Global health

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The headquarters of the World Health Organization in Geneva, Switzerland.

Global health refers to the health of populations in a global context. Global Health transcends the perspectives and concerns of individual nations.[1][a] In global health, problems that transcend national borders or have a global political and economic impact are often emphasized.[3] It has been defined as 'the area of study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide'.[4] Thus, global health is about worldwide health improvement, reduction of disparities, and protection against global threats that disregard national borders.[5] The application of these principles to the domain of mental health is called Global Mental Health.[6]

The predominant agency for international health is the World Health Organization (WHO). Other important agencies impacting global health include UNICEF, World Food Programme (WFP), and the World Bank. Additionally, the United Nations Millennium Declaration and the globally endorsed Millennium Development Goals is also a major global health initiative.[7]

Definition[edit]

Global health implies a global perspective on public health.[8] It has been described as

...an area for study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide.[9]

Global health employs several perspectives that focus on the determinants and distribution of health in international contexts:

Both individuals and organizations working in the domain of global health often face many questions regarding ethical and human rights. Critical examination of the various causes and justifications of health inequities is necessary to the success of proposed solutions.

History[edit]

As early as the Age of Discovery or also known as the Age of Exploration, which is the period from the early 15th century and continuing into the mid-17th century, there has been a correlation between Globalization and Disease. Different types of exchanges took place that affected the way people lived in every continent. The advancement in shipbuilding, navigation and the formation of trade routes that brought people from Africa, Europe, America and Asia doesn’t only transferred goods, technologies, ideas and cultures but also diseases to native lands who had not previously exposed.

Aside from trade, the slavery in Africa also played a very important part in carrying diseases. The slaves and the crew members were not the only living things aboard but also diseases that were transmitted easily because of the poor hygiene, lack of clean water, poor health condition and the way slaves were packed together in the slave ship.

The slave trade at that time, overlapped with European witchcraft, where the treatment of diseases was often focused on magic, religion and soul cleansing rather than focusing on a few symptoms like modern medicine. This leads to an illogical practice, where more natives were killed by disease and germs than by violence brought about by rampant colonization.

It was not until Louis Pasteur and his Germ Theory of Diseasein the 1800s that humans began to recognize germs and microbes as the causes of diseases. Major discoveries in medicineand public health in the 19th century eventually followed that came to influence the field of global health. The Broad Street cholera outbreak of 1854 was central to the development of modern epidemiology. The microorganisms responsible for malaria and tuberculosis were identified in 1880 and 1882, respectively. The 20th century saw the development of preventive and curative treatments for many diseases, including the BCG vaccine and penicillin in the 1920s. The eradication of smallpox, with the last naturally occurring case recorded in 1977, raised hope that other diseases could be eradicated as well.

Important steps were taken towards global cooperation in health with the formation of the United Nations (UN) and the World Bank Group in 1945, after WWII. In 1948, the member states of the newly formed United Nations gathered together to create the World Health Organization (WHO). A cholera epidemic that took 20,000 lives in Egypt in 1947 and 1948 helped spur the international community to action.[10] In 1977, the concept of essential medicines was published by WHO and also mentioned in the 1978 Alma Ata declaration which underlined the importance of primary health care.[11]

At a United Nations Summit in 2000, member nations declared eight Millennium Development Goals (MDGs) reflecting major challenges facing human development globally, to be achieved by 2015.[12] Three of the eight MDGs focus explicitly on health, while others address broad social conditions. Across all goals, there are 18 targets, supported by 48 health indicators. The declaration has been matched by unprecedented global investment by donor and recipient countries. The UN report released on July 2, 2012 reveals that several MDG targets have been met ahead of the 2015 timeline, there is progress on others, and some e.g., goal 5, are seriously lagging.[13]

Measurement[edit]

Measurement of global health includes the collection of health indicators followed by analysis to draw a conclusions. Several measures exist: disability-adjusted life year (DALY), quality-adjusted life years (QALYs), and mortality measurements. The choice of measures can be controversial and include both practical and ethical considerations.[14]

Life expectancy[edit]

Life expectancy is a statistical measure of the average life span (average length of survival) of a specified population. It most often refers to the expected age to be reached before death for a given human population (by nation, by current age, or by other demographic variables). Life expectancy may also refer to the expected time remaining to live, and that too can be calculated for any age or for any group.

