the age of 5, as compared to have problem-solving experiences in poor areas, while 60 years ago, when my interest in global health was they are still in school. kindled. In addition to smallpox, we stand at the brink This text also addresses the very real shortcomings of eradicating Guinea worm disease and polio. The of how global health is organized. We are often critical number of measles© deathsJones has & declinedBartlett by Learning, more than LLCof the World Health Organization© Jones &(WHO) Bartlett and Learning,other LLC 95% and, accordingNOT to theFOR World SALE Bank, OR 250,000 DISTRIBUTION peo- agencies without acknowledgingNOT FOR that SALE we organized OR DISTRIBUTION ple move out of poverty every day. It is a miraculous them to be dysfunctional. WHO has regional offices time for global health. that can undercut the WHO headquarters decisions And science marches on, in ways that promise because the United States insisted, 70 years ago, on even© Jones more &benefits Bartlett in theLearning, next decade. LLC Immuniza- strong ©regional Jones offices & Bartlett in its attempt Learning, to protect LLC the Pan tionNOT rates FOR are SALEimproving, OR newDISTRIBUTION vaccines are becoming AmericanNOT Health FOR Organization. SALE OR WeDISTRIBUTION imposed the bur- available, and the world is slowly moving to address den of 195 health ministers as WHO’s board of direc- chronic diseases, environmental health problems, and tors, and annually tell WHO to reduce its budget. Then injury control in larger geographic areas. Even the we condemn WHO for an inadequate response to the health problems associated with global warming now Ebola virus. It is time to ask what has been learned © Jones & Bartlettengage many Learning, countries, LLC including the largest polluters© Jones in &70 Bartlett years and Learning, how we can LLC use that experience to NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© Jonesimprove & Bartlett our global Learning, organizations LLC to better protect the © Jonesdepartments & Bartlett in every Learning, country. Moreover,LLC keeping health of all. people healthy helps to keep them productive. The NOT FOR SALE OR DISTRIBUTION NOT FOR SALEFinally, ORWHO DISTRIBUTION promoted primary health care world will not be a great place for any of us until it is at the Alma Ata conference 40 years ago, yet we a great place for all of us. are still struggling to implement village-level inter- Drs. Merson, Black, and Mills have again brought ventions and better understand the social deter- us a comprehensive text that helps to make sense of minants of health. This© Jones year the & Bartlettworld will Learning, again an LLC enlarging and challenging field.© Jones It is an & enormously Bartlett Learning, LLC come together at a conferenceNOT FOR in SALE Kazakhstan OR DISTRIBUTION to valuable guide for students, NOTteachers, FOR practitioners, SALE OR DISTRIBUTION recommit to strengthening primary health care in and researchers alike, which helps to map out the jour- order to achieve universal health coverage and the neys of those who will change the future and make our Sustainable Development Goals. No risk factor is planet a healthier one. as great© asJones poverty. & BartlettNevertheless, Learning, while progress LLC is © Jones & Bartlett Learning, LLC being made and the World Bank has championed William Foege NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the cause, deliberate action to reduce poverty is still Professor Emeritus, Rollins School of Public Health, an underdeveloped tool in the daily lives of health Emory University

he three of us are privileged to serve as faculty determinants of health and develop strategies that will © Jonesat universities & Bartlett that provideLearning, education LLC every year address© these Jones determinants, & Bartlett thereby Learning, sharing LLC goals to NOT toFOR hundreds SALE of OR graduate DISTRIBUTION and undergraduate improveNOT the healthFOR SALEof populations. OR DISTRIBUTION These disciplines Tstudents motivated to learn about global health issues and professional fields include social and behavioral and challenges. Many of these students plan to or have sciences (including sociology, economics, psychol- already begun careers in global health research, policy, ogy, anthropology, political science, and international © Jones & Bartlettpractice, Learning,teaching, or administration.LLC This text is ©writ Jones- relations), & Bartlett biomedical Learning, and LLCenvironmental sciences, NOT FOR SALEten for OR these DISTRIBUTION students around the world, as well asNOT for FORengineering, SALE OR business DISTRIBUTION and management, public policy, those who teach and mentor them. In this Introduc- law, history, and divinity. Furthermore, while efforts to tion, we define global health, provide a brief history reduce health disparities should focus on prevention, of the field, and summarize its manyaccomplishments treatment, care, and curative strategies must also be and challenges. We then explain how we put this Fourth addressed when developing solutions to global health Edition together and© Jones how we &think Bartlett it can best Learning, be used. LLCchallenges. This call for© Jonesmultipronged & Bartlett action furtherLearning, LLC NOT FOR SALE OR DISTRIBUTIONemphasizes the need forNOT a multidisciplinary FOR SALE approach. OR DISTRIBUTION ▸▸ What Is Global Health? In addition, while social justice must continue to be a central pillar of health, the approach to achiev- Global health is a burgeoning field, which has seen a ing health equity and finding solutions to reducing major© Jones surge &of Bartlettinterest as Learning,an area of academic LLC study in health ©disparities Jones &must Bartlett now Learning,much more LLCstrongly theNOT last FOR decade. SALE Essentially, OR DISTRIBUTION global health has replaced emphasizeNOT global FOR cooperation. SALE OR Rather DISTRIBUTION than following international public health in both concept and reality. a model that transfers ideas and resources from high- International public health focuses on the application income countries, organizations, or funding agencies of the principles of public health to health problems to low- and middle-income settings, it is imperative and challenges that affect low- and middle-income to pursue “a real partnership, a pooling of experience © Jones & Bartlettcountries Learning, (LMICs) and LLC to the complex array of global© Jones and & knowledge,Bartlett Learning, and a two-way LLC flow between devel- NOT FOR SALEand localOR DISTRIBUTIONdeterminants that influence them. GlobalNOT FORoped SALE and developing OR DISTRIBUTION countries” when implementing health maintains this focus, but places much greater health interventions or programs (Koplan et al., 2009, emphasis on health issues that concern many coun- p. 1995). tries or that are affected greatly by transnational deter- Today we live in an increasingly connected world, minants, such as© climateJones change& Bartlett or urbanization. Learning, LLCbut the challenges to ©reduce Jones health & Bartlett disparities Learning, are LLC This greater emphasisNOT FORon the SALE scope ORand locationDISTRIBUTION of considerable, and the tenetsNOT of FOR global SALE health OR provide DISTRIBUTION health problems provides the opportunity to address a unique insight and strategic approach to addressing cross-border issues as well as domestic health dispari- them. Given this evolution in our thinking, there has ties in high-income countries. been an understandable interest in defining global While international public health primarily health. In 1997, the U.S. Institute of Medicine (IOM) applies© Jones the &principles Bartlett of Learning,public health, LLC there is now released© aJones report &that Bartlett broadly Learning,defined global LLC health agreementNOT FOR that SALE success OR and DISTRIBUTION progress in improving as “healthNOT problems, FOR SALE issues, OR and DISTRIBUTION concerns that tran- health around the world requires a multidisciplinary scend national boundaries, may be influenced by cir- and interdisciplinary approach that includes, yet cumstances or experiences in other countries, and are extends beyond, public health. Professionals from best addressed by cooperative actions and solutions” © Jones & Bartlettmany disciplines Learning, and academicLLC fields possess the skills© Jones (Board & Bartlett on International Learning, Health, LLC 1997, p. 1). More than and knowledge needed to understand the various 10 years later, IOM amended its definition, describing NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© Jonesglobal & Bartlett health “not Learning, just as a state LLC but also as the goal of © Joneshelps to &draw Bartlett out global Learning, health’s distinctive LLC qualities. improving health for all people by reducing avoidable (EXHIBIT I-1). NOT FOR SALE OR DISTRIBUTION NOT FORdisease, SALE disabilities, OR DISTRIBUTION and deaths” (Committee on the U.S. Commitment to Global Health, 2009, p. 5). Although a number of other definitions for global ▸▸ A Brief History of Global Health health have been proposed, we prefer the definition of global health that was adopted© Jones by &the Bartlett Consortium Learning, of Tracing LLC the roots of global health© Jones brings & Bartlettus to the Learning, LLC Universities for Global NOTHealth FOR (CUGH). SALE CUGH OR DISTRIBUTIONwas history of international publicNOT health. FOR This SALE history OR DISTRIBUTION formed to promote, facilitate, and enhance the growth encompasses the origins of public health and can be of global health as an academic field of study. It has viewed as the story of how populations experience defined global health as follows: health and illness; how social, economic, and political systems create the possibilities for healthy or [A]n© Jonesarea for &study, Bartlett research, Learning, and practice LLC unhealthy lives;© howJones societies & Bartlett create the Learning, preconditions LLC thatNOT places FOR a priority SALE onOR improving DISTRIBUTION health for the productionNOT FORand transmission SALE OR of DISTRIBUTION disease; and and achieving equity in health for all people how people, both as individuals and as social groups, worldwide. Global health emphasizes trans- attempt to promote their own health or avoid illness national health issues, determinants, and (Rosen & Morman, 1993). A number of authors have © Jones & solutions;Bartlett involvesLearning, many LLC disciplines within © Jonesdocumented & Bartlett this history Learning, (Arnold, LLC1988; Basch, 1999; NOT FOR SALEand beyond OR theDISTRIBUTION health sciences and promotes NOTLeff FOR & Leff, SALE 1958; OR Rosen DISTRIBUTION & Morman, 1993; Winslow & interdisciplinary collaboration; and is a syn- Hallock, 1933). A brief history is presented here pri- thesis of population-based prevention with marily to provide a perspective for the challenges that individual-level clinical care. (Koplan et al., face us today (EXHIBIT I-2). 2009, p. 1995) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC When providing thisNOT definition, FOR SALE an effortOR DISTRIBUTION was The Origins of Public HealthNOT FOR SALE OR DISTRIBUTION made to explain the differences between public health, It is difficult to select a date for the origins of the field international health, and global health. While these of public health. Some would begin with Hippocrates, terms certainly share areas of overlap, this comparison whose book Airs, Waters, and Places, published around © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION EXHIBIT I-1 Global Health, International Health, and Public Health

Global Health International Health Public Health

© Jones Focuses& Bartlett on issues Learning, that directly LLC or Focuses on health ©issues Jones of countries & Bartlett Focuses Learning, on issues LLCthat impact NOT FORindirectly SALE impact OR DISTRIBUTION health but can other than one’s own,NOT especially FOR SALE ORthe health DISTRIBUTION of the population of a transcend national boundaries . those of LMICs . particular community or nation .

