Table Of ContentOxford Textbook of
Global Public Health
VOLUME 1
Oxford Textbook of
Global Public
Health
SIXTH EDITION
Edited by
Roger Detels
Distinguished Professor of Epidemiology and Infectious Diseases,
Schools of Public Health and Medicine, University of California,
Los Angeles, CA, USA
Martin Gulliford
Professor of Public Health, Department of Primary Care and Public Health Sciences,
King's College London, UK
Quarraisha Abdool Karim
Associate Scientific Director, CAPRISA; Professor in Epidemiology, Columbia
University, USA; Adjunct Professor in Public Health and Family Medicine,
University of KwaZulu-Natal, South Africa
and
Chorh Chuan Tan
President and Professor of Medicine, National University of Singapore, Singapore
1
1
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© Oxford University Press 2015
Chapters 3.8, 10.3, 11.10 and 11.13 © World Health Organization 2015
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First edition 1984
Second edition 1991
Third edition 1997
Fourth edition 2002 (reprinted in paperback 2004, 2005 twice)
Fifth edition 2009
Sixth edition 2015
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Preface to the sixth edition
There have been important developments in public health over the from Hong Kong, spread across the world in days to weeks under-
last decade, and these are reflected in the focus of this new edi- scores the rapidity with which epidemics can develop in the 21st
tion of the Oxford Textbook of Public Health. There has been a dra- century and the consequent challenges of controlling their rapid
matic decline in infant mortality and a commensurate increase spread. The evolution of the internet while proving to be a useful
in life expectancy, but at the same time, the disparities in health tool in the control of disease through information sharing and dis-
between rich and poor countries and between rich and poor semination of preventive and control strategies, has also greatly
within countries have increased. As life expectancy has increased enabled activities that are detrimental to public health such as the
in most regions of the world, so has the number of years individu- sale of counterfeit drugs, propagation of misinformation about dis-
als spend with significant disabilities from illnesses as reflected in ease and strategies to control disease and spreading sexually trans-
higher disability-adjusted life years. The response to HIV/AIDS has mitted diseases through websites facilitating sexual liaisons.
forged new alliances between industry and public health and dem- Chronic diseases have now overtaken infectious diseases as
onstrated the potential synergy between treatment and prevention the major global health problem even in developing countries
approaches for control of infectious diseases. The speed of transmis- (Chapters 8.1–8.6). Developing countries must now face the dual
sion of severe acute respiratory syndrome (SARS) in 2003 and the challenge of rapidly increasing incidence of chronic diseases and
recent influenza epidemics which spread across continents within the persistence of infectious diseases, many of which are becoming
weeks have underscored the interdependency of nations, the need resistant to available drugs e.g. for tuberculosis, malaria, gonorrhea,
for international cooperation and the development of international etc. Many countries are now experiencing an epidemic of diabetes
and cross-border surveillance and control programs. The epidemic and obesity related to changing lifestyles associated with increasing
of chronic diseases has spread to middle- and low-income countries prosperity.
which now have the majority of cancer, diabetes, and heart disease As the physical health of the global population has generally
occurring globally. Urbanization is occurring at an unprecedented improved, there has been growing awareness of the increasing
rate and scale in rapidly emerging economies, bringing many new prevalence of mental illness, especially depression, a leading cause
health and social challenges. These events, trends, and programs are of morbidity and non-productivity (Chapter 8.7). Concomitant
rapidly changing the scope, reach, and character of public health. with the increasing prevalence of mental illness, there has been an
Since the publication of the last edition it has become increasingly increase of overtreatment with anti-depressants and other drugs
clear that public health must adopt a global perspective in assess- for mental illness which introduce drug-related problems. Overuse
ing needs, developing interventions and ensuring good governance and abuse of anti-microbial drugs has also promoted the emer-
(Chapters 1.5, 11.13). This is underscored by the decision of the gence of drug-resistant organisms. For a number of infectious dis-
editors to change the title of the textbook to the Oxford Textbook eases, there remains only one effective drug and in some cases, no
of Global Public Health which better reflects the scope of the book effective drug leaving the population vulnerable to infections which
and the issues covered in it. To capture this new perspective, we had previously been considered to be under control.
have updated all the chapters, added new chapters and recruited Globalization has spurred internal migration of rural poor to
new authors with particular expertise in the rapidly changing scope urban centers, especially in developing countries, overwhelm-
and responsibilities of public health. ing the ability of cities to provide essential services such as clean
water and safe disposal of waste (Chapters 1.5, 2.7, 6.2, 9.7, 10.1).