Disability-adjusted life years[edit]

The DALY is a summary measure that combines the impact of illness, disability and mortality on population health. The DALY combines in one measure the time lived with disability and the time lost due to premature mortality. One DALY can be thought of as one lost year of 'healthy' life and the burden of disease as a measurement of the gap between the current health status and an ideal situation where everyone lives into old age free of disease and disability. For example, DALYs for a disease are the sum of the years of life lost due to premature mortality (YLL) in the population and the years lost due to disability (YLD) for incident cases of the health condition. One DALY represents the loss of one year of full health equivalent .

Quality-adjusted life years[edit]

QALYs are a way of measuring disease burden including both the quality and the quantity of life lived, as a means of quantifying in benefit of a medical intervention. The QALY model requires utility independent, risk neutral, and constant proportional tradeoff behaviour.[15] QALYs attempt to combine expected survival with expected quality of life into a single number: if an additional year of healthy life expectancy is worth a value of one (year), then a year of less healthy life expectancy is worth less than one (year). QALY calculations are based on measurements of the value that individuals place on expected years of survival. Measurements can be made in several ways: by techniques that simulate gambles about preferences for alternative states of health, with surveys or analyses that infer willingness to pay for alternative states of health, or through instruments that are based on trading off some or all likely survival time that a medical intervention might provide in order to gain less survival time of higher quality. QALYs are useful for utilitarian analysis, but does not in itself incorporate equity considerations.[14]

Infant and child mortality[edit]

Life expectancy, DALYs and QALYs represent the average disease burden well. However, infant mortality and under-five child mortality are more specific in representing the health in the poorest sections of a population. Therefore, changes in these classic measures are especially useful when focusing on health equity.[16] These measures are also important for advocates of children's rights. Approximately 56 million people died in 2001. Of these, 10.6 million were children under 5 years of age, 99% of these children were living in low-and middle-income countries.[17] That translates to roughly 30,000 children dying every day.[18]

Morbidity[edit]

Morbidity measures include incidence rate, prevalence and cumulative incidence. Incidence rate is the risk of developing some new condition within a specified period of time. Although sometimes loosely expressed simply as the number of new cases during some time period, it is better expressed as a proportion or a rate with a denominator.

Health conditions[edit]

The main diseases and health conditions prioritized by global health initiatives are sometimes grouped under the terms "diseases of poverty" versus "diseases of affluence", although the impacts of globalization are increasingly blurring any such distinction.

Respiratory infections[edit]

Infections of the respiratory tract and middle ear are the major causes of morbidity and mortality worldwide.[17] Some respiratory infections of global significance include tuberculosis, measles, influenza and pneumonias caused by pneumococci and Haemophilus influenzae. The spread of respiratory infections is often increased in crowded conditions, and poverty is associated with more than 20-fold increase in the relative burden of lung infections.[19]

Diarrhoeal diseases[edit]

Diarrhea is the second most common cause of child mortality worldwide, responsible for 17% of under-5 deaths worldwide.[20] Poor sanitation can increase transmission of bacteria and viruses through water, food, utensils, hands and flies. Dehydration due to diarrhoea can be effectively treated through oral rehydration therapy (ORT) with dramatic reductions in mortality.[21][22] Important nutritional measures include the promotion of breastfeeding and zinc supplementation. Rotavirus is a major cause of severe diarrhoea and death in children. While hygienic measures alone may be insufficient for the prevention of rotavirus diarrhoea,[23] it can be prevented by a safe and potentially cost-effective vaccine.[24]

Maternal health[edit]

Maternal health clinic in Afghanistan (source: Merlin)

Complications of pregnancy and childbirth are the leading causes of death among women of reproductive age in many developing countries. A woman dies from complications from childbirth approximately every minute.[25] According to the World Health Organization's World Health Report 2005, poor maternal conditions are the fourth leading cause of death for women worldwide, after HIV/AIDS, malaria, and tuberculosis.[26] Most maternal deaths and injuries can be prevented and have been largely eradicated in the developed world.[27]

HIV/AIDS[edit]

Human immunodeficiency virus (HIV) is transmitted through unprotected sex, unclean needles and blood transfusions or from mother to child during birth or lactation. Globally, HIV is primarily spread through sexual intercourse. The infection damages the immune system, leading to acquired immunodeficiency syndrome (AIDS) and eventually, death. Antiretroviral drugs prolong life and delay the onset of AIDS by minimizing the amount of HIV in the body.

