Posted: September 19th, 2022

Health Determinants

Overview:

In this writeup, you will prepare a short written response about health determinants to the prompt below. Please save your file in or x format. Your response should be complete and your final document should comply with APA writing requirements.

Attachment: Charter 2 of ebook (the answer in this pdf)

Instructions:

  1. Explain the differences between indirect and direct health determinants.
  2. In your explanation, include key factors that influence those determinants.

Courtesy of Mark Tuschman

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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
Created from indianatech-ebooks on 2022-09-10 00:46:19.

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CHAPTER 2
Health Determinants,
Measurements, and the Status
of Health Globally

LEARNING OBJECTIVES

By the end of this chapter, the reader will be able to do the
following:

■ Describe the determinants of health
■ Define the most important health indicators and key terms

related to measuring health status and the burden of
disease

■ Discuss the status of health globally and how it varies by
country income group, region, and age group

Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
Created from indianatech-ebooks on 2022-09-10 00:46:19.

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M
▶ Vignettes

aria is a poor woman who lives in the highlands of Peru.
She is from an ethnic group called Quechua. In Peru, poor

people tend to live in the mountains and be indigenous, be less
educated, and have worse health status than other people. In
Eastern Europe, the same issues occur among ethnic groups that
are of lower socioeconomic status, such as the Roma people. In
the United States, there are also enormous health disparities, as
seen in the health status of African Americans and Native
Americans, compared to white Americans. If we want to
understand and address differences in health status among
different groups, how do we measure health status? Do we
measure it by age? By gender? By socioeconomic status? By level
of education? By ethnicity? By location?

Yevgeny is a 56-year-old Russian male. Life expectancy in Russia
in 1985 was about 64 years for males and 74 years for females. It
then fell to about 59 years for males and 72 years for females in
2001, before rising again to 67 for males and 77 for females in
2016. What does life expectancy at birth measure? What are the
factors contributing to the earlier decline in life expectancy at birth
in Russia? What has happened to trends in life expectancy in
other countries? Which countries have the longest and shortest life
expectancies, and why?

Sarah is a 27-year-old woman in northern Nigeria. While women in
high-income countries very rarely die of pregnancy-related causes
and have a maternal mortality ratio of about 10 per 100,000 live
births, the maternal mortality ratio for women in low-income
countries like Sarah is about 500 per 100,000 live births. This is
50 times higher than that in the best-off country income group.
What does the maternal mortality ratio suggest about a country?

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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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What does it say about the status of women in that country? What
does it indicate about the access of women to obstetric and
emergency obstetric care of appropriate quality?

Abdul is a 4-year-old in northern India. For every 1,000 children
born in South Asia in 2016, about 50 will die before their fifth
birthday. The rate of child death is even higher in sub-Saharan
Africa. In the cohort of 1,000 children born there in 2016, almost
80 will die before they are five. These two regions have the worst
child mortality rates.5

Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
Created from indianatech-ebooks on 2022-09-10 00:46:19.

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▶ The Importance of Measuring Health
Status

If we want to understand the most important global health issues
and what can be done to address them, then we must understand
what factors have the most influence on health status, as well as
how health status is measured.

This chapter, therefore, covers two distinct but closely related
topics. The first section concerns what are called the determinants
of health. That section examines the most important factors that
relate to people’s health status. The second section reviews some
of the most important indicators of health status and how they are
used.

Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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▶ The Determinants and Social
Determinants of Health

Why are some people healthy and some people not healthy?
When asked this question, many of us will respond that good
health depends on access to health services. Yet, as you will
learn, whether or not people are healthy depends on a large
number of factors, many of which are interconnected, and most of
which go considerably beyond access to health services.

The World Health Organization (WHO) defines the determinants
of health as the “range of personal, social, economic and
environmental factors which determine the health status of
individuals or populations.” WHO defines the social determinants
of health as the “conditions in which people are born, grow, live,
work and age.”

There has been considerable writing about the determinants and
social determinants of health, which different organizations depict
in a range of ways. The next section builds on the work of a
number of actors and agencies. It briefly discusses the
determinants and social determinants of health and how they
influence health. It is essential to understand these concepts if one
wants to understand why people are healthy or not and what can
be done to address different health conditions in different settings.
FIGURE 2-1 shows one way of depicting the determinants of
health.

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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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FIGURE 2-1 The Determinants of Health

Reproduced from Dahlgren, G., & Whitehead, M. (1991). Policies and strategies to

promote social equity in health. Stockholm, Sweden: Institute for Futures Studies.

Retrieved from

http://www.iffs.se/media/1326/20080109110739filmZ8UVQv2wQFShMRF6cuT

The first group of factors that helps to determine health relates to
the personal and inborn features of individuals. These include
genetic makeup, sex, and age. Our genetic makeup contributes to
what diseases we get and how healthy we are. One can inherit, for
example, a genetic marker for a particular disease, such as
Huntington’s disease, which is a neurological disorder. One can
also inherit the genetic component of a disease that has multiple
causes, such as breast cancer. Sex also has an important
relationship with health. Males and females are physically

Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
Created from indianatech-ebooks on 2022-09-10 00:46:19.