Development and implementation Development and implementation Development and implementation of solutions often require global of solutions usually involve of solutions usually do not involve cooperation . © Jones & Bartlettbinational Learning, cooperation . LLC global cooperation© Jones . & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Embraces both prevention in Embraces both prevention in Mainly focused on prevention populations and clinical care of populations and clinical care of programs for populations . individuals . individuals .

Health© equity Jones among & Bartlett nations and Learning, for Seeks LLC to help people of other © JonesHealth &equity Bartlett within aLearning, nation or LLC all peopleNOT is aFOR major SALE objective OR . DISTRIBUTIONnations . NOTcommunity FOR SALE is a major OR objectiveDISTRIBUTION .

Highly interdisciplinary and Embraces but has not emphasized Encourages multidisciplinary multidisciplinary within and beyond multidisciplinarity . approaches, particularly within health sciences . health sciences and with social © Jones & Bartlett Learning, LLC © Jones & Bartlettsciences Learning, . LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & BartlettEXHIBIT Learning, I-2 History LLC of Global Health: A Summary© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 400 BC: Hippocrates presents the causal relationship between environment and disease . First century AD: Romans introduce public sanitation and organize a water supply system . 14th century: The “Black Death” (bubonic plague) leads to quarantine and cordon sanitaire . Middle Ages: Colonial© Jones expansion & Bartlett spreads infectiousLearning, diseases LLC around the world . © Jones & Bartlett Learning, LLC 1750–1850: TheNOT Industrial FOR Revolution SALE resultsOR DISTRIBUTION in extensive health and social improvementsNOT in citiesFOR in SALE Europe andOR theDISTRIBUTION United States . 1850–1910: Knowledge about the causes and transmission of communicable diseases is greatly expanded . 1910–1945: Significant reductions in child mortality occur . Schools of public health and international foundations and ©intergovernmental Jones & Bartlett agencies Learning, interested inLLC public health are established ©. Jones & Bartlett Learning, LLC NOT1945–1990: FOR SALEThe World OR Bank, DISTRIBUTION World Health Organization (WHO), and otherNOT United FOR Nations SALE agencies OR DISTRIBUTION are created . WHO eradicates smallpox . The Alma Ata conference gives emphasis to primary health care . The HIV/AIDS pandemic begins . The United Nations Children’s Fund (UNICEF) leads efforts to ensure universal childhood immunization . Greater attention is given to noncommunicable diseases (NCDs) . © Jones & Bartlett1990–2000: Learning, Priority isLLC given to health-sector reform,© the Jones impact & of Bartlett and responses Learning, to globalization, LLC cost-effectiveness, and public–private partnerships in health . NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 2000–2010: Priority is given to equity, social determinants of health, health and development, use of innovative information and communications technologies, declaration of the Millennium Development Goals (MDGs), and response to influenza . 2010–2020: Priority is given to climate change’s impact on health, growing burden of NCDs, increasing threat of emerging and re-emerging© diseases, Jones global & Bartlett health security, Learning, universal LLC health coverage, proliferation© of Jonesinnovative & technologies Bartlett Learning, for LLC delivery of preventionNOT and FOR care SALEservices, ORand theDISTRIBUTION declaration of the Sustainable DevelopmentNOT Goals FOR (SDGs) SALE . OR DISTRIBUTION

400 BC, was the first systematic effort to present the and other institutions to provide medical care and causal relationships between environmental factors social assistance. At the same time, many European and© Jones disease &and Bartlett offer a theoretical Learning, basis LLC for an under- countries© Jonesbegan to& Bartlettexpand their Learning, horizons LLC abroad, standingNOT FOR of endemic SALE ORand DISTRIBUTIONepidemic diseases. Others by exploringNOT FORand colonizing SALE OR new DISTRIBUTION lands. The travel- would cite the introduction of public sanitation and ers brought some diseases with them (e.g., influenza, an organized water supply system by the Romans in measles, smallpox), and those who settled in these the first century AD. Many would select the bubonic colonial outposts were forced to confront diseases © Jones & Bartlettplague (“Black Learning, Death”) LLC pandemic of the 14th century,© Jones that & hadBartlett never Learning,been seen in LLC Europe (such as syphi- which began in Central Asia; was carried on ships to lis, dysentery, malaria, and sleeping sickness). Euro- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Constantinople, Genoa, and other European ports; pean explorers also carried pathogens from one part and then spread inland, killing 25 million persons of Africa to another, and from one area of the globe to in Europe alone. In responding to this devastating another (e.g., from Africa to North America through infectious disease, the Great Council of the city of the slave trade). On long voyages, the greatest enemy Ragusa (now Dubrovnik,© Jones Croatia) & Bartlett followed Learning, a conta- LLCof the sailor was often© scurvy—atJones & leastBartlett until Learning, 1875, LLC gion theory, whichNOT recommended FOR SALE the OR separation DISTRIBUTION of when the British governmentNOT FORissued SALEits famous OR order DISTRIBUTION healthy and sick populations; it issued a document that all men-of-war should carry a supply of lemon stating that outsiders entering the city must spend juice as a preventive measure. 30 days in the restricted location of nearby islands The Age of Enlightenment (1750–1830) was a piv- (Stuard© Jones & NetLibrary, & Bartlett 1992). Learning, The length LLC of time for otal period© Jones in the &evolution Bartlett of Learning,public health. LLC It was a this isolation period, dubbed trentino, was eventually time of social action in relation to health, as reflected NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION increased from 30 to 40 days, introducing the con- by the new interest taken in the health problems of cept of the modern quarantine (Gensini, Yacoub, & specific population groups. During this period, rapid Conti, 2004). advances in technology led to the development of fac- The Middle Ages was also the period when many tories. In England and elsewhere, this industrialization © Jones & Bartlettcities in Learning,Europe, particularly LLC through the formation© Jones was & paralleledBartlett Learning,by expansion LLC of the coal mines. The NOT FOR SALEof guilds, OR tookDISTRIBUTION an active part in establishing hospitalsNOT FORIndustrial SALE Revolution OR DISTRIBUTION had arrived. During this period,

