Textbook of Global Health

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Textbook of Global Health

FOU RT H E DI T ION

Anne-​Emanuelle Birn, MA, ScD

Professor of Critical Development Studies and Global Health,
University of Toronto, Toronto, Canada

Yogan Pillay, PhD

Deputy Director-​General: HIV/​AIDS, TB and Maternal,
Child and Women’s Health National Department
of Health, Pretoria, South Africa

Timothy H. Holtz, MD, MPH, FACP, FACPM

Adjunct Associate Professor of Global Health, Rollins School of Public Health
Emory University, Atlanta, United States

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Library of Congress Cataloging-​i n-​P ublication Data

Names: Birn, Anne-Emanuelle, 1964- author. | Pillay, Yogan, author. | Holtz, Timothy H., author.
Title: Textbook of global health / Anne-Emanuelle Birn, Yogan Pillay, Timothy H. Holtz.
Other titles: Textbook of international health
Description: Fourth edition. | Oxford ; New York : Oxford University Press, [2016] |
Preceded by Textbook of international health / Anne-Emanuelle Birn,
Yogan Pillay, Timothy H. Holtz. 2009. | Includes bibliographical references and index.
Identifiers: LCCN 2016046206 (print) | LCCN 2016048722 (ebook) |
ISBN 9780199392285 (hardback : alk. paper) | ISBN 9780199392292 (e-book) |
ISBN 9780199392308 (e-book)
Subjects: | MESH: Global Health | Socioeconomic Factors | Health Policy |
International Cooperation
Classification: LCC RA441 (print) | LCC RA441 (ebook) | NLM WA 530.1 |
DDC 362.1—dc23
LC record available at https://lccn.loc.gov/2016046206

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To all those rocking the boat for health and social justice, across the world
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CONTENTS

List of Illustrations: Figures, Tables, and Boxes • xi

Acknowledgments • xvii
Introduction: Why Global Health? • xix
Some Abbreviations and Acronyms • xxxiii

1. The Historical Origins of Modern International (and Global) Health • 1

Antecedents of Modern International Health: Black Death, Colonial Conquest, and the
Atlantic Slave Trade • 2
Health, “the Tropics,” and the Imperial System • 8
Industrialization, Urbanization, and the Emergence of Modern Public Health • 14
The Making of International Health • 20
International Health Institution-​Building: The LNHO and the Inter-​War Years • 30

2. Between International and Global Health: Contextualizing the Present • 43

The Post-​World War II International (Health) Order • 44
The Rise of the WHO and “Third World” Development • 50
Straddling International and Global Health • 75

3. Political Economy of Health and Development • 89

Political Economy of Health (and Development) • 89
Political Economy of Development (and Health) • 109
Recent Development and Global Health Approaches • 122

4. Global Health Actors and Activities • 141

Snapshot of Global Health Actors, Agencies, and Programs • 143
Political Economy of Global Health Actors and Activities • 182

5. Data on Health: What Do We Know, What Do We Need to Know, and Why Does it Matter • 193
Why Health Data Matter • 193
Types of Health Data • 199

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viii Contents

6. Epidemiologic Profiles of Global Health and Disease • 231

Leading Causes of Morbidity and Mortality Across Societies and the Life
Cycle • 231
Epidemiology and the Political Economy of Disease • 248
Diseases of Marginalization and Deprivation • 249
Diseases of Modernization and Work • 257
Diseases of Marginalization and Modernization • 259
Diseases of Emerging (Global) Social and Economic Patterns • 268

7. Health Equity and the Societal Determinants of Health • 285

How is Health Societally Determined and What Explains Health
Inequities: Pathways and Possibilities • 286
From Political, Economic, Social, and Historical Context to Population Health
and Health Inequities • 292
Societal Governance and Social Policies • 305
From Living Conditions to Embodied Influences • 313
Addressing Health Inequities and the Societal Determinants of Health • 321

8. Health Under Crises and the Limits to Humanitarianism • 335

Ecological Disasters and their Implications • 337
Famine and Food Aid • 341
War, Militarism, and Public Health • 343
Refugees and Internally Displaced Persons: Numbers, Types, and Places • 351
Complex Humanitarian Emergencies • 355
Political Economy of Disasters and CHEs: Where Does Humanitarianism
Fit In? • 363

9. Globalization, Trade, Work, and Health • 377

Globalization and Its (Dis)Contents • 377
Health Effects of Neoliberal Globalization • 384
Work and Occupational Health and Safety Across the World • 403
Signs of Hope for the Future: Resistance to Neoliberal Globalization • 411

10. Health and the Environment • 425

Framing Environmental Health Problems: The Motors and Drivers • 427
Health Problems as Environmental Problems and Vice Versa • 437
Climate Change • 446
What Is to Be Done?: Multiple Levels of Change • 451

11. Understanding and Organizing Health Care Systems • 477

Principles of Health Care Systems • 482
Health Care System Archetypes • 484
Primary Health Care, Its Renewal, and the Turn to Universal Health
Coverage • 496
Health Care System Reform • 500
Building Blocks of a Health Care System • 508
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Contents ix

12. Health Economics and the Politics of Health Financing • 529

Economic Approaches to Public Health and Medical Spending • 532
Health Care Financing Redux • 535
Cost Analyses of Health Sector Interventions • 545
Market Approaches to Health in LMICs • 550
The Role of International Agencies in Health Care Financing • 553
Contrasting Approaches to Investing for Health (and Health Equity) • 554