Global health problems Crowding in slums created by these migrants promotes the rapid
of the 21st century spread of many infectious diseases, a hazard to all segments of
the urban population. Internal migration also often leads to the
The development of real-time communication systems, rapid global break up of the family structure as it is the male who is more
travel and the pervasive use of the social media has had a huge likely to migrate causing social disruption and the loss of the main
impact on health and disease (Chapter 4.3). The outbreak of SARS, social support system and social safety net in many developing
which began in Guangdong province in China in late 2002 and countries.
vi PREFACE TO THE SIXTH EDITION
Globalization has also been associated with the rapid develop- The late 20th and early 21st centuries have witnessed the increasing
ment of industrialization and a steep increase in the number of commitment of some sections of the private sector to the health of
vehicles, both of which have caused a severe increase in air and the public as part of their corporate responsibility (Chapter 11.12).
water pollution which in turn has increased the rate of climate The private sector now plays a significant role in international pub-
change and its associated problems. The steep rise in water and lic health through the contribution of pharmaceutical and other
air pollution and the impact of these on climate change transcend companies and foundations supported by the private sector such
national boundaries and will require not only more comprehen- as the Ford Foundation, the Rockefeller Foundation and more
sive national responses but also greater international cooperation recently the Gates Foundation. While it is clear that they can play a
(Chapters 7.1–7.5). significant role in promoting health, it is crucial that they recognize
Violence, only recently recognized as being in the sphere of the importance of working with developing countries in develop-
public health, has been increasing in many parts of the world ing their health agendas so as to maximize their impact. The devel-
(Chapters 9.5, 9.6). The root causes of violence involve social opment of guidelines for health assistance such as those put forth
inequality and the lack of access by much of the world’s poor to in the Paris Declaration on Aid Effectiveness (2005), the Accra
basic social, economic and health resources. Thus, inequality, both Agenda for Action (2008) and the International Health Partnership
between nations and within nations, a fundamental cause of the and Related Initiatives (2007) provide guidance for the private sec-
failure of many to attain the basic human right of good health, also tor to maximize the contributions to international public health
affects the quality of life through promotion of violence. Although (Chapter 11.13).
inequality is basically a political issue, public health must also play a The United Nations has spurred the contribution of devel-
role in reducing inequality (Chapters 2.2, 3.3). A component of this oped countries to international health through the creation of
inequality affecting health is the lack of health professionals in both the Global Fund to Fight AIDS, Tuberculosis and Malaria. This
developing and developed countries (Chapter 11.9). Developing has been augmented by national bilateral and multilateral funds
countries are effectively subsidizing the health of developed coun- such as the US President’s Emergency Plan for AIDS Relief and
tries, as many of their citizens trained as healthcare profession- the programs of the European Union. These programs have made
als migrate to the more attractive positions offered in developed significant contributions to control of disease and promotion of
countries exacerbating the problem of health inequality suffered by global health.
developing countries. The costs of drugs, protected by international trade and patent
agreements, have been a major barrier to the control of such dis-
Strategies to address public health eases as HIV/AIDS. Recently, however, pharmaceutical companies
problems in the 21st century have been providing these drugs to developing countries at afford-
able prices and through outright donations (Chapter 8.3).
