What new IT Ethics challenges exist?

What new IT Ethics challenges exist?

Here is a description of the project assignment for which you must address all of the following criteria as that is the basis for rubric grading.

Objective: Prepare a text-only report with a total minimum of 750 words based on the following assignment criteria.

Note: You must produce this project report in your original expression. Also, do not quote any source text and do not include any graphics of any kind in your project papers. Only use text and original expression – only that will be counted in addressing the minimum word count and addressing the topic criteria. Submission Requirements: Submit the assignment response for grading in your corresponding project Assignments Folder as a single attached Microsoft Word file (as an .rtf or .doc format file) before 11:59PM ET on the last day of course week 8.

Consider this report as a reflective of your individual learning outcomes as it applies to ethics in information technology. It describes your Ah-ha moments. I hope this course made you think about the ethical trade-offs that occur in your personal and professional contexts and how we go about making our ethical choices.

You can use the ideas you learned from this course; how you will synthesize what you learned from your research about your topic including – over-arching issues, readings, discussion from class, and conclusions from other assignments that apply to your research.

Address each the following questions as required headings in this order:

What were your Take-aways?

From an individual learning perspective, what were some of your learning outcomes (aka, takeaways)?

What were the Impacts?

How has this learning experience impacted your understanding of the ethical issues?

What will you do differently?

In what manner might your newly acquired understanding influence your subsequent response to situations in information technology that possess an ethical dimension?

What would influence your career?

How might what you have learned in this course influence your career?

What new IT Ethics challenges exist?

With the continuing trend towards globalization and other emerging trends, what specific new challenges do you anticipate relating to ethics in IT?

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Prepare a 350- to 700-word paper in which you explain your thought process while completing the You Make the Call: Discretion in Criminal Justice Police Patrol simulation

Prepare a 350- to 700-word paper in which you explain your thought process while completing the You Make the Call: Discretion in Criminal Justice Police Patrol simulation

Include the following in your paper:

Describe the thinking and critical thinking skills you used to make decisions during the simulation.

Describe ways in which you think you can improve your personal thought processes.

Explain how critical thinking skills are used by police officers, as well as how professional and personal barriers may affect the use of critical thinking skills by police officers.

Format your paper consistent with APA guidelines.

Select the Assignment Files tab to submit your assignment.

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Thinking Versus Critical Thinking assignment

Thinking Versus Critical Thinking assignment

Write a 350- to 700-word paper in which you explain your thought process while completing the You Make the Call: Discretion in Criminal Justice Police Patrol simulation. Include the following in your paper:

Describe the thinking and critical thinking skills you used to make decisions during the simulation.

Describe ways in which you think you can improve your personal thought processes.

Explain how critical thinking skills are used by police officers, as well as how professional and personal barriers may affect the use of critical thinking skills by police officers.

Format your paper consistent with APA guidelines.

Select the Assignment Files tab to submit your assignment.

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Globalization and infectious disease

Globalization and infectious disease

UNICEF/UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases (TDR)

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SPECIAL TOPICS NO.3

Globalization and infectious diseases: A review of the linkages

TDR/STR/SEB/ST/04.2

The “Special Topics in Social, Economic and Behavioural (SEB) Research” series are peer-reviewed publications commissioned by the TDR Steering Committee for Social, Economic and Behavioural Research.

For further information please contact:

Dr Johannes Sommerfeld Manager Steering Committee for Social, Economic and Behavioural Research (SEB) UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland

E-mail: sommerfeldj@who.int

Globalization and infectious diseases: A review of the linkages

Lance Saker,1 MSc MRCP Kelley Lee,1 MPA, MA, D.Phil. Barbara Cannito,1 MSc Anna Gilmore,2 MBBS, DTM&H, MSc, MFPHM Diarmid Campbell-Lendrum,1 D.Phil.

1 Centre on Global Change and Health London School of Hygiene & Tropical Medicine Keppel Street, London WC1E 7HT, UK

2 European Centre on Health of Societies in Transition (ECOHOST) London School of Hygiene & Tropical Medicine Keppel Street, London WC1E 7HT, UK

TDR/STR/SEB/ST/04.2

TDR/STR/SEB/ST/04.2

Copyright © World Health Organization on behalf of the Special Programme for Research and Training in Tropical Diseases 2004 All rights reserved.

The use of content from this health information product for all non-commercial education, training and information purposes is encouraged, including translation, quotation and reproduction, in any medium, but the content must not be changed and full acknowledgement of the source must be clearly stated. A copy of any resulting product with such content should be sent to TDR, World Health Organization, Avenue Appia, 1211 Geneva 27, Switzerland. TDR is a World Health Organization (WHO) execut- ed UNICEF/UNDP/World Bank/World Health Organization Special Programme for Research and Training in Tropical Diseases.

This information product is not for sale. The use of any information or content whatsoever from it for publicity or advertising, or for any commercial or income-generating purpose, is strictly prohibited. No elements of this information product, in part or in whole, may be used to promote any specific individual, entity or product, in any manner whatsoever.

The designations employed and the presentation of material in this health information product, including maps and other illus- trative materials, do not imply the expression of any opinion whatsoever on the part of WHO, including TDR, the authors or any parties cooperating in the production, concerning the legal status of any country, territory, city or area, or of its authori- ties, or concerning the delineation of frontiers and borders.

Mention or depiction of any specific product or commercial enterprise does not imply endorsement or recommendation by WHO, including TDR, the authors or any parties cooperating in the production, in preference to others of a similar nature not men- tioned or depicted.

The views expressed in this health information product are those of the authors and do not necessarily reflect those of WHO, including TDR.

WHO, including TDR, and the authors of this health information product make no warranties or representations regard- ing the content, presentation, appearance, completeness or accuracy in any medium and shall not be held liable for any dam- ages whatsoever as a result of its use or application. WHO, including TDR, reserves the right to make updates and changes with- out notice and accepts no liability for any errors or omissions in this regard. Any alteration to the original content brought about by display or access through different media is not the responsibility of WHO, including TDR, or the authors.

WHO, including TDR, and the authors accept no responsibility whatsoever for any inaccurate advice or information that is pro- vided by sources reached via linkages or references to this health information product.

Acknowledgement The authors wish to thank colleagues at the Centre on Global Change and Health, London School of Hygiene and Tropical Medicine, for their helpful advice in the writing of this paper. We are particularly grateful to Professor David Bradley for his detailed comments and expertise in reviewing the final draft..

Design and layout: Lisa Schwarb

TABLE OF CONTENTS

LIST OF TABLES, FIGURES AND BOXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

ABBREVIATIONS AND ACRONYMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

  1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
  2. BACKGROUND 2.1 What is globalization? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2.2 Global burden of infectious disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
  3. GLOBALIZATION AND THE CHANGING NATURE OF INFECTIOUS DISEASE . . . . . . . . . . . 9
  4. ECONOMIC GLOBALIZATION AND INFECTIOUS DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 4.1 World Trade Organization and multilateral trade agreements . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 4.2 The global trade in food . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 4.3 The global trade in pharmaceuticals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

5 GLOBAL ENVIRONMENTAL CHANGE AND INFECTIOUS DISEASE . . . . . . . . . . . . . . . . . . . . . 17 5.1 Global climate change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

5.1.1 Global warming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 5.1.2 Global weather change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 5.1.3 Vulnerability to global climate changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

5.2 Water supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 5.2.1 Large dams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 5.2.2 Small water projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 5.2.3 Displacements, disruptions, distant effects and migrations . . . . . . . . . . . . . . . . . . . . . . . 29

5.3 Deforestation and land clearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 5.3.1 Deforestation, land clearance and “new” or “emerging” infections . . . . . . . . . . . . . . . 31 5.3.2 Vector-borne infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 5.3.3 Pharmacological implications of loss of biodiversity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

6 GLOBAL DEMOGRAPHIC CHANGE AND INFECTIOUS DISEASE 6.1 Globalization and population mobility

6.1.1 Trends in population mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 6.1.2 The causes of population mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 6.1.3 Population mobility and infectious disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

6.2 Refugees and displaced persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 6.3 Long-term migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

6.3.1 Migration to low-income countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 6.3.2 Migration to high-income countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

6.4 Urbanization 6.4.1 The growth in urban populations and the influence of globalization . . . . . . . . . . . . . . 39 6.4.2 Urbanization and infectious disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

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7 GLOBAL TECHNOLOGICAL CHANGE AND INFECTIOUS DISEASE . . . . . . . . . . . . . . . . . . . . . . 45 7.1 Information and communication technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 7.2 Transportation technologies: the growth in short-term travel . . . . . . . . . . . . . . . . . . . . . . . . . . 46

7.2.1 The growth in short-term travel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 7.2.2 Short-term travel and infectious diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 7.2.3 Transport of goods and infectious diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

7.3 Medical technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

8 CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Special Topics No. 3 • Globalization and infectious diseases: A review of the linkages v

BOXES

Box 1: Transmission of infectious diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Box 2: Infectious diseases and the natural environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Box 3: Preventing and treating human infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Box 4: Projections of the health impacts of global environmental change . . . . . . . . . . . . . . . . . . 17

Box 5: The scientific evidence for global environmental change . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Box 6: Global climate change and vector-borne diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

Box 7: Climate effects on vectorial capacity, basic reproductive number, vector abundance and distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Box 8: El Niño and infectious diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Box 9: Infection and water projects along the Nile river . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Box 10: Malaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Box 11: Dengue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Box 12: Infectious disease and the Haj . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

FIGURES

Figure 1: Alternative scenarios of future development and associated climate change

developed by the IPCC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Figure 2: Global average near-surface temperatures, 1860-1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Figure 3: The global average temperature rise predicted from the unmitigated emissions scenario, and the emission scenario which stabilizes CO2 concentrations at 750 ppm and at 550 ppm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