13. Building Healthy Societies: From Ideas to Action • 565

Vertical Health Programs and Global Health Interventions: Successes and
Limitations • 567
Healthy Societies: Case Studies • 574
Healthy Public Policy: Health Promotion, Healthy Cities, and Emerging
Frameworks • 586

14. Towards a Social Justice Approach to Global Health • 603

Recapping the Global Health Arena: Dominant Approaches, Ongoing
Challenges, and Points of Inspiration • 604
A Social Justice Approach to Practicing Global Health: Individuals,
Organizations, and the Logic of the World Order • 620

Index • 647
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LIST OF ILLUSTRATIONS: FIGURES, TABLES, AND BOXES

FIGU R ES

1-​1 Isolating yellow fever using the Marchoux chamber, Hospital S. Sebastião, Rio de Janeiro, Brazil
(photo originally published in 1909) 23
1-​2 Caribbean laborers felling trees for swamp drainage and canal construction at New Market Creek
Swamp, Panama, circa 1910 24
1-​3 Administering hookworm treatment at Karapa (India). Rockefeller Foundation International
Health Board’s Cooperative Hookworm Campaign, 1920s 29
3-​1 Demographic transition 95
3-​2 Tuberculosis mortality and medical interventions 97
3-​3 Political economy of global health framework 103
3-​4 Trends in life expectancy by region (5-​year averages), 1950–​2015 105
3-​5 Trends in life expectancy in selected sub-​Saharan African countries (5-​year averages),
1950–​2015 105
3-​6 Life expectancy in EU member states and the Commonwealth of Independent States,
1970–​2012 106
3-​7 Long-​term LMIC trends of ODA, remittances, debt service, and total stock of external debt
(constant 2013 US$ billions), 1970–​2014 121
3-​8 Percentage of population in LMICs living in poverty (2005 PPP$), 1990–​2011 126
4-​1 Total ODA and ODA as a percentage of GNI by country, 2014 156
4-​2 Development assistance for health by source, 1990–​2015 182
5-​1 Additional information to be included in routine data collection to enable measurement of health
inequities and societal determinants of health 198
5-​2 Age pyramids for populations of three countries, 2015 202
5-​3 Population size estimates with and without the effect of AIDS, Southern Africa, 2015 203
5-​4 International form of medical certificate of cause of death 211
5-​5 Infant mortality in India by state and union territory (highest and lowest IMR states),
2001 and 2011 213
5-​6 Coverage of vital registration of deaths (%), World, 2004–​2012 215
5-​7 Distribution of disease burden (in DALYs) by age group and income group, 2012 223
6-​1 Leading causes of death in the world, 2013 233

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xii List of Illustrations: Figures, Tables, and Boxes

6-​2 Leading causes of death in Italy, 2012 234

6-​3 Leading causes of death in Indonesia, 2013 234
6-​4 Leading causes of death in Kenya according to IHME and the Kenya National Bureau
of Statistics, 2013 235
6-​5 Age-​standardized mortality rate among selected countries, 2012 235
6-​6 Trends in under-​5 child mortality, 1970–​2015 237
6-​7 Global distribution of deaths among children under 5 by cause, 2015 238
6-​8 Maternal mortality ratios and percentage of births attended by skilled health personnel, 2015 243
6-​9 Deaths by typology as a proportion of all deaths in LMICs and HICs, 2013 249
6-​10 Cholera cases reported to WHO by year and by continent (1989–​2013) 252
6-​11 Estimated TB incidence rate, by country, 2014 262
6-​12 Annual estimates on the number of AIDS-​related deaths, new HIV infections, and people living
with HIV globally (2000–​2015) 264
6-​13 Percentage of adults and children receiving antiretroviral therapy among all people living with HIV,
by region (2010–​2015) 267
7-​1 Infant mortality rate by wealth quintile, selected countries 295
7-​2 Life expectancy at birth by socioeconomic/​occupational classification for men in England and
Wales since the Black Report 298
7-​3 Age-​adjusted cancer mortality rate among men over age 20 in Chile, by education level 310
7-​4 Age-​adjusted cancer mortality rate among women over age 20 in Chile, by education level 311
7-​5 Piped water on premises and infant mortality rates, 2015 316
7-​6 Percentage of population with access to “improved sanitation,” 1990–​2015 317
8-​1 World military expenditures, 2005–​2015 (constant 2014 US$ billion) 344
8-​2 Trend of global displacement and proportion of world population displaced, 1996–​2015 351
8-​3 Map of complex humanitarian emergencies causing internal displacement, 2015 352
9-​1 Child laborers at Indiana Glass Works, at midnight, 1908 379
9-​2 Child spinning wool, India 380
9-​3 Pathways of neoliberal globalization and effects on health 385
10-​1 Political ecology of health: Determinants, effects, and responses 430
10-​2 Ambient air pollution attributable deaths per 100,000 people, 2012 438
10-​3 Passenger vehicles per 1,000 people by region, 1970–​2013 439
10-​4 Passenger vehicles per 1,000 people in selected countries, 2011 440
10-​5 Garbage “pickers,” Nepal 444
10-​6 Per capita CO2 emissions, selected countries and regions, 2012 448
10-​7 Ecological footprints: A global snapshot, 2012 453
12-​1 Health care expenditures as percent of GDP in the US and Canada, 1975–​2014 542
12-​2 Administrative costs as a percent of total hospital costs in selected countries 545
12-​3 The Preston Curve applied to health spending: Annual health care expenditures per capita and life
expectancy at birth, 2014 (180 countries) 558
14-​1 People’s Health Assembly, Cape Town, South Africa, July 2012 635