Traditionally public health professionals have relied on death rates,
including infant mortality rates, to gauge the health status of a Public health challenges
country. However, many diseases including mental illness and acci- in the 21st century
dents impact the ability of individuals to function without neces-
sarily increasing their probability of dying. The development of new The problems cited above persist in the 21st century, and will
metrics such as disability adjusted life years, years of healthy life lost require international cooperation, research and public health action
and other strategies has provided important new ways to estimate to address effectively. Many of the preventable infectious diseases
the impact of these non-fatal diseases on health and the ability of have been brought under control through immunization programs
individuals to function to their full potential (Chapter 5.17). The although not eradicated (Chapters 8.11, 11.3, 11.4). Eradication of
estimates developed from these strategies have contributed greatly polio is within sight, but political issues in Pakistan and Nigeria
to our ability to characterize health problems and to prioritize lim- have been associated with the killing of vaccinators, presenting a
ited health resources to address key issues. difficult problem not easily addressed by strategies available to pub-
The 20th century also witnessed a rapid development of new tech- lic health.
nologies, including more sensitive approaches to identify genetic Drug resistance will be an increasing problem that transcends
determinants of disease (Chapter 2.5). These technologies have national boundaries. New drugs need to be developed rapidly,
been put in the service of public health and will play an increas- but the issue of misuse of drugs, the cause of developing resist-
ingly role in the future. However, the development and application ance to many drugs, needs to be urgently addressed as well
of these new technologies to assess health and to identify those at (Chapters 8.12–8.15).
risk of disease also raise serious ethical issues (Chapter 3.2). Although many infectious diseases have been brought under
Surveillance has been an essential tool to monitor the mag- control, that control is very fragile and dependent on continued
nitude and spread of disease in human and animal populations vigilance. Complacency is perhaps the worst enemy of vigilance
(Chapter 5.19). The increasing recognition that disease agents undermining the considerable effort necessary to assure continued
do not respect national boundaries and that emerging infectious control of these preventable diseases (Chapter 11.13).
diseases can spread between continents within days to weeks has The epidemics of obesity and diabetes and the continuing prob-
highlighted the need to strengthen international surveillance strat- lems of cardiovascular diseases and cancer need to be addressed
egies and cooperation to provide early warning of emerging and in the 21st century (Chapters 8.1 and 8.2). This will be a partic-
re-emerging health threats such as pandemic influenza so that ular challenge as it primarily involves changes in lifestyle from a
more timely and effective strategies for containment can be imple- sedentary existence requiring little effort to engaging in physical
mented (Chapter 3.2). activities, changing eating habits and modifying many comfortable
PREFACE TO THE SIXTH EDITION vii
habits to which the public have become accustomed (Chapter 6.4). demonstrated through research to improve health. Thus, the field
Prevention of chronic diseases requires taking personal responsi- of ‘implementation science’, which deals with issues of how to bring
bility for one’s health. It is the job of public health to promote the effective strategies to a scale which will impact the health of the
assumption of that responsibility by the public (Chapter 8.4). public, has gained prominence as an important research thrust
As rates of infant mortality have declined markedly in the late (Chapters 6.3, 6.4).
20th century and duration of life has been extended, the population
of the world is aging (Chapter 6.3). Thus the ratio of the productive The sixth edition of the Oxford
age individuals to dependent age individuals has declined. Hence, a
Textbook of Global Public Health
shrinking working age population will be responsible for supporting
an increasing population of elderly. Increased worker productivity It is the intention of this 6th edition of the Oxford Textbook of Global
will be key to sustaining and improving the economic well-being of Public Health to provide comprehensive insights into global health
the global population. Increased health and the ability to function problems now and in the future, and to present strategies and
at full capacity will be key factors for increasing worker productiv- initiatives to address these problems. Although public health pro-
ity and are the responsibility of public health (Chapters 3.1, 10.8). fessionals will agree on the problems that need to be addressed,
However, youth are increasingly vulnerable to drugs, violence, pov- there is a diversity of opinions on the optimal approaches to tackle
erty, the changing make-up of the family, and mental health prob- them. It is also our intention to review the diversity of these opinions
lems, exacerbated by increasing economic disparities between rich and to present our views and those of our expert contributors on
and poor globally and nationally (Chapters 8.7, 9.2, 9.5, 10.1, 10.4). the merits and shortcomings of these proposed strategies.
