Global issues in medicine

Conclusion: Toward a Science of Implementation Public-health strategies draw largely on quantitative methods—from epidemiology and biostatistics, but also from economics. Clinical practice, including internal medicine, draws on a rapidly expanding knowledge base but remains focused on individual patient care; clinical interventions are rarely population-based. In fact, neither public-health nor clinical approaches alone will prove adequate in addressing the problems of global health.

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Health Systems and the "Brain Drain" A significant and oft-invoked barrier to effective health care in resourcepoor settings is the lack of medical personnel. In what is termed the brain drain, many physicians and nurses emigrate from their home countries to pursue opportunities abroad, leaving behind health systems that are understaffed and illequipped to deal with the epidemic diseases that ravage local populations.

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Diabetes The International Diabetes Federation reports that the number of diabetics in the world is expected to increase from 194 million in 2003 to 330 million by 2030, when 3 of every 4 sufferers will live in developing countries. Because diabetics are far more frequently under the age of 65 in developing nations, the complications of micro- and macrovascular disease take a far greater toll. In 2005, an estimated 1.1 million people died of diabetes-related illnesses, and 80% of these deaths occurred in low- and middle-income countries.

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In stark contrast to the extraordinary lengths to which patients in wealthy countries will go to treat ischemic cardiomyopathy, young patients with nonischemic cardiomyopathies in resource-poor settings have received little attention. These conditions account for as many as 25–30% of admissions for heart failure in sub-Saharan Africa and include poorly understood entities such as peripartum cardiomyopathy (which has an incidence in rural Haiti of 1 per 300 live births) and HIV cardiomyopathy.

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Limited success in scaling-up ITN coverage reflects the inadequately acknowledged economic barriers that prevent the destitute sick from accessing critical preventive technologies. Despite proven efficacy and what are considered "reasonable costs," the 2003 RBM report reveals disappointing levels of ITN coverage. In 28 African countries surveyed, only 1.3% (range, 0.2–4.9%) of households owned at least one ITN, and

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Chronic Noncommunicable Diseases While the burden of communicable diseases—especially HIV infection, tuberculosis, and malaria—still accounts for the majority of deaths in resourcepoor regions such as sub-Saharan Africa, close to 60% of all deaths worldwide in 2005 were due to chronic noncommunicable diseases (NCDs). Moreover, 80% of deaths attributable to NCDs occurred in low- and middle-income countries, where 85% of the global population lives. In 2005, 8.

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Malaria We turn now to the world's third largest infectious killer, which has taken its greatest toll among children, especially African children, living in poverty. The Cost of Malaria Malaria's human toll is enormous. An estimated 250 million people suffer from malarial disease each year, and the disease annually kills between 1 million and 2.5 million people, mostly pregnant women and children under the age of 5.

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Tuberculosis Chapter 158 offers a concise overview of the pathophysiology and treatment of TB, which is closely linked to HIV infection in much of the world. Indeed, a substantial proportion of the resurgence of TB registered in southern Africa may be attributed to HIV co-infection. Even before the advent of HIV, however, it was estimated that fewer than half of all cases of TB in developing countries were ever diagnosed, much less treated.

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Nearly 20% (10.6 million) of the 56 million dead in 2001 were children

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Chapter 182 provides an overview of the AIDS epidemic in the world today. Here we will limit ourselves to a discussion of AIDS in the developing world. Lessons learned in tackling AIDS in resource-constrained settings are highly relevant to discussions of other chronic diseases, including noncommunicable diseases, for which effective therapies have been developed. We highlight several of these lessons below.

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The Economics of Global Health Political and economic concerns have often guided global health interventions. As mentioned previously, early efforts to control yellow fever were tied to the completion of the Panama Canal. However, the precise nature of the link between economics and health remains a matter for debate. Some economists and demographers argue that economic development is the key to improving the health status of populations, while others maintain that ill health is the chief barrier to development in poor countries.

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The optimism born of the world's first successful disease-eradication campaign invigorated the international health community, if only briefly. Global consensus regarding the right to primary health care for all was reached at the International Conference on Primary Health Care in Alma-Ata (in what is now Kazakhstan) in 1978. However, the declaration of this collective vision was not followed by substantial funding, nor did the apparent consensus reflect universal commitment to the right to health care. Moreover, as is too often the case, success paradoxically weakened commitment. ...

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