TA BLES

2-​1 Major WHO Activities 54

2-​2 Costs of the Smallpox Eradication Programme 69
2-​3 Continuities and Differences between International and Global Health Conceptualizations and
Rationales 77
3-​1 Critical Political Economy Questions from the Writings of Vicente Navarro 104
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List of Illustrations: Figures, Tables, and Boxes xiii

3-​2 Causes of and Therapeutics for Diarrhea According to Contrasting Approaches to Health 108
3-​3 Selected IFI Development Strategies 115
4-​1 Typology of Global/​I nternational Health Actors and Programs 143
4-​2 Selected UN Organizations 145
4-​3 Selected UN Autonomous Specialized Agencies 146
4-​4 Major United Nations Meetings (with Health-​R elated Dimensions) since 2010 146
4-​5 WHO Regional Offices 147
4-​6 Voting Power as a Function of Shareholding 150
4-​7 Selected Bilateral Agency Budgets and Priorities 155
4-​8 Endowments and Current Priorities of Selected Foundations 164
4-​9 Selected Religious Agencies—​Spending and Activities 174
4-​10 Largest Current Global Health Actors 184
5-​1 Some Uses and Limitations of Population Health Data 194
5-​2 Commonly Used Health Indicators 195
5-​3 Some Topics Recommended by the UN World Population and Housing Census Programme and
Various National Census Agencies for Inclusion in a National Population Census 204
5-​4 Some Personal/​Social and Administrative Uses of Vital Records 206
5-​5 Major Subdivisions of the International Classification of Diseases, Tenth Revision, 1994 210
5-​6 Countries with Highest and Lowest Infant Mortality Rates (IMR) and Corresponding Neonatal
Mortality Rates (NMR), 2015 212
5-​7 Infant Mortality Rate by Region, Brazil, 2010 213
5-​8 The 12 Leading Causes of Death in the World, 2013 (and Rank Order in 2000) 220
5-​9 The 10 Leading Causes of Death by Country Income Level, 2012 221
5-​10 Leading Causes of Disease Burden (in DALYs) for Males and Females, Worldwide, 2012 222
6-​1 Public Health Epidemiologic Terms 232
6-​2 Selected Indigenous Populations and Related Health Indicators 246
6-​3 Some Enteric Agents that Can Cause Acute or Chronic Diarrhea 250
6-​4 Selected “Neglected Tropical Diseases” 253
6-​5 Some (Re-) Emerging Infections and Probable Factors in their Emergence and Spread 270
6-​6 Some Factors in the (Re-)Emergence and Spread of Infectious Diseases 271
7-​1 Theories Explaining Health and Disease Patterns (and their Contribution to Understanding
Societal Determinants and Health Inequities) 290
8-​1 Main Origins of the World’s Refugees, 2015 353
8-​2 Total Population of Concern to UNHCR by Region of Asylum, 2015 354
8-​3 Comparison of Mortality Before and During War: ​Violence in the DRC and Iraq 361
9-​1 Key Definitions Relating to Globalization, Trade, and Work 382
9-​2 Selected WTO Trade Agreements and their Influence on Health 393
9-​3 Recent Examples of Human Rights Violations Linked to Transnational Corporate Activity 399
9-​4 Estimated Number of Children Exploited through Prostitution 408
9-​5 Key Labor Policies and OSH Measures to Improve Working Conditions and Protect Workers’
Health 409
10-​1 Selected Pollution Hotspots 433
10-​2 Agents of Environmental Health Problems and their Consequences: Air 441
10-​3 Agents of Environmental Health Problems and their Consequences: Water 442
10-​4 Agents of Environmental Health Problems and their Consequences: Places 445
10-​5 World CO2 Emissions (Billion Metric Tons) by Region, 1990–​2012 447
10-​6 Hierarchy of IPCC Projections of Changes in Climate-​R elated Phenomena for
2050–​2100 and their Health Consequences 449
10-​7 Actions to Confront Environment and Health Threats 454
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xiv List of Illustrations: Figures, Tables, and Boxes

11-​1 Public vs. Private Financing and Delivery of Health Care Services 480
11-​2 Evolution of Health Systems 481
12-​1 Spending on Health: Examples of the Extent of Inequities (in US$), 2014 530
12-​2 How the Health Care Sector Differs from Markets 533
12-​3 Comparison of Health Indicators: Cuba, the United States, and Iceland, 2014 537
12-​4 Private (Including Out-​of-​Pocket) Expenditures as % of Total Health Care Spending in Selected
Countries, 2014 537
12-​5 Organization and Effects of Single-​Payer versus Multiple-​Payer Health Care Systems 543
12-​6 Provider Remuneration Mechanisms 544
12-​7 Using Cost-​Effectiveness Analysis to Determine Health Priorities 549
12-​8 GDP, Debt, Health Expenditures, and Donor Funding in Selected Countries (2014) 553
12-​9 Neoliberal and Social Justice Approaches to Health Compared 556
13-​1 Health and Social Indicators for Selected Welfare States, 2015 576
13-​2 Data on Selected Determinants of Health and Mortality Rates for Three LMICs and the United
States 577
13-​3 Selected Population Indicators, Kerala and India 582
14-​1 Summary of State Obligations with Respect to the Right to Health 616

