The World Health Organization (WHO) is a multilateral agency involving approximately 193 countries. It was founded to be “the world’s health advocate” more than 50 years ago (WHO, 1998). Although it is associated with the UN, it has its own budget and decision-making processes. Policy decisions and direction are decided by delegates of the member nations at their annual World Health Assembly held in Geneva, Switzerland. The WHO is funded by fees and voluntary contributions from member countries.

The WHO provides both technical support and health care services to member nations, with an emphasis on poorer countries. It directs and coordinates international health projects, collaborates with other organizations and agencies in health care programs, and monitors and reports on worldwide disease conditions, much like the Centers for Disease Control and Prevention (CDC) does for the United States.

The WHO is leading the effort to establish international standards for medications and vaccines. One standard will ensure that the quality and dosage of medications are safe and at therapeutic levels. It also operates thousands of individual country projects, usually in conjunction with the country’s health ministry, the governmental body responsible for health care. Countries receive help with health planning—for example, distribution or establishment of health care services. The WHO helps run immunization programs, build health care infrastructure, and improve sanitation levels.

The primary mission of the PAHO is to strengthen international and local health systems to improve the health and living standards of the population of the Americas. It provides expertise on disease and environmental management, supports research and scholarship efforts, and monitors diseases. The organization has a major emphasis in Latin America, an area of great need. The PAHO has worked hard to provide childhood immunization and other methods of care to reduce infant mortality. For example, the celebration of the ninth Annual Vaccination Week in the Americas (April 23-30, 2011) brought the total number of individuals immunized against vaccine-preventable diseases to over 323 million (PAHO, 2011). Several other WHO regions initiated vaccination weeks during that time, moving toward a global disease prevention effort.

The United Nations Children’s Fund (UNICEF) (formerly the United Nations International Children’s Emergency Fund) concentrates its efforts in the area of maternal and child health. It is currently working in 190 countries (UNICEF, 2011a). It is an agency of the UN, from which it receives funding. In the past, UNICEF has concentrated on the control of specific communicable diseases. Although still maintaining that focus, it has expanded into the area of primary prevention. More recent efforts are geared toward ensuring fresh water and safe food supplies and providing health education for mothers, education for girls, and immunization programs aimed at reducing or eliminating vaccine-susceptible communicable diseases.

The World Bank is “not a bank in the common sense,” since it is composed of “two unique development institutions owned by 187 member countries.” It has over 100 offices worldwide, and is headquartered in Washington, DC (World Bank, 2011).

The U.S. Agency for International Development (USAID) is an arm of the U.S. State Department. The USAID provides expertise and funding to countries that need economic development. The USAID is an example of a bilateral agency in which one donor, in this case the United States, works with one recipient country. Other governments provide similar services to developing countries. Most of the USAID activities that are publicized are related to agricultural and infrastructure development. In the course of these activities, sanitation and water supplies, essential elements for increasing the level of health in populations, are also improved. In 2007, the USAID was also assisting many countries with activities to combat avian flu, mostly by providing grants and technical assistance (USAID, 2007). In 2009, it procured 42 million poultry avian flu vaccine doses for distribution by the Indonesian Ministry of Health. The USAID also provides millions of bed nets for malaria prevention and hospital equipment worth millions of dollars for the world’s poorest regions (USAID, 2009b). Its continuing work in Afghanistan will be discussed in the section on War and Terrorism below.

The Global Health Council (GHC) is “the world’s largest membership alliance dedicated to saving lives by improving health throughout the world.” Its mission is to provide information and resources needed for successful work toward global health improvement. It serves and represents thousands of public health professionals from more than 103 countries on six continents (Global Health Council, 2011b).

Many organizations are involved in health service to developing countries. Some of these are foundations, privately funded philanthropic organizations, or other types of service agencies. A selection of these organizations is listed in Box 5-2. There are many more voluntary organizations engaged in improving the status of health worldwide.