LIST OF TABLES, BOXES AND FIGURES

ACL anthroponotic cutaneous leishmaniasis

AVL anthroponotic visceral leishmaniasis

CME WHO Commission on Macroeconomics and Health

DALY disability adjusted life year

DNA deoxyribonucleic acid

ENSO El Niño Southern Oscillation

EWE extreme weather events

FAO Food and Agriculture Organization

FDI foreign direct investment

GATS General Agreement on Trade in Services

GATT General Agreement on Tariffs and Trade

GBDS Global Burden of Disease Study

GDP gross domestic product

GIS geographical information system

HIV/AIDS human immunodeficiency virus/acquired immunity deficiency syndrome

ICT information and communication technologies

ID infectious diseases

IHA International Health Regulations

ILO International Labour Organization

IPCC Intergovernmental Panel on Climate Change

JBE Japanese B encephalitis

MDR-TB multidrug resistant tuberculosis

MTA multilateral trade agreement

NCD non-communicable disease

RVF Rift Valley fever

SAP structural adjustment programme

STD sexually transmitted disease

TB tuberculosis

TBT Agreement on Technical Barriers to Trade

TDR UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases

TNC transnational corporation

TRIPS Agreement on Trade Related Intellectual Property Rights

UNAIDS United Nations Joint Programme on HIV/AIDS

UNDP United Nations Development Programme

UNITeS United Nations Information Technology Service

WHO World Health Organization

WTO World Trade Organization

WTO World Tourism Organization

ZVL zoonotic visceral leishmaniasis

ABBREVIATIONS AND ACRONYMS

EXECUTIVE SUMMARY

Special Topics No. 3 • Globalization and infectious diseases: A review of the linkages 1

G lobalization is a complex and multi-faceted set of processes having diverse and widespreadimpacts on human societies worldwide. It can be defined as “changing the nature of humaninteraction across a wide range of spheres including the economic, political, social, technological and environmental…… the process of change can be described as globalizing in the sense that bound- aries of various kinds are becoming eroded. This erosion can be seen to be occurring along three dimen- sions: spatial, temporal and cognitive” (Lee, 2003).

Globalization is driven and constrained by a number of forces: Economic processes, technological developments, political influences, cultural and value systems, and social and natural environmental factors. These varied forces, as part of the processes of globalization, impact directly and indirectly on health at a number of different levels.

As globalization spreads across the world, there is much to be understood about how the wide-rang- ing changes are impacting on infectious diseases. This paper reviews the existing evidence about the links between globalization and infectious diseases in terms of changes in disease distribution, trans- mission rate and, in some cases, management of disease. The aims of the paper are to:

• improve understanding of how globalization influences infectious diseases, particularly in the devel- oping world;

• explore how the processes of globalization impact on the epidemiology of, risk factors for, and capacity to control, infectious diseases;

• examine how efforts to control infectious diseases need to take account of globalization processes.

Reviewing the evidence for the four spheres of change – economic, environmental, demographic, tech- nological – this paper explores the complex causal relationships that may be arising. It shows both positive and negative consequences for the infectious disease burden potentially arise from globaliza- tion:

• Globalization appears to be causing profound, sometimes unpredictable, changes in the ecological, biological and social conditions that shape the burden of infectious diseases in certain populations. There is accumulating evidence that changes in these conditions have led to alterations in the prevalence, spread, geographical range, and control of many infections, particularly those transmit- ted by vectors.

• Individuals and population groups show varying degrees of gains and losses from economic global- ization, and thus differential vulnerability to infectious diseases. Studies of globalization processes show increasingly that the processes of change impact on the lives of individuals and populations in many different ways. Crude assessments of globalization as “good” or “bad” are neither accurate nor useful to effective management of global change.

• Epidemiology in general, and disease surveillance in particular, offer useful analytical tools and methods for identifying and measuring transborder patterns of infectious disease arising as a con- sequence of globalization. Such approaches are needed in studying how globalization may be chang- ing the distribution of health and disease within and across countries and regions of the world.

• Attention to the linkages between globalization and infectious diseases so far shows a dispropor- tionate focus on selected acute and epidemic infections. While there are clearly real risks from such diseases, which pose obvious challenges to an effective response from public health systems both nationally and internationally, it is important to consider the wide range of infections potentially affected by globalization processes.

• Due to inequalities in capacity and access to disease surveillance and monitoring systems between the industrialized and developing world, there is a danger of underestimating the infectious disease

burden faced by poorer countries. There is a particular need to develop surveillance systems that can be used effectively in low-tech, developing world contexts in order that true impact can be accu- rately identified. It is also imperative to ensure that, when changes in disease patterns are detect- ed, the information is transmitted to those able to implement appropriate action.

• The impacts of globalization on infectious diseases described in this report support the need for appropriate forms of global governance on key issues to improve systems of prevention, control and treatment.

• There is need for enhanced training on the global dimensions of infectious diseases. Medical prac- titioners would benefit from a greater understanding of the potentially changing profile of infec- tious diseases as a result of increased population mobility, intensified trade in goods and services, climate change, and other factors linked to globalization.

• The findings of this report support the need to pay greater attention to the impacts on the infec- tious disease burden of policy decisions taken in other sectors e.g. trade and investment, large infra- structure projects (e.g. dam building), migration, agriculture, transportation, communications.

• It is clear that improving action regarding the impact of globalization on infectious diseases on an a priori basis is a highly cost-effective policy intervention. It is increasingly recognized that the long-term sustainability of globalization requires greater attention to the social (including health) costs of current forms of globalization. What needs to be understood more fully is that resources committed to infectious diseases prevention, treatment and control in a globalizing world is a worthwhile investment.

Globalization and infectious diseases: A review of the linkages • Special Topics No. 32

Special Topics No. 3 • Globalization and infectious diseases: A review of the linkages 3

1 INTRODUCTION

Although there is a flourishing literature on globalization and health,1 much remains to be understood about how the processes of globalization affect health outcomes, and consequently about what local and global public health responses are appropriate. One major focus of this literature has been the links between globalization and infectious disease. There are particular concerns that globalization is impacting on the epidemiology of infectious disease, and on the capacity to effectively prevent, con- trol and treat these diseases. It may, for example, influence the risk factors for specific diseases, and at the same time enhance the opportunities for improving surveillance, monitoring and reporting capacity through global information and communications technologies.

This paper reviews the current evidence for links between globalization and infectious disease. In par- ticular, it identifies changes in disease distribution, transmission rate, and in some cases, management of disease. The aims of the paper are to:

• improve understanding of how globalization influences infectious diseases, particularly in the devel- oping world;

• explore how the processes of globalization impact on the epidemiology of, risk factors for, and capacity to control, infectious diseases;

• examine how efforts to control infectious diseases need to take account of globalization processes.

The paper extensively reviews the relevant published English language literature and, where possible, literature in other languages. It also reviews a substantial amount of “grey” literature. The focus is on the priority diseases of the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR).

1 For a review of the literature see: Lee K. Globalization and health policy: a review of the literature and proposed research and policy agenda. In: Bambas A et al., eds. Health and human development in the new global economy. Washington DC, Pan American Health Organization, 2000:15-41. Also see: Lee K. Globalization and health, an introduction. London, Palgrave Macmillan, 2003.

Special Topics No. 3 • Globalization and infectious diseases: A review of the linkages 5

2 BACKGROUND

2.1 What is globalization?

Despite widespread interest in its emergence and impact, there is limited agreement in the literature on precisely what globalization is. Frequently it is understood and defined according to selected aspects. Thus, for economists, globalization concerns the increasingly globalized nature of the emerg- ing world economy. For lawyers, it concerns the threatened changes in legal status of states and their citizens. For environmentalists, it is the changes in the world’s climate and other biosystems. And for information technology experts, it is the global spread and integration of information systems (Lee, 2003). However, such disciplinary-based perspectives can neglect the multiplicity of change processes, and hence fail to appreciate their complex direct and indirect impacts.

The numerous definitions of globalization in the literature also reflect a renaming of existing phenom- ena. In understanding the links between globalization and infectious disease, it is important to be aware of how the term ‘globalization‘ is used interchangeably with terms such as ‘internationalization’, ‘liberalization’, ‘universalization’ and ‘westernization’.2 A strict definition of globalization distinguishes between cross-border and transborder flows. ‘Cross-border’ concerns the interactions across two or more countries through, for example, the documented movement of people, official trade of goods and serv- ices, or capital flows such as foreign direct investment (FDI) across national borders. Cross-border flows have increased quantitatively since the end of the Second World War but can be more accurately described as internationalization. ‘Transborder’ or transnational, in contrast, concerns flows of people, goods and services, capital, values and ideas, and other entities in a way that does not recognize national borders. Such flows are ‘supraterritorial’ in the sense that they are disconnected from territo- rial geography. While intensified cross-border flows can overwhelm the capacity of the state to regulate them, transborder flows are seen as potentially eroding or even redefining existing territorial bound- aries separating human societies from one another (Scholte, 2000). Examples include global environ- mental change, undocumented population mobility (e.g. trafficking of people), and money laundering.

Along with changes to spatial boundaries, Lee (2003) argues that globalization is leading to changes in how we experience and perceive time. Globalization is shaping the timeframe in which natural and human-induced phenomena take place, as well as the time available and necessary for responding to these phenomena. For example, the time taken for some infectious diseases to spread across territorial space has become much quicker as a result of the increased amount, frequency, and speed of popula- tion mobility. Similarly, the potential capacity to detect and report disease outbreaks has quickened due to the advent of global information and communication systems.

Finally, in a variety of ways, globalization is influencing how we think about ourselves and the world around us. This cognitive dimension of global change arises from the proliferation of a range of indi- viduals and institutions with global reach, which are concerned with the production and exchange of knowledge, values and beliefs. They include the mass media, think tanks, research institutions, consul- tancy firms, advertising agencies, religious groups, educational institutions and policy-making organi- zations. While some argue that this is leading to the emergence of a ’global culture’ dominated by west- ern values and beliefs, others believe the spread of ideas and principles on human rights, labour stan- dards, and other social values across national or regional boundaries is a progressive force. Some writ- ers point to the flourishing of competing ideologies and value systems, resulting at times in a ’clash of civilizations’ in the form of religious or political conflict (Huntingdon, 2002).

2 For a useful discussion of the distinct meanings of these terms, see: Scholte JA. Globalization, a critical introduction. London, Palgrave Macmillan, 2000.