BOXES

1-​1 Smallpox Vaccination During Late Spanish Colonialism 6

1-​2 Rationales for Colonial Health and Tropical Medicine 9
1-​3 Imperialism, Health, and the Rubber Industry 13
1-​4 Rockefeller Foundation Principles of International Health Cooperation 30
1-​5 Early International Health Organizations, Location, and Year of Founding/Establishment 31
2-​1 Preamble to the WHO Constitution (1946) 52
2-​2 Eras of International Health Activity 53
2-​3 Development as Modernization versus Development as Dependency 61
2-​4 Bilateral Assistance and the Making of Population Control as an International Health Concern 64
2-​5 Critiques of Disease Eradication Programs 70
3-​1 Key Political Economy Definitions 93
3-​2 What’s in a Name?: Categorizing Countries by “Development” Level 110
3-​3 The Human Development Index 124
3-​4 Health-​R elated Millennium Development Goals and Selected Targets 125
4-​1 Definitions 142
5-​1 Age Adjustment 201
5-​2 Million Death Study in India 216
6-​1 Approaches to Prevention and Control of NCDs 236
6-​2 Cholera 250
6-​3 Food-​R elated Morbidity and Mortality 251
6-​4 Measles 257
6-​5 Social Impact of HIV and AIDS in sub-​Saharan Africa 265
6-​6 Case Study: Brazil’s National AIDS Program 266
7-​1 SDOH and Health Equity Definitions 286
7-​2 Main Pathways Linking Racism to Health Effects 303
8-​1 Definitions and Classifications 336
8-​2 Drug Wars 345
8-​3 The Movement Against Landmines 346
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List of Illustrations: Figures, Tables, and Boxes xv

8-​4 Chemical Weapons and Environmental Health 348

9-​1 Is Sugar the New Tobacco? 397
9-​2 The Union Carbide Disaster in Bhopal: A Case Study of TNC Impunity 398
9-​3 Transnationals, the WTO, and Infant Formula: A Case Study of Unethical Practices 401
9-​4 Trade Liberalization and the Export of Hazard 402
9-​5 Farming and Mining as Hazardous Occupations 405
10-​1 Definitions 426
10-​2 Lead Contamination 431
10-​3 Disastrous Consequences of Energy Extraction and Production 434
10-​4 Endocrine Disrupting Chemicals 435
10-​5 Child Health and the Environment 437
10-​6 Asthma and Air Pollution 441
10-​7 Environmental Protection and Decisionmaking: EIA and the Precautionary Principle 450
10-​8 Ecological Footprint 453
10-​9 Some Key International Environmental Conferences and Agreements and their Health
Dimensions 456
10-​10 Cooperating to Phase Out Chlorofluorocarbons: The Montreal Protocol 458
11-​1 Basic Features of Germany’s Social Insurance System 485
11-​2 Basic Features of the NHS 487
11-​3 Basic Features of the (Former) Soviet Model 489
11-​4 Basic Features of Health Care under China’s “Market Socialism” 492
11-​5 Basic Features of Health Care Financing and Delivery in the United States 494
11-​6 Selections from the Declaration of Alma-​Ata 497
11-​7 Characteristics of Health Sector Reform 501
11-​8 Political Economy of Ebola and Health Care System Crises in West Africa 507
11-​9 Long-​Term Care Facilities and Hospices 510
11-​10 Decentralization and District Health Systems 518
12-​1 Two Sides of Turkey’s Experiences with Changes in Health Care Financing 539
12-​2 Medical Tourism 541
12-​3 Corruption in the Health Sector 555
13-​1 Factors Contributing to the Success of Cuba’s Social Services 581
13-​2 ALAMES’s Guiding Principles and Key Aspects of its Political Agenda 584
13-​3 Wherefore International Efforts? Promise and Limitations of the Framework Convention on
Tobacco Control 588
13-​4 Promoting Health for All and Social Justice in the Era of Global Capitalism: A Call to Action by the
People’s Health Movement at the 8th Global Conference on Health Promotion (2013) 589
14-​1 Global Health Research and its Ethical Dimensions 608
14-​2 Health and Human Rights 615
14-​3 Social Justice-​Oriented South-​South Health Diplomacy and Cooperation 618
14-​4 Health Solidarity in El Salvador 623
14-​5 Inspiring Individuals: Dr. Denis Mukwege 624
14-​6 Alternative Media/​Activist Outlets 628
14-​7 Challenging Gender Norms to Address Gender-​Based Violence and HIV Prevention 631
14-​8 Health Alliance International: Cooperantes Working in Solidarity to Create Healthy Societies 632
14-​9 Key Questions Individuals and Organizations Should Consider in Carrying Out Global Health
Projects 634
14-​10 Indigenous Movements Influencing the Societal Determinants of Health 637
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ACKNOWLEDGMENTS