© Jonessanitaire & Bartlett the populations Learning, of LLCthe cities of England and © Jonescommunicable & Bartlett diseases Learning, were discovered LLC in laborato- other industrialized nations grew enormously, with ries in North America and Europe. The development NOT FOR SALE OR DISTRIBUTION NOT FORovercrowded, SALE OR unsanitary DISTRIBUTION conditions in these urban of this knowledge base was paralleled by related dis- areas leading to outbreaks of cholera and other epi- coveries in the sciences of physiology, metabolism, demic diseases, which ultimately resulted in high rates endocrinology, and nutrition. Dramatic decreases of child mortality. Near the end of this period, signif- were soon seen in child and adult mortality thanks to icant efforts were made© Jonesto address & Bartlett these problems. Learning, improvements LLC in social and economic© Jones conditions, & Bartlett dis- Learning, LLC Improvements were madeNOT in urban FOR water SALE supplies OR DISTRIBUTION and covery of vaccines, and implementationNOT FOR of SALE programs OR DISTRIBUTION sewerage systems, municipal hospitals arose through- in health education. The way was now clear for the out cities in Europe and the east coast of the United development of public health administration based on States, laws were enacted limiting children’s ability to a scientific understanding of the principles involved in work, and© Jones data on &deaths Bartlett and birthsLearning, began toLLC be sys- the transmission© Jones of communicable & Bartlett diseases. Learning, LLC tematically collected in many places. The first two decades of the 20th century wit- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION As industrialization continued, it became obvious nessed the establishment of three formal intergovern- that more efforts to protect the health of the public mental public health bodies: the International Sanitary were needed. These changes occurred first in England, Bureau to serve nations in the western hemisphere regarded as the first modern industrial country, (in 1904); l’Office Internationale d’Hygiene Publique © Jonesthrough & Bartlett the efforts Learning, of the noted LLC social reformer Edwin © Jonesin Paris, & which Bartlett was concernedLearning, with LLC prevention and NOT FORChadwick. SALE BeginningOR DISTRIBUTION in 1832, he headed up the royal NOTcontrol FOR of SALEthe main OR quarantinable DISTRIBUTION diseases (in 1909); Poor Law Commission, which undertook an extensive and the League of Nations Health Office (LNHO) in survey of health and sanitation conditions throughout Geneva, Switzerland, which provided assistance to the country. The work of this commission led in 1848 countries on technical matters related to health (in to the Public Health Act,© Jones which &created Bartlett a General Learning, 1920). LLC In 1926, LNHO commenced© Jones publication & Bartlett of Learning, LLC Board of Health that was empowered to appoint local Weekly Epidemiological Record, which evolved into a NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION boards of health and medical officers of health to deal weekly publication of the World Health Organization effectively with public health problems. The impact of (WHO) and still is published today. LNHO also estab- these developments was felt throughout Europe and lished many scientific and technical commissions, especially in the United States, where it stimulated cre- issued reports on the status of many infectious and ation of© health Jones departments & Bartlett in manyLearning, cities and LLC states. chronic diseases,© Jones and sent & Bartlettits staff around Learning, the world LLC Cholera,NOT FORwhich SALE in the OR first DISTRIBUTION half of the19 th to assist nationalNOT governments FOR SALE in OR dealing DISTRIBUTION with their century spread in waves from South Asia to the Mid- health problems. dle East and then to Europe and the United States, In North America and countries in Europe, the did the most to stimulate the formal international- explosion of scientific knowledge in the latter part of ization of public health. The policy of establishing a the 19th century and the belief that social problems © Jonescordon & Bartlett sanitaire Learning,—an action LLC applied by many Euro- © Jonescould be & solved Bartlett stimulated Learning, universities, LLC such as Johns NOT FORpean SALE nations OR in anDISTRIBUTION effort to control the disease—had NOTHopkins, FOR SALEto establish OR DISTRIBUTIONschools of public health. In become a major restraint on trade, necessitating an France, public subscriptions helped to fund the Insti- international agreement. In 1851, the First Interna- tut Pasteur (named in honor of Louis Pasteur) in Paris, tional Sanitary Conference was convened in Paris to which subsequently developed a network of institutes discuss the role of quarantine© Jones in the & control Bartlett of cholera, Learning, throughout LLC the francophone world© Jones that produced & Bartlett sera Learning, LLC plague and yellow fever,NOT which FOR were SALEcausing OR epidem DISTRIBUTION- and vaccines and conducted researchNOT FOR on a wide SALE variety OR DISTRIBUTION ics throughout Europe. Although no real agreement of tropical diseases. Another significant development was reached, the conference laid the foundations for during this period was the founding of the Rockefel- international cooperation in health. ler Foundation (in 1909) and its International Health The latter part of the 19th century was distin- Commission (in 1913). During its 38 years of opera- guished© byJones the enormous & Bartlett growth Learning, of knowledge LLC in tion, the commission© Jones cooperated & Bartlett with Learning, many govern LLC- the areaNOT of FORmicrobiology, SALE ORas exemplified DISTRIBUTION by Louis ments in campaignsNOT FOR against SALE endemic OR diseases DISTRIBUTION such as Pasteur’s proof of the germ theory of disease, Robert hookworm, malaria, and yellow fever. The Rockefeller Koch’s discovery of the tubercle bacillus, and Walter Foundation also provided essential financial support Reed’s demonstration of the role of the mosquito in to help establish medical and public health schools © Jonestransmitting & Bartlett yellow Learning, fever. Between LLC 1880 and 1910, the © Jonesaround &the Bartlett world; Learning,and later international LLC health NOT FORetiologic SALE causes OR DISTRIBUTIONand means of transmission of many NOTprograms FOR SALEin a number OR DISTRIBUTION of American and European

© Jones & Bartlettschools ofLearning, medicine andLLC public health. All of these© Jones eliminated & Bartlett the Learning,disease in 1981LLC and stimulated the developments were paralleled by the development and establishment of the Expanded Program on Immu- NOT FOR SALE OR DISTRIBUTION NOT FOR SALEstrengthening OR DISTRIBUTION of competencies in public health among nization, which focused on the delivery of effective the militaries of the United States and the countries vaccines to infants. Also, during the 1970s, two large of Europe, stimulated in great part by the buildup to international research programs were initiated under and realities of World War I. Following the war, there the co-sponsorship of various United Nations agen- was increasing recognition© Jones that & Bartlett much ill healthLearning, in the LLCcies: The Special Program© Jones for Research & Bartlett on HumanLearning, LLC colonial world wasNOT not FOR easily SALE solvable OR with DISTRIBUTION medical Reproduction (focusingNOT on development FOR SALE and OR testing DISTRIBUTION interventions alone, but rather was intractably linked of new contraceptive technologies) and the Tropical to malnutrition and poverty. Disease Research Program (providing support for the Some historians would date the beginning of development of better means of diagnosis, treatment, international© Jones & public Bartlett health Learning, to the end of LLC World War II. and prevention© Jones of & sixBartlett tropical Learning, diseases, includingLLC The ending of European colonialism, the need to malaria). Greater attention also was gradually given NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION reconstruct the economies of the United States and the to chronic diseases, commonly known as noncom- countries of Western Europe, and the rapid emergence municable diseases (NCDs), such as cardiovascular of newly independent countries in Africa and Asia and cerebrovascular diseases and cancer. were all forces that led to the creation of many new In 1978, WHO organized a conference in Alma © Jones & Bartlettintergovernmental Learning, organizations. LLC The United Nations© Jones Ata & inBartlett the former Learning, Soviet Union LLC that prioritized the NOT FOR SALEMonetary OR DISTRIBUTIONand Financial Conference, held in BrettonNOT FORdelivery SALE of primary OR DISTRIBUTION healthcare services and set the goal Woods, New Hampshire, in 1944 and attended by rep- of “health for all by the year 2000.” Rather than focus- resentatives from 43 countries, resulted in the estab- ing solely on control of specific diseases, this confer- lishment of the International Bank for Reconstruction ence called for international efforts to strengthen the and Development© (moreJones commonly & Bartlett known Learning, as the LLCcapacities of LMICs to© extend Jones their & Bartletthealth services Learning, LLC World Bank) and the International Monetary Fund. to populations with poor access to prevention and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The former initially lent money to countries only at care. The concerns of tropical medicine, which were prevailing market interest rates, but in 1960 it began to concentrated on the infectious diseases of warm cli- provide loans to poorer countries at much lower inter- mates, were replaced by an emphasis on the provision est rates and with far better terms through its Interna- of health services to reduce morbidity and premature tional© Jones Development & Bartlett Association. Learning, It was LLC not until the mortality© Jonesin resource-poor & Bartlett settings Learning, (De Cock, LLC Lucas, earlyNOT 1980s, FOR however, SALE OR that DISTRIBUTIONthe World Bank began to Mabey,NOT & Parry, FOR 1995). SALE Given OR the DISTRIBUTIONlimited financial and accelerate greatly its provision of loans to countries for managerial capacities of many governments, increased programs in health and education. By the end of that attention was paid to the role of nongovernmental decade, these loans had become the greatest source of organizations (NGOs) in providing these services. foreign assistance to LMICs (Ruger, 2005). As a result, many mission hospitals, particularly in © Jones & BartlettIn the Learning, decade after LLC World War II, many other© Jones sub-Saharan & Bartlett Africa, Learning, expanded LLC their activities in their NOT FOR SALEUnited OR Nations DISTRIBUTION organizations (e.g., UNICEF) NOTand FORlocal SALE communities, OR DISTRIBUTION the number of local NGOs began specialized agencies (such as WHO) were formed to to increase, and a number of international NGOs (e.g., assist countries in strengthening their health, social, Save the Children, Oxfam, Médecins Sans Frontières) and economic sectors. In addition, most of the wealth- greatly expanded their services, often with support ier industrialized© countries Jones &established Bartlett Learning,agencies or LLCfrom bilateral agencies. Disease-specific© Jones & Bartlett efforts—most Learning, LLC bureaus that fundedNOT bilateralFOR SALE projects OR inDISTRIBUTION specific notably UNICEF’s ChildNOT Survival FOR Program, SALE OR with DISTRIBUTION its LMICs. Among the historical colonial powers, such acronym GOBI (growth charts, oral rehydration, assistance was most often provided to their former breastfeeding, immunization) and its goal of univer- colonies. sal childhood immunization by 1990—were seen by Many of the international health efforts in the many as programs that both focused on specific health 1960s© Jones and 1970s & Bartlett were dedicated Learning, to the LLC control of spe- problems© Jonesand provided & Bartlett a means Learning, of strengthening LLC cificNOT diseases.FOR SALE A global OR effort DISTRIBUTION to control malaria was health NOTsystems. FOR SALE OR DISTRIBUTION hampered by a number of operational and technical The emergence of what is sometimes called difficulties, including the vector’s increasing resis- “the new public health” was heralded by the Ottawa tance to insecticides and the parasite’s resistance to Charter of 1986, which was meant to provide a plan © Jones & Bartlettavailable Learning,antimalarial LLC drugs. In contrast, the cam© Jones- of &action Bartlett to achieve Learning, the “health LLC for all” targets set NOT FOR SALEpaign OR to eradicate DISTRIBUTION smallpox, led by WHO, successfullyNOT FORforth SALE at Alma OR Ata. DISTRIBUTION The Ottawa Charter pioneered the