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In summary, globalization is a complex and multi-faceted set of processes that are having diverse and widespread impacts on human societies worldwide. Globalization can be defined as a set of processes that are:

Changing the nature of human interaction across a wide range of spheres including the economic, politi- cal, social, technological and environmental. …the process of change can be described as globalising in the sense that boundaries of various kinds are becoming eroded. This erosion can be seen to be occurring along three dimensions: spatial, temporal and cognitive (Lee, 2003).

Overall, it is clear that globalization is driven and constrained by a number of forces: economic processes, technological developments, political influences, cultural and value systems, and social and natural environmental factors. These varied forces, as part of the processes of globalization, impact directly and indirectly on health at a number of different levels. For example, globalization can alter health status through changes in basic living conditions and household incomes. It can affect the availability of health workers and other resources in health care systems through changes in patterns of population mobility, impact on government health expenditure through changes in macroeconomic policy, and encourage the adoption and spread of health standards and principles through interna- tional and global agreements (Woodward et al., 2001). At different levels, therefore, global change can bring either health benefits or costs, depending on who you are and where you live. For poorer pop- ulations, there is substantial evidence to suggest that, so far, globalization has posed more negative than positive impacts on health, including risks from infectious disease.

2.2 Global burden of infectious disease

Historically, infectious diseases (IDs) have been the most important contributor to human morbidity and mortality until relatively recent times, when non-communicable diseases (NCDs) began to rival, and sometimes exceed, infections. Today, IDs still account for a large proportion of death and dis- ability worldwide and in certain regions remain the most important cause of ill health. The Global Burden of Disease Study (GBDS) estimates that, in the year 2000, infectious diseases were responsi- ble for 22% of all deaths and 27% of disability-adjusted life years (DALYs) worldwide (WHO, 2002). Although infectious diseases can affect people of all ages, they impose a particular burden on the young, notably on children under five. This is not only because younger age groups have a lower preva- lence of NCDs, but because they are more susceptible than adults to new infections, lacking the pro- tective mechanisms to reduce the impact of these illnesses. Consequently, in regions where a high pro- portion of the population is made up of young people – Africa, Latin America and many other devel- oping regions – infectious diseases usually extract a relatively high toll on the population. For exam- ple, GBDS estimates for 2002 were that infectious diseases were responsible for 52% and 50% respec- tively of all deaths and DALYs in sub-Saharan Africa but only 11% and 5% in the established market economies (WHO, 2000).

The term ‘infectious disease’ does not refer to a homogeneous set of illnesses but rather to a broad group of widely varying conditions. The relative and absolute importance of particular infections or groups of infections varies dramatically across regions. In high-income countries, deaths from IDs are overwhelmingly due to respiratory infections and HIV/AIDS. In sub-Saharan Africa, respiratory infec- tions, diarrhoeal diseases, HIV/AIDS, TB and malaria account for roughly similar proportions of total ID deaths (Murray and Lopez, 1997a). In addition, rates of specific infectious diseases are generally much higher in poor countries, regardless of the relative importance of these diseases. Therefore, in both relative and absolute terms, IDs are a considerably higher burden in low-income than high- income countries. An analysis of GBDS data concludes that the poorest 20% of the world’s population experiences a far higher burden of infectious disease compared to the remaining 80% of the world’s population (Gwatkin et al., 1999).

It should be noted that estimates of the burden of infectious disease at regional or global level can obscure the importance of specific infections in particular populations. For instance, tropical diseases impose a heavy burden on some of the poorest populations in the world but, since they occur almost exclusively in certain climates, can be recorded as making a proportionately small contribution to the overall infectious disease burden (Murray and Lopez, 1997a). Also, certain diseases such as dengue fever vary greatly with environmental and other determinants, and can rapidly assume epidemic proportions. This is often poorly represented in estimates of average annual disease incidence and prevalence. Finally, in most assessments, certain illnesses with a strong infectious component, such as liver cancer and several important neurological diseases, are not considered part of the infectious diseases burden (Satcher, 1995).

Estimates of the future burden of infections fall into two categories: predictions for individual diseases, and calculations of the overall impact of infectious diseases in the future. Examples of the former include those for HIV/AIDS and multidrug resistant tuberculosis, which often predict significant rises in prevalence and mortality (WHO, 1997; WHO, 2002). The most influential summation of the likely over- all future burden of infectious diseases predicts a gradual decline in both the rates of infection and their proportionate contributions to overall disease burden in all regions of the world (Murray and Lopez, 1996). However, these estimates assume that disease patterns will evolve in much the same way as they have in high-income countries over the past 100 or so years, and that current efforts to contain their impacts will be sustained. One finding from this review is that the future impact of many infections is uncertain because globalization is impacting on human societies and the natural environment in ways hitherto not experienced. Also, cases of certain infectious diseases (particularly vector-borne infec- tions) have either been rare or entirely absent in most high-income countries during the last 100 years (Murray and Lopez, 1996). Finally, shifts in political and economic values may lead to changes in cur- rent resources for infectious disease control, particularly in low and middle-income countries (Lee, 2003).

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3 GLOBALIZATION AND THE CHANGING NATURE OF INFECTIOUS DISEASE

The processes of globalization potentially influence a broad range of biological, environmental and social factors that affect the burden of many important human infections. This report considers the nature of infections and how, in simple terms, globalization may increase or decrease the distribution, spread and impact of infectious diseases in a given population.

An infection occurs when a micro-organism survives and multiplies within another, usually larger, organ- ism. The infected organism (e.g. human being) is called the host. In infectious diseases, unwanted signs and symptoms usually result from damage to the tissues and organs of the host, and the micro-organ- ism is known as a pathogen. A huge variety of pathogens cause human infections, ranging from sub- cellular viruses that cause lung infections in children to complex protozoan (e.g. the malaria parasite) and multicellular (e.g. filarial worms) organisms.

To trigger infection, pathogens must first reach the host., where they may survive unnoticed unless an internal or external event (for example, the herpes virus) triggers the disease. In most cases, pathogens reach the human host from the external environment through a variety of transmission systems (see examples in Box 1). The transmission system in operation determines which factors are capable of enhancing or inhibiting the spread of a particular infectious disease.

Box 1: Transmission of infectious diseases

Some pathogens live in the environment and are transmitted to humans directly, for instance, from the soil. Other pathogens can survive only in a host (an animal or human). If a pathogen survives in two (or more) animal species (e.g. humans and another type of animal) then the species within which the pathogen preferentially survives and multiplies is known as the pri- mary host; the other is known as the secondary or intermediate host. An intermediary agent (usually a biting insect or arthropod) that spreads a pathogen to humans is known as a vector, and an infection so transmitted is a vector-borne disease. Most TDR diseases are vector-borne infections. When pathogens spread directly from host to host, it is direct transmission. If direct transmission occurs between humans (or animals) the infection is contagious. Infections spreading between humans, without another animal reservoir host being involved (whether or not an intermediate host or vector is involved), are termed anthroponotic infections. When spread of an infection to a human or animal involves an intermediate host, it is indirect trans- mission. An infection that can be maintained in vertebrate animal populations, and is trans- missable between animals or from animals to humans, is known as a zoonotic infection. The mode of transmission influences which factors impact on the spread and overall impact of a specific infection. For instance, transmission of vector-borne diseases is influenced by factors which affect vector numbers (e.g. warmer temperature increases mosquito reproduction rates), contact between humans and vectors (e.g. tourism brings people to areas where malaria-carry- ing mosquitoes thrive), susceptibility of humans to vector-borne pathogens (e.g. migration of non-immune people to areas where malaria is prevalent), intermediate host numbers (e.g. dams provide breeding grounds for snails carrying schistosomiasis), or human or animal behaviour (e.g. warmer temperatures encourage people to bathe in pools, which may be contaminated by schistosome larvae).

A pathogen in a human host will only cause infectious disease if it is able to survive and multiply with- in the person. The success of this ‘amplification process’ is influenced by the presence or absence of many factors. For example, the person must be susceptible or non-immune to the infectious agent. People who are resistant to the pathogen are immune to the disease, typically as a result of a previous infection that has led to the production of protective antibodies or cells, or through immunization. There must also be sufficient numbers of pathogens present to overcome the body’s natural resistance to a foreign organism, and certain pathogens require physiological circumstances favourable to their multiplication; for instance, Clostridium perfringens infection usually requires the presence of dead or dying tissue.

Thus, amplification processes and transmission systems depend on multiple factors that determine not only whether a specific pathogen can survive and spread in the environment, but also whether an indi- vidual will become infected after the agent has reached this host, and whether the infection will cause disease (Jacob, 1998). These links can be appreciated through consideration of the ‘basic reproductive rate’ (or Ro) of an infectious agent, which refers to the average number of infections produced by a sin- gle case of the infectious disease in question. Where Ro is >1, the prevalence of the infection will increase, and where Ro is <1, it will decrease (Anderson and May,1991). Therefore, the effect of an eco- logical or other type of change on an infection can be considered by asking how this change will affect the Ro of the infectious agent.

Since, in general, the rate at which a single case of human infection produces new infections depends on a mixture of biological and social factors, transmission is affected not only by the population of infectious agents but also by the living conditions of the human population. Ro is affected by changes in, for example, the environment, and social and cultural practices, as well as by population size, age- distribution and density (May, 1994). Changes in the environment (Box 2) are particularly important to vector-borne infections since the proliferation and behaviour of vectors and (where appropriate) inter- mediate hosts are especially dependent on availability of the right conditions. Changes in all variables (economic, environmental, demographic), either individually or combined, may carry Ro from below to above unity (Ro = 1) or vice versa, thereby influencing the emergence, re-emergence or disappearance of specific infectious diseases. An understanding of the interactions between ecological factors and

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Box 2: Infectious diseases and the natural environment

Pathogens are highly sensitive to their environments. There are two main reasons for this: first, their ability to survive and multiply depends on the availability of the right climatic and nutri- tional conditions; second, to cause new infections, local conditions must facilitate a pathogen’s spread to a susceptible host. With human disease, this means that the environment must sup- port the survival of humans and, where necessary, the secondary host or vector, or contain an appropriate natural niche within which the free-living pathogen can flourish. There must be adequate means for humans to come into contact with the pathogen, either from other people or animals or the natural environment. Diverse environmental factors, such as ambient climate and the presence or absence of overcrowding, clean water or particular types of flora and fauna, influence a pathogen’s chances of flourishing and causing disease. Some pathogens thrive in warm and wet climates while others only survive in colder, drier conditions. Still others can sur- vive almost anywhere. Thus some pathogens cause disease worldwide while others are only found in well-defined areas where the local environment is favourable to their propagation. The latter is particularly true for vector-borne diseases since here the local environment needs to support the survival and multiplication of not only the offending pathogen but also the rele- vant vector and often a third host as well.

infectious diseases is therefore vital to predicting the future impact of infectious diseases and devel- oping appropriate measures for their control.