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http://www.iffs.se/media/1326/20080109110739filmZ8UVQv2wQFShMRF6cuT

different, for example, and may get different diseases. Females
face the risks involved in childbearing. They also get cervical and
uterine cancers that males do not. Females have higher rates of
certain health conditions, such as thyroid and breast cancers. For
similar reasons, age is also an important determinant of health.
Young children in low- and middle-income countries often die of
diarrheal disease, whereas older people are much more likely to
die of heart disease, to cite one of many examples of the
relationship between health and age.

Individual lifestyle factors, including people’s own health practices
and behaviors, are also important determinants of health. Being
able to identify when you or a family member is ill and needs
health care can be critical to good health. One’s health also
depends greatly on how one eats, or if one smokes tobacco,
drinks too much alcohol, or drives safely. We also know that being
active physically and getting exercise regularly is better for one’s
health than is being sedentary.

The extent to which people receive social support from family,
friends, and community also has an important link with health.
The stronger the social networks and the stronger the support that
people get from those networks, the healthier people will be. Of
course, culture is also an extremely important determinant of
health.

Living and working conditions also exert an enormous influence on
health. These include, for example, housing, access to safe water
and sanitation, access to nutritious food, and access to health
services. Crowded housing, for example, is a risk factor for the
transmission of tuberculosis. The lack of safe water and sanitation,
coupled with poor hygiene in many settings, is one of the major
risk factors for the diarrheal disease that is associated with so
much illness and death in young children. Nutrition is central to
health, beginning at conception, and families have to be able to

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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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access appropriate foods to promote good health. Of course, even
if other factors are such important determinants of health, one’s
health does depend on access to appropriate healthcare services.
Even if one is born and raised healthy and engages in good health
behaviors, access to health services of appropriate quality is
important to maintaining good health. To address the risk of dying
from a complication of pregnancy, for example, one must have
access to health services that can carry out an emergency
cesarean section if necessary. Even if the mother has had the
suggested level of prenatal care and has prepared well in all other
respects for the pregnancy, in the end, certain complications can
only be addressed in a healthcare setting.

PHOTO 2-1 The circumstances in which people live have a
profound impact on their health. This is a slum in Jakarta,

Indonesia. In what ways would living here influence the health of
the slum dwellers?

© Nikada/E+/Getty Images.

Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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A range of socioeconomic factors, including culture, education,
and socioeconomic status, are important determinants of health.
The broader environment is also a critical health determinant.
Socioeconomic status refers to a person’s economic, social, and
work status. It is highly correlated with educational attainment.
People with higher educational attainment have better economic
opportunities, higher socioeconomic status, and more control over
their lives than people of lower educational status. As one’s
socioeconomic status improves, so does his or her health.

More specifically, education is a powerful determinant of health for
several reasons. First, it brings with it knowledge of good health
practices. Second, it provides opportunities for gaining skills,
getting better employment, raising one’s income, and enhancing
one’s social status, all of which are also related to health. Studies
have shown, for example, that the single best predictor of the
birthweight of a baby is the level of educational attainment of the
mother. Most of us already know that throughout the world there
is an extremely strong and positive correlation between the level of
education and all key health indicators. People who are better
educated eat better, smoke less, have less obesity, have fewer
children, and take better care of their children’s health than do
people with less education. It is not a surprise, therefore, that they
and their children live longer and healthier lives than do less well-
educated people and their children.

Culture also exerts a profound impact on health. Culture shapes
how one feels about health and illness, how one uses health
services, and the health practices in which one engages. In
addition, the gender roles that are ascribed to women in many
societies also have an important impact on health. In some
settings, women may be treated more poorly than men and this, in
turn, may mean that women have less income, less education,

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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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and fewer opportunities to engage in employment. All of these
militate against their good health.

The environment, both indoor and outdoor, is a powerful
determinant of health. Related to this is the safety of the
environment in which people work. Although many people know
about the consequences of outdoor air pollution for health, fewer
people are aware of the consequences of indoor air pollution to
health. In many low- and middle-income countries, families, and
usually women, cook indoors with poor ventilation, thereby
creating an indoor environment that may be full of smoke and that
increases the risk of respiratory illness and asthma. The lack of
safe drinking water and sanitation is a major contributor to ill
health in poor countries. In addition, many people in those same
countries work in environments that are unhealthy. Because they
lack skills, socioeconomic status, and opportunities, they may
work without sufficient protection from hazardous chemicals, in
polluted air, or in circumstances that expose them to occupational
accidents.

Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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PHOTO 2-2 The lack of access to safe water and sanitation
causes people to seek water from unsafe sources and is a
major risk factor for child deaths. Children are shown here
washing their dishes in a river. What can be done to improve
access to safe water and sanitary disposal of human waste in

resource-poor environments?

Courtesy of Mark Tuschman.

The approach that governments take to different policies and
programs in the health sector and in other sectors also has an
important bearing on people’s health. People living in a country
that promotes high educational attainment, for example, will be
healthier than people in a country that does not promote
widespread education of appropriate quality because better-
educated people engage in healthier behaviors. A country that has
universal health insurance is likely to have healthier people than a
country that does not insure its entire population because the
uninsured may lack needed health services. The same would be
true, for example, for a country that promoted safe water supply
for its entire population, compared to one that did not.

Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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As we think about the determinants of health, we should be aware
that increasing attention is being paid to the social determinants of
health. In 2005, WHO created a Commission on the Social
Determinants of Health. WHO published the commission’s report
in 2008. The report highlighted some of the following themes :

■ Health status is improving in some places in the world but not
in others.

■ There are enormous differences in the health status of
individuals within countries, as well as across countries.

■ The health differences within countries are closely linked with
social disadvantage.

■ Many of these differences should be considered avoidable, and
they relate to the way in which people live and work and the
health systems that should serve them.

■ People’s life circumstances, and therefore their health, are
profoundly related to political, social, and economic forces.

■ Countries need to ensure that these forces are oriented toward
improving the life circumstances of the poor, thereby enabling
them to enjoy a healthier life as well. The global community
should also work toward this end.

We should also note the importance to health of child
development, including the ways in which families nourish and
care for infants and young children, beginning at conception.
Being born premature or of low birthweight can have important
negative consequences on health over the life course. There is a
strong correlation between the nutritional status of infants and
young children and the extent to which they meet their biological
and intellectual potential, enroll in school, or stay in school. In
addition, poor nutritional status in infancy and early childhood may
be linked with a number of noncommunicable diseases later in life,
including diabetes and heart disease. There is also considerable
evidence that a range of stressors, including poverty, abuse, and

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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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discrimination, have a powerful impact on the health of children
that may continue through adulthood.

Finally, as we think about the determinants and social
determinants of health, it is important to consider how, directly and
indirectly, different factors influence health. One framework for
such consideration is shown in FIGURE 2-2. This framework
places the determinants of health into three categories based on
the directness of their influence on health: root causes at the
macro/societal level; underlying causes at the meso/community
level; and proximal causes at the immediate/interpersonal level.
Viewing the determinants of health in this manner should also be
helpful in assessing why health conditions exist and what can be
done to address them.

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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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FIGURE 2-2 Selected Examples of Root, Underlying, and
Immediate Determinants of Health

Modified with permission from Bouwman, L., Wentink, C., & Ormond, M. (2017, April

6). Global Health, W3 Tutorial 3: Determinants [Powerpoint Slides], Based on

Northridge.

Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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▶ Key Health Indicators
It is critical that we use data and evidence to understand and
address key global health issues. Some types of health data
concern the health status of people and communities, such as
measures of life expectancy and infant and child mortality, as
discussed further hereafter. Some concern health services, such
as the number of nurses and doctors per capita in a country or the
indicators of coverage for certain health services, such as
immunization. Other data concern the financing of health, such as
the amount of public expenditure on health or the share of national
income represented by health expenditure.

There are a number of very important uses of data on health
status. We need data, for example, to know from what health
conditions people suffer. We also need to know the extent to which
these conditions cause people to be sick, be disabled, or die. We
need data to carry out disease surveillance. This helps us
understand if particular health problems such as cancer, influenza,
polio, or malaria are occurring, where they are infecting people,
who is getting infected, and what might be done to address these
conditions. Other forms of data also help us to understand the
burden of different health conditions, the relative importance of
them to different societies, and the importance that should be
given to dealing with them.

If we are to use data in the previously mentioned ways, then it is
important that we use a consistent set of indicators to measure
health status. In this way, we can make comparisons across
people in the same country or across different countries. There
are, in fact, a number of indicators that are used most commonly
by those who work in global health and in development work.
These are listed and defined in TABLE 2-1.

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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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TABLE 2-1 Key Health Status Indicators

The section that follows will examine these key indicators of health
status in two ways, first by World Bank region and second by
country income group. The graphics will reflect a number of points
quite starkly:

■ There is a very strong correlation between country income
group and health status. The lower the income group, the lower
the status; the higher the income group, the higher the status.

■ In all cases, sub-Saharan Africa has the worst health indicators
of all World Bank regions, and South Asia has the second worst
health indicators.

You will understand better as you progress in your study of global
health that part of the relatively low health status of sub-Saharan
Africa and South Asia is related to the fact that these are the two
regions with the lowest per capita income. However, as you will

Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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read about here and elsewhere, their relatively low health status
also has to do with government policies and programs, the lack of
safe water and sanitation, low levels of education, and a number
of other factors.

It is also important to understand that country income level does
not have to determine a country’s health status. Rather, as you will
also read about throughout this text and elsewhere, resource-poor
countries that make wise policy choices in fair ways can enable
better health for their people than their income level might
suggest. This has certainly been the case for a number of
countries whose development history is well known, such as
Cuba, Sri Lanka, and China. Thus, it will be essential as you think
about key issues in global health to always keep in mind questions
about which policies can help to achieve the best health for any
population at the least cost and in fair, doable, and sustainable
ways. In light of all this, let us now turn to exploring the specific
health indicators.