© Jonesdefinition & Bartlett of Learning,health as a resource LLC for development, © Joneson health-sector & Bartlett reform, Learning, cost-effectiveness LLC as an rather than merely a desirable outcome of develop- important principle in the choice of interventions, and NOT FOR SALE OR DISTRIBUTION NOT FORment. SALE The ORprerequisites DISTRIBUTION for health that were outlined public–private partnerships in health, paralleled by a in the charter were diverse and included peace, shelter, rapid expansion of innovative technologies. education, food, income, a stable ecosystem, sustain- Although rising incomes have long been known able resources, social justice, and equity. Moreover, the to improve health status, increased attention has been charter emphasized the© importance Jones & of Bartlett structural Learning, fac- paid LLC to the relationship between© Jones health & Bartlettand pov- Learning, LLC tors that affect health NOTon a societal FOR SALElevel, rather OR DISTRIBUTIONthan erty, and the importance of aNOT healthy FOR population SALE ORfor DISTRIBUTION focusing only on the risk behaviors of individuals. It achieving economic development. Participation of called on the worldwide health community to address sectors other than the health sector is now viewed health disparities by engaging and enabling peo- as essential for achieving a healthy population. More ple to take© Jones charge &of Bartlett their health Learning, at community LLC and and more countries© Jones are experiencing & Bartlett the Learning, demographic LLC policy-making levels. This shift from a “risk behavior” transition to societies with rapidly increasing num- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION focus to an emphasis on “risk environment” contin- bers of middle-aged and older adults, and in turn are ues to resonate in contemporary public health practice being challenged with providing preventive and care and research. services that address health problems of both the poor One hugely influential development in the 1980s and the wealthy simultaneously. Increasing life expec- © Joneswas & theBartlett onset ofLearning, the human LLC immunodeficiency virus © Jonestancy, urbanization, & Bartlett andLearning, resultant LLCchanging lifestyles NOT FOR(HIV)/acquired SALE OR immunodeficiencyDISTRIBUTION syndrome (AIDS) NOThave FOR contributed SALE ORto anDISTRIBUTION ever-increasing burden of pandemic. By the time a simple laboratory test to NCDs. India and China, for example, now have high detect HIV was discovered in 1985, more than 2 mil- rates of cardiovascular disease, stroke, and diabetes. lion persons in sub-Saharan Africa had been infected. Not surprisingly, issues regarding equity in the avail- In 1987, WHO formed© theJones Global & BartlettProgramme Learning, on ability LLC of drugs and vaccines© and Jones in access & Bartlett to other Learning, LLC AIDS, which within 2 years became the largest inter- technological advances have drawn greater attention. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION national public health effort ever established, with an Healthy populations are also now viewed as essential annual budget of $90 million and 500 staff working in for domestic security. Geneva, Switzerland, and in more than 80 LMICs. In The first decade of the 21st century witnessed the 1995, with some 20 million persons infected with HIV addition of new multifaceted and complex issues to the (mostly© living Jones in LMICs),& Bartlett and Learning,with the understand LLC - list of global health© Jones challenges—among & Bartlett Learning, them, human LLC ing thatNOT the pandemic FOR SALE could OR be brought DISTRIBUTION under control migration andNOT displacement, FOR SALE bioterrorism, OR DISTRIBUTION emerging only through a multisectoral effort, the program was pathogens, climate change, and disaster preparedness. transformed into a joint effort of UN agencies known It was within this context that the United Nations Gen- as the Joint United Nations Programme on HIV/AIDS eral Assembly adopted the Millennium Declaration in (UNAIDS). The global response to HIV/AIDS helped September 2000 as a set of guiding principles and key © Jonesto & shape Bartlett the field Learning, of global healthLLC from its emphasis on © Jonesobjectives & forBartlett international Learning, cooperation. LLC The declara- NOT FORintersectoral SALE OR collaboration, DISTRIBUTION health and human rights, NOTtion FOR underscored SALE ORthe needDISTRIBUTION to address inequities that global advocacy for health, and focus on prevention have been created or worsened by globalization, and and treatment. to form new international linkages to achieve and protect peace, disarmament, poverty eradication, gender The Origin and Growth© Jones of Global & Bartlett Health Learning,equality, LLC a healthy environment,© Jones human & rights, Bartlett and Learning, LLC NOT FOR SALE OR DISTRIBUTIONgood governance. The goals NOTdealing FOR specifically SALE ORwith DISTRIBUTION The end of the Cold War ushered in dramatic changes development and poverty eradication become known that stimulated the development of the new concept of as the Millennium Development Goals (MDGs); three global health. Major shifts in political and economic of them pertained primarily to health (shown in bold ideologies led to a reconsideration of the role of gov- in EXHIBIT I-3). In addition, Goal 1 included reduction ernments,© Jones including & Bartlett how they Learning, should finance LLC and in childhood© undernutrition. Jones & Bartlett All 191 Learning, member states LLC deliverNOT public FOR services. SALE Greater OR DISTRIBUTIONattention was given of the UN pledgedNOT toFOR meet SALE the MDGs OR byDISTRIBUTION 2015. to increasing the role of civil society and the private Building on the achievements of the MDGs (cov- sector in achieving universal health coverage. Indeed, ered later), as well as learning from their limitations, global health as it relates to health systems in the last the United Nations adopted the 2030 Agenda for Sus- © Jonesdecade & Bartlett of the 20 Learning,th century and LLC the first two decades of © Jonestainable &Development Bartlett Learning, in 2015. Central LLC to this agenda NOT FORthe SALE21st century OR DISTRIBUTIONcan be characterized by its emphasis NOTare FORthe SDGs SALE which OR comprise DISTRIBUTION 17 goals, 169 associated

© Jones & BartlettEXHIBIT Learning, I-3 Millennium LLC Development Goals © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 1 . Reduce extreme poverty and hunger by one-half 2 . Achieve universal primary education 3 . Promote gender equality and empower women 4. Reduce under-5 mortality by two-thirds 5. Reduce maternal© Jones mortality & Bartlett by three-fourths Learning, LLC © Jones & Bartlett Learning, LLC 6. Reverse theNOT spread FOR of HIV/AIDS, SALE OR malaria, DISTRIBUTION tuberculosis, and other major diseasesNOT FOR SALE OR DISTRIBUTION 7 . Ensure environmental sustainability 8 . Develop a global partnership for development, with targets for aid, trade, and debt relief

Goal 1: End poverty in all its forms everywhere Goal 2: End hunger, achieve food security and improved nutrition, and promote sustainable agriculture © Jones & BartlettGoal 3: Learning, Ensure healthy LLC lives and promote well-being© Jones for all at& allBartlett ages Learning, LLC NOT FOR SALEGoal OR 4: Ensure DISTRIBUTION inclusive and equitable quality educationNOT and FOR promote SALE lifelong OR learning DISTRIBUTION opportunities for all Goal 5: Achieve gender equality and empower all women and girls Goal 6: Ensure availability and sustainable management of water and sanitation for all Goal 7: Ensure access to affordable, reliable, sustainable, and modern energy for all Goal 8: Promote sustained, inclusive, and sustainable economic growth, full and productive employment, and decent work for all © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Goal 9: Build resilientNOT infrastructure, FOR SALE promote OR inclusiveDISTRIBUTION and sustainable industrialization, andNOT foster FOR innovation SALE OR DISTRIBUTION Goal 10: Reduce inequality within and among countries Goal 11: Make cities and human settlements inclusive, safe, resilient, and sustainable Goal 12: Ensure sustainable consumption and production patterns Goal 13: Take urgent action to combat climate change and its impacts ©Goal Jones 14: Conserve & Bartlett and sustainably Learning, use the LLC oceans, seas, and marine resources© Jones for sustainable & Bartlett development Learning, LLC NOTGoal 15:FOR Protect, SALE restore, OR and DISTRIBUTION promote sustainable use of terrestrial ecosystems,NOT FOR sustainably SALE OR manage DISTRIBUTION forests, combat desertification, halt and reverse land degradation, and halt biodiversity loss Goal 16: Promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build effective, accountable, and inclusive institutions at all levels Goal 17: Strengthen the means of implementation and revitalize the global partnership for sustainable development © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION targets, and 230 indicators to guide global sustainable achieving the three health-related MDG goals cited development through to 2030; the goals are shown earlier. First, mortality among children younger in EXHIBIT I-4. The SDGs seek a more integrated than age 5 dropped 56%, from 12.6 million deaths approach to address© Jones the challenges & Bartlett of an increasinglyLearning, LLCin 1990 to 5.6 million deaths© Jones in 2016 & Bartlett(WHO, 2017a). Learning, LLC global and integratedNOT world. FOR While SALE there OR is DISTRIBUTION only one Second, maternal mortalityNOT worldwide FOR SALE decreased OR DISTRIBUTION by health-specific goal—Goal 3: “Good health and well- 44% between 1990 and 2015 (WHO, 2016b). Third, being”—it has 13 associated targets and there are there was an almost 26% reduction in malaria deaths many linkages between health and the other SDGs between 2006 and 2016 (Global Burden of Disease and associated targets. For example, Goal 2 includes [GBD] Causes of Death Collaborators, 2017). In addi- elimination© Jones &of Bartlettnutritional Learning, deficiencies. LLC Achieving the tion, in© 2016, Jones the number & Bartlett of people Learning, who were LLC infected SDGsNOT willFOR require SALE consistent OR DISTRIBUTION monitoring and evalua- annuallyNOT with FOR HIV SALEdeclined OR to DISTRIBUTION1.8 million—a more tion and both global and national commitment. than 50% reduction since 1996, when there were In the years since the previous edition of this text 3.5 million new infections. The number of AIDS- was published, there have been a number of note- related deaths fell by 48% (to 1 million deaths) since © Jones & Bartlettworthy successes Learning, in globalLLC health, partly due to ©the Jones the & peak Bartlett in 2005 Learning, (UNAIDS, LLC 2017a. In addition, for NOT FOR SALEMDGs. OR Notably, DISTRIBUTION substantial progress was madeNOT in FORthe firstSALE time OR since DISTRIBUTION the eradication of smallpox, we are