Appreciation of transmission systems and amplification processes also helps in understanding how infections can be prevented, controlled and treated. Interrupting the transmission of pathogens to sus- ceptible people will prevent infections, while eliminating or controlling a pathogen’s ability to survive and multiply in an established case will curtail the infection. Where treatment of an infectious case also renders that case non-infectious, it will also prevent further transmission. Box 3 lists some of the meth- ods available for preventing or treating infections.

In any situation, the appropriate preventive and treatment strategy depends on the particular pathogen or clinical disease to be controlled. Vector control is, for example, crucial to the prevention of vector- borne infections; the environment can be modified to deprive vectors of favourable breeding sites, or people may be advised to avoid areas where vectors flourish. Sometimes such modifications may enhance proliferation of one disease’s vector while inhibiting that of another’s, and therefore strategies must be appropriate not just in terms of their effect on a particular infection but also in terms of their effect on the whole infectious disease burden in a given area or population. In addition, for some dis- eases a quantitative or qualitative distinction is drawn between the measures required to control epi- demic versus endemic infections.3

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Box 3: Preventing and treating human infections

To prevent human infection, interrupt transmission of an infectious agent to humans by: • eliminating sites where pathogens, vectors, or intermediate hosts proliferate • reducing human exposure to pathogens or vectors through:

  • regulating the natural and built environment and/or trade – using protective equipment (e.g. bednets to prevent malaria) – using chemoprophylaxis (e.g. antimalarial drugs to prevent malaria) – modifying behaviour (e.g. not engaging in unprotected sex to prevent HIV/AIDS) – isolating and treating infected cases (human or animal) to prevent them from spreading

the infection to others (e.g. identifying and treating TB cases as soon as possible to prevent transmission to others)

• increasing human immunity to pathogens through vaccination programmes.

To treat established infections, control multiplication of a pathogen in an infected person by: • administering chemotherapy to kill pathogens • using surgery or medical treatment to remove any continued source of infection, such as

an abscess • providing supportive treatment to enhance a person’s ability to destroy the pathogen

using his/her natural immunity to infectious agents.

3 For example, controlling epidemics of arthropod borne viral encephalitides might require intensification of measures that already play a part in controlling endemic disease. Thus vector control might be enhanced through fogging or spraying of suitable insecticides from airplanes and, in the case of Japanese B encephalitis, immunization of pigs might be considered. For typhoid fever or cholera, qualitatively different measures might be required to control an outbreak, e.g. chlorination of water supplies (Beneson AS, ed. Control of communicable diseases manual, 16th edition. Washington DC, American Public Health Association, 1995).

Globalization may profoundly influence many of the biological, social and environmental factors that impact on a pathogen’s potential to survive, spread and cause human disease. In addition, at both glob- al and local levels, the processes of globalization can influence the chances of successfully implement- ing measures to prevent, control and treat infections. Although good quality disease surveillance sys- tems can help detect changes in disease patterns, it is difficult to conclusively prove that globalization is itself responsible for changes in the spread or distribution of particular infections, or of infectious dis- eases in general. To prove that globalization is responsible for the increasing prevalence of a specific infection would require standardized monitoring of the exposure (the process of globalization being studied), the outcome (incidence of a particular infectious disease), and other determinants of disease (e.g. immunity, treatment, socioeconomic factors) over many years. The necessary studies would be extremely difficult to construct, and highly vulnerable to confounding due to new and unforeseen fac- tors developing out of the enormous transformations occurring in most aspects of contemporary politi- cal, economic and cultural life. In addition, surveillance systems describing the incidence and prevalence of infectious diseases over time are very rare, particularly for populations in developing countries, who are often the most likely to experience the adverse health effects of global transformations. Even if a causal association were detected, there would likely be considerable dispute over whether the relevant process, for instance global warming, was in fact caused by globalization.

Thus, the assessment of health risks associated with globalization must accommodate much unavoidable uncertainty. This does not mean that no conclusions should be drawn on the influence of global process- es on past, present and future disease levels. Indeed, poor or absent supportive evidence for the bene- fits of globalization has not dissuaded proponents of unregulated economic globalization from arguing forcefully for its introduction. The need to respond in situations where we do not have full and incon- trovertible evidence for our actions is well expressed by the precautionary principle: ’Where there are threats of serious or irreversible damage, lack of full scientific certainty shall not be used for postpon- ing cost-effective measures.’4

Given the broad approach to globalization adopted by this paper (as described in Section 2.1), this review discusses four major aspects of globalization – economic, environmental, political and demo- graphic, and technological change. After a general discussion of each sphere of global change, consid- eration is given to how it may be influencing the distribution and spread of specific infectious diseases, and the severity of disease within certain population groups, in different parts of the world. This review focuses, in particular, on how the global change may impact on the distribution, spread, treatment and control of the TDR priority diseases. Admittedly, this subdivision is a simplification of a complex set of interrelated processes. For example, the links between global environmental change and infectious dis- ease cannot be seen independently from global economic change. Similarly, global economic change affecting the availability of resources for infectious disease control cannot be separated from shifts in political ideology shaping policy change at the national and global levels. These linkages are illustrated by the complex inter-relationships between the various aspects of globalization and malaria and dengue fever (see Boxes 10 and 12). For example the geographical reach and prevalence of malaria have been influenced by the economic, environmental, political and demographic aspects of globalization through economic adversity, increase in trade, spread of drug resistance, global warming, conflict, urbanization, and tourism, while technological advances have improved our understanding of the disease and should ultimately help improve its control. There have been various efforts to develop a conceptual framework to explain the linkages among these various spheres of change.5 Nonetheless, systematic assessment of each sphere provides a heuristic framework. It is a useful starting point to consider each sphere of glob- alization in terms of risk factors, epidemiology and transmission (including vectors), and control (includ- ing treatment and surveillance) of infectious disease. This also enables an examination of the positive and negative consequences of global change, and is a first step towards identifying key gaps in current knowledge.

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4 UN Conference on the Environment and Development, Rio de Janeiro, 1992 5 For example see Woodward D et al. Globalization and health: a framework for analysis and action. Bulletin of the World Health

Organization, 2001, 79:875-81; and Labonte R. Brief to the World Trade Organization: World Trade and Population Health. IUHPE Board of Trustees, 1999.

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6 For a detailed discussion see: Held D et al., Global transformations, politics, economics and culture. Stanford, Stanford University Press, 1999.

7 For a discussion of the public health implications of specific multilateral trade agreements see: WHO. WTO agreements and public health. Geneva, WHO/WTO, 2002.

4 ECONOMIC GLOBALIZATION AND INFECTIOUS DISEASE

Economic globalization describes the restructuring of the world economy, from one centred on produc- tion and exchange relations between economic entities located in different countries (international economy), towards “a highly complex, kaleidoscope structure involving the fragmentation of many pro- duction processes and their geographical relocation on a global scale in ways which slice through national boundaries” (Dicken, 1998). While this transition from an international to global economy has been a gradual one spanning many centuries, the processes of change have accelerated since the end of the Second World War and particularly since the early 1970s with major events such as the collapse of the gold standard, oil crises, and increased debt burden.6 These fundamental changes to economies worldwide are believed to be having a range of impacts on infectious diseases.

4.1 World Trade Organization and multilateral trade agreements

The emergence of the global economy has been facilitated, since 1945, by the significant growth of international trade, as well as of regional and international organizations that govern trade relations. Since the creation of the General Agreement on Tariffs and Trade (GATT) in 1944, member states have undertaken successive rounds of negotiations to reduce barriers to trade. In 1995, GATT was replaced by the World Trade Organization (WTO), a permanent body responsible for administering and enforcing a number of binding multilateral trade agreements (MTAs). These include the Agreement on Trade Related Intellectual Property Rights (TRIPS), General Agreement on Trade in Services (GATS), and Agreement on Technical Barriers to Trade (TBT).7

The economic impact of this proliferation in bilateral, regional and international trade agreements has been enormous. Since 1950, gross world production has increased five-fold while world trade has increased fourteen-fold (Lang, 2001). Marked changes were seen during the 1990s, when many coun- tries embarked on rapid economic reforms encompassing market liberalization, deregulation and priva- tization. Within a decade, populations living within market economies, or in countries engaged in mar- ket-oriented reforms, rose from one billion to roughly five and a half billion (Lehmann, 2001). A sub- stantial increase in all forms of international economic activity – FDI, capital markets, trade of goods and services, information and technology transfer – followed. As well as this internationalization of the world economy, there has been growing economic globalization in the form of restructuring of key sectors such as telecommunications, pharmaceuticals and food production.

There remains substantial debate about the precise impacts of trade on social welfare and, in particu- lar, on health. Proponents argue that trade is the “motor force” of the global economy and “human progress”, and that “more trade leads to more wealth, which in turn improves health” (Feachem, 2001). Others point to a more complex relationship, highlighting the need to ensure targeted protection of “human needs, social welfare, quality of life, indigenous understanding of knowledge and property” as well as to regulate goods and services that are harmful to health (Baris and McLeod, 2000; Lee, 2003). Although there is a strong relationship between increasing national wealth and overall health status, as income reaches US$ 5000 per capita, gains in health status and other economic factors, such as

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degree of income equality, become more important (Wilkinson, 1996). Furthermore, there is growing evidence that trade is leading to growing socioeconomic inequalities within and between countries (UNDP, 1999). While some writers continue to dispute the methodology behind such analyses (Ravallion, 1997), it is widely acknowledged that economic growth per se must be considered sepa- rately from the distribution of those benefits (Dikhanov and Ward, 2001). For many poor people, increased trade can lead to greater inequalities (Lunderg and Squire, 1999, as cited in Carpenter, 2000) that, in turn, have detrimental consequences for human health (Cornea, 2001; Goesling, 2001). The precise impact of MTAs on health, therefore, must be considered in relation to specific terms of trade and the resultant balance of winners and losers arising from them.