Among the most commonly used indicators of health status is life
expectancy at birth. Life expectancy at birth is “the average
number of additional years a newborn baby can be expected to
live if current mortality trends were to continue for the rest of that
person’s life.” In other words, it measures how long a person
born today can expect to live, if there were no change in their
lifetime in the present rate of death for people of different ages.
The higher the life expectancy at birth, the better the health status
of a country. In the United States, a high-income country, life
expectancy at birth in 2016 was about 79 years; in Jordan, a
middle-income country, life expectancy was 74 years; in Sierra
Leone, a very low-income country, life expectancy was 52 years.

FIGURE 2-3 shows life expectancy at birth by country income
level. This figure shows an exceptional correlation between
country income group and life expectancy. It also shows the range

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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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of life expectancy across country income groups, from 63 years in
low-income countries to 29 percent higher, or 81 years, in high-
income countries.

FIGURE 2-3 Life Expectancy at Birth by World Bank Country
Income Group, 20

16

Data from The World Bank. (n.d.). Data: Life expectancy at birth, total (years).

Retrieved from https://data.worldbank.org/indicator/SP.DYN.LE00.IN?

end=2016&locations=XD-XT-XN-XM&start=2016&view=bar

FIGURE 2-4 shows life expectancy by World Bank region. It
reflects the points noted previously, with sub-Saharan Africa and
South Asia having the lowest life expectancy. It is also important to
note that the region with the highest life expectancy has a life
expectancy that is 19 years, or about 30 percent, greater than the
region with the lowest life expectancy.

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https://data.worldbank.org/indicator/SP.DYN.LE00.IN?end=2016&locations=XD-XT-XN-XM&start=2016&view=bar

FIGURE 2-4 Life Expectancy at Birth by World Bank Region,
2016

Data from The World Bank. (n.d.). Data: Life expectancy at birth, total (years).

Retrieved from https://data.worldbank.org/indicator/SP.DYN.LE00.IN?

end=2016&locations=Z4-ZG-8S-ZJ-Z7-ZQ&start=2016&view=bar

The maternal mortality ratio is a measure of the risk of death
that is associated with childbirth. Because these deaths are more
rare than infant and child deaths, the maternal mortality ratio is
measured as “the number of women who die as a result of
pregnancy and childbirth complications per 100,000 live births in a
given year.” The rarity of maternal deaths and the fact that
they largely occur in low-income settings also contribute to
maternal mortality being quite difficult to measure. Very few
women die in childbirth in rich countries; for example, the maternal

16(p28)

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https://data.worldbank.org/indicator/SP.DYN.LE00.IN?end=2016&locations=Z4-ZG-8S-ZJ-Z7-ZQ&start=2016&view=bar

mortality ratio in Sweden in 2016 was 4 per 100,000 live births. On
the other hand, in very poor countries, in which women have low
status and where there are few facilities for dealing with obstetric
emergencies, the ratios can be over 700 per 100,000 live births,
as they were in 2016, for example, in the Central African Republic,
Liberia, Nigeria, Somalia, and South Sudan. In the worst-off
country for maternal health, Sierra Leone, the maternal mortality
ratio is estimated to be 1,360 per 100,000 live births.

FIGURE 2-5 gives the maternal mortality ratio by country income
group, and FIGURE 2-6 shows the same data by World Bank
region.

18

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FIGURE 2-5 Maternal Mortality Ratio by World Bank Country
Income Group, 2015

Data from The World Bank. (n.d.). Data: Maternal mortality ratio (modeled estimate,

per 100,000 live births). Retrieved from

https://data.worldbank.org/indicator/SH.STA.MMRT?end=2014&locations=XM-

XD-XT-XN&start=2014&view=bar

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https://data.worldbank.org/indicator/SH.STA.MMRT?end=2014&locations=XM-XD-XT-XN&start=2014&view=bar

FIGURE 2-6 Maternal Mortality Ratio by World Bank Region,
2015

Data from World Bank. (n.d.). Data: Maternal mortality ratio (modeled estimate, per

1,000 live births). Retrieved from

https://data.worldbank.org/indicator/SH.STA.MMRT?end=2015&locations=Z4-

8S-ZG-Z7-XU-ZJ-ZQ&start=2015&view=bar

As suggested earlier, the pattern of the maternal mortality ratio, by
both country income group and region, is similar to that for life
expectancy. However, the differences among regions and country
income groups are even greater. The low-income group, with the
worst maternal mortality ratio, has a 50 times greater ratio than the
high-income group. Sub-Saharan Africa has a ratio that is 42 times
greater than in North America. Many people believe that the
maternal mortality ratio is the indicator that is most sensitive to a

Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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https://data.worldbank.org/indicator/SH.STA.MMRT?end=2015&locations=Z4-8S-ZG-Z7-XU-ZJ-ZQ&start=2015&view=bar

country’s overall development status and best reflects the place of
women in different societies.

Another important and widely used indicator is the infant
mortality rate. The infant mortality rate is “the number of deaths
of infants under age 1 per 1,000 live births in a given year.”
This rate is expressed in deaths per 1,000 live births. In other
words, it measures how many children younger than 1 year of age
will die for every 1,000 who were born alive that year. Each
country seeks as low a rate of infant mortality as possible, but we
will see that the rate varies largely with the income status of a
country. Afghanistan, for example, had an infant mortality rate in
2016 of 53 infant deaths for every 1,000 live births, whereas in
Sweden only about 2 infants die for every 1,000 live births.
FIGURE 2-7 shows the infant mortality rate by country income
group. FIGURE 2-8 shows the infant mortality rate by World Bank
region.