Malaria[edit]

Malaria is a mosquito-borne infectious disease caused by the parasites of the genus Plasmodium. Symptoms may include fever, headaches, chills and nausea. Each year there are approximately 500 million cases of malaria worldwide, most commonly among children and pregnant women in developing countries.[28] Malaria can hinder a nation's economic development as a result of decreased work productivity, treatment cost, and time spent getting treatment.[28] The use of insecticide-treated bednets is a cost-effective way to reduce Malaria deaths, as is prompt artemisin-based combination therapy, supported by intermittent preventive therapy in pregnancy.

Nutrition[edit]

Malnutrition can take the form of hunger and inadequate nutrition, or overweight and obesity. About 104 million children worldwide (2010) are underweight, and undernutrition contributes to about one third of all child deaths.[29] Undernutrition impairs the immune system, increasing the frequency, severity, and duration of infections (including measles, pneumonia and diarrhoea). Infection is also an important cause and contributor to malnutrition.[30]Micronutrient deficiencies including lack of vitamin A, iron, iodine and zinc are common worldwide and can compromise intellectual potential, growth, development and adult productivity.[31][32][33][34][35][36] Interventions to prevent malnutrition include micronutrient supplementation, fortification of basic grocery foods, dietary diversification, hygienic measures to reduce spread of infections, and promotion of breastfeeding.

Violence against women[edit]

Violence against women is a major threat to social and economic development.[37] that has been defined as “physical, sexual and psychological violence occurring in the family and in the general community, including battering, sexual abuse of children, dowry-related violence, rape, female genital mutilation and other traditional practices harmful to women, non-spousal violence and violence related to exploitation, sexual harassment and intimidation at work, in educational institutions and elsewhere, trafficking in women, forced prostitution and violence perpetrated or condoned by the state."[38] In addition to causing injury, violence may increase “women’s long-term risk of a number of other health problems, including chronic pain, physical disability, drug and alcohol abuse, and depression".[39]

Although statistics can be difficult to obtain as many cases go unreported, it is estimated that one in every five women faces some form of violence during her lifetime, in some cases leading to serious injury or even death.[40] Risk factors for being a perpetrator include low education, past exposure to child maltreatment or witnessing violence between parents, harmful use of alcohol, attitudes accepting of violence and gender inequality.[41] Equality of women has been addressed in the Millennium development goals.

Surgical disease burden[edit]

While infectious diseases such as HIV exact a great health toll in low-income countries, surgical conditions including trauma from road traffic crashes or other injuries, malignancies, soft tissue infections, congenital anomalies, and complications of childbirth also contribute significantly to the burden of disease and impede economic development.[42] [2]. It is estimated that surgical diseases comprise 11% of the global burden of disease, and of this 38% are injuries, 19% malignancies, 9% congenital anomalies, 6% complications of pregnancy, 5% cataracts, and 4% perinatal conditions.[43] The majority of surgical DALYs are estimated to be in South-East Asia (48 million), though Africa has the highest per capita surgical DALY rate in the world.[44]

As discussed above, injuries are the largest contributor to the global surgical disease burden, with road traffic accidents (RTAs) contributing the largest share. According the WHO, more than 3500 RTA related deaths occur daily with millions permanently injured or disabled. Road traffic accidents are projected to rise from the ninth leading cause of death and DALYs lost globally in 2004, to the top five in 2030. This would place injuries ahead of infectious diseases by 2030.[45] [3]

Chronic disease[edit]