At a macroeconomic level, such changes can influence the overall level of resources available to gov- ernments for health expenditure. Rapid economic transition in central and eastern Europe during the 1990s, for example, was found to have undermined government capacity to provide for health care, and marked increases in the rates of several infections were reported (Maclehose et al., 2002). The Asian financial crisis in the late 1990s had a similar impact on public health spending. There is evidence to suggest that this, in turn, had detrimental effects on the rates of certain infections such as HIV/AIDS, tuberculosis and sexually transmitted diseases (STDs) (Sivaraman S, 1998). Reduced spending on vec- tor-borne disease control programmes in Africa during periods of structural adjustment has led to fail- ures to control diseases such as malaria, as well as to resurgence of some parasitic infections such as African trypanosomiasis (Sanders and Chopra, 2002). Furthermore, outbreaks of infectious diseases are themselves associated with significant costs in terms of lost trade and tourism revenue, and there is some evidence that fear of economic penalties has sometimes led authorities to under-report epi- demics, risking serious public health consequences. More comparative empirical analysis of the effects of trade liberalization on the epidemiology of infectious diseases is much needed.

Trade in specific products may have a more direct impact on infectious diseases. The most obvious examples are trade in food products and pharmaceuticals, and these are explored in more detail below. More esoteric examples also exist. For instance, the trade in used car tyres has led to the spread of dengue fever to cities, as examined below (section 6.4.2i). Economic change also leads to migration, and to alterations in land use and water requirements, which in turn have impacts on infectious dis- eases. This is also considered below.

4.2 The global trade in food

Consequences for infectious diseases arise from intensified trade in particular goods and services; this can be observed in the trends towards globalization of the food industry. Over recent decades, huge increases in international trade have transformed the availability of food products, particularly for inhabitants of high-income countries. This, in turn, has led to changes in dietary habits, and there is now a demand for year round availability of fresh fruit and vegetables, and for so-called “ethnic” foods. The convergence of tastes in many countries has meant greater demand for generic rather than local produce; cheaper transport systems of global reach now allow companies to manufacture many food products in less expensive labour markets, using ingredients from different parts of the world, and then to transport them worldwide.

The largest ten transnational corporations (TNCs) in the food industry are North American or European in ownership (Lang, 2001). Four companies control 90% of the world’s exports of coffee, tea, corn, wheat, pineapples and tobacco (Lee and Patel, 2002). In addition, large agrochemical TNCs are involved in the increasingly globalized food industry and account for 85% of the world market (Lang, 2001). Hence, a small number of large concerns now wield powerful control over the entire food chain, including agricultural production, processing and packaging, transporting and marketing (Lang, 1999). In 1994, the value of food trade was more than 300% greater than twenty years earlier (Kaferstein et al., 1997).

Although poor statistics make it difficult to estimate the global incidence of foodborne diseases, and there is substantial under-reporting, data from industrialized countries indicate that up to 10% of pop- ulations are affected annually by foodborne diseases (Kaferstein et al., 1997). Mass production, han- dling procedures, environmental factors, new and emerging pathogens, and poor regulation are believed to be contributing to a marked increase in worldwide incidence (Lang, 2001; Kaferstein et al., 1997; Swerdlow and Altekruse, 1998). Several factors may be responsible. First, the increasing reliance on producers abroad means that food may be contaminated during harvesting, storage, pro- cessing and transport, long before it reaches overseas markets. For example, outbreaks of Salmonella poona infection in the US associated with eating imported melons from Mexico have been linked to unhygienic irrigation and packaging practices at source farms. Low-income countries may also culti- vate non-indigenous crops to meet the needs of the export market, and these may be more suscepti- ble to indigenous pathogens. This happened when Guatemalan raspberries became contaminated with the protozoan Cyclospora, causing outbreaks of gastroenteritis in the US and Canada.

Second, centralized processing and mass distribution may lead to widespread dissemination of con- taminated foods. This risk has been augmented by changes in methods of food production such as the rearing of huge poultry flocks in communal housing, which practice generates large numbers of birds with common risk profiles. Similarly, outbreaks of E. coli O157:H7 have been traced to hamburgers from multiple outlets of a fastfood chain in the US, and clusters of gastroenteritis to flocks of Salmonella typhimurium infected poultry throughout Europe (Altekruse et al, 1997). Contaminated animal feeds may also be widely disseminated throughout the world, as exemplified by the bovine spongiform encephalopathy variant Creutzfeldt-Jakob disease (BSE/vCJD) crisis in the UK.

“New” pathogens not previously associated with human illness, such as Cyclospora and E. coli O157:H7, were first identified through epidemics of foodborne disease. Emerging zoonotic pathogens are becom- ing increasingly resistant to antimicrobial agents, largely because of widespread use of antibiotics in the animal reservoir. For example, Campylobacter isolated from human patients in Europe is now increasingly resistant to fluoroquinolone drugs, after these were introduced for use in animals (Endtz, 1991). Overall, there is a need to understand better how the global trade in food has spread hitherto local risks more widely, and has created new risks from increased economies of scale and changing methods of production.

4.3 The global trade in pharmaceuticals

In low and middle-income countries, pharmaceuticals account for about 30% of total health expendi- ture. The potential health benefits and risks posed by trade liberalization to access to pharmaceuticals are varied. Baris and McLeod (2000) argue that, as freer trade reduces tariffs on imported pharmaceu- ticals, drug imports will increase. In theory, countries will benefit from enhancing the range of drugs available, particularly where there is little or no domestic capacity to produce such products, and for- eign competition should exert pressure on prices overall. In practice, however, the effects on produc- tion and consumption are more complex given the changing structure of the pharmaceutical industry. Like the food industry, pharmaceuticals are increasingly dominated by a small number of large TNCs. In 1992, the top ten pharmaceutical companies were based in the US and Europe, accounting for about one-third of total combined sales worldwide (Baris and McLeod, 2000).

No low-income country appears in this super league (with the exception of China, which produces all of its essential drugs), but such countries do have the advantage of cheap labour and indigenous medicinal plants. Hence, there is a thriving generics industry in the developing world, and rapidly grow- ing international trade. However, increased access by large TNCs to markets in the developing world could undermine these local producers. Under the TRIPS agreement, domestic subsidies on drugs could be deemed an unfair trade advantage, and there may be a tightening of regulations around the pro- duction and trade of generic drugs.

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In relation to drug development, an emerging global market for pharmaceuticals raises concerns about a greater focus on conditions and markets deemed most profitable, regardless of the global burden of disease. How drugs will be developed for infectious diseases afflicting the poorest population groups within such a context remains unclear. For example, only 13 of the 1223 new chemical entities com- mercialized between 1975 and 1997 were for tropical diseases (Pecoul et al, 1999), and no new drugs for tuberculosis have been developed for over 30 years because, despite its enormous toll, only 5% of the 16 million infected can afford medication.8 These inequities contribute to the 10/90 gap in which 90 per cent of research funds address the health needs of 10 per cent of the world’s population (Global Forum for Health Research, 1999).

Finally, unregulated access to, and inappropriate consumption of, pharmaceuticals in a global market- place raises the issue of drug resistance. These factors have, for example, contributed to the spread of multidrug resistant tuberculosis (MDR-TB) worldwide, and will lead to further spread of resistance to antiretrovirals for HIV, particularly given the important role that the unregulated private sector plays in providing care for stigmatizing conditions (Brugha, 2003).9 Control of such diseases could therefore be jeopardized, and the misuse of pharmaceutical products facilitated, if sufficient regulatory mecha- nisms (including proscribed standards of use with adequate monitoring and enforcement) are not implemented alongside globalization of the pharmaceutical industry.

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8 Global Alliance for TB Drug Development, www.tballiance.org/2_3_C_NoRandDin30years.asp (accessed 27 August 2003).

9 As cited at www.tballiance.org/2_3_C_NoRandDin30years.asp.

Special Topics No. 3 • Globalization and infectious diseases: A review of the linkages 17

5 GLOBAL ENVIRONMENTAL CHANGE AND INFECTIOUS DISEASE

The environment consists of not only the natural world but also the built and social environments, and it plays an important role in shaping human health. The natural environment is modified by local influ- ences, such as local weather conditions, physical disasters or building developments, as well as global forces, such as changes in the great biophysical systems of the world that alter the global environment. Both local and global environmental change may be either natural or human-induced. Anthropogenic (human-induced) changes are increasingly linked to the processes of globalization (McMichael and Haines, 1997). Over the past 50 years, huge increases in economic and industrial activity have led to unprecedented effects on air, land and water environments, and the resulting changes have important and wide-ranging implications for human health, with different populations facing varying degrees of vulnerability to positive and negative impacts. This section explores the known and expected impacts on infectious diseases.

Box 4: Projections of the health impacts of global environmental change

Current knowledge can be used to make ‘best guesses’ of whether climate change is likely to have broadly positive or negative effects. Experts on the Intergovernmental Panel on Climate Change (IPCC) concluded that climate change is likely to expand the geographical distribution of several vector-borne diseases, including malaria, dengue and leishmaniasis, to higher alti- tudes (high confidence) and higher latitudes, assuming limited public health defences (medi- um/low confidence), and to extend transmission seasons in some locations (medium/high con- fidence). Climate change may decrease transmission of vector-borne diseases in some locations by reducing rainfall or raising temperatures to levels too high for transmission (medium/low confidence) (McMichael, 2001).

