More than 1 billion people entered the twenty-first century without benefiting from the health care revolution. Enormous population growth presents a threat to the health and the economy of many nations. The exponential nature of world population growth is evident. In 1804, after 2 to 5 million years of human existence, the world population exceeded 1 billion. Between 1804 and 1927, the population reached 2 billion and, between 1927 and 1960, 3 billion. The population soared to 4 billion between 1960 and 1974 and 5 billion between 1974 and 1987. In 1999, the world population grew to 6 billion and, in 2006, 6.6 billion. The population is projected to reach 8 billion by 2025 and 10 to 12 billion by midcentury (United Nations Population Division, 2008). Ninety-nine percent of the growth is expected to occur in resource-poor countries (Population Reference Bureau [PRB], 2006).

In any society, large populations create pressure. For example, feeding a population becomes problematic in developing countries when famine, international trade problems, and war occur. Malnutrition, disease, or death may be the outcome. Pressures from population growth are also felt in industrialized nations. Although food may be plentiful, overcrowding leads to pollution, stress, disease, and violence. Each of these challenges represents a major barrier to economic growth. The poor suffer this burden of excess mortality and morbidity disproportionately. Thus, improving quality of life (QOL) through health promotion, effective health care delivery systems, and the enhancement of the environmental infrastructure will address the origins of poverty and ultimately increase productivity and improve QOL.

World population distribution is uneven. More than 50% of the population lives in China (1.3 billion), India (1.1 billion), the United States (299 million), and Indonesia (225 million) (PRB, 2006). In 2007, 30% of the world population consisted of children. 8% were over 60 (WHO, 2009). In developed countries life expectancy is increasing; however, in countries severely affected by the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic, life expectancy has dropped to 35 to 40 years. In these countries the working age population has dwindled while the birth rate has risen. At today’s age-specific mortality rates, a girl born in Zambia can expect to live 43 years whereas a girl born in Japan can expect to live 86 years. Malcolm Potts, a world-renowned population theorist, predicted that “by the twenty-first century the world may end up divided not into political or economic groups but by demographic structure,” where countries will be classified into slow-growth or fast-growth countries instead of rich or poor countries. This will eventually further divide the rich and poor (Potts, 1994).

As the world population grows, a global trend toward urbanization occurs; people live closer together and migrate to urban areas for employment. For example, in 1975, 38.5% of the world’s population lived in urban areas. By 1994, the proportion of urban dwellers swelled to 45%; this proportion is expected to reach 50% by 2015 (United Nations Population Division, 2008). With increasingly dense living arrangements and global travel, the health of the general population is threatened by environmental factors and disease, for example, the H1N1 influenza pandemic.

Lifestyles, health and cultural beliefs, infrastructure, economics, and politics affect existing illnesses and society’s commitment to prevention. Disease patterns vary throughout the world; therefore primary causes of mortality differ in developed and developing countries. Racial, ethnic, and access disparities exist within and between countries. Of 57 million deaths worldwide in 1 year, 33 million are from noncommunicable disease, 18 million are from communicable disease, and 5 million are from injuries and violence (Marmot, 2008).

Cardiovascular disease (CVD), cancer, respiratory disease, stroke, violence, and traumatic injury are the primary causes of mortality in developed countries. Infections, malnutrition, and violence are the primary causes of mortality in developing countries; however, CVDs are becoming more prevalent. Once plagued with high rates of infectious disease, developed countries significantly reduced high mortality rates from these diseases through improved sanitation, nutrition, immunization, and improved health care. Most developed countries have a more stable economy and a wide range of industrial and technological development. These countries experience an epidemiological transition. For example, the morbidity and mortality profile of a country changes from a lesser developed country profile to a developed country profile. Many developed countries experienced an epidemiological transition from having an infectious disease profile to having a chronic disease profile and are now plagued by chronic diseases such as CVD, respiratory disease, and cancer, secondary to air pollution and the tobacco use pandemic. This altered profile has created a demographic transition from traditional societies, where almost everyone is young, to societies with rapidly increasing numbers of middle-aged and elderly people.

Among the infectious diseases that contribute to high rates of mortality in developing countries are AIDS, tuberculosis (TB), endemic malaria, hepatitis B, rheumatic heart disease, parasitic infection, and dengue fever. These diseases claim the lives of millions, yet it is estimated that these diseases could be reduced by up to 50% through effective public health interventions. Many of these diseases will join smallpox as a disease known only to history through the development and implementation of immunization programs or to the twenty-first century threats of bioterrorism. Immunization is the most powerful and cost-effective strategy at our disposal for many infectious diseases (Centers for Disease Control and Prevention [CDC], 2005). TB recommendations included in the “Commission for Africa” report were presented to world leaders attending the G8 summit in Scotland in 2005. The paper calls for wealthy nations to double their aid to Africa in order to rebuild systems to deliver public health services, provide staff training, develop new medicines, and provide better sexual and reproductive health services. The WHO “two diseases, one patient” strategy should be supported to provide integrated TB and HIV care; 70% of the 14 million people worldwide who have both HIV and TB are in Africa (WHO, 2005b). The bacille Calmette-Guérin (BCG) vaccine series induces active immunity, but it does not reduce the transmission of infectious types of TB. At least one third of the world’s population harbors the TB pathogen, Mycobacterium tuberculosis. The WHO programs “Roll Back Malaria,” “Stop TB,” “HIV/AIDS Control,” “Tobacco Free Initiative (TFI),” “Avian Influenza Pandemic Preparedness,” and more recently the H1N1 pandemic target key infectious and chronic disease issues of the twenty-first century.