© Joneson & the Bartlett verge of Learning,eliminating anotherLLC major global dis- © JonesAfrica—a & Bartlett population Learning, that accounts LLC for more ease from the world: 2017 saw the lowest case count than 70% of new HIV infections among ado- NOT FOR SALE OR DISTRIBUTION NOT FORof polio SALE in recorded OR DISTRIBUTION history (Polio Global Eradication lescents. (USAID, 2017) Initiative, 2017). The recent successes in fighting malaria and HIV/ We have seen infectious diseases travel from AIDS are attributable in great part to the expansion of endemic regions to previously unaffected areas (e.g., access to treatment, financed© Jones primarily & Bartlett by the Learning,Global Zika LLC virus), and others newly© Jonesemerge. & The Bartlett 2013- Learning, LLC Fund to Fight AIDS, TuberculosisNOT FOR andSALE Malaria OR DISTRIBUTION(the 2016 Ebola outbreak in WestNOT Africa FOR was SALEan alarm OR- DISTRIBUTION Global Fund), and the President’s Emergency Plan for ing wake-up call regarding the danger of epidemics AIDS Relief (PEPFAR). Moreover, the Global Fund’s in urban areas and the frail state of our global health performance-based funding and decision-making security. The underlying causes of many emerging processes© Joneshave made & Bartlett important Learning, contributions LLC to the infectious diseases© Jones can be& tracedBartlett to human-initiatedLearning, LLC practice of aid, particularly in encouraging manage- social and environmental changes, including climatic NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ment for results, participation of civil society, mutual and ecosystem disturbances, trends in food con- accountability, and broad-based country and local sumption and production, close proximity of humans ownership. and animals in household settings, and unsafe medical practices (Kuiken, Fouchier, Rimmelzwaan, & © Jones & Bartlett Learning, LLC © JonesOsterhaus, & Bartlett2003). This Learning, relationship LLC has given rise to NOT FOR▸▸ SALECurrent OR DISTRIBUTIONChallenges in NOTthe FORdisciplines SALE of OneOR Health,DISTRIBUTION an approach that seeks Global Health to address and mitigate the effects on health arising from the interfaces between humans, animals, and We have witnessed major improvements in the environments (Gibbs, 2014) and Planetary Health, health of populations over© Jones the past & century, Bartlett with Learning, the which LLC studies the health of human© Jones civilizations & Bartlett and Learning, LLC pace of change increasing rapidly in LMICs since the systems—political, economic, and social—on NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the Bretton Woods Conference. Global health—and, which they depend (The Lancet Planetary Health, more broadly, an improved understanding of how 2017). Furthermore, globalization forces, including social, behavioral, economic, and environmental fac- increased trade and movement of people, have led tors influence the health of populations—has con- to far greater opportunities for infectious disease to tributed© toJones these &improvements Bartlett Learning, to a greater LLC extent spread around© theJones world & quickly, Bartlett as evidenced Learning, by theLLC than expandedNOT FOR access SALE to medical OR DISTRIBUTION care. Nevertheless, severe acute respiratoryNOT FOR syndrome SALE (SARS)OR DISTRIBUTION epidemic in these improvements have not been universal, dispar- 2002–2003. In 2012, an estimated 12.6 million deaths ities between rich and poor both between and within were attributable to environmental factors, many of countries remain, and the challenges of global health which were related to effects of climate change (Pruss- have never been greater. Ustun, Wolf, Corvalan, Bos, & Neira, 2016). Other © Jones & DespiteBartlett recent Learning, progress, LLC we still have far to go in © Joneshealth consequences & Bartlett Learning,of climate change LLC and environ- NOT FORterms SALE of maternal OR DISTRIBUTION and child health. Millions of chil- NOTmental FOR biodegradation SALE OR DISTRIBUTION will be experienced through dren still die before reaching the age of 5 due to dis- increased water and food insecurity, extreme cli- eases that could be simply and affordably prevented mactic events, displaced populations, and vulnerable and treated (UNICEF, 2016). Hundreds of thousands human settlements (Jamison et al., 2013). Resistance of women continue to die© Jonesannually & from Bartlett preventable Learning, to LLC antibiotics is also rising among© Jones populations & Bartlett around Learning, LLC complications of pregnancyNOT and FOR childbirth, SALE andOR most DISTRIBUTION the globe, making infections harderNOT FORand more SALE expen OR- DISTRIBUTION of these deaths occur in LMICs (WHO, 2016b). sive to treat and threatening the gains we have made in combatting infectious diseases. Infectious diseases—once thought to have NCDs were once considered a problem afflicting been vanquished as major killers—have only high-income nations whose populations had emerged© Jones or reemerged & Bartlett around Learning, the world LLC as achieved long© life Jones expectancies. & Bartlett Today, Learning, NCDs are theLLC topNOT threats FOR to health SALE and OR well-being. DISTRIBUTION Despite leading causesNOT of death FOR worldwide; SALE OR they DISTRIBUTION accounted for recent progress, the AIDS pandemic is far more than 70% of global deaths in 2016, an increase from over. In particular, prevention efforts of 16% since 2006 (GBD Causes of Death Collabo- need to be targeted toward vulnerable popula- rators, 2017). Ischemic heart disease and stroke are © Jones & tionsBartlett who areLearning, still at high LLC risk for HIV/AIDS, © Jonesthe leading & Bartlett causes of Learning, death globally, LLC accounting for NOT FOR SALEsuch as girlsOR andDISTRIBUTION young women in sub-Saharan NOT15 millionFOR SALE deaths ORin 2015 DISTRIBUTION (WHO, 2017b). The rise of

© Jones & BartlettNCDs is Learning,especially apparent LLC in LMICs, where 78%© of Jones others & Bartlett like them, Learning, will surely LLCplay a pivotal role in the global NCD deaths occurred in 2015 (WHO, 2017b). future of global health. NOT FOR SALE OR DISTRIBUTION NOT FOR SALEGlobalizing OR DISTRIBUTION forces that have imported Western life- In recent years, the growth in the number of ref- style habits, such as increased trade and trade liber- ugees and displaced persons around the world has alization, tobacco use, and increased consumption of been startling. By the middle of June 2017, more processed foods, have fueled these disease trends. In than 65 million people had been forced to leave their addition, despite ©the Jones high burden & Bartlett imposed Learning, by men- LLChomes (United Nations ©High Jones Commissioner & Bartlett for Learning,Refu- LLC tal illness, and especiallyNOT FOR depressive SALE ORdisorders, DISTRIBUTION and gees, 2017)— the highestNOT number FOR recorded SALE in OR 70 years DISTRIBUTION the high percentage of global disability and mortality (Mohammadi, 2016). In addition to humanitarian and attributable to them, only recently have these disor- economic repercussions, this population upheaval ders been given the attention they deserve (Summer- puts displaced populations at increased risk for both grad,© Jones 2016). &As Bartlett a result ofLearning, the overall LLC increase in all infectious© Jonesand NCDs & Bartlettdue to overcrowding, Learning, poor LLC san- types of NCDs and the lingering problem of infec- itation, and lack of access to health care, and overbur- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION tious diseases, many LMICs face a double burden dens the health systems in the refugees’ host countries. of disease, putting more strain on their already frail There is a broad consensus that poverty is the healthcare systems. most important underlying cause of preventable The importance of improving the performance death, disease, and disability on a global level. While © Jones & Bartlettof health Learning, systems to achieveLLC reductions in mortality© Jones the & number Bartlett of peopleLearning, living LLCin poverty remains unac- NOT FOR SALEand morbidity OR DISTRIBUTION has become widely accepted, includNOT- FORceptably SALE high, OR progress DISTRIBUTION has been made in reducing ing the need to address the global health workforce the global poverty rate: 10.7% of the world popula- crisis (WHO, 2006). Health systems need adequate tion lived below the poverty line in 2013, compared to resources to meet the changing and growing needs of 42% in 1981 (The Economist, 2017). This progress has the populations they© Jones serve. An & estimatedBartlett 40Learning, to 50 mil- LLCbeen partly due to advances© Jones made & in Bartlett literacy, accessLearning, LLC lion new health and social care workers will be needed to housing, safe water, sanitation, food supplies, and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION by 2030 to reach the SDGs, 18 million of whom are urbanization. Even so, 50% of the world’s extremely needed in LMICs (WHO, 2016a). WHO has identi- poor live in sub-Saharan Africa (Hollenhorst, 2016), fied the critical need to strengthen health systems so reflecting the particular challenges of social and eco- as to fight poverty, foster development, and maintain nomic development in that region. and© Jones improve & the Bartlett health ofLearning, people around LLC the world. Meeting© Jones the global & Bartlett health challenges Learning, we face LLC today ItNOT has setFOR the SALEgoal of achievingOR DISTRIBUTION universal health cov- and in NOTthe future FOR will SALE require OR new DISTRIBUTION forms of financing erage, meaning that all persons can access needed and cooperation. Changing global economies have health services of sufficient quality to be effective altered traditional global health funding mechanisms. and not cause financial hardship. As the world faces Contributions to health assistance from donor coun- increasing threats from emerging and re-emerging tries have more or less flattened in recent years, while © Jones & Bartlettinfectious Learning, diseases, strong LLC basic healthcare systems© Jones LMICs & Bartlett are rightfully Learning, taking onLLC more responsibility for NOT FOR SALEwill also OR be DISTRIBUTION essential to support global health securityNOT FORfinancing SALE their OR DISTRIBUTIONdomestic health sector due in part to and to avoid crippling national and global pandemics the increasing economic growth in these countries. In (Horton, 2018). 2015, for example, domestic resources accounted for One means for expanding access to health ser- 57% of total HIV/AIDS funding (UNAIDS, 2017b). vices has been the© use Jones of mobile & Bartlett phone technology. Learning, By LLCHowever, many low-income© Jones countries & Bartlett are far Learning,from LLC 2021, 5.5 billion peopleNOT areFOR predicted SALE to OR have DISTRIBUTION access to being able to raise enoughNOT domestic FOR revenue SALE toOR replace DISTRIBUTION mobile phones, and more people in Africa will have development assistance for health. International and access to mobile phones than to running water (Thorn- intersectoral cooperation between UN agencies with ton, 2017). Mobile phone initiatives are now aimed at an established health role, other international bodies improving healthcare services in many countries, as such as the World Trade Organization, regional bod- they© Jones are increasingly & Bartlett being Learning, used for disaster LLC manage- ies such© asJones the European & Bartlett Union, Learning, bilateral LLCagencies, ment,NOT remindersFOR SALE for people OR DISTRIBUTION to get vaccinations, health NGOs,NOT foundations, FOR SALE and the OR private DISTRIBUTION sector, including screening tests, and social marketing. Emerging drone pharmaceutical companies, will need to be enhanced. technology also has been harnessed to improve access Global organizations such as the Bill & Melinda Gates to health care by transporting blood, contraceptive Foundation, the Global Fund, and GAVI, the Vac- © Jones & Bartlettproducts, Learning, and medical LLC supplies to remote areas,© or Jones cine & BartlettAlliance, Learning,have taken onLLC significant leadership NOT FOR SALEduring OR natural DISTRIBUTION disasters. These technologies,NOT and FORroles SALE and in OR many DISTRIBUTION cases have surpassed the older,