16(p28)

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FIGURE 2-7 Infant Mortality Rate by World Bank Country
Income Group, 2016

Data from The World Bank. (n.d.). Data: Mortality rate, infant (per 1,000 live births).

Retrieved from https://data.worldbank.org/indicator/SP.DYN.IMRT.IN?

locations=XD-XT-XN-XM

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https://data.worldbank.org/indicator/SP.DYN.IMRT.IN?locations=XD-XT-XN-XM

FIGURE 2-8 Infant Mortality Rate by World Bank Region, 2016

Data from The World Bank. (n.d.). Data: Mortality rate, infant (per 1,000 live births).

Retrieved from https://data.worldbank.org/indicator/SP.DYN.IMRT.IN?

end=2016&locations=Z4-ZG-8S-ZJ-Z7-ZQ-XU&start=2016&view=bar

There are no surprises for these data either, which vary in the
same directions as life expectancy and the maternal mortality
ratio. In this case, however, the highest rates of infant mortality are
both about 10 times greater than the lowest rates.

Although the infant mortality rate is a powerful indicator of the
health status of a country, most children younger than 1 year of
age who die actually die in the first month of life. Thus, the
neonatal mortality rate is also an important health status
indicator. This rate measures “the number of deaths to infants
younger than 28 days of age in a given year, per 1,000 live births

16(p60)

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https://data.worldbank.org/indicator/SP.DYN.IMRT.IN?end=2016&locations=Z4-ZG-8S-ZJ-Z7-ZQ-XU&start=2016&view=bar

in that year.” Like the infant mortality rate, this rate will
generally vary directly with the level of income of different
countries. Poorer countries will usually have a much higher
neonatal mortality rate than richer countries. Sierra Leone, among
the poorest countries in the world, had a neonatal mortality rate of
33 per 1,000 live births in 2016. In Norway, one of the highest-
income countries in the world, the rate that year was 2 per 1,000
live births. The neonatal mortality rate by country income group
is given in FIGURE 2-9, and the data by World Bank region are
portrayed in FIGURE 2-10.

16(p60)

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FIGURE 2-9 Neonatal Mortality Rate by World Bank Country
Income Group, 2016

Data from The World Bank. (n.d.). Data: Mortality rate, neonatal (per 1,000 live births).

Retrieved from https://data.worldbank.org/indicator/SH.DYN.NMRT?

end=2016&locations=XD-XT-XN-XM&start=2016&view=bar

Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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https://data.worldbank.org/indicator/SH.DYN.NMRT?end=2016&locations=XD-XT-XN-XM&start=2016&view=bar

FIGURE 2-10 Neonatal Mortality Rate by World Bank Region,
2016

Data from The World Bank. (n.d.). Data: Mortality rate, neonatal (per 1,000 live births).

Retrieved from https://data.worldbank.org/indicator/SH.DYN.NMRT?

end=2016&locations=Z4-Z7-XU-ZG-8S-ZQ-ZJ&start=2016&view=bar

The poorest countries have a neonatal mortality rate that is 9
times that of the best-off countries. The two regions with the worst
rates have neonatal mortality rates that are 7 times higher than the
region with the best rate.

The under-5 child mortality rate is also called the child mortality
rate. This is “the probability that a newborn will die before reaching
age five, expressed as a number per 1,000 live births.” Like the
infant mortality rate, this rate is expressed per 1,000 live births.

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https://data.worldbank.org/indicator/SH.DYN.NMRT?end=2016&locations=Z4-Z7-XU-ZG-8S-ZQ-ZJ&start=2016&view=bar

This rate also varies largely with the wealth of a country. In the
highest-income countries, the rate is generally about 3 to 5 per
1,000 live births. However, in some of the poorest countries, such
as Chad, the rate can be over 125 per 1,000 live births. The
under-5 child mortality rate is depicted in FIGURE 2-11 by country
income group and in FIGURE 2-12 by World Bank region.

FIGURE 2-11 Under-5 Mortality Rate by World Bank Country
Income Group, 2016

Data from The World Bank. (n.d.). Data: Mortality rate, under-5 (per 1,000 live births).

Retrieved from https://data.worldbank.org/indicator/SH.DYN.MORT?

end=2016&locations=Z4-Z7-ZJ-ZG-8S-XU-ZQ&start=2016&view=bar

21

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https://data.worldbank.org/indicator/SH.DYN.MORT?end=2016&locations=Z4-Z7-ZJ-ZG-8S-XU-ZQ&start=2016&view=bar

FIGURE 2-12 Under-5 Mortality Rate by World Bank Region,
2016

Data from The World Bank. (n.d.). Data: Mortality rate, under-5 (per 1,000 live births).