Quantitative statements about the impact of climate change on the burden of infectious dis- eases can be arrived at by coupling data from existing studies with estimates of expected glob- al climate change. For instance, data from the Peru diarrhoea study cited above can be applied to IPCC projections to make approximate estimates of how much the worldwide incidence of diarrhoea might increase with global warming (McMichael et al., 2003). More complex models have been used to investigate the possible effects of climate change on geographic distribu- tion of, and vectorial capacity in, vector-borne diseases. These either integrate climate effects on various components of the transmission cycle (e.g. Jetten and Focks, 1997; Martens et al., 1999), or simply make a statistical correlation between the current distribution of diseases and the most important climate variables (e.g. Hales et al., 2002; Rogers and Randolph, 2000).

Although these models should improve in the future, particularly as better quality health mon- itoring data become available, they will remain subject to major uncertainties, partly around the likely extent of future climate change but also around the relationships between climate and health outcomes, as other factors change. Socioeconomic factors, in particular, are often more important determinants of infectious disease burden, therefore global models based on climate alone are unlikely to give accurate predictions, particularly at the local level. Climate change will tend to increase risk over what would have been expected if no change had

5.1 Global climate change

Current concerns about global climate change can be divided into two main subjects: rising global aver- age land and sea surface temperatures (“global warming”), and increasing frequency of extreme weath- er conditions in many parts of the world. These are aetiologically linked, but since each is associated with different patterns of infectious disease, they will be discussed separately. In general, climate con- strains the range of infectious diseases, while weather affects the timing and intensity of outbreaks (Dobson and Carper, 1993).

5.1.1 Global warming

There is now substantial evidence that global average land and sea surface temperatures have increased by 0.6°C since the mid-nineteenth century. Most of this change has taken place since 1976, and 14 of the warmest years on record have occurred since 1980. In 1999, the UN Intergovernmental Panel on Climate Change (IPCC) predicted that average global temperatures would increase by 1.4-5.8°C by 2100.

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occurred, but socioeconomic development and control interventions could reduce both the existing (i.e. climate change independent) risk, and the vulnerability of populations to climate change. This is well illustrated in the context of diarrhoea. The provision of clean water and sanitation, combined with increased handwashing with soap, should not only cause very large reductions in diarrhoea rates, but by reducing the relative importance of water-borne and food- borne bacterial infections (which tend to respond positively to higher temperatures), compared to viral infections (which do not), the effects of climate change should become less important.

Fig. 1: Alternative scenarios of future development and associated climate change developed by the IPCC

Source: United Kingdom Climate Impacts Programme (UKCIP). Socio-economic scenarios for climate change impact assessment. A guide to their use in the UK Climate Impacts Programme. UKCIP, Oxford, 2000.

Globalization

Regionalization

Special Topics No. 3 • Globalization and infectious diseases: A review of the linkages 19

A rise of this magnitude would be faster than anything encountered since the inception of agriculture around 10 000 years ago. Although the causes are controversial, IPCC has concluded that much of the warming observed in the last 50 years can be attributed to human activity (Albritton et al., 2001), prin- cipally due to excessive and inefficient combustion of fossil fuels, leading to the build up of greenhouse gases that trap heat within the atmosphere (McMichael, 1993). Patterns of precipitation have also changed: arid and semi-arid regions are becoming drier, while other areas, especially in mid-to-high lat- itudes, are becoming wetter, with a disproportionate increase in frequency of the heaviest precipitation events.

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Source: Climatic Research Unit, Norwich, UK.

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Global warming may alter the range and prevalence of many infections. As described in Box 5, higher ambient air temperatures, along with changes in precipitation and humidity, can affect the biology and ecology of disease vectors and intermediate hosts, the pathogens that they transmit, and consequent- ly the risk of transmission (Githeko et al., 2000). Diseases carried by mosquito vectors are particularly sensitive to meteorological conditions since these insects have fastidious temperature thresholds for survival and are especially susceptible to changes in average ambient temperature (Epstein, 2001a). Anopheles spp. mosquitoes can only transmit Plasmodium falciparum malaria parasites if the tempera- ture remains above 16°C, while the eggs, larvae and adults of Aedes aegypti mosquitoes that spread dengue fever and yellow fever are killed by temperatures below 10°C (Martens et al., 1997). Furthermore, within their survival range, warmth accelerates the biting rate of mosquitoes, and the mat- uration of parasites and viruses within them (McArthur, 1972), and, since insects have short lifespans, this increases the chances of their having two crucial blood meals – one from an infected person and the second for transmission of the pathogen to another person. The life cycle of the malaria parasite or other pathogen carried by the vector is thus accelerated. The precise effect on transmission requires continued study to determine whether shorter, more intense, lifespans lower or increase transmission, on balance.

Globalization and infectious diseases: A review of the linkages • Special Topics No. 320

Fig. 3: The global average temperature rise predicted from the unmitigated emissions scenario (red), and the emission

scenario which stabilizes CO2 concentrations at 750 ppm (blue) and at 550 ppm (green).

Source: Hadley Centre. Climate change and its impacts: stabilisation of CO2 in the atmosphere 1999. Hadley Centre, UK, 1999.

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The Impact of the Globalization of Infectious Disease on Today’s Public Health Agenda

The Impact of the Globalization of Infectious Disease on Today’s Public Health Agenda

Instructions of the assignment:

Referring to the example of the Case Study on the malaria control efforts in Zambia, prepare a 2-page (single-spaced) brief for use by a public broadcasting news reporter on the impact of the globalization of infectious disease on today’s public health agenda. Included in your discussion should be evidence-based information (literature review) reflecting the foundational competency and the SLO stated below. Conduct a literature review of peer-reviewed journals and appropriate government documents.

MPH 19: Communicate audience-appropriate public health content, both in writing and through oral presentation.

SLO4: Synthesize the inter-relatedness of the public health disciplines and the ways in which these disciplines connect with a community or population group around a public health event.

Use the following articles to write this paper in addition to extra sources, please.

https://www.ncbi.nlm.nih.gov/books/NBK56591/
https://www.healthypeople.gov/2020/topics-objectives/topic/global-health
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1299207/
https://www.sciencedirect.com/science/article/pii/S147149221500207X

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CASES IN GLOBAL HEALTH DELIVERY

CASES IN GLOBAL HEALTH DELIVERY

Vanessa Redditt, Kileken ole-­‐‑MoiYoi, William Rodriguez, Julie Rosenberg, and Rebecca Weintraub prepared this case for the purposes of classroom discussion rather than to illustrate either effective or ineffective health care delivery practice.

Cases in Global Health Delivery are produced by the Global Health Delivery Project at Harvard. Case development support was provided in part by The Pershing Square Foundation. Publication was made possible free of charge thanks to Harvard Business Publishing. © 2012 The President and Fellows of Harvard College. This case is licensed Creative Commons Attribution-­‐‑ NonCommercial-­‐‑NoDerivs 3.0 Unported.

We invite you to learn more at www.globalhealthdelivery.org and to join our network at GHDonline.org.

GHD-­‐‑24S APRIL 2012

CONDENSED VERSION

Malaria Control in Zambia

Dr. Elizabeth Chizema, coordinator of Zambia’s National Malaria Control Centre (NMCC), reviewed the results of the newly released 2008 Malaria Indicator Survey (MIS), a national household survey. Zambia’s new malaria control strategy seemed to be producing positive results. The MIS reported dramatic increases in the number of households participating in indoor residual spraying (IRS) campaigns and accessing insecticide-­‐‑treated bednets (ITNs) and a significant decline in the incidence of malaria since 2006. However, difficulties in the delivery and appropriate use of malaria interventions, including antimalarial drugs and bednets, continued. With the 2009 annual budgeting and planning process approaching, Chizema considered how the NMCC and its partners could address the lingering challenges.

Zambia

Zambia is a landlocked country in southern Africa with more than 70 ethnic groups and a population density of 16 people per square kilometer; rural areas were sparsely populated (see Exhibit 1 for map).1,2 Upon independence from Great Britain in 1964, Zambia was one of the most affluent countries in sub-­‐‑ Saharan Africa.3 Over the next decade, however, the declining price of copper and periods of prolonged drought severely strained the economy. The government borrowed money, accumulating a significant debt by 1981,3 and soon diverted revenue from development and social services to loan repayments. Per capita income declined from more than USD 700 at independence to USD 358 in 2003.3 In 2005, debt payments still accounted for 31% of Zambia’s GDP (see Exhibit 2 for socioeconomic and demographic indicators and Exhibit 3 for health indicators).4

Health System

In the early 1990s the size and scope of the Ministry of Health’s (MOH) responsibilities were significantly reduced and limited to allocating public health budgets, interacting with donors, setting national policies, and performing other legislative and administrative tasks.5 The country’s 72 districts became the main administrative units in the health sector.6 District Health Management Teams (DHMT) were established to plan, implement, and monitor health activities and to supervise health centers. Provincial health offices managed, coordinated, and supervised districts. Neighborhood health committees,

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composed of both locally elected and volunteer representatives, were established to enhance community participation. Community health workers (CHWs) and community leaders were also involved in care delivery through health centers.

Health facilities were responsible for providing a package of essential services, called the Basic Health Care Package, that prioritized the 11 diseases and conditions with the highest levels of morbidity and mortality.*5 The government removed user fees from all public rural health facilities on April 1, 2006.

Zambia’s Medical Stores Limited (MSL) managed the storage and distribution of drugs for the national supply chain. The MOH contracted an international supply and logistics company to manage the MSL to improve the drug supply chain. Each month, MSL received orders from the health facilities via the districts, then packaged the drugs by facility and delivered them to the districts. The biggest challenge to maintaining a reliable supply of drugs was the long, often-­‐‑unpredictable lead time for procurement. While maintaining a higher buffer stock could prevent stockouts, the additional staff and warehouse space required to maintain the extra stock was considered too costly.7

Malaria in Zambia

In 2004 malaria infection accounted for 45% of hospitalizations and outpatient visits in Zambia.8 About one-­‐‑fifth of children under five, mostly among the rural poor, were positive for malaria parasites in 2006, and 13% suffered from severe anemia.9 By 2007 there were 4.4 million cases of malaria, and it was the leading cause of morbidity and second leading cause of mortality in the country.10 It was endemic in all nine provinces of Zambia.11

The National Malaria Control Centre (NMCC) was established in 1997, under the directorate of the Public Health and Research division in the MOH, to coordinate malaria control across the country. In April 2000 the Minister of Health signed the Abuja Declaration,6 marking a turning point for malaria control in Zambia. The country adopted its first national malaria strategic plan to achieve the Abuja Declaration targets, and the NMCC encouraged individual provinces and districts to prioritize malaria in planning and budgeting.6 With increasing global interest in malaria, largely facilitated by the Roll Back Malaria (RBM) Partnership, new partners approached Zambia to become involved in malaria control and existing partners increased their contributions. Informal monthly partner meetings evolved into a National Malaria Working Group to enhance partner coordination.