This fourth edition of the Textbook of Global Health, like its immediate predecessor, is written by a trio of
authors with a range of research, practice, teaching, and leadership experience in various regions of the
world involving policymaking, epidemiology, international cooperation, and historical and political analy-
sis. At different moments we have worked with and for local and national governments, NGOs, multilateral
organizations, universities, and social movements.
Even with our diversity of backgrounds and work trajectories, we could not possibly have produced this
volume alone. Consistent with the solidarity principles espoused herein, this volume has benefited enor-
mously from a global collective of comrades, friends, and acquaintances who have generously shared their
time, wisdom, and experience to help sharpen the analysis, relay expertise, correct misunderstandings, and
improve this volume in a myriad ways. Of course, all shortcomings and errors are the authors’ alone. Those
who have supported us constitute a veritable global health network in and of themselves, hailing from every
continent and dozens of countries.
Our heartfelt thanks go to:
Abtin Parnia Devaki Nambiar Jillian Clare Kohler
Albert Berry Donald Cole Jingjing Su
Alex Scott-​Samuel Eduardo Siqueira Joan Benach
Alina Salganicoff Eileen Dunne Joel Lexchin
Amit Sengupta Elia Abi-​Jaoude John MacArthur
Andrea Vigorito Ellen ‘t Hoen John Serieux
Andrew Pinto Esperanza Krementsova Judith Richter
Antonio Torres-​R uiz Eugenio Villar Judith Teichman
Arne Rückert Faraz Vahid Shahidi Juliana Martínez Franzoni
Barry Levy Gabriela Martínez Malagón Kathleen Ruff
Beverly Bradley Gregg Mitman Kathy Moscou
Bridget Lloyd Hani Serag Kim Lindblade
Brook Baker Hans Pols Krista Lauer
Carles Muntaner Howard Waitzkin Krista Maxwell
Carlos Quiñonez Ida Hellander Lesley Doyal
Cesar Victora Ilker Kayi Leslie London
Christopher Sellers Janet Rodriguez Iraola Lída Lhotská
Denis Holdenried Jannah Wigle Matthew Anderson
Denise Gastaldo Jason Beckfield Meri Koivusalo

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xviii

xviii Acknowledgments

Mira Lee Ryan Isakson Sukarma Tanwar

Miriam Gross S. Patrick Kachur Suzanne Sicchia
Mitch Wolfe Samuel Yingst Victoria Blackwell-​Hardie
Nandini Oomman Simon Szreter Wanda Cabella
Pam Dougherty Sofia Gruskin Zinzi Bailey
Raúl Necochea López Solomon Benatar
Rick Rowden Sonja Olsen
We are especially grateful to colleagues (including current and former University of Toronto students)
who reviewed one or two chapters of the book and shared their deep insights and suggestions:

Andrea Cortinois Gilberto Hochman Robert Chernomas

Andrea Gerstenberger Héctor Gómez Dantés Suzanne Jackson
Ben Brisbois John Pringle Ted Schrecker
Carmen Concepción José Tapia Granados Theodore Brown
Claudia Chaufan Kavita Sivaramakrishnan William Ventres
Deika Mohamed Lori Hanson
Franziska Satzinger Paul Hamel

Several former research and teaching assistants reviewed the 3rd edition of the Textbook and provided
invaluable recommendations around what to keep, what to chuck, and how to reorganize and update.
Profound appreciation goes to: Ghazal Fazli, Andrew Leyland, and Marrison Stranks.
A few people went above and beyond the call of collegiality to review multiple chapters and provide
ongoing intellectual and other forms of sustenance. With neverending gratitude to these true comrades:
Laura Nervi, Nancy Krieger, Nikolai Krementsov, and Ramya Kumar.
Expert research and reference assistance was provided by Sarah Silverberg, Tanveer Singh, and
Tanyawarin Janthiraj.
No one shared the scholarly joys and pains of this volume more than our amazing research assistant,
Mariajosé Aguilera! Tireless, committed, astute, persistent, and level-​headed, she pushed us incessantly
to improve clarity and narrative flow, pursued every last research avenue, and challenged us to refine and
substantiate our analysis in an enormously productive way. This book would have been impossible without
Mariajosé’s incredibly hard work, expertise, and good humor. ¡Mil y más gracias!
At Oxford University Press, Chad Zimmerman has been a variously patient and impatient editor, wise
and witty almost always in the right measure, and supportive to the very end. Thank you, thank you. We also
appreciate the work of Devi Vaidyanathan and the production team at Newgen.
This revision lasted far longer than we expected (involving numerous power and internet outages; per-
haps a dozen pairs of broken reading/​computer glasses; several kg of lost girth; and moves across 4 conti-
nents). Nobody suffered more than our families. While we know that merci, kob khun ka, xièxie, gracias,
grazie, sthoothi, obrigado, nandri, danke, and spasibo are never enough, we express our thanks nonetheless,
from heart and soul.
xix

INTRODUCTION: WHY GLOBAL HEALTH?