Retrieved from https://data.worldbank.org/indicator/SH.DYN.MORT?

end=2016&locations=Z4-Z7-ZJ-ZG-8S-XU-ZQ&start=2016&view=bar

As expected, the relative standing of different regions in under-5
child mortality, as shown in the figures, looks very similar to that
for neonatal mortality and for infant mortality. In both cases for
under-5 child mortality, however, the highest rates are about 15
times the lowest rates. To a large extent, this reflects the fact that
in high-income countries the risks for young child death post-
infancy are relatively few, but in the least well-off regions,
especially in sub-Saharan Africa, there are substantial risks to

Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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https://data.worldbank.org/indicator/SH.DYN.MORT?end=2016&locations=Z4-Z7-ZJ-ZG-8S-XU-ZQ&start=2016&view=bar

child health not only for neonates and infants but also between a
child’s first and fifth years. This is illustrated in FIGURE 2-13.

FIGURE 2-13 Under-5, Infant, and Neonatal Mortality Rate, by
World Bank Region, 2016

Data from the World Bank. Data. Mortality rate, infant (per 1,000 live births), Mortality

rate, under-5 (per 1,000 live births), Mortality rate, neonatal (per 1,000 live births).

Retrieved from https://data.worldbank.org/

A few other concepts and definitions are important to understand
as we think about measuring health status. The first is morbidity.
Essentially, this means sickness or any departure, subjective or
objective, from a psychological or physiological state of well-being.
Second is mortality, which refers to death. A death rate is the
number of deaths per 1,000 population in a given year. The16(p25)

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https://data.worldbank.org/

third is disability. Although some conditions cause people to get
sick or die, they might also cause people to suffer the “temporary
or long-term reduction in a person’s capacity to function.”

There will also be considerable discussion in most readings on
global health of the prevalence of health conditions. This refers to
the number of people suffering from a certain health condition over
a specific time period. It measures the chances of having a
disease. For global health work, one usually refers to point
prevalence of a condition, which is “the proportion of the
population that is diseased at a single point in time.” Let’s
say, for example, that the point prevalence of HIV/AIDS among
adults in South Africa was estimated to be 18.9 on the last day of
2016. This means that 18.9 percent of all adults between the ages
of 15 and 49 in South Africa were estimated that day to be HIV-
positive.

The incidence rate is also a very commonly used term. This
measures how many people get a disease, for a specified number
of people at risk, for a given period of time. The denominator for
the rate usually depends on how commonly the disease occurs in
a year and is often per 1,000 or per 100,000 people. In India, for
example, the incidence rate for tuberculosis (TB) in 2016 was 211
per 100,000 people. This means that for every 100,000 people in
India, 211 got active TB disease in 2016.

Many people confuse incidence rate and prevalence rate. It may
be convenient to think of prevalence as the pool of people with a
disease at a particular time and incidence as the flow of new
cases of people with that disease into that pool. You should note,
of course, that the size of the pool will vary as new cases flow into
the pool and old cases flow out, as they die or are cured.

We will also speak about primary prevention, secondary
prevention, and tertiary prevention. These are defined as

22(p51)

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follows:

Primary prevention: Intervening before health effects
occur, through measures such as vaccinations,
altering risky behaviors (poor eating habits, tobacco
use, etc.), and banning substances known to be
associated with a disease or health condition.

Secondary prevention: Screening to identify
diseases in the earliest stages, before the onset of
signs and symptoms, through measures such as
mammography and regular blood pressure testing.

Tertiary prevention: Managing disease post
diagnosis to slow or stop disease progression
through measures such as chemotherapy,
rehabilitation, and screening for complications.

Finally, one needs to be familiar with how diseases get classified.
When you read about health, there will be discussions of
communicable diseases, noncommunicable diseases, and
injuries. Communicable diseases are also called infectious
diseases. These are illnesses that are caused by a particular
infectious agent and that spread directly or indirectly from people
to people, animals to people, or people to animals. Examples of
communicable diseases include influenza, measles, and HIV.
Noncommunicable diseases are illnesses that are not spread by
any infectious agent, such as hypertension, coronary heart
disease, and diabetes, even though they might have an infectious
cause, such as cervical cancer. Injuries include, among other
things, road traffic injuries, falls, drownings, poisonings, and
violence.

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▶ Vital Registration
The quality of data on population and health depends in many
ways on the extent to which countries maintain a system of vital
registration that can accurately record births, deaths, and the
causes of death. Unfortunately, this is not the case in many low-
and lower middle-income countries. They generally have only
rudimentary systems for vital registration, which cannot fulfill either
their statistical or their legal purposes. In addition, access to vital
registration systems is highly inequitable, with higher-income
groups enjoying much better access than less well-off people
(FIGURE 2-14). UNICEF estimates that about 25 percent of all of
the births in the world are never registered.

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FIGURE 2-14 Percentage of Children Under 5 Whose Births
Have Been Registered, by Income Quintile for Selected UNICEF

Regions, 2005–2012

Data from UNICEF. (2013). Every child’s birth right: Inequities and trends in birth

registration. Retrieved from

http://www.unicef.org/media/files/Embargoed_11_Dec_Birth_Registration_report_low_res

There are also cultural barriers to timely vital registration because
people in many countries wait until a child is a certain age before
registering the birth. Coupled with the lack of access to vital
registration, this means the existence of some children is never
officially known because they die before their births are registered.
There are also enormous difficulties with accurate indications of
causes of death in countries that have weak health systems and a
limited number of well-trained physicians. This is especially so for
causes of death of adults.