A contributing cause to about one third of deaths in children worldwide is undernutrition. The global recession which began in 2008 has increased the current risk of child malnutrition because of falling incomes and rising food prices. Although between 1990 and 2005, there was a global decline in the number of underweight children less than 5 years of age (from 25% to 18%), the progress has not steadily continued. Prevalence of undernutrition is increasing in some countries, and stunted growth affects many millions of children (WHO, 2010f).

Stunting of growth, manifested as height for age below normal standards, results from long periods of malnutrition. Damage caused by malnutrition during fetal development and the first two years of life may be irreversible. It is associated with lower intelligence quotient (IQ) scores and difficulties in school among children and less productivity and income among adults. Malnourished children whose mothers have little or no education are at greatest risk of stunting of growth. “In Nigeria, nearly one-half, and in India, nearly 60 percent of the children whose mothers had no education were stunted” (Population Reference Bureau, 2008a). Political unrest, intermittent warfare, and an increasing population contribute to the problem of stunted growth.

Substantial worldwide effort has led to a number of interventions, which have been somewhat successful in reducing malnutrition and starvation. Immediate food delivery to war-ravaged and famine-impacted countries provides only short-term help. Long-term activities, which are the major focus of worldwide efforts, include helping countries and their peoples with the following:

The other end of the malnutrition spectrum is obesity. This is becoming a more obvious public health problem. In developing countries, well over 100 million people risk chronic illnesses and premature death from diabetes, cardiovascular disease, hypertension, and stroke. “Aware that obesity is predominantly a ‘social and environmental’ disease, WHO is helping to develop strategies that will make healthy choices easier to make” (WHO, 2011a).

Perhaps the most heartbreaking problem is death from diarrhea because it is easily controllable. Diarrhea continues to be the second leading cause of death from infectious diseases among children under age 5 (WHO, 2005). Diarrhea has many causes, most of which are associated with poor sanitation and contaminated water supplies. Cholera is one example of an illness that causes severe diarrhea. Diarrheal disease is exacerbated by poverty, lack of knowledge about the importance of personal hygiene and community sanitation, and lack of medical supplies and personnel. Reductions in mortality are the result of simple measures, including the following:

The WHO has actively discouraged bottle-feeding because mothers in poor countries incorrectly use prepared formula. Canned formula is expensive, so mothers dilute the formula with water; as a result, infants do not receive adequate nutrition. The HIV/AIDS epidemic has complicated WHO’s policy against bottle-feeding. Mothers with HIV infection who are not receiving antiretroviral (ARV) therapy are advised not to breast-feed their children. If the mother is on ARV, the WHO/UNICEF/Joint United Nations Program recommends exclusive breast-feeding for the first 6 months of the infant’s life. This should be followed by breast-feeding along with replacement foods (UNICEF, 2011b). Breast-feeding should stop once a nutritionally adequate diet is available.

The AIDS epidemic was first reported in 1981, and 30 years later, in 2011, there are more than 33 million people living with HIV/AIDS worldwide, with at least 2 million of them being children under 15 years of age. In 2009, cases of new infections were estimated to be 2.6 million, and AIDS deaths were recorded at 1.8 million (WHO, 2009b). There has been “a 16-fold increase in the number of people receiving antiretroviral therapy between 2003 and 2010,” although about 9 million eligible people are still not receiving it (WHO, 2011f). AIDS no longer appears on the list of 10 leading causes of death in high-income countries, where antiretroviral drugs are readily available (WHO, 2011k). Global coverage of services for prevention of mother-to-child transmission of HIV exceeded 50% in 2009 (WHO, 2011l). It is expected that there will be much more widespread availability of AIDS medications as a result of the upcoming price concessions for 70 of the world’s poorest countries. The lower prices were negotiated with eight Indian pharmaceutical companies by British and American foreign aid organizations (McNeil, 2011). Effective treatment is crucial for the social and economic restoration of self-worth needed for patients to combat the HIV/AIDS stigma (Campbell et al., 2011). Table 5-2 shows the prevalence of HIV in different parts of the world.

AIDS has disrupted the lives of many families, leaving their children with few adult supports. By the end of 2007, there were at least 15 million “AIDS orphans” worldwide, with 12 million of them in sub-Saharan Africa. AIDS orphans are children under 18 who have lost one or both parents to AIDS (Orphans Against AIDS, 2011). Sometimes, whole families are ravaged by the disease, depriving children of their parents, grandparents, and other relatives and leaving them to scavenge for food and shelter to survive on their own.