H1N1 influenza. Diabetes. Ebola. Antimicrobial resistance. Zika. Whether in New York or New Delhi,
almost every year another sensationalized potential or actual pandemic grabs global headlines and raises
alarms among politicians, business executives, United Nations (UN) agencies, celebrities, humanitarian
organizations, magnates, and the wider public.
To highlight just one among many, in May 2015, the Brazilian government confirmed the first locally-​
acquired case of Zika virus (primarily transmitted by Aedes aegypti mosquitoes; also communicable
between humans) in the Americas. Generally causing a mild illness accompanied by fever, joint pain, and
neurological symptoms, Zika was first identified in Uganda in 1947, with subsequent, likely under-​reported,
outbreaks in Africa, Southeast Asia, and the Pacific. The situation in Brazil escalated as evidence mounted
that an upsurge in microcephaly (small head size, linked to incomplete brain development) among new-
borns was due to intrauterine Zika infection (Lessler et al. 2016). With the 2016 Rio de Janeiro Olympic
Games approaching and the virus spreading across the Americas, Zika garnered widespread media cover-
age and sparked alarmism, including in some public health quarters.
By February 2016, the World Health Organization (WHO) declared Zika a “Public Health Emergency
of International Concern,” recommending that pregnancy be postponed among those living in or visiting
areas where there is Zika virus transmission (WHO 2016a). Several governments made similar (contentious)
recommendations, despite restricted access to contraception in many Latin American countries. Moreover,
the focus on pregnancy prevention belies the larger context of Zika’s emergence and impact (Ventura 2016).
The combination of rapid urbanization, poverty, climate change, and intense deforestation—driven by
logging, agribusiness, mining, and oil and gas development—has accelerated the proliferation of a range
of old and new vector-​borne diseases, including dengue, malaria, and chikungunya. Critically, over 90%
of Brazil’s 1,800 Zika-​related microcephaly cases have been in the country’s poor northeast region, where
housing, sanitation, and public health measures are inadequate, leading mosquito breeding sites to multiply
(for example in household water storage containers) and facilitating human-​vector contact (Possas 2016;
WHO 2016b). Although the microcephaly cases (and possible association with Guillain-​Barré syndrome)
are certainly worrisome—​a nd dozens of countries throughout the Americas and the Caribbean now have
Zika outbreaks—​some are questioning whether global fear-​mongering is over-​reactive given the many
other threats beyond Zika posed by the insalubrious social and economic conditions that favor its prolifera-
tion (Galea, Thea, and Annas 2016).
To be sure, global health is not simply a matter of emerging diseases and epidemic threats. Virtually
every crisis has global health implications affecting up to hundreds of millions of people, whether related
to financial collapse, precarious employment, wars and displacement, ecological disasters, climate change,

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xx Introduction: Why Global Health?

or any other catastrophe, including due to political instability, social insecurity, and dismantling of social
infrastructure, such as health care services. To name but one example, the escalating global refugee crisis,
stemming from war and violence in Syria, Yemen, Afghanistan, South Sudan, and Somalia, among other
countries, has led to over 65 million people being forcibly displaced from their homes as of 2015 due to con-
flict and persecution—​t he highest number ever recorded (UNHCR 2016).
Yet visible situations of crisis can also mask day-​to-​day problems of social injustice: preventable dis-
ease, disability, and premature death related to poor living and working conditions, limited health care
access, discrimination, and, ultimately, the gross inequities across population groups due to highly skewed
distribution of wealth, power, and resources among the world’s over 7.5 billion people. Indeed, pervasive
occupational epidemics, such as “non-​t raditional” chronic kidney disease linked to poor agricultural work-
ing conditions and pesticide exposure—​a nd soaring rates of cancer and heart disease in workplaces where
exploitation and the absence of labor protections feed on one another—​a re under-​prioritized by the global
health agenda despite their importance in ill health and premature mortality terms. Meanwhile, a range
of (other) preventable ailments remain major killers among poor populations, notably tuberculosis (TB),
HIV, child diarrhea, and malaria.
Although inequities are particularly pronounced between high-​income (HIC) and low-​and middle-​
income countries (LMICs), they are also present within countries, including wealthy ones, generating
attendant negative health effects. A prime example is the high level of lead-​contaminated drinking water
detected in 2015 in Flint, Michigan, a US town with a majority low-​i ncome African-​A merican population.
Exposure to lead in childhood is linked to permanent cognitive damage, hearing problems, and behavioral
disorders. In pregnant women it can provoke miscarriage and fetal growth problems, and in all age groups
it is associated with heart, kidney, and neurological problems. Outrageously, Flint’s elevated lead exposure
and burgeoning health problems resulted from a deliberate local government cost-​savings policy to switch
the town’s water supply to a known contaminated source, flagrantly violating public health and ethical stan-
dards (Hanna-​A ttisha et al. 2016).
Given the innumerable pressing concerns across the world, what is needed to promote global health and
social justice in the 21st century? This fourth edition of Oxford University Press’s Textbook of Global Health
responds to this question by examining the field’s historical origins, the patterns and underlying causes of
leading health problems, distinct approaches to resolving these issues, the players and priorities of contem-
porary global health, as well as the development of global health as a field of study, research, and practice.
We carry out this analysis paying close attention to how health, locally and globally, relates to the organiza-
tion of political and economic activity, social structures and relations, and the distribution of power and
control over wealth and resources.
In a nutshell, this textbook aims to:

1. Convey an understanding of global health as shaped by the interaction of global, national, regional, and
local forces, processes, and conditions
2. Provide grounding in the epidemiologic, economic, political, ethical, historical, environmental, and
social underpinnings of health and disease patterns within and across countries and populations
3. Show the consequences of these patterns at global, societal, and community levels
4. Present a range of transnational, national, and local approaches to improving health and effectuating
change that unfold via scientific and social knowledge and practices, public health measures and health
care systems, social and political movements, and overall public policymaking