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http://www.unicef.org/media/files/Embargoed_11_Dec_Birth_Registration_report_low_res

The former director-general of WHO, Lee Jong-Wook, noted in a
speech to his colleagues: “To make people count, we first need to
be able to count people.” To overcome the lack of effective
vital registration systems in many low- and middle-income
countries, a number of tools, such as surveys and projection
models, have been developed. Some, like the Demographic and
Health Surveys, have become an important source of information
about health, population, nutrition, and HIV in low-income
countries.

In the longer term, however, the world would be better served by
helping countries further develop their own vital registration
systems. This would allow countries and their development
partners to more accurately gauge the nature of key demographic
and health issues and the progress made toward resolving them.
Moving in this direction will require assessments of vital
registration systems. It will also require programs to improve the
organization and functioning of vital registration departments. This
will have to include, among other things, strengthening their
methods to improve the quality of vital statistics, including for the
causes of death, and enhancing their approach to publishing
data.

29(p1569)

27

Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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▶ Main Messages
To understand the most important global health issues, we must
understand the determinants of health, how health status is
measured, and how health status varies by country income group,
region, age, and sex. There are a number of factors that influence
health status, including genetic makeup, sex, and age. Social and
cultural issues and health behaviors are also closely linked to
health status. The determinants of health also include education,
nutritional status, and socioeconomic status. The environment is
also a powerful determinant of health, as is access to health
services, and the policy approaches that countries take to their
health sectors and to investments that could influence the health
of their people. Increasing attention is being paid to the social
determinants of health. Some determinants have a more direct
influence than others, whose influence is more indirect.

There are a number of uses of health data, including measuring
health status, carrying out disease surveillance, making decisions
about investments in health, and assessing the performance of
health programs. Those working in health use a common set of
indicators to measure health status, including life expectancy,
infant and neonatal mortality, under-5 child mortality, and the
maternal mortality ratio. Vital registration systems are weak in low-
income countries and need to be strengthened to improve the
quality of health data.

There has been progress in all regions of the world in increasing
life expectancy over the last several decades. In addition, the pace
of those increases has been exceptionally rapid in East Asia and
the Pacific. However, it is clear that the basic health indicators are
much worse in sub-Saharan Africa than in any other region and
that these indicators also lag substantially in South Asia.

Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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Study Questions
1. What do we mean when we talk about “the determinants

of health”?
2. Which determinants have a more direct and which have a

less direct impact on people’s health?
3. Why are the social determinants of health considered to

be so important?
4. What are the factors that have most determined your

personal health?
5. What are the factors that would most determine the health

of a poor person in a low-income country?
6. If you could pick only one indicator to describe the health

status of a low-income country, which indicator would you
use and why?

7. In your own country, what population groups have the best
health indicators and why?

8. In your country, what population groups have the worst
health status and why?

9. What might prevent a country from having an effective vital
registration system, and how could such systems be
strengthened?

10. How much credence should you put in data on key global
health indicators?

References
1. World Health Organization. (2004). A global emergency: A
combined response. In The world health report 2004—
Changing history (pp. 1–10). Geneva, Switzerland: Author.

2. The World Bank. (n.d.). Data: Life expectancy at birth, males
(years). Retrieved from
https://data.worldbank.org/indicator/SP.DYN.LE00.MA.IN?
view=map

Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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https://data.worldbank.org/indicator/SP.DYN.LE00.MA.IN?view=map

3. The World Bank. (n.d.). Data: Life expectancy at birth,
females (years). Retrieved from
https://data.worldbank.org/indicator/SP.DYN.LE00.FE.IN?
view=map

4. The World Bank. (2015). Data: Maternal mortality ratio
(modeled estimate, per 100,000 live births). Retrieved from
https://data.worldbank.org/indicator/SH.STA.MMRT?
end=2014&locations=XM-XD-XT-
XN&start=2014&view=bar

5. The World Bank. (n.d.). Data: Mortality rate, under-5 (per
1,000 live births). Retrieved from
https://data.worldbank.org/indicator/SH.DYN.MORT?
end=2016&locations=Z4-Z7-ZJ-ZG-8S-XU-
ZQ&start=2016&view=bar

6. World Health Organization. (1998). Determinants of health. In
Health promotion glossary (p. 6). Retrieved from
http://www.who.int/healthpromotion/about/HPR%20Glossary%201998 ?
ua=1

7. World Health Organization. (n.d.). About social determinants
of health. Retrieved from
http://www.who.int/social_determinants/sdh_definition/en/

8. Reblin, M., & Uchino, B. N. (2008). Social and emotional
support and its implication for health. Current Opinion in
Psychiatry, 21(2), 201.