When 2002 drug efficacy studies in Zambia revealed 60% malaria parasite resistance to the antimalarial chloroquine, a multidisciplinary Drug Technical Advisory Group reviewed alternatives for treating malaria. It recommended artemisinin-­‐‑lumefantrine, an artemisinin-­‐‑based combination therapy (ACT) that had proven therapeutic efficacy in Zambia and was the only ACT available as a fixed–dose combination at the time.12 The chosen artemisinin-­‐‑lumefantrine formulation—Coartem®, manufactured by Novartis—was 40 times more costly than chloroquine.12 The MOH’s decision to offer Coartem® despite the cost made Zambia the first African country to provide ACTs as first–line treatment available for free in the public sector.12 Chizema recalled, “There were no funds . . . but the government just said ‘we’ll go for it.’”

In 2003 the NMCC received Round 1 Global Fund funding to purchase quinine for treating severe malaria, diagnostic tests, and ACTs; it sprayed five urban areas; trained health workers in the administration of ACTs and intermittent preventive treatment for malaria in pregnancy (IPTp); and hired

  • Child health; nutrition; environmental health; control and management of communicable disease, including malaria, tuberculosis, sexually transmitted infections, and HIV/AIDS; mental health; control and management of noncommunicable disease; epidemic and disaster prevention, preparedness, and response; school health; and oral health.5

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additional NMCC staff. The government also increased malaria control funding and eliminated taxation on malaria control commodities, including nets, insecticides, and antimalarials.11

The New Malaria Strategic Plan

When Zambia was falling short of the Abuja target to cover 60% of the population with malaria interventions in 2005, the NMCC resolved to intensify its efforts. It transitioned to the RBM-­‐‑recommended “scale-­‐‑up for impact” approach (see Exhibits 4a and 4b for more information on the approach) guided by the “three ones”: one national plan, one coordination mechanism for implementation, and one monitoring and evaluation system.13 It called for rapid national dissemination of comprehensive, evidence-­‐‑based malaria prevention, control, and treatment. The MOH estimated 6.5% of total health finances would be needed for malaria control from 2006 to 2010.5

The NMCC and its partners, including provincial and district representatives, developed a joint strategic plan. The NMCC sought to surpass the targets set forth by the Abuja Declaration by reaching 80% coverage of key interventions, reducing malaria incidence by 75%, and reducing deaths attributable to malaria significantly by the end of 2011(see Exhibit 5 for the evolution of malaria targets in Zambia).14 Chizema began as the NMCC coordinator in 2006, bringing valuable insight and experience as a former district director.

Financing

Zambia’s progress and commitment to improve malaria control by 2005 attracted the attention of donors, NGOs, and the private sector. It received financial commitments from the World Bank Malaria Booster Program, the Malaria Control and Evaluation Partnership in Africa which brought funding from the Bill & Melinda Gates Foundation, and the United States Agency for International Development (USAID) via the President’s Malaria Initiative.8 Other partners, such as UNICEF, the Global Fund, the Japanese International Cooperation Agency, and the World Health Organization (WHO), remained involved with steady or increased resources (see Exhibits 6 and 7 for NMCC’s resource allocation and budget and Exhibit 8 for partners’ roles in malaria control).

Implementation

Technical working groups for each intervention (ITNs, IRS, etc.), consisting of NMCC officials and representatives of other malaria service providers, met quarterly to report progress and challenges, plan future activities, and develop guidelines to support the program. The technical working groups also contributed to the annual action plans, which incorporated the roles of domestic partners and were intended to support provincial and district teams in developing malaria control plans. They were different from previous plans, which had sidestepped provincial authorities, “so when the action plan was developed for 2007, it really had everyone’s input,” Chizema explained (see Exhibit 9 for the national planning process). Provincial teams acted as an extension of the NMCC; by monitoring and coordinating the districts, they effectively gave the NMCC “legs on the ground.”

The NMCC housed some international partners directly in its headquarters to enhance integration and communication, and the Zambia Malaria Foundation brought together domestic organizations and advocates to support the program. Chizema and her team at the NMCC retained ultimate control of policy decisions while the global and African malaria control objectives—the Abuja targets, the RBM Partnership goals, and the Millennium Development Goals—also helped align the groups involved.

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Key Interventions

Insecticide-Treated Nets

With increased funds in 2005, the NMCC began mass ITN distribution campaigns. Initially, the NMCC allocated nets to districts based on the government’s population estimates. Households that were not initially reached by IRS received three nets each through regional free net distribution campaigns, antenatal clinics, equity programs providing free nets to vulnerable populations, or commercial sales. The NMCC mandated that only the WHO-­‐‑recommended Long-­‐‑Lasting Insecticidal Nets (LLINs), such as Permanet® and Olyset®, be procured and distributed in Zambia from 2006 onward; at the time LLINs cost about USD 7.40 per net.

Many communities received an inadequate supply of nets, however. The NMCC developed ITN distribution guidelines and standardized reporting forms to try to coordinate distribution. It continuously updated a central ITN database to track coverage and needs. The NMCC also instructed partners to link with the DHMTs in their distribution efforts. In 2006 the DHMTs partnered with neighborhood health committees to survey individual households about ITN needs and distribute the required nets directly. The NMCC and DHMTs also coordinated mass ITN distribution with vaccination campaigns, Child Health Week activities, and primary schools. Health facility staff stamped standard antenatal and under-­‐‑five patient record cards to track free LLIN distribution. The NMCC and its partners increased net distribution from 4 million nets between 2003 and 2006 to 3 million free nets in 2007 alone (see Exhibit 10 for ITN partner contributions).10

To circumvent storage shortages, suppliers delivered ITNs directly to districts starting in 2007, saving both time and delivery costs. According to some estimates, distribution directly to districts saved USD 250,000 for every 300,000 ITNs delivered.15 DHMTs recruited partners, such as the World Food Program, to assist with local storage and transport of ITNs. One partner commented:

Before, we operated sort of like “cowboys.” We took everything on our own. There was less reporting on what we were doing. You reported towards the end of the year on what we did. But, now we have quarterly meetings. There’s an ITN technical working group . . . All the partners come in and talk about the challenges with ITNs, the bottlenecks, and so on. That has really improved the working relationship.

In 2008 Chizema and the NMCC decided to raise the bednet target to 100% household coverage, an increase from the 80% target established in the initial 2006–2011 strategic plan. According to the 2008 MIS, 62% of households had a least one ITN,16 compared with 13.6% in 2002.17 While ITN coverage had increased dramatically nationwide, utilization—those who actually slept under the nets—was only 41.1% among children under five and 43.2% among pregnant women.16 This was still a significant improvement over the 2002 figures, which showed that only 6.5% of young children and 8% of pregnant women slept under a net.17

Indoor Residual Spraying

The NMCC reincorporated IRS into national malaria control efforts in 2003 and continued increasing the number of districts receiving IRS in a phased approach, from 5 in 2003, to 15 in 2007, to 36 in 2008. The NMCC prioritized IRS in densely populated, high-­‐‑burden areas and in economically important locales. Districts had to have sufficient human resources available and the capacity to handle IRS operations.14 Spray operators used different formulations for mud, grass, plastered, or painted walls to improve the effectiveness of the spraying. Prior to 2007 the NMCC provided a given district with either IRS or ITNs, but with continued success and demands for IRS, some districts became eligible for both. During the first quarter of 2007, the NMCC, with partners and the DHMTs, conducted needs assessments to estimate the

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number of structures in eligible districts, the number of spray operators required, and needed supplies. The MOH Procurement Unit then procured pumps and insecticides.

The DHMTs and neighborhood health committees recruited spray operators. In a 21-­‐‑day training course, district supervisors taught the new operators practical spraying drills and oriented them in the basic science of IRS. Spray operators received small stipends for their work and covered about 12 to 15 houses per day over 20 to 60 days, depending on the size of the district. Using local community members enhanced households’ acceptance of spraying.

In 2007 the NMCC, with the help of the Malaria Control and Evaluation Partnership in Africa and neighborhood health committees, introduced geo-­‐‑coding to improve IRS accuracy. After a three-­‐‑day training, select community members with at least a high school education geo-­‐‑coded using a personal digital assistant (PDA) and door-­‐‑to-­‐‑door surveys. They recorded the geographical location, number of rooms, number of household members, type of wall surface, net ownership, and history of previous spraying to refine procurement details and enhance IRS logistics.

The NMCC convened meetings immediately post-­‐‑spraying to evaluate the implementation of the program and to capture key challenges and successes to inform the following year’s activities. The program was able to reduce the cost of IRS each year by improving the accuracy of commodity procurement, encouraging higher performance from spray operators, and increasing household acceptance rates to reduce wasted supplies and improve overall efficiency.

Malaria in Pregnancy Campaign

The NMCC worked closely with the MOH’s Reproductive Health Unit to strengthen the malaria component of antenatal care, which was offered for free in health facilities using midwives and nurse-­‐‑ midwives across Zambia. Only 0.5% of women took IPTp during pregnancy in 200217; the MOH aimed to provide at least 80% of pregnant women with a malaria intervention package by 2008. The package included three full courses of IPTp and an LLIN. Nearly every Zambian woman made at least one antenatal visit during her pregnancy,14 but many women did not return for follow-­‐‑up visits or presented too late to receive all three IPTp doses, taking only one dose. With the new strategic plan, by 2008, more than 80% of pregnant women received at least one dose of IPTp and more than 60% received two or more doses.16

Vector Management

Before 2007 the NMCC received little donor support for mosquito-­‐‑larval control and environmental management. In 2008 the NMCC procured 5,000 liters of larvicides that community-­‐‑based workers applied to mosquito breeding grounds in select districts. In urban areas, districts and neighborhood health committees promoted environmental modifications such as digging drainage ditches and filling land to eliminate stagnant water.