This introduction proceeds with an exploration of global health’s underpinnings and some of the persis-
tent dilemmas of the field. Then we outline a critical political economy framework and provide a snapshot of
the key themes, ideologies, elements of, and approaches to global health examined throughout this volume.
The introduction culminates with a brief guide on how to navigate the textbook.
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Introduction: Why Global Health? xxi

CONCEPTS A N D FR AMEWORKS

Global health is connected to various health-​related concepts (population health, social and societal deter-
minants of health, health inequities, etc., which will be covered in later chapters), but it also draws from
values and ideas around equity, solidarity, social justice, ethics, and human rights. While perhaps not always
visible, these ideas have influenced global health practice, aspirations, institutions, and movements. Here
we highlight a few of these notions to launch our discussion.

Some Key Concepts Related to Global Health

Health: According to the preamble of WHO’s Constitution, “Health is a state of complete physical,
mental, and social well-​being and not merely the absence of disease or infirmity.” This idealistic and
expansive definition—​which nonetheless leaves out important dimensions of social justice and spiri-
tual well-​being—​is much cited but rarely heeded by major global health actors.
Public health: Coined in the early 19th century to distinguish government efforts from private
actions around the preservation and protection of health, public health was famously defined a cen-
tury later by one of the field’s most prominent US leaders, C.-​E .A. Winslow (1920, p. 30), as:

the science and art of preventing disease, prolonging life, and promoting physical health and
efficiency through organized community efforts for the sanitation of the environment, the
control of community infections, the education of the individual in principles of personal
hygiene, the organization of medical and nursing service for the early diagnosis and preventive
treatment of disease, and the development of the social machinery which will ensure to every
individual in the community a standard of living adequate for the maintenance of health.

Because of public health’s association with governmental efforts, it has also been contested and
challenged through an alternative concept of collective health, which emerged in Brazil in the 1970s
in the context of a dictatorship that was repressive, unrepresentative, and unresponsive to the collec-
tive needs of the population (Lima, Santana, and Paiva 2015). Collective health emphasizes the role
and agency of ordinary people, communities, health workers, health justice organizations, and social
movements in shaping and promoting health (Granda 2004).
Health and social justice: “A broad term for action … [that strives for] genuine equality, fairness,
and respect among peoples” (Office of Multicultural Affairs 2014) and leads toward equitable dis-
tribution of power, wealth, and other resources, and to fair and inclusive decisionmaking processes,
affecting health and the societal determinants of health (Buettner-​Schmidt and Lobo 2011).

The Making of Global Health Today

The term global health is relatively recent. Its predecessor, “international health,” came into use circa 1900
after sovereign countries recognized the value of intergovernmental cooperation and began to establish
permanent bodies to address health issues of mutual interest, albeit in a context of intense inter-​imperial
competition. Imperial powers—​though sometimes reluctant to exchange information with commercial
and political rivals—​were especially intent on fending off epidemics of deadly diseases such as cholera and
plague that interrupted trade and generated social unrest (see ­chapter 1).
A century later, international health was recast as global health, focused on “improvement of health
worldwide, the reduction of disparities, and protection of societies against global threats that disregard
national borders” (Macfarlane, Jacobs, and Kaaya 2008, p. 383). Global health is meant to rise above
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xxii Introduction: Why Global Health?

international health’s association with colonial medicine, as well as the Cold War development context (in
which health cooperation was deployed in the ideological and geopolitical rivalry between US and Soviet
blocs), to connote a common global experience of and responsibility for health (for a fuller discussion on
competing definitions and meanings of global health, see c­ hapter 2).
Notwithstanding the invoked distinctions, there is considerable conflation, and many similarities,
between international health and global health. Some consider global health to be a collection of prob-
lems (Kleinman 2010). Many see it as an arena for ensuring domestic security from external threats, as
a big business and “big data” opportunity, or as a “soft power” foreign policy instrument. Others view
global health as an opportunity for institutional and career advancement, while still others see it as a
domain for small nongovernmental organizations (NGOs), solidarity efforts, and struggles for health
and social justice. So contested and subject to multiple interpretations is the notion of global health that
many use it more as “a ‘brand name’ than a robust concept—​a politically expedient term to denote any pro-
gram dealing with health outside of [or among marginalized groups in] one’s own country, while appealing
to an ideal of broad reach and holistic focus” (Garay, Harris, and Walsh 2013).
Moreover, insufficient attention is given to the role of power in global health—​who wields it and how it
is utilized to privilege certain meanings and roles (and exclude others) and why particular actors are able
to exert legitimacy to define problems and set the global health agenda (Lee 2015; Marten 2016). Some hold
that “the gradual construction of a global society” based on shared sovereignty (Frenk, Gómez-​Dantés,
and Moon 2014, p. 96) will lead to the betterment of health outcomes globally. Missing from this stance is
recognition of the role of the overarching global political order of neoliberal capitalism: policymaking is not
shared democratically but skewed in favor of powerful countries and corporate interests. As such, national
“sovereignty remains a safe bet, offering both a defense against the narrow self-​i nterest of global economic
forces and an advantageous context for the struggle for health” (De Ceukelaire and Botenga 2014, p. 952).
This textbook advocates for a more socially just arrangement of global health agenda-​setting, especially
prioritizing the health issues and underlying factors most overlooked by the leading global health actors.