9. Public Health Agency of Canada. (2018). Social determinants
of health and health inequalities. Retrieved from
http://www.phac-aspc.gc.ca/ph-sp/determinants/index-
eng.php

10. Centers for Disease Control and Prevention. (2014). Social
determinants of health: Definitions. Retrieved
http://www.cdc.gov/socialdeterminants/Definitions.html

Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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https://data.worldbank.org/indicator/SP.DYN.LE00.FE.IN?view=map

https://data.worldbank.org/indicator/SH.STA.MMRT?end=2014&locations=XM-XD-XT-XN&start=2014&view=bar

https://data.worldbank.org/indicator/SH.DYN.MORT?end=2016&locations=Z4-Z7-ZJ-ZG-8S-XU-ZQ&start=2016&view=bar

http://www.who.int/healthpromotion/about/HPR%20Glossary%201998 ?ua=1

http://www.who.int/social_determinants/sdh_definition/en/

http://www.phac-aspc.gc.ca/ph-sp/determinants/index-eng.php

http://www.cdc.gov/socialdeterminants/Definitions.html

11. Hobcraft, J. (1993). Women’s education, child welfare and
child survival: A review of the evidence. Health Transition
Review, 3(2), 159–173.

12. World Health Organization. (2008). Commission on social
determinants of health. Closing the gap in a generation.
Retrieved from
http://www.who.int/social_determinants/thecommission/finalreport/en/index.html

13. The World Bank. (2006). Repositioning nutrition as central to
development—A strategy for large-scale action. Washington,
DC: Author.

14. Shonkoff, J. P., Garner, A. S., The Committee on
Psychosocial Aspects of Child and Family Health, Committee
on Early Childhood, Adoption, and Dependent Care, &
Section on Developmental and Behavioral Pediatrics. (2012).
The lifelong effects of early childhood adversity and toxic
stress. Pediatrics, 129(1), e232–e246.

15. Basch, P. (2001). Textbook of international health (2nd ed.).
New York, NY: Oxford University Press.

16. Haupt, A., & Kane, T. T. (2004). Population handbook.
Washington, DC: Population Reference Bureau.

17. The World Bank. (n.d.). Data: Life expectancy at birth, total
(years). Retrieved from
https://data.worldbank.org/indicator/SP.DYN.LE00.IN

18. The World Bank. (2015). Data: Maternal mortality ratio
(modeled estimate, per 100,000 live births). Retrieved from
https://data.worldbank.org/indicator/SH.STA.MMRT

19. The World Bank. (n.d.). Data: Mortality rate, infant (per 1,000
live births). Retrieved from
https://data.worldbank.org/indicator/SP.DYN.IMRT.IN

20. The World Bank. (n.d.). Data: Mortality rate, neonatal (per
1,000 live births). Retrieved from
https://data.worldbank.org/indicator/SH.DYN.NMRT

Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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http://www.who.int/social_determinants/thecommission/finalreport/en/index.html

https://data.worldbank.org/indicator/SP.DYN.LE00.IN

https://data.worldbank.org/indicator/SH.STA.MMRT

https://data.worldbank.org/indicator/SP.DYN.IMRT.IN

https://data.worldbank.org/indicator/SH.DYN.NMRT

21. The World Bank. (n.d.). Data: Mortality rate, under-5 (per
1,000 live births). Retrieved from
http://data.worldbank.org/indicator/SH.DYN.MORT

22. Last, J. M. (2001). A dictionary of epidemiology (4th ed.). New
York, NY: Oxford University Press.

23. The World Bank. (n.d.). Data: Prevalence of HIV, total (% of
population ages 15–49). Retrieved from
https://data.worldbank.org/indicator/SH.DYN.AIDS.ZS?
view=chart

24. The World Bank. (n.d.). Data: Incidence of tuberculosis (per
100,000 people). Retrieved from
https://data.worldbank.org/indicator/SH.TBS.INCD

25. U.S. Centers for Disease Control and Prevention. (n.d.).
Prevention: Picture of America. Retrieved from
https://www.cdc.gov/pictureofamerica/pdfs/picture_of_america_prevention

26. Lopez, A. D., Mathers, C. D., & Murray, C. J. L. (2006). The
burden of disease and mortality by condition: Data, methods,
and results for 2001. In A. D. Lopez, C. D. Mathers, M. Ezzati,
D. T. Jamison, & C. J. L. Murray (Eds.), Global burden of
disease and risk factors (pp. 45–240). New York, NY: Oxford
University Press.

27. Setel, P. W., Macfarlane, S. B., Szreter, S., Mikkelsen, L.,
Jha, P., Stout, S., & AbouZahr, C. (2007). A scandal of
invisibility: Making everyone count by counting everyone. The
Lancet, 370(9598), 1569–1577.

28. UNICEF. (2017). Birth registration. Retrieved from
https://data.unicef.org/topic/child-protection/birth-
registration/

29. World Health Organization. (2003). Address to WHO staff.
Geneva, Switzerland: Author. Retrieved from
http://www.who.int/dg/lee/speeches/2003/21_07/en/

Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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http://data.worldbank.org/indicator/SH.DYN.MORT

https://data.worldbank.org/indicator/SH.DYN.AIDS.ZS?view=chart

https://data.worldbank.org/indicator/SH.TBS.INCD

https://www.cdc.gov/pictureofamerica/pdfs/picture_of_america_prevention

Birth registration

http://www.who.int/dg/lee/speeches/2003/21_07/en/

Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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