© Jonesmore & Bartlett traditional Learning, actors in global LLC health governance. © Jonesthat remain & Bartlett are a small Learning, price to pay LLC for fulfilling our These organizations have not only injected signifi- goal of providing the reader with the highest-quality NOT FOR SALE OR DISTRIBUTION NOT FORcant SALE amounts OR of fundsDISTRIBUTION into the global system, but also content. brought a new, more informal and personal style of Another consequence of the dynamic nature of operation. Ensuring the ideal structure, effective func- global health is the occasional difficulty in providing tioning, and financing of this global health system will the most up-to-date epidemiologic information on itself be an enormous challenge© Jones for & the Bartlett next decade Learning, of all LLC causes of mortality and morbidity.© Jones To& Bartlettassist the Learning, LLC global health (NationalNOT Academies FOR ofSALE Sciences, OR Engi DISTRIBUTION- reader in obtaining this information,NOT FOR we SALEhave pro OR- DISTRIBUTION neering, and Medicine, 2017). vided salient references in various chapters, including internet resources. This is the fourth edition of the text. In planning ▸▸ Use© Jonesand Content & Bartlett of Learning, This Text LLC its preparation,© weJones sought & adviceBartlett on howLearning, to improve LLC it from those who prepared chapters in the first three NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION This text has been prepared with future global health editions, as well as from faculty in various countries challenges foremost in mind. Its focus is on diseases, who were using the text in their courses; we also exam- programs, health systems, and health policies in LMICs, ined important current and emerging trends in global making reference to and using examples from the health. The text has 21 chapters, including four new © JonesUnited & Bartlett States, Western Learning, Europe, LLC and other high-income © Joneschapters & that Bartlett have been Learning, added in response LLC to feedback NOT FORcountries SALE as OR appropriate. DISTRIBUTION1 Individual chapters present NOTfrom FOR these SALE reviewers. OR DISTRIBUTION information on health issues that transcend national The first four chapters set the background. The boundaries and are of concern to many countries. Measures of Health and Disease in Populations chapter Our intent has been, first and foremost, to pro- reviews the importance of using quantitative indica- vide a text for graduate© studentsJones &from Bartlett various Learning, dis- tors LLC for decision making in health.© Jones It presents & Bartlett the latest Learning, LLC ciplines and professions who are studying global developments in the measurement of health status and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION health. Given its broad range of content, the text as a the global burden of disease, including the increasing whole may serve as the main source for an introduc- use of composite measures of health that combine the tory graduate course on global health. Experience effects of disease-specific morbidity and mortality on with the previous editions has shown that it also can populations. It then reviews current estimates and be used© as Jones a reference & Bartlett text for undergraduate Learning, LLC courses future trends ©in Jonesselected countries& Bartlett and Learning, regions, as well LLC in globalNOT health. FOR Alternatively,SALE OR DISTRIBUTION some chapters (or as the global burdenNOT FOR of disease. SALE OR DISTRIBUTION parts of chapters) can be used in graduate or under- The Culture, Behavior, and Health chapter exam- graduate courses dedicated to more specific subjects ines the social, cultural, and behavioral parameters and topics. Ideally, students who use the text in this that are essential to understanding public health way will be stimulated to explore other chapters once efforts. This chapter describes key concepts in the © Jonesthey & Bartletthave read Learning, the assigned LLC material. Moreover, the © Jonesfield of & anthropology, Bartlett Learning, particularly LLC as they relate to NOT FORtext SALE can serve OR as DISTRIBUTION a useful reference for those already NOThealth FOR belief SALE systems. OR DISTRIBUTIONIt presents theories of health working in the field of global health in government behavior that are relevant to behavior change with agencies, health and development agencies, NGOs, examples of specific national and community pro- or the private sector. grams in various areas of health. The importance of Because of the many© dynamicJones &areas Bartlett and subjects Learning, combining LLC qualitative and quantitative© Jones & methodol Bartlett- Learning, LLC we wanted to cover, we choseNOT to FOR prepare SALE an edited OR text.DISTRIBUTION ogies in measuring and assessingNOT healthFOR SALEstatus and OR DISTRIBUTION We selected content experts for each chapter rather programs is emphasized. than presuming to have the expertise to write the The 1946 WHO constitution established that “the entire text ourselves. We recognize that an edited text highest attainable standard for health as a fundamen- has its shortcomings, such as some inconsistencies in tal right of every human being” (WHO, 2014, p. 1). style and© presentationJones & Bartlett and occasional Learning, overlap LLC in chap- The Global Health,© Jones Human & Bartlett Rights and Learning, Ethics chapter LLC ter content.NOT We FOR have SALE done ourOR best DISTRIBUTION to limit these dis- is new to thisNOT edition FOR of the SALE text in OR recognition DISTRIBUTION of the advantages, and hope the reader will agree that those inextricable link between human rights and health.