The relative importance of chronic non-communicable disease is increasing. For example, the rates of type 2 diabetes, associated with obesity, have been on the rise in countries traditionally noted for hunger levels. In low-income countries, the number of individuals with diabetes is expected to increase from 84 million to 228 million by year 2030.[46] Obesity is preventable and is associated with numerous chronic diseases including cardiovascular conditions, diabetes, stroke, cancers and respiratory diseases. About 16% of the global burden of disease, measured as DALYs, has been accounted for by obesity.[46]

In September 2011, the United Nations is hosting its first General Assembly Special Summit on the issue of non-communicable diseases.[47] Noting that non-communicable diseases are the cause of some 35 million deaths each year, the international community is being increasingly called to take important measures for the prevention and control of chronic diseases, and mitigate their impacts on the world population especially on women, who are usually the primary caregivers. Current non-communicable disease efforts include global oncology.

Health interventions[edit]

Many low-cost, evidence-based health care interventions for improved health and survival are known. Priority global targets for improving maternal health include increasing coverage of deliveries with a skilled birth attendant. Interventions for improved child health and survival include: promotion of breastfeeding, zinc supplementation, vitamin A fortification and supplementation, salt iodization, handwashing and hygiene interventions, vaccination, treatment of severe acute malnutrition. In malaria endemic regions, use of insecticide treated bednets and intermittent pharmacological treatment reduce mortality.[48][49][50] Based on such studies, the Global Health Council suggests a list of 32 treatment and intervention measures that could potentially save several million lives each year.[51]

Progress in coverage of health interventions, especially relating to child and maternal health (Millennium Development Goals 4 and 5), is tracked in 68 low-income countries by a WHO- and UNICEF-led collaboration called Countdown to 2015. These countries are estimated to account for 97% of maternal and child deaths worldwide.[52]

To be most effective, interventions need to be appropriate in the local context, be timely and equitable and achieve maximum coverage of the target population. Interventions with only partial coverage may not be cost-effective. For example, immunization programs with partial coverage often fail to reach those who are at greatest risk of disease. Furthermore, coverage estimates may be misleading if distribution is not taken into account. Thus, mean national coverage may appear fairly adequate, but may nevertheless be insufficient when analyzed in detail. This has been termed 'the fallacy of coverage'.[53]

Although health intervention programs are in place, there are paradoxes affecting their capability to make a difference. As Farmer states in his article, many populations are facing the ‘outcome gap’, meaning that some populations have access to medical treatment while others do not. The reason for this is that the countries supporting these populations do not have sustainable infrastructure. The unfortunate problem with this is that a more effective treatment will leave many untreated solely for the reasons that their country does not have sustainable infrastructure to support it. Human rights is central with this problem because sustaining health in a population should be universal and accessible to all. It is also noted in the article that lack of infrastructure is commonly referenced to for a lack of healthcare in a country, demonstrating its prevalence in global health. In making progress with health interventions, taking into account the 'outcome gap' is vital to a programs success and whether or not treatments will be able to reach those who need it. It is important to note that although we do have these interventions in place, many external factors influence how effective (if at all) a program can be. [54]

Journalist Laurie Garrett argues that the field of global health is not plagued by a lack of funds. There are many funds available to the global health field at the present time through many different agencies. But more funds does not always translate into any positive outcomes. The problem lies in the way these funds are allocated to different issues; they are very narrow in their approach where the focus is on one single disease. This stove-piping approach disregards other dire health issues in global health, particular disease can more funds due to interest of the donors and not to what is actually needed. Efforts need to be coordinated rather than focusing on single disease. Most money that is given comes with strings attached clauses where the money is spent at the wishes of the donor. More money is needed where there are no conditions attached. Donors must figure out how to build not only effective local health infrastructures but also local industries, franchises, and other profit centers that can sustain and thrive from increased health-related spending.[55]

While investments by countries, development agencies and private foundations has increased substantially in recent years with aim for improving health intervention coverage and equitable distribution including for measuring progress towards the achievement of the Millennium Development Goals, attention is also being increasingly directed to addressing and monitoring the health systems and health workforce barriers to greater progress.[56] For example, in its World Health Report 2006, the WHO estimated a shortage of almost 4.3 million doctors, midwives, nurses and support workers worldwide, especially in sub-Saharan Africa, in order to meet target coverage levels to achieve the Millennium Development Goals 4 and 5.[57]

