Global Health and Disease
Carleen H. Stoskopf and James A. Johnson
▸ Introduction
In the development and management of a coun-
try’s healthcare system, an essential component is an
understanding of the environment or national con-
text in terms of (1) the social and cultural beliefs and
ehaviors; (2) the physical environment, such as expo-
sures to environmental hazards, levels of sanitation,
and food and water supply safety; (3) the political cli-
mate, including legal issues that impact the provision
of health care; (4) the design for financing health care
and the distribution of health resources; (5) economic
development, including poverty levels, distribution of
wealth, types of industry, and agriculture; (6) other
social structures, such as the education and judicial
systems; and finally, (7) the types of diseases that are
present in the population (mo
idity) and rates of
mortality, the disease burden. Assessment of the pop-
ulation’s health needs in light of the national profile
should drive how medical resources are distributed
and health services are provided. Healthcare systems
are called on to do disease prevention, primary treat-
ment, secondary treatment, and tertiary treatment.
Integration of the healthcare system with the public
health system is essential for effective intervention in
the cycles of disease that plague many populations.
Public health systems can provide a variety of
nonmedical services, such as sanitation improve-
ments, environmental hazard control, vector con-
trol, health promotion, community interventions to
improve health and well-being, and setting health
policy for the financing and distribution of health
services. The public health systems are also responsi-
le for the surveillance of disease in populations. The
activity of disease surveillance is vitally important to
healthcare systems that are often called on to decide
how few and precious resources are to be deployed.
Understanding the disease profile of a population
and the burden of disease that exists in that popula-
tion is essential to planning and implementation of
health programs. For example, in the case of malaria,
healthcare providers must rapidly identify and treat
specific types of malaria, as well as asymptomatic
cases, to prevent further transmission. The public
health system must work to eliminate vectors through
destruction of
eeding sites and use of safe and effec-
tive pesticides. Equally important is the role of health
educators who work with the community to change
ehavior by encouraging use of bed nets at night and
emptying local water receptacles. Simultaneously,
esearchers must continue the search for safe and
cost-effective new treatments, for methods to quickly
identify asymptomatic individuals, and for a new vac-
cine. No campaign to eliminate or substantially reduce
malaria will be successful without all of these compo-
nents; therefore, it is incumbent on healthcare systems
to understand the populations they serve and to work
with their communities through public health efforts
and other social institutions to effect change. BOX 2-1
identifies the 10 essential public health functions.
21
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case fatality rate, that is, the rate of death among
those who have the disease reported per 1,000 or
100,000 people with the disease. For example, 720
out of 1,000 men with prostate cancer that has
spread to other areas of the body will die within
5 years. Mortality rates are often reported based on
age groups or other demographic variables.1 A list
of commonly used health indicators can be found
in TABLE 2-1.2
The burden of disease is expressed by statis-
tics that attempt to determine the impact of disease
on a population through measuring disability and
healthy-life years lost. The World Health Organiza-
tion (WHO) initiated the Global Burden of Disease
study in 1992 that continues to the present. The study
selected disability-adjusted life years for its measure-
ment.3,4 Other measures include quality-adjusted life
years, health expectancies, and healthy life years.1
Implicit in these measures is the idea that one can
apply cost-benefit analyses in terms of the cost to a
population to prevent and treat diseases versus the
cost that population pays for years lived with disabil-
ity and/or early mortality from those same diseases.
Healthcare providers who avail themselves of these
types of measures as applied to their populations
can make better decisions in appropriating scarce
esources. National health policymakers can use the
economic data applied to loss of healthy life years
to understand better the impact of diseases upon
their nation’s population and therefore its produc-
tivity as measured in gross domestic product (GDP).
An understanding of the burden of disease results
in better decision making in terms of allocation of
esources for specific programs for prevention, treat-
ment, eradication, and control of specific diseases
that severely impact their populations and ultimately
the economic viability of the country. A good exam-
ple of this is the burden that malaria places on popu-
lations where it is endemic.
The collection of health statistics is difficult and
complicated, even in countries with well-developed
health systems like the United States. Collection of
these statistics requires standardized definitions of
diseases, consistent standards for diagnosis of these
diseases, and a well-defined population at risk for
these diseases. For developing countries struggling
to provide the most basic healthcare needs of their
communities, the collection of useful statistics can
e a daunting but nevertheless vital task. TABLE 2-2
illustrates the burden of disease, both communica-
le and noncommunicable, for the countries pre-
sented in this book, allowing a comparison across
counties.
BOX 2-1 Ten Essential Public Health Functions
Monitor health statuses to identify and solve
community health problems .
Diagnose and investigate health problems and health
hazards in the community .
Inform, education, and empower people about health
issues .
Mobilize community partnerships to identify and solve
health problems .
Develop policies and plans that support individual and
community health efforts .
Enforce laws and regulations that protect health and
ensure safety .
Link people to needed personal health services and
assure the provision of health care when otherwise
unavailable .