© Jones1A & classification Bartlett ofLearning, countries can beLLC found on the World Bank’s website:© Joneshttps://datahelpdesk.worldbank.org/knowledgebase/topics & Bartlett Learning, LLC NOT FOR/19280-country-classification. SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & BartlettIt begins Learning,by defining LLC global health in the context© Jonesof also & Bartlettaddresses Learning,concerns about LLC antimicrobial resis- human rights and ethics and by describing the importance. Examples of successful control programs are NOT FOR SALE OR DISTRIBUTION NOT FOR SALEtance ORof these DISTRIBUTION concepts in global health approaches. described, as are the challenges and obstacles that Ebola, Zika, HIV/AIDS, and sugar-sweetened bev- confront LMICs in implementing them. erages are used as case studies to explore the role of Nutritional concerns in LMICs are diverse, rang- human rights and ethics in a global health response. ing from deprivation and hunger to consequent Finally, the chapter© Jones discusses & Bartlettthe many Learning, challenges LLCdeficiencies in health, ©survival, Jones and & Bartlettquality of Learning,life in LLC faced in implementingNOT theseFOR approaches. SALE OR DISTRIBUTIONsome regions. The NutritionNOT chapterFOR SALE focuses OR on DISTRIBUTIONsev- Addressing the underlying causes of ill health eral spheres of nutrition that are of utmost concern that stem from complex social, political, historical, in these countries, including undernutrition and its economic, and environmental factors is crucial to components of protein- and energy-related malnutri- improving© Jones health & Bartlett and addressing Learning, health LLC inequity. tion and© micronutrientJones & Bartlett deficiencies Learning, at various LLC stages The Understanding and Acting on Social Determi- of life; food insecurity; the interaction of nutrition NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION nants of Health and Health Equity chapter presents and and infections; the role of breastfeeding and comple- explains these determinants. It focuses on the devel- mentary feeding in ensuring healthy children; and opment and application of conceptual frameworks for currently implemented nutrition-specific interven- understanding the social determinants of health, the tions and programs. It also considers the nutrition © Jones & Bartlettimplications Learning, of social determinantsLLC on health systems© Jones transition & Bartlett and theLearning, growing problem LLC of overweight and NOT FOR SALEand services, OR DISTRIBUTION the role of social determinants of healthNOT FORrelated SALE metabolic OR DISTRIBUTION diseases in adults observed in more in an increasingly globalized world, and the impor- affluent segments of populations in rapidly develop- tance of evaluating actions that address social deter- ing countries. Finally, the chapter discusses the cost- minants and health equity. effectiveness of nutritional interventions. The next three© Joneschapters & are Bartlett devoted Learning, to the three LLC The next four chapters© Jones address & Bartlettthe shifting Learning, and LLC greatest public health challenges traditionally faced emerging global health priorities in NCDs, injury, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION by LMICs: reproductive health, infectious diseases, mental health, environmental and occupational and nutrition. Reproductive health has long been health, and complex emergencies. addressed primarily through family planning pro- NCDs are generally characterized by a long grams directly intended to reduce fertility, and latency period, prolonged course of illness, noncon- through© Jones programs & Bartlett that prevent Learning, sexually LLC transmitted tagious© origin, Jones functional & Bartlett impairment Learning, or disability,LLC infections.NOT FOR The SALEReproductive OR DISTRIBUTION Health chapter presents and incurability.NOT FOR The SALE Chronic OR Diseases DISTRIBUTION and Risks chap- more current views of this area that broaden the con- ter covers the global epidemiology of these diseases, cept to include empowerment of women in making particularly their prevalence in LMICs, as well as the decisions about their health and fertility. It provides impact they have on health and economies. The chap- information on population growth and demographic ter also discusses the four key risk factors—poor diet, © Jones & Bartlettchanges aroundLearning, the world, LLC reviews how women con© Jones- tobacco, & Bartlett alcohol Learning, and substance LLC abuse, and low physi- NOT FOR SALEtrol their OR fertility, DISTRIBUTION indexes the effects of various socialNOT FORcal activitySALE— ORthat DISTRIBUTION serve as determinants and proposes and biological determinants of fertility, and exam- approaches, programs, and policies required to ade- ines the impact of family-planning services and quately prevent and manage these diseases at national programs. and global levels. Collectively, infectious© Jones diseases& Bartlett have Learning,historically LLC The Unintentional Injuries© Jones and & Violence Bartlett chapter Learning, LLC been the most importantNOT FOR causes SALE of premature OR DISTRIBUTION mor- discusses both unintentionalNOT injuriesFOR SALE (ones for OR which DISTRIBUTION tality and morbidity in LMICs. TheInfectious Dis- there is no evidence of predetermined intent, such as eases chapter presents the descriptive epidemiologic road accidents and occupational injuries) and inten- features and available prevention and control strat- tional injuries or violence that is planned or intended egies for the infectious diseases that are of greatest (including injuries related to self-directed, interper- public© Jones health & significanceBartlett Learning, in these countries LLC today— sonal, and© Jones collective & Bartlettviolence). Learning, The chapter LLC provides namely,NOT FOR vaccine-preventable SALE OR DISTRIBUTION diseases; diarrhea and an overviewNOT ofFOR the globalSALE burden OR DISTRIBUTION of injuries, outlines acute respiratory infections in children; tuberculo- the causes of and risk factors for them, describes sis, influenza, malaria, and other parasitic diseases; evidence-based interventions that can successfully HIV/AIDS and other sexually transmitted diseases; reduce their impact, and considers the opportunities © Jones & Bartlettand emerging Learning, infectious LLC diseases and new dis© Jones- and & challengesBartlett Learning,that can move LLC forward an injury pre- NOT FOR SALEease threats,OR DISTRIBUTION including Zika and Ebola. The chapterNOT FORvention SALE agenda OR at DISTRIBUTION the global level.

© Jones &Mental Bartlett health Learning, is finally LLC starting to receive the © Jonesimprove &the Bartlett health of Learning, their populations. LLC The Design attention commensurate with its great importance to of Health Systems chapter focuses mainly on the NOT FOR SALE OR DISTRIBUTION NOT FORthe disabilitySALE OR and DISTRIBUTION disease burden in LMICs. The Global healthcare system. It provides a conceptual map of the Mental Health chapter charts the historical develop- health system along with its key elements; addresses ment of public mental health; considers various con- the fundamental and often controversial question as cepts and classifications of mental disorders, taking to the role of the state; and considers the key functions into account the influence© Jones of cultural & Bartlett factors Learning,in the of LLC any health system—namely,© Jones regulation, & Bartlett financ- Learning, LLC development of psychiatricNOT classifications; FOR SALE and OR reviews DISTRIBUTION ing, resource allocation, andNOT services FOR provision. SALE OR It DISTRIBUTION what is known about the epidemiology and etiology of includes extensive references to country experiences the more common disorders, including anxiety and in strengthening the various dimensions of health sys- mood disorders, psychotic disorders, substance abuse tems, and reviews current issues. Five country exam- disorders,© Jones epilepsy, & Bartlettdevelopmental Learning, disabilities, LLC and ples are used ©throughout Jones & the Bartlett chapter Learning,to illustrate keyLLC dementia. The chapter reviews mental health policies, differences in health systems across the world. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION human resources for mental health care, and the evi- Public Health Infrastructure is a new chapter that dence for the prevention and treatment of major men- defines public health functions and the tangible and tal disorders, and provides guidance on implementing intangible aspects that make up the public health mental health services into health systems. Lastly, infrastructure. These include the institutions, knowl- © Jonesthe & chapter Bartlett addresses Learning, the importance LLC of research and © Jonesedge, and & commodities Bartlett Learning, involved in LLC supporting public NOT FORemerging SALE research OR DISTRIBUTION priorities. NOThealth FOR at local, SALE national, OR DISTRIBUTION and global levels. The chapter The Environmental and Occupational Health discusses ways to strengthen the public health sys- chapter provides a comprehensive review of environ- tem, including universal health coverage, human and mental and occupational health issues in LMICs, and material resources, and emergency response systems. its new title reflects an© increasedJones & focus Bartlett on occupa Learning,- It LLCalso examines issues surrounding© Jones global & Bartlett health Learning, LLC tional health and its link to environmental health. The security, the International Health Regulations, and the NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION chapter examines the global burden of environmen- need for research and development to improve public tal health hazards in five categories: household (e.g., health practice. water and sanitation), workplace (e.g., on farms, in As multipurpose and multidisciplinary endeav- mines, and in factories), community (e.g., outdoor air ors, health systems require coordination among pollution),© Jones and regional & Bartlett and global Learning, levels (e.g., LLC climate numerous individuals© Jones and & Bartlettunits. Thus Learning, they require LLC change,NOT ozone FOR depletion, SALE and OR biodiversity). DISTRIBUTION It covers effective andNOT efficient FOR SALEmanagement OR DISTRIBUTIONand planning. The important methodology issues in the field and pro- Management and Planning for Global Health chapter is vides several case studies on the most pressing issues. dedicated to this topic. It details the important aspects The chapter concludes with a discussion on future pri- of the political, social, and economic context in which orities for environmental health research and policy. a management process must operate; discusses the © Jones & TheBartlett Complex Learning, Emergencies LLC chapter focuses on the © Jonesorganizational & Bartlett structures Learning, under which LLC healthcare sys- NOT FORglobal SALE health OR challenges DISTRIBUTION that characterize conflicts NOTtems FOR may SALEbe organized, OR DISTRIBUTION including the role of the pri- that occur within and across state boundaries, have vate sector; examines the critical processes of planning political antecedents, and are protracted in duration. and priority setting; looks at issues in the management It considers the causes of complex emergencies (par- of resources, focusing on finance, resource allocation, ticularly the political causes)© Jones and their & Bartlett impact on Learning, pop- staffing, LLC transport, and information;© Jones and & concludes Bartlett by Learning, LLC ulations and health systems,NOT and FOR reviews SALE the ORtechnical DISTRIBUTION discussing some cross-cuttingNOT themes, FOR such SALE as man OR- DISTRIBUTION interventions that can limit their adverse effects on agement style, accountability, and sustainability. the health of populations. Attention is drawn to the The Pharmaceuticals chapter is dedicated to this importance of an effective and efficient early response key element of a health system. It focuses on access, in influencing the long-term survival of populations availability (both upstream issues and country-level and health© Jones systems & and Bartlett the nature Learning, of any post-conflict LLC distribution and© Jones management & Bartlett systems), Learning, and afford LLC- societyNOT that is FOR established. SALE The OR chapter DISTRIBUTION also reviews the ability of pharmaceuticalsNOT FOR SALEand their OR safe DISTRIBUTION and effective impact of natural disasters. use. It also discusses the pharmaceutical system archi- The next three chapters are concerned with the tecture and reflects on coordination and priority set- development and implementation of effective health ting in a complex global environment. © Jonessystems, & Bartlett which Learning, have a crucial LLC influence on the abil- © JonesHealth & Bartletttechnology Learning, and innovation LLC resources have NOT FORity ofSALE countries OR DISTRIBUTIONto address their disease burden and NOTgrown FOR exponentially SALE OR in DISTRIBUTIONrecent years and have the ability