Challenges[edit]

Health care workforce[edit]

The World Health Organization (WHO) estimates that the world faces a shortage of 4.3 million health professionals required for delivering essential health care services to populations in need. According to the WHO's 2006 World Health Report, 57 countries face severe shortages in their health care workforce, mostly in sub-Saharan Africa. The WHO Global Code of Practice on the International Recruitment of Health Personnel was developed in a context of raising awareness of international health worker migration and addressing global imbalances in health workforce distribution. The World Health Assembly adopted the Code in 2010[58] to facilitate the strengthening of health workforces with skills relevant to population needs.

In addition it takes appropriate conditions, health-care systems, and basic working infrastructure to improve the general health of the public in developing countries. However, long term neglect of basic infrastructure has made hospitals, local health clinics, and medical schools with educated individuals in the health field scarce. Thus, the cash flow and funds from public and private sectors end up being spent less effectively.

Aid effectiveness[edit]

In year 2005, over 100 donors and developing countries agreed to the Paris Declaration on Aid Effectiveness.[59] Among the distinguishing features was a commitment to hold each other to account for implementing its principles at the country level, and to achieve joint progress by 2010 and beyond, through attention to the following elements:

Ownership - Developing countries set their own strategies for poverty reduction, improve their institutions and tackle corruption.

Alignment - Donor countries align behind these objectives and use local systems.

Harmonization - Donor countries coordinate, simplify procedures and share information to avoid duplication.

Results - Developing countries and donors shift focus to development results and results get measured.

Mutual Accountability - Donors and partners are accountable for development results.

Furthermore, the type of aid given to improve global health is often associated with short term goals. For example, increasing the amount of people receiving specific treatment, decreasing pregnant women with HIV (aids), or increasing the number of bed nets. Few donors realize that it will take up to at least one full generation or more to substantially improve the public health, and that the focus should be less on particular diseases and more on populations general well-being.[60]

Sustainable development goals[edit]

Just as some of the MDGs have been met and several others are beginning to show success,[61] the focus for new global health policy initiatives is converging with one of the main outcomes of the Rio+20 Conference (June 20–22, 2012), namely agreement by the member States to launch a process to develop a set of Sustainable Development Goals (SDGs), which will build upon the Millennium Development Goals and converge with the post 2015 development agenda.[62] Implicit within this remain key challenges for health, as a central component of human development.

Sustainable development is most frequently defined as the "development that meets the needs of the present without compromising the ability of the future generations to meet their own needs.”[63] Human health is thus embodied within an ecological context of sustainable development: all aspects of human ecology fundamentally dependent on the quality of the natural environment, such as clean water, clean air, wholesome nutrition and recreation.[64] This duly recognized, the challenges encountered in sustainable development for health not only include environmental and social determinants, but are also substantively influenced as well by organizational and technological systems.[65]

For example major reductions in the burden of malaria have been achieved by improved prevention and treatment. Yet, such success cannot be taken for granted: tuberculosis control is now threatened by the emergence of multiple antibiotic-resistant strains. While this disease has social and environmental determinants, it is a health systems and technological challenge as well. Similarly, while health promotion and primary prevention are critical in combating the NCD pandemic, they are much less than 100% effective: hundreds of millions of people are developing NCDs, most of them poor; affordable technologies must be made accessible to assist in their management. The world must respond to this challenge as well, as is now being addressed by the World Health Organization, in a new Global Action Plan for the Prevention and Control of Non-Communicable Diseases 2013-2020.[66]

Criticisms[edit]

A neglected Health Care Among Urban Refugees and Asylum-Seekers in Developing Countries[edit]

With the increasing trend in refugee urbanisation, growing numbers of refugees are diagnosed with chronic noncommunicable diseases (NCDs). However, with few exceptions, the local and international communities prioritise communicable diseases.[67] In addition to the problem, refugees are not always welcomed into urban areas of the host country, and usually live in shanty towns and slums in and around cities where they compete for services with other immigrants and the autochthonous urban poor. The change in refugee demographics has consequences for refugee policies, protection and the provision of services, including health care.[68]