The world needs to ensure universal coverage of affordable health The 6th edition, as with previous editions, is targeted primarily
care and to increase the investment in the development and train- at public health professionals, particularly those entering the field
ing of health professionals who will lead the essential public health who wish to learn about the scope and diversity of global public
initiatives of the 21st century. Distribution of this health workforce health. Public health is an exciting field in which to work and has
must be more equal and part of an effort to reduce health and social the ability and potential to substantially improve the health of mil-
disparities (Chapters 2.2–2.4 and 11.3). lions of people all over the world. Above all, it is our intention to
Recently there has been greater recognition of the need to convey the excitement and the power of public health to promote
scale up the effective implementation of strategies that have been ‘health for all’ through this 6th edition.
Introduction to Volume 1:
The scope of public health
The scope of public health is vast and continues to evolve rap- chapter on poverty, justice and health (Chapter 2.2) discusses the
idly, seeking to address the daunting challenges to health in the meaning of justice as applied to health and focuses on factors that
twenty-first century while seizing new opportunities for advancing contribute to social inequities in health in both developed and
the well-being of the peoples of the world. From an earlier focus on resource-constrained countries. These issues are taken up in detail
population health, it has grown to encompass a greater emphasis in the following chapters on socio-economic inequalities in health
on equity as encapsulated by the World Health Organization’s goal in high-income countries (Chapter 2.3), and reducing health ine-
of ‘health for all’ and, more recently, expanded into the concept of qualities in developing countries (Chapter 2.4).
global health in recognition of the profound impact of globaliza- Beyond the social determinants of health and disease, dramatic
tion on health and its determinants. Volume 1 of the 6th edition advances in genomics research are providing new insights into the
of the Oxford Textbook of Global Public Health traces the salient causes and pathogenesis of diseases, and their genetic determi-
aspects of this evolution for countries at different stages of develop- nants. The application of genomics research techniques to public
ment, and provides in-depth overviews of long-standing as well as health and epidemiology, a topic covered in Chapter 2.5, also offers
emerging issues of critical importance within the broad scope of the potential for better designed public health programmes as well
public health. as more accurate stratification of sub-populations and individuals
Volume 1 maps the breadth of public health through three fully at significantly increased risk of specific diseases, raising the pros-
updated sections, namely, the history and development of public pect for targeted public health interventions.
health; determinants of health and disease; and public health poli- The chapters that follow provide updated reviews of
cies, law and ethics. long-standing public health concerns which remain critically
Section 1 sets the broad context and framework with Chapter 1.1 important, namely water and sanitation; nutrition and food
providing a high-level overview of contemporary health issues and safety; and the environment with a strengthened focus on the
the expanded functions of public health. The three chapters that fol- public health impact of climate change. The high and rising prev-
low describe how history, the phase of economic development and alence of chronic non-communicable diseases throughout the
regional particularities have influenced the contours and directions world which have their roots in risk factors linked to lifestyles
of public health development in rich, low- and middle-income, and and behaviours, has led to heightened interest in the behavioural
emerging economies respectively. All these countries, however, are determinants of health and disease, an important subject covered
experiencing the immense and growing impact of globalization on in Chapter 2.9. The widespread adoption of health-promoting
health and its determinants. Chapter 1.5 reviews the major forces behaviours, at the level of individuals and societies, is arguably
and drivers associated with a much more globalized world, and the one of the most important challenges for public health in this cen-
complex and varied influences that these are exerting on health and tury. Section 2, with its focus on social and health inequalities, is
healthcare systems in different geographies. To respond adequately aptly rounded off with Chapter 2.10 which addresses key issues
to these new challenges and dynamics, a much higher extent and in access to healthcare, and the importance of universal cover-
depth of international coordination and cooperation across many age and equitable access to affordable and cost-effective health
sectors will be required. interventions.
These considerations set the essential backdrop for Section 2 The last section of Volume 1 which focuses on public health
which covers the determinants of health and disease, the thorough policies, law and ethics, builds on the issues and considerations
understanding of which is crucial to the development of effective discussed in the preceding sections. Section 3 starts with a discus-
and sustainable long-term interventions for public health prob- sion on the need for, and the changing forms of, leadership in pub-
lems. Chapter 2.1 provides a new overview of the determinants of lic health. Chapter 3.2 considers key ethical issues in public health
health, emphasizing their complexity and inter-relatedness. A new and the evolution of principles and guidelines for its practice and