Assure a competent public and personal healthcare
workforce .
Evaluate effectiveness, accessibility, and quality of
personal and population-based services .
Research for new insights and innovative solutions to
health problems .
Reproduced from Centers for Disease Control and Prevention. The public health system and the 10
essential public health services. http:
www.cdc.gov/nphpsp/essentialServices.html. March 2014.
No healthcare system can be successful without a close
working relationship with the public health system. In
an ideal world, they would blend seamlessly.
▸ Burden of Disease
Disease is measured in many ways. In public health,
the term prevalence is used to measure the number
of individuals with a disease in a specific population
at a discrete point in time. Incidence is the number
of new cases of a disease in a population over a
specified period of time.1 A vast amount of data
are available on the incidence and prevalence of
diseases (mo
idity data) by country, states, regions,
and cities and by population demographics, such as
age, gender, and race/ethnicity. Disease severity is
commonly measured by disease-specific mortality for
that disease. Disease-specific mortality is the number
of deaths due to a given disease per time, usually
expressed per 1,000 or 100,000 people per year. An
example is the mortality from prostate cancer (25 per
100,000 in 2000 in Germany).
To communicate the magnitude of a disease in
different populations, it can also be reported as a
22 Chapter 2 Global Health and Disease
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of approximately 60 million deaths worldwide each
year, over half are the result of chronic disease. Car-
diovascular disease is now the leading cause of death
in the world and is the number one cause of death in
all regions except sub-Saharan Africa, where the com-
ination of HIV/AIDS and malaria are the culprits.
Communicable, or infectious, diseases are caused by
a pathogen or infectious agent spread from person to
person or from animal to person, whereas noncommu-
nicable diseases are in many ways the opposite, as they
do not spread from person to person by an infectious
agent. Chronic diseases also tend to last a long time
▸ Noncommunicable / Chronic
Diseases
As we enter the second decade of the 21st century, we
are also facing a growing prevalence of noncommunica-
le chronic disease. As shown in EXHIBIT 2-1, this trend
is expected to be even more dramatic in coming years.
Diseases such as heart disease, stroke, cancer, chronic
espiratory disease, mental illness, and diabetes have
eached epidemic status in low- and middle-income
countries, as well as in high-income countries.5 In fact,
TABLE 2-1 Commonly Used Population Health Indicators
Indicator* Definition**
Crude birth rate Number of live births per 1,000 people in a population during a specific
period of time
Crude death rate per 100,000 people Number of deaths per 100,000 people in a population during a specific
period of time
Specific death rate per 100,000 people
(age, gender, cause)
Deaths by age, gender, or per 100,000 people in a population during a
specific period of time
Infant mortality rate per 1,000 live births Deaths under one year of age per 1,000 live births in a population
Neonatal mortality rate per 1,000 live
irths
Deaths < 28 days of age per 1,000 live births in a population
Maternal mortality rate per 100,000
women
Deaths from maternal causes per 100,000 women of childbearing age
Proportionate mortality Percentage of deaths that can be attributed to a particular disease,
calculated out of all deaths within that population
Incidence rate New cases for a condition per 1,000 or 100,000 people in a population
during a specific period of time
Prevalence (point in time) Number of cases of a condition at a specific point in time per 100,000
people in a population
Disease-specific mortality rate Number of deaths from a specific condition in a defined population group
per 1,000 or 100,000 people during a specified period of time
Case fatality rate Number of deaths among those with a specific condition per 1,000
people suffering from that condition
* All indicators are per year.
** All definitions are per a defined population.
Data from Basch PF. Textbook of International Health. 2nd ed. New York: Oxford University Press; 1999, pp. 80, 81; World Health Organization. WHO Global Health Observatory Data. https:
www.cia
.gov/li
ary/publications
esources/the-world-factbook/CIA. Accessed June 8, 2016.
23Noncommunicable / Chronic Diseases
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TABLE 2-2 Major Causes of Death per 100,000 Population, 2016, in Selected Countries
Country All causes of death Communicable
diseases
Noncommunicable
diseases
Injuries
Australia XXXXXXXXXX
Bangladesh XXXXXXXXXX
Botswana 1, XXXXXXXXXX
Brazil XXXXXXXXXX
Canada XXXXXXXXXX
China XXXXXXXXXX
DR Congo 1, XXXXXXXXXX
France XXXXXXXXXX
Germany XXXXXXXXXX
Ghana 1, XXXXXXXXXX
India 1, XXXXXXXXXX
Ireland XXXXXXXXXX
Israel XXXXXXXXXX
Japan XXXXXXXXXX
Jordan XXXXXXXXXX
Mexico XXXXXXXXXX
Nigeria 1, XXXXXXXXXX
Peru XXXXXXXXXX
Korea XXXXXXXXXX
Russia XXXXXXXXXX
Turkey XXXXXXXXXX
United Kingdom XXXXXXXXXX
United States 488 31