International efforts have concentrated on primary prevention. A few examples of primary prevention efforts are education about the cause and spread of HIV; advocacy of the use of condoms and other protective measures during sexual activity; improvement in the procurement, storage, and administration of blood; and advocacy efforts aimed at women and men who are at risk because they have multiple sexual partners.

Early prevention work tended to focus on Western World theories of individual behavioral change. The field has moved toward broader attention on social groups and communities of hard-to-reach populations. This move required acknowledgment that target audiences will not adopt behaviors that are not within their cultural norm (McKee et al., 2004)

Many workplaces in Kenya are integrating activities toward combating HIV, especially peer education programs, into their daily operations. Employers have found that it is easier and cheaper to educate and/or treat employees than to train another person for the job vacated by someone who died from AIDS (Taravella, 2005). In 60 schools of the North East Province of Kenya, peer health educators are being trained for leading “chill clubs” to promote HIV/AIDS awareness and teach preventive strategies against the infection (United Nations Programme on HIV/AIDS [UNAIDS], 2011).

Voluntary counseling and testing (VCT) is a major strategy of the HIV prevention and treatment programs in the community. With the help of trained counselors, people learn how to reduce their risk of infection. They can also learn about their HIV status and enroll for treatment, if necessary. A limited number of mobile VCT services exist, and they are helpful in getting more people tested (Kresge, 2006). A recent innovation in mobile VCT services is “moonlight voluntary counseling and testing,” in which HIV/AIDS counselors in remote areas of East Africa bring a tent at night to areas where alcohol and drugs are sold and thus do VCT work in a more confidential setting (because of the stigma) than those used in daytime VCT work (UNAIDS, 2011).

HIV has defeated efforts at vaccine development for almost 30 years. Failure of two promising vaccine candidates over the last 10 years raised concerns about whether a vaccine could ever be developed against the many existing subtypes of HIV. But in 2009, a large clinical trial in Thailand showed that even though protection afforded by the new vaccine candidate was only 31.2%, it brought hope for future prevention of HIV infection (Berkley, 2010; UNAIDS, 2009).

In the meantime, in the summer of 2011, news about two landmark preexposure prophylaxis studies in Africa was published in the popular literature as well as in public health reports. A new combination drug, Truvada, lowered the risk of infection by at least 63% in the treatment populations. “Such treatment-as-prevention strategies may curb the AIDS epidemic by blocking the spread of HIV before it can do more harm” (New Hope Against HIV, 2011).

Malaria is the most important vector-transmitted disease in the world. It is spread by the bite of the plasmodium infected female Anopheles mosquito. It is endemic to most of Asia, Africa, and Latin America. In 2009, it caused at least 225 million cases and 781,000 deaths worldwide, with over 90% of deaths occurring in Africa among children under 5 years of age. Nearly half of the global population is at risk for the illness (Centers for Disease Control and Prevention [CDC], 2011a).

A number of global partnerships for malaria eradication have been established during the past 10 years. These include the Roll Back Malaria control program; the Global Fund to Fight AIDS, Tuberculosis, and Malaria; the World Bank program; and the U.S. President’s Malaria Initiative. The UN Millennium Development Goals discussed earlier also target malaria

Currently, the most recommended interventions for malaria control are being expanded in sub-Saharan Africa. Use of bed nets treated with insecticide has been shown to reduce child mortality and could save as many as 5.5 lives per 1000 children sleeping under the nets. Spraying the interior walls of houses with insecticide reduces malaria, especially when done throughout communities. Different sprays should be employed if vector resistance occurs. Clinical management of malaria involves outsmarting parasite resistance to first-line treatment such as chloroquine and using the new artemisinin derivatives with other antimalarials that have different modes of action. During pregnancy, both maternal anemia and placental disease are treated preventively with sulfadoxine-pyrimethamine. Instituting these practices has resulted in far fewer inpatient cases and deaths from malaria in countries that can employ these prevention and treatment strategies. There is still no effective vaccine for malaria, although several are in development. A current clinical trial using an upgrade to a vaccine produced a 35% reduction in illness and a 49% reduction for up to 6 months in severe childhood malaria (CDC, 2011b).