Critical Political Economy Framework

A child born today will be over 80 years old as we enter the 22nd century, that is, if they attain the life expec-
tancy of Japan (currently the longest). Whether this child will be alive and healthy in 2100 will depend on
the type of future we aspire to and the decisions made today around the environmental, social, political, and
economic forces that shape our world and the forms of resistance and reshaping we engage in, from street
action to organizational efforts toward building truly equitable societies and a socially just global order.
People experience good and poor health individually, but illness and death are also social phenomena
shared by households, friends and kin, classmates and work colleagues, caregivers and healers, and the
larger society. At the same time, the societal context—​how people live, work, and recreate, and the differ-
ences between rich and poor and other kinds of dominant and subordinate social groups at national, local,
and global levels—​g reatly affects who becomes ill (and of what diseases), disabled, or dies prematurely. Yet
the majority of global health strategies focus on disease-​control measures (based on behavioral and bio-
medical approaches to health), garnering a great deal of attention and resources for certain diseases while
ignoring, or only superficially supporting, health care systems (Storeng 2014) and especially the larger soci-
etal context influencing health and health inequities.
This Textbook of Global Health employs a critical political economy framework to describe, explain,
and analyze health in the context of the social, political, and economic structures of societies, that is,
who owns what, who controls what, and how these factors are shaped by and reflect the social and insti-
tutional fabric—​c lass, racial/​ethnic/​gender structures and relations, existence of a redistributive wel-
fare state, and so on (Navarro 2009) (see ­c hapter 3 for further explanation). Behavioral, biological, and
medical/​health care system factors are not excluded from this framework but rather understood as part of
larger societal forces that influence health and well-​being. A powerful illustration stems from the global
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Introduction: Why Global Health? xxiii

noncommunicable disease (NCD) crisis: the growing epidemic of diabetes, for example, is typically
linked to soda consumption and household food decisions. But far larger factors are also at play: with
soaring and volatile prices of basic foodstuffs starting in 2007, people across LMICs had to work harder
to feed their families, leaving less time for food preparation. This double effect of price hikes and time
pressures ushered millions to switch from traditional to processed and packaged foods, a dietary shift
that endured even after food prices stabilized (Scott-​V illiers et al. 2016). (Meanwhile, the sugar industry
has long sought to mask scientific evidence about the connections between sugar consumption and heart
disease [Kearns, Schmidt, and Glantz 2016].)
Our critical political economy framework separates this textbook from dominant ways of understanding
global health based on tackling diseases with technical tools and behavioral approaches, purveyed through
programs, prescriptions, and incentives emanating centrifugally from powerful HICs, global health agen-
cies, and, increasingly, private sector actors. In this text, we present both the nuts and bolts of global health,
its ideologies, practices, and institutions and analyze and explain each topic—​f rom health data to disease
patterns, disasters, and development and health cooperation—​through a critical political economy lens
that contextualizes and fundamentally alters the way these issues are understood and addressed.
Other global health textbooks certainly mention the role of social (and sometimes political, but rarely
world order) determinants of health as topics of interest, but these are typically presented as just another topic
and remain unintegrated with the main approach. Political economy has also been reduced by some to con-
sidering political and economic variables without asking how and why power is distributed asymmetrically
and in whose interest, what is the impact on health, and how the world order might be re-​imagined and rear-
ranged. This text, by contrast, makes links among factors that are often considered unconnected—​such as
the relation of capital flight and oppression to health—​and asks tough questions that do not necessarily yield
straightforward or rapid solutions, and that challenge existing local and global power relationships. In this way,
the production of health, disease, and death are understood as endpoints of a constellation of influences and
processes. Not only do we intend for this textbook to provide readers with a comprehensive understanding
of diverse aspects of global health, we anticipate that the framework will be useful at distinct career stages. In
sum, this approach may be rather different from others encountered by many students, yet (we hope) essen-
tial to forming a comprehensive and deeply critical perspective on the forces shaping global health, past and
present.

OVERVIEW OF THE TEXTBOOK

Key Themes
Disease Distribution and Health Inequities
The global health field brings good news, bad news, and complicated news. At the aggregate level, health
is improving, as measured by a global life expectancy higher than ever before, increasing from 52.5 years
in 1960 to 71.6 years today. What is more, UN member countries came together in 2015 to endorse the
Sustainable Development Goals (SDGs), heralding a new commitment to improving health and well-​being
on the aspirational heels of the predecessor Millennium Development Goals.
Yet health inequities have not disappeared, and many of the problems plaguing (particularly poor and
marginalized) people across the globe are recurrences of diseases previously under control. Stopping yellow
fever outbreaks was among the original rationales for international sanitary cooperation in the 19th century.
After an effective vaccine was developed in the 1930s, the disease was believed eminently preventable. Yet
existence of a vaccine is not enough: yellow fever has returned in recent years, with an initially little noticed
2016 epidemic in Angola and the Democratic Republic of Congo contributing to ballooning global yellow
fever deaths of up to 50,000 annually—​90% in Africa, especially in rural settings where there is little access
to health services and overall social conditions are appalling.