© Jones & Bartlettto transform Learning, healthcare LLC delivery. The newly added© Jones added & Bartlett a new International Learning, TradeLLC and Health chapter Innovation, Technology, and Design chapter exam- that examines the relationships among international NOT FOR SALE OR DISTRIBUTION NOT FOR SALEines the OR process DISTRIBUTION of technical innovation and design, trade, determinants of health, and health care. It out- and explores the impact it can have on health. The lines international trade agreements, describes the chapter focuses on three critical areas of innovation surrounding political context, and reviews the global in global health: mobile health technologies; point-of- health community’s involvement in this field. care diagnostics; ©and Jones improved & Bartlett access technologies. Learning, LLC Finally, the Global Health© Jones Governance & Bartlett and DiploLearning,- LLC As innovative technologiesNOT FOR achieve SALE their OR full DISTRIBUTION potential macy chapter addressesNOT the roleFOR of SALEgovernance OR DISTRIBUTIONand only when they are successfully scaled up, the chapter globalization in global health, bringing together mate- outlines methods on how to ensure technologies can rial included in the previous edition’s two chapters on be translated into the field. It concludes by discussing cooperation in global health and globalization and some© Jones of the &gaps Bartlett in health Learning, care that might LLC potentially health. ©It covers Jones the & various Bartlett institutional Learning, arrangements LLC be addressed by new innovations. that respond to global health needs through collective NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The Evaluations of Large-Scale Health Programs action, considers how these have shifted over time, chapter covers the important area of evaluation sci- and assesses the governance challenges faced by the ence and addresses the rationale for and the design global health community. It concludes with thoughts of summative impact evaluation of programs being on how to strengthen global health governance and its © Jones & Bartlettscaled up Learning, and delivered LLC to large populations ©and Jones institutional & Bartlett architecture Learning, in theLLC future. NOT FOR SALEaimed OR at delivering DISTRIBUTION several biological and behavioralNOT FOR SALEMany case OR studies DISTRIBUTION can be found in exhibits scat- interventions together. To describe the planning, tered throughout the text. They provide concrete design, and execution of program evaluations and examples and illustrations of key points and con- data analyses, the authors use three evaluations as cepts covered in each chapter. At the conclusion of examples: An Integrated© Jones Community & Bartlett Case Learning, Manage- LLCeach chapter is a list of questions© Jones that & Bartlettcan help course Learning, LLC ment of Childhood Illness program, an accelerated instructors stimulate classroom discussions about NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION child survival development initiative, and a voucher important issues covered in the chapter. scheme for insecticide-treated bed nets. The editors recognize that this text could include Health and health systems interrelate with a nation’s separate chapters on many other topics—maternal economy in two main ways. The first, as noted earlier, and child health and implementation or delivery sci- comprises© Jones the& Bartlett bidirectional Learning, relationships LLC between ence, for© example.Jones & We Bartlett have opted Learning, instead to LLC provide healthNOT statusFOR andSALE national OR DISTRIBUTIONincome and development. in-depthNOT information FOR SALE on the OR core DISTRIBUTION subjects that were For example, health affects income through its impact selected, although we did our best to cover some on labor productivity, saving rates, and age structure; aspects of these and other topics in one or more in turn, a higher income improves health by increasing chapters. the capacity to produce food and have adequate hous- In many ways, global health stands today at an © Jones & Bartletting and education,Learning, and LLC through incentives for fertility© Jones important & Bartlett crossroads. Learning, Its greatest LLC challenge is to con- NOT FOR SALElimitation. OR DISTRIBUTIONThe second type of interaction concernsNOT FORfront SALE global ORforces, DISTRIBUTION while at the same time promoting linkages among healthcare delivery institutions, health local, evidence-based, cost-effective, and responsive financing (including insurance) policies, and economic programs that deal with both disease-specific prob- outcomes. The Health and “The Economy” chapter lems and more general issues, such as poverty and reviews both of these© Jones challenging & Bartlett and closely Learning, related LLCgender inequality. Global© Joneshealth–related & Bartlett research Learning, is LLC topics, which are criticalNOT FOR to government SALE OR policy DISTRIBUTION makers essential to gain a betterNOT understanding FOR SALE of the OR deter DISTRIBUTION- seeking the best ways to improve the quality of life of minants of illness and of innovative approaches to pre- their populations, and are particularly important for vention and care, as well as to find means of improving those countries transitioning between low-, middle-, the efficiency and coverage of health systems. Whether and high-income status. as practitioners, policy makers, or researchers, global © JonesThe global & Bartlett trading Learning,system has LLCboth direct and health professionals© Jones & canBartlett make an Learning, enormous differenceLLC indirectNOT FOR impacts SALE on the OR health DISTRIBUTION of populations, but is by beingNOT well FORtrained SALE and sensitive OR DISTRIBUTION to the beliefs, cul- a factor that is often overlooked by health profession- ture, and value systems of the populations with whom als and was addressed only tangentially in the previ- they collaborate or serve. We hope this text will aid in ous edition of this text. Given its importance, we have this process. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones▸ ▸&References Bartlett Learning, LLC © JonesPruss-Ustun, & A.,Bartlett Wolf, J., Corvalan, Learning, C., Bos, LLC R., & Neira, M. (2016). NOT PreventingFOR SALE disease OR through DISTRIBUTION healthy environments: A global NOT FORArnold, SALE D. (1988). OR Introduction:DISTRIBUTION Disease, medicine, and empire. assessment of the burden of disease from environmental risks. Imperial medicine and indigenous societies (pp. 1–26). Geneva, Switzerland: World Health Organization. Manchester, UK/New York, NY: Manchester University Press/ Rosen, G., & Morman, E. T. (1993). A history of public health. St. Martin’s Press. Baltimore, MD: Johns Hopkins University Press. Basch, P. F. (1999). Textbook of international health. New York, NY: Ruger, J. P. (2005). The changing role of the World Bank in global Oxford University Press.© Jones & Bartlett Learning, LLChealth. American Journal of Public© Health Jones, 95(1), & 60–70. Bartlett Learning, LLC Board on International Health,NOT Institute FOR ofSALE Medicine. OR (1997). DISTRIBUTION Stuard, S. M., & NetLibrary. (1992).NOT A state FORof deference: SALE Ragusa/ OR DISTRIBUTION America’s vital interest in global health: Protecting our people, Dubrovnik in the medieval centuries. Philadelphia, PA: enhancing our economy, and advancing our international University of Pennsylvania Press. interests. Washington, DC: Institute of Medicine. Summergrad, P. (2016). Investing in global mental health: The Committee on the U.S. Commitment to Global Health. (2009). time for action is now. The Lancet Psychiatry, 3(5), 390–391. The© U.S. Jones commitment & Bartlett to global Learning, health: Recommendations LLC The Economist. (2017).© Jones Fewer but & still Bartlett with us: The Learning,world has made greatLLC for the new administration. Washington, DC: Institute of progress in eradicating extreme poverty. Retrieved from https:// Medicine.NOT FOR SALE OR DISTRIBUTION www.economist.com/news/international/21719790-going-willNOT FOR SALE OR DISTRIBUTION De Cock, K. M., Lucas, S. B., Mabey, D., & Parry, E. (1995). -be-much-harder-now-world-has-made-great-progress Tropical medicine for the 21st century. British Medical Journal, The Lancet Planetary Health. (2017). Welcome to the Lancet 311(7009), 860–862. Planetary Health. The Lancet Planetary Health, 1(1), e1. Gensini, G. F., Yacoub, M. H. & Conti, A. A. (2004). The concept Thornton, J. (2017). Drones and phones: How mobile tech © Jones &of Bartlettquarantine Learning,in history: From LLC plague to SARS. Journal of © Jonesis fighting & Bartlett global diseases. Learning, London LLC School of Hygiene & NOT FOR InfectionSALE, 49OR(4), 257–261.DISTRIBUTION NOT TropicalFOR SALEMedicine. OR Retrieved DISTRIBUTION from https://www.lshtm.ac.uk Gibbs, E. P. J. (2014). The evolution of One Health: A decade /research/research-action/features/drones-and-phones-how of progress and challenges for the future. Veterinary -mobile-tech-fighting-global-diseases Record, 174(4), 85–91. UNAIDS. (2017a). Fact sheet: Latest statistics on the status of the Global Burden of Disease (GBD) 2016 Causes of Death AIDS epidemic. Retrieved from http://www.unaids.org/en Collaborators. (2017). Global,© Jones regional, & Bartlettand national Learning, age- LLC/resources/fact-sheet © Jones & Bartlett Learning, LLC sex specific mortality for 264 causes of death, 1980–2016: A UNAIDS. (2017b). Resources and financing. Retrieved from systematic analysis for theNOT Global FOR Burden SALE of Disease OR StudyDISTRIBUTION http://www.unaids.org/en/topic/resourcesNOT FOR SALE OR DISTRIBUTION 2016. The Lancet, 390(10100), 1151–1210. UNICEF. (2016). The state of the world’s children 2016: A fair Hollenhorst, M. (2016). Global poverty declines even amid chance for every child. Retrieved from https://www.unicef economic slowdown, World Bank says. North Carolina Public .org/publications/files/UNICEF_SOWC_2016.pdf Radio. Retrieved from https://www.npr.org/sections/thetwo United Nations High Commissioner for Refugees. (2017). Figures -way/2016/10/02/496099777/global-poverty-declines-even© Jones & Bartlett Learning, LLC at a glance.© RetrievedJones &from Bartlett http://www.unhcr.org/en-us Learning, LLC -amid-economic-slowdown-world-bank-saysNOT FOR SALE OR DISTRIBUTION /figures-at-a-glance.htmlNOT FOR SALE OR DISTRIBUTION Horton, R. (2018). Offline: From 1918 to 2018—the lessons of USAID. (2017). Dreams: Partnership to reduce HIV/AIDS in influenza. The Lancet, 391(10115), 14. adolescent girls and young women. Retrieved from https:// Jamison, D. T., Summers, L. H., Alleyne, G., Arrow, K. J., Berkley, www.usaid.gov/what-we-do/global-health/hiv-and-aids S., Binagwaho, A., & Ghosh, G. (2013). 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