Tuberculosis (TB) is the second leading infectious disease cause of death in adults worldwide (only HIV/AIDS exceeds it). The largest numbers of new cases occur in the WHO South-East Asia Region (WHO, 2010f). New smear-positive cases worldwide in 2008 were estimated to be 9.4 million, and over 1.8 million TB deaths occurred that year. Because people are often co-infected with TB and HIV/AIDS, “tuberculosis case rates have more than tripled, and deaths have quadrupled over the past 15 years in African countries with the highest rates of HIV infection.” The full scope of the problem is not clear because of inadequate surveillance data and diagnostic facilities in that part of the world (Center for Global Health Policy, 2010).

TB, by itself, is easily treated with medication, although effective drug therapy is not always available to people in developing countries. New drug-resistant strains of the TB-causing organism (Mycobacterium tuberculosis) are complicating the treatment regimen for TB. Most of these strains arose as a result of incomplete treatment or poorly supervised treatment. For this reason, in the countries with the highest rates, a short course of directly observed therapy (DOTS), in which medical supervision, drug therapy, and laboratory surveillance are combined to combat the disease, has become the standard treatment for TB. Individuals receiving DOTS are supervised as they take their medication for the entire treatment period, which can be from 6 months to 2 years. DOTS produces a remission rate of up to 95%. Globally, nearly all patients with TB under care are being treated using DOTS (WHO, 2009d).

As noted above, co-infection with HIV and M. tuberculosis is especially prevalent in Africa, and often results in death from TB. Co-infection complicates the treatment of each illness because each expedites the progression of the other. A significant contributor to new disease in countries with scarce resources for health care services is the ongoing transmission between patients with HIV and those with TB who congregate in clinic waiting areas (Center for Global Health Policy, 2010). The reservoirs of both multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB, which is resistant to almost all TB drugs) are steadily expanding. Globally, the WHO estimates that a half million new MDR cases occurred in 2007, with 85% of these in 27 specific countries (WHO, 2010f). Medicines for patients with MDR-TB are 50 to 200 times more expensive compared with standard drugs, and “one case of XDR-TB can cost $600,000 or more to treat,” with death as likely an outcome as cure (Center for Global Health Policy, 2010).

The Bacille Calmette-Guerin (BCG) vaccine, the only TB vaccine, offers limited protection for children and is not protective against pulmonary TB in adults. Efforts to develop a more effective vaccine are underway in the United States and Europe by two nonprofit organizations supported by charities such as the Bill and Melinda Gates Foundation. They are hopeful that “the first new TB vaccine could be ready for use by 2016” (Cookson, 2010).

In the poorest countries of the world, nearly 11 million children under 5 years of age die every year from easily preventable and treatable illnesses such as diarrhea, lower respiratory tract infections, measles, and malaria. Malnutrition contributes to half of these deaths. Most of these children die at home, and at least 40% of those that died never received any treatment at a health facility (UNICEF, 2009).

The WHO Expanded Program of Immunization (EPI) was the first global effort to immunize children against vaccine-preventable diseases. The resulting increase in vaccination delivery was further improved with the formation of the Global Alliance for Vaccines and Immunizations (GAVI), a public–private enterprise to boost child vaccination rates. Despite these efforts, the same preventable illnesses have continued to kill thousands of children annually. In recent years, the WHO and the UNICEF developed the Integrated Management of Childhood Illness (IMCI) program. It has been adopted into the health systems of over 80 countries, with the main areas of focus on “improving health worker skills, improving health systems, and improving family and community practices.” All of these efforts have resulted in 78% fewer deaths from measles worldwide between 2000 and 2008. However, measles is still a leading cause of death among children, with most of the 164,000 deaths from measles occurring globally in 2008 in the under-5 age group (WHO, 2009c). Figure 5-3 shows preparations for vaccine administration at a rural health care facility.