AIDS continues to be a grave global concern. The WHO “3 by 5 Initiative” (WHO, 2005c) proposed treating 3 million people living with HIV/AIDS by the end of 2005. In 2004, more than 28.5 million adults and children were estimated to be living with AIDS in sub-Saharan Africa, and 40 million adults and children worldwide were living with this disease. The total number of AIDS deaths from 1981 to 2008 exceeds 25 million (UNAIDS, 2009). The worldwide number of people living with HIV is 33.4 million (UNAIDS, 2009). Newly infected HIV cases totaled 2.7 million, and AIDS deaths were 2.0 million in 2008 (UNAIDS, 2009).

Although AIDS is a global epidemic, it varies demographically in different parts of the world. For example, the estimated male-female ratio of HIV infections in North America is 5:2, whereas in Africa the ratio is 1:1 (WHO, 2007a). Urbanization and within-country migration play a role in the spread of AIDS. For instance, in Rwanda the HIV seroprevalence is 14 to 20 times higher in urban areas versus rural areas. Annually, HIV threatens more lives as more people migrate to the world’s largest cities. In 2010, 50% of the developing world lived in cities. This is an increase from 25% in 1970.

Substantial reductions in HIV seroprevalence occurred after several countries deployed “ABC” (Abstinence, Be faithful, Condom use) strategies. In 1985, 35% of those infected with HIV were women. By 2004, 50% of infected people worldwide were women (Dworkin and Ehrhardt, 2007).

Malaria is a life-threatening parasitic disease transmitted by mosquitoes. Today approximately 40% of the world’s population is at risk for malaria. Malaria is found throughout the tropical and subtropical regions of the world and causes more than 300 million acute illnesses and at least 1 million deaths annually. Malaria kills an African child every 30 seconds. Effective low-cost strategies are available for its prevention, treatment, and control, including insecticide-treated nets and new generation medications, including artemisinin-based combination therapies (WHO, 2005a). Efforts are ongoing to develop a malarial vaccine.

With 4.9 million deaths annually worldwide, tobacco control is a critical component of the international health care agenda. By 2020, an estimated one in seven deaths will be tobacco related. Since 1990, tobacco control and secondhand smoke policies have been implemented at various political levels in the United States and abroad. The magnitude and consequences of the tobacco pandemic were unexpected. Smoking prevention and cessation programs, state and federal mandates, tobacco taxation, the tobacco settlement, antitobacco media campaigns, strict licensing of tobacco retailers, the elimination of tobacco vending machines and point-of-sale advertising, and the elimination of tobacco sales by pharmacies have made an impact on tobacco sales in the United States. Because of health concerns and cost, many countries from Ireland to New Zealand have developed tobacco-free policies. Although American adults have enrolled in cessation programs, the tobacco industry has targeted youth and dramatically increased international exports. A global commitment to tobacco control can avert millions of premature deaths in the next half century.

In 2003 the first global public health treaty was adopted at the World Framework Convention on Tobacco Control. The treaty was designed to reduce tobacco-related deaths and diseases around the world (WHO, 2007a). In 2005, the WHO Tobacco Free Initiative (TFI) group, in furthering the aims and objectives of the WHO Framework Convention on Tobacco Control (tobacco product regulation provisions) and on the recommendation of the WHO Study Group on Tobacco Product Regulation, five meetings have been convened by the WHO Tobacco Laboratory Network most recently in Rio de Janeiro.

Proposed activities included:

The global approach to tobacco control can guide the development of effective interventions based upon best evidence and best practice. Countering potential threats to health resulting from economic crises, unhealthful environments, or risky behavior is critical. Promotion of a healthy lifestyle underpins a proactive strategy for risk reduction, tobacco use prevention and cessation, immunization provision, cleaner air and water, adequate sanitation, healthful diets, fitness and exercise programs, and safe transportation.

Promoting worldwide health is humankind’s greatest challenge. Several global agencies, such as the WHO, the Pan American Health Organization (PAHO), the United Nations, the United Nations International Children’s Emergency Fund (UNICEF), the World Bank, the CDC, and nongovernmental organizations play important roles in improving the health of all nations. Founded in 1948, the World Health Organization (WHO) is an international health agency of the United Nations. With six regional offices in the United States, Congo, Denmark, Egypt, India, and the Philippines, the WHO directs and coordinates international health efforts, producing and disseminating global health standards and guidelines, helping countries to address public health issues, and supporting health research (WHO, 2007a). The WHO goal of “health for all by the year 2000” was framed at the Alma-Ata conference in the former USSR in 1978. The conference defined “health for all” as “the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life” (WHO, 1999, p. 65). The target year for achievement was extended to 2010, once again without attainment.

The Alma-Ata conference on primary health care expressed the need for urgent action by all governments. The WHO statement of beliefs, goals, and objectives is outlined in the Declaration of Alma-Ata, which is presented in Box 15-1. The concept of primary health care stresses health as a fundamental human right for individuals, families, and communities; the unacceptability of the gross inequalities and disparities in health status; the importance of community involvement; and the active role of all sectors. Primary health care seeks to obtain the highest level of health care for all people. The program promotes seven elements of primary health care, including health education regarding disease prevention and cure, proper food supply and nutrition, adequate supply of safe drinking water and sanitation, maternal and child health care, immunizations, control of endemic diseases, and the provision of essential drugs.