One of the clear consequences for refugee is death. Globally, NCDs are the leading cause of death. Approximately 80 per cent of deaths linked to NCDs occur in developing countries.[69] And although communicable diseases remain the main cause of death in most developing countries, the probability of death from NCDs, particularly in urban areas, is greater than that in the developed world.[70] For example, in the case of Iraqi refugees, NCDs were the predominant health problems.[71] The international community faced numerous challenges to attend to refugees’ health care needs. The management of chronic health conditions is expensive and depletes the already limited resources available for refugee health care.[72]

Availability and Affordability of the World Health Organization’s Essential Medicines in Developing Countries[edit]

One initiative of the World Health Organization(WHO) aim to improve the accessibility of safe and effective medicines and the first step in achieving this goal is to obtain a baseline measure of access to essential medicines, which includes the concepts of availability and affordability. In the case of developing countries, specifically Guatemala, A subset of the public sector, Programa de Accessibilidad a los Medicamentos (PROAM), had the lowest average availability (25%) compared to the private sector (35%). In the private sector, highest and lowest priced medicines were 22.7 and 10.7 times more expensive than their international reference price comparison. Treatments were generally unaffordable, costing as much as 15 days wages for a course of ceftriaxone.[73] Meanwhile in Pakistan, Public sector procurement procedures can achieve lower prices than international reference prices, but chronic shortages and lack of basic essential medicines in the public sector facilities is a major barrier to access. Limited availability of low priced generics for certain disease in private pharmacies means some medicines would be unaffordable to low income segment of the society and generally they are unaffordable the poor living below the poverty line.[74]

See also[edit]

References[edit]

Notes[edit]

  1. ^ White and Nanan distinguish global health from international health, even though the two domains are closely related. International health is defined as a well-established branch of public health, with origins in the health situation of developing nations and the efforts of industrialized countries to assist them.[2]

Footnotes[edit]

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  2. ^ White F, Nanan DJ (2008). "Ch. 76: International and Global Health". In Maxcy-Rosenau-Last. Public Health and Preventive Medicine (15th ed.). McGraw Hill. pp. 1252–8. 
  3. ^ Global Health Initiative (2008). Why Global Health Matters. Washington, DC: FamiliesUSA. 
  4. ^ Koplan JP, Bond TC, Merson MH, et al. (June 2009). "Towards a common definition of global health". Lancet 373 (9679): 1993–5. doi:10.1016/S0140-6736(09)60332-9. PMID 19493564. 
  5. ^ Macfarlane SB, Jacobs M, Kaaya EE (December 2008). "In the name of global health: trends in academic institutions". J Public Health Policy 29 (4): 383–401. doi:10.1057/jphp.2008.25. PMID 19079297. 
  6. ^ Patel V, Prince M (May 2010). "Global mental health: a new global health field comes of age". JAMA 303 (19): 1976–7. doi:10.1001/jama.2010.616. PMC 3432444. PMID 20483977. 
  7. ^ "Millennium Development Goals". Un.org. Retrieved 2013-03-15. 
  8. ^ Skolnik, Richard (2012). Global Health 101. Jones & Bartlett Learning. p. 7. ISBN 978-0-7637-9751-5. 
  9. ^ Koplan JP et al. (2009). "Towards a common definition of global health". The Lancet 373 (9679): 1993–1995. doi:10.1016/S0140-6736(09)60332-9. PMID 19493564. 
  10. ^ History of WHO, http://www.who.int/library/historical/access/who/index.en.shtml
  11. ^ World Health Organization and UNICEF. Report of the International Conference on Primary Health Care, Alma-Ata, USSR September 6–12. Geneva: World Health Organization; 1978.
  12. ^ Resolution adopted by the General Assembly, 55/2. United Nations Millennium Declaration. United Nations Fifty Fifth Session, 18 September 2000
  13. ^ United Nations. The Millennium Development Goals Report 2012. New York 2012.
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  15. ^ Pliskin, Shepard and Weinstein (1980, Operations Research)
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  23. ^ "Rotavirus Vaccine Access and Delivery - PATH". Rotavirusvaccine.org. 2011-12-07. Retrieved 2013-01-12. 
  24. ^ Valencia-Mendoza A, Bertozzi SM, Gutierrez JP, Itzler R (2008). "Cost-effectiveness of introducing a rotavirus vaccine in developing countries: the case of Mexico". BMC Infect. Dis. 8: 103. doi:10.1186/1471-2334-8-103. PMC 2527317. PMID 18664280. 
  25. ^ UNICEF: Improve Maternal Health
  26. ^ World Health Organization. 2005. World Health Report 2005: make every mother and child count. Geneva: WHO http://www.who.int/whr/2005/en/index.html
  27. ^ Science Daily: "Most Maternal Deaths in Sub-Saharan Africa Could Be Avoided" 2 March 2010, accessed 3 March 2011
  28. ^ a b Birn, A., Pillay, Yogan, Holtz, T. (2009). Textbook of International Health. 3rd Edition. Oxford University Press. pg 273
  29. ^ WHO Nutrition http://www.who.int/nutrition/challenges/en/index.html
  30. ^ Schaible UE, Kaufmann SH (May 2007). "Malnutrition and infection: complex mechanisms and global impacts". PLoS Med. 4 (5): e115. doi:10.1371/journal.pmed.0040115. PMC 1858706. PMID 17472433. 
  31. ^ Vitamin A supplementation
  32. ^ Lynch S, Stoltzfus R, Rawat R (December 2007). "Critical review of strategies to prevent and control iron deficiency in children". Food Nutr Bull 28 (4 Suppl): S610–20. PMID 18297898. 
  33. ^ Walker SP, Wachs TD, Gardner JM, et al. (January 2007). "Child development: risk factors for adverse outcomes in developing countries". Lancet 369 (9556): 145–57. doi:10.1016/S0140-6736(07)60076-2. PMID 17223478. 
  34. ^ Lazzerini M (October 2007). "Effect of zinc supplementation on child mortality". Lancet 370 (9594): 1194–5. doi:10.1016/S0140-6736(07)61524-4. PMID 17920908. 
  35. ^ Fischer Walker CL, Ezzati M, Black RE (May 2009). "Global and regional child mortality and burden of disease attributable to zinc deficiency". Eur J Clin Nutr 63 (5): 591–7. doi:10.1038/ejcn.2008.9. PMID 18270521. 
  36. ^ Lazzerini M, Ronfani L (2008). "Oral zinc for treating diarrhoea in children". In Lazzerini, Marzia. Cochrane Database Syst Rev (3): CD005436. doi:10.1002/14651858.CD005436.pub2. PMID 18646129. 
  37. ^ World Health Organization. Addressing Violence Against Women And Achieving The Millennium Development Goals [e-book]. 2005. Available from: Family & Society Studies Worldwide, Ipswich, MA. Accessed September 20, 2012.
  38. ^ The United Nations Population Fund. 2005. Violence Against Women Fact Sheet. Retrieved from http://www.unfpa.org/swp/2005/presskit/factsheets/facts_vaw.htm
  39. ^ Ellsberg M, and Heise L. Researching Violence Against Women: A Practical Guide for Researchers and Activists. Washington DC, United States: World Health Organization, PATH; 2005. Accessed September 19, 2012.
  40. ^ World Health Organization. Addressing violence against women and achieving the Millennium Development Goals. Geneva, Switzerland: World Health Organization; 2005. Retrieved from http://www.who.int/gender/documents/MDGs&VAWSept05.pdf
  41. ^ World Health Organization. (2011). Violence against women: Intimate partner and sexual violence against women fact sheet. Retrieved from http://www.who.int/mediacentre/factsheets/fs239/en/
  42. ^ Discussion of the surgical disease burden,Global Partners in Anesthesia and Surgery [1].
  43. ^ Debas H, Gosselin R, McCord C, Thind A. Surgery. In: Jamison D, ed. Disease control priorities in developing countries. 2nd edn. New York: Oxford University Press; 2006.
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