Diagnosis

The gold standard in Zambia for malaria diagnosis was microscopy, but inadequate human and financial resources had limited its availability. In 2006, 38% of malaria patients had access to laboratory diagnostics.8 That year the NMCC collaborated with the National Tuberculosis Program to train 279 lab staff in microscopy,8 and the NMCC used donor funds to equip more health facilities with microscopes.

Also in response to human resource shortages, the NMCC introduced rapid diagnostic tests (RDTs) to provide alternate means of malaria diagnosis if microscopy was unavailable. Using a phased approach, the NMCC gradually expanded RDT coverage from pilot sites to national coverage. The NMCC first introduced RDTs in 2004 in facilities that lacked microscopy. Teams of NMCC staff and partner representatives

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conducted RDT trainings with DHMTs, who then trained and supervised district health workers, including nurses, clinical officers, doctors, midwives, and auxiliary health workers. In 2006 the NMCC distributed 400,000 Global Fund–supported RDTs to rural health centers that lacked microscopy.8 In 2008 the NMCC had distributed 2 million RDTs.10

Many clinicians were reluctant to use RDTs. They had been taught that “fever equals malaria” and were often distrustful of negative RDT results; they presumptively treated patients for malaria based on their clinical symptoms. Patients with fever also expected antimalarials and often pressured clinicians to prescribe them. Faced with time constraints and long patient queues, clinicians often skipped RDTs. Although RDTs were significantly faster than microscopy for diagnosing malaria, in areas with no history of diagnosis, RDTs were viewed as an added step that required health workers to spend more time with each patient. In 2008, only 10.9% of febrile children under five received a finger or heel stick for diagnosis.16

Chizema stressed the need to change diagnostic practices, saying, “We really want health care workers to understand that diagnosis is important. We can no longer continue treating fever as malaria.” She observed that implementing RDTs during the high-­‐‑transmission season led to greater acceptance among clinicians. In addition, the DHMTs’ enforcement of a policy requiring positive diagnostic results prior to prescription of antimalarials led to improvements in clinical practice.

Treatment

In 2005 the ACT Coartem® cost roughly USD 1.33 per course, and overall treatment of an uncomplicated case of malaria with ACTs, including diagnosis, drugs, and personnel, cost an estimated USD 7.34.18 Despite the increased cost of treating malaria, the drug policy change to ACTs drastically improved the treatment of uncomplicated malaria, leading to reductions in malaria mortality (see Exhibit 11 for trends in malaria mortality).

The NMCC’s aim was that by 2008 at least 80% of malaria patients would receive ACTs within 24 hours of symptom onset. In sparsely populated rural areas, access to health care remained limited, however. Health facilities were long distances from households, and transport was a significant obstacle. Many rural patients with malaria did not present to a health facility in time for treatment, if at all. The NMCC decided to involve CHWs in “home management” of malaria. In 2007 the NMCC conducted a feasibility study and determined that volunteer CHWs meeting educational and literacy requirements were capable of administering RDTs and ACT for uncomplicated malaria. In 2008 CHWs in 11 districts received training and had Coartem® and RDTs added to their home management kits.

By 2008, 64% of children under five with fever were brought for treatment within 24 hours of symptom onset,16 an increase from 4.5% in 2006.9 The percentage of children with fever who received ACTs within 24 hours rose from 8.3% in 20069 to 12.7% in 2008.16

Beyond reaching patients, Zambia struggled to ensure adequate supplies of ACTs were consistently available at the district level. Although national supplies of Coartem® at Medical Stores Limited were generally adequate and MSL’s delivery of drugs to the district pharmacies was efficient, poor transport, stocking, and ordering at the district level resulted in frequent ACT stockouts at health centers. In 2007, 40% of health facilities had ACT stockouts for one to two weeks, and some reported monthly stockouts.19 At times, patients were referred to private pharmacies where Coartem® cost USD 5 to 10. The NMCC and its partners implemented district-­‐‑level inventory management trainings and developed a study to investigate how district-­‐‑level transport and human resource interventions could affect distal supply chain issues.

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Information, Education and Communication and Behavior Change Communication

The NMCC recognized that, although the average Zambian’s knowledge of malaria was high and despite its effort to increase the availability of malaria commodities, utilization of interventions remained insufficient. In 2005 the NMCC began supplementing isolated, event-­‐‑driven campaigns, such as World Malaria Day, with more routine education lasting throughout the year. In 2006 Chizema and her team intensified their information, education and communication (IEC) and behavior change communication (BCC) efforts to encourage communities to adopt positive malaria control behavior and aimed to generate political will and mobilize resources needed for control efforts. The IEC technical working group assisted all NMCC units with their communication needs, such as IRS acceptance, prompt care-­‐‑seeking behavior, and adherence to RDT results by health workers. The NMCC engaged high-­‐‑level politicians and popular musicians to raise the profile of malaria control across the country through television, community radio, community theater performances, posters and educational materials, and door-­‐‑to-­‐‑door campaigns. In 2007 the NMCC and its partners conducted a BCC workshop with select DHMTs that provided training in analyzing community needs and generating effective malaria education messages through appropriate communication channels.

Recognizing that local leaders were highly influential in their communities, in 2007 the NMCC engaged the national House of Chiefs—30 chiefs from all nine provinces who governed chiefs across the country—in malaria control. The 30 chiefs responded favorably to NMCC recommendations, such as promoting mass ITN distribution campaigns and encouraging IRS acceptance, and requested further participation from all chiefs.

Monitoring and Evaluation

In 2003 the NMCC established the Malaria Information System in 10 sentinel districts to improve data tracking, analysis, and dissemination. The NMCC also developed a database and activity reports for ITN distribution, IRS coverage, and other interventions and extracted malaria-­‐‑specific data from the national Health Management Information System.

In 2006, in accordance with the new strategic plan, the NMCC made revisions to the health management information system’s malaria indicators to better assess program performance and the burden of malaria.20 It also advocated for monthly rather than quarterly reports from the health management information system to produce more actionable data. Finally, with the help of partners, the NMCC augmented facility data with the Demographic and Health Survey’s household data to assess disease incidence and program performance (see Exhibit 12 for progress in malaria control).

Incomplete reporting caused by a shortage of health workers was a key impediment to effective monitoring of key health indicators. Because of high clinical demands, few clinicians kept adequate records. Increased supervision of health facilities was required to enhance the reliability of malaria and other disease indicators. The operational research branch of the NMCC had the mandate of assessing the effectiveness of malaria control interventions and responding to challenges in implementation. It conducted drug efficacy studies to continually monitor resistance and addressed specific questions NMCC technical working groups presented. To build research capacity, the branch assembled multidisciplinary research groups and included university students and district staff on research teams.

In addition to informing program development, the NMCC’s monitoring and evaluation activities demonstrated progress and contributed to reports the NMCC could share with the government, donors, and implementers. Demonstrating progress was key to maintaining partner attention. As one NMCC officer put it, “Everyone wants to be associated with winners.”

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Looking to the Future

Malaria parasite prevalence in children had declined from 21.8% in 20069 to 10.2% in 2008,16 and severe anemia dropped from 13.3% in 20069 to 4.3% in 2008.16 In 2007 in-­‐‑patient malaria cases and deaths were lower by 33% and 24%, respectively, as compared with the average from 2001 to 2003.21 When the 2008 MIS was released, Minister of Health Dr. Brian Chituwo commented:

These are remarkable figures -­‐‑-­‐‑ something all of us should be proud of. These achievements have been possible because of the strong partnership that the Ministry enjoys with partners. But, at this moment we cannot pat ourselves on the back and say we’re done. No. We must maintain what we have achieved and with this momentum, galvanize our efforts and press for even greater successes.22

Like the Minister, Chizema feared that the positive press and the progress reports the NMCC had generated could have a paradoxical effect of making donors consider the job done. Preparing for the 2009 annual action plan meetings, Chizema reflected on the persistent gaps in malaria control in Zambia— effective bed net utilization, ACT stockouts, case management, and incomplete reporting—and how the NMCC would sustain the progress made and ensure the continued support of its partners.

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Appendix List of Abbreviations

ACT artemisinin-­‐‑based combination therapy BCC behavior change communication CHW community health worker DHMT District Health Management Team IEC information, education, communication IPTp intermittent preventive treatment for malaria in pregnancy IRS indoor residual spraying ITN insecticide-­‐‑treated net LLIN long-­‐‑lasting insecticide-­‐‑treated net MIS Malaria Indicator Survey MOH Ministry of Health MSL Medical Stores Limited NMCC National Malaria Control Centre RBM Roll Back Malaria RDT rapid diagnostic test UNICEF United Nations Children’s Fund USAID United States Agency for International Development USD United States dollars WHO World Health Organization

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Exhibit 1 Map of Zambia

Source: United Nations. Exhibit 2 Basic Socioeconomic and Demographic Indicators

INDICATOR YEAR

UN Human Development Index ranking 165 out of 177 2007 Population (thousands) 12,620 2008

Fertility rate (total births per woman) 5.8 2008 Urban population (%) 35 2008

Drinking water coverage (%) 58 2006 Poverty rate (% living under USD 1.25 per day) 64 2008

Gini index 50.7 2004 GDP per capita in PPP

(constant 2005 international dollars) 1,251 2008

GDP per capita (constant 2000 USD) 387 2008 Adult literacy (%) 70.7 2008

Sources: United Nations agencies and the World Bank.

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Exhibit 3 Health System and Epidemiologic Indicators

Sources: World Bank and National Health Strategic Plan 2006–2o10.

INDICATOR YEAR

Average life expectancy at birth (total/female/male) 45/46/45 2008 Maternal mortality ratio (per 100,000 live births) 470 2008 Under-­‐‑five mortality rate (per 1,000 live births) 145 2008 Infant mortality rate (per 1,000 live births) 88 2008 Vaccination rates (% of DTP3 coverage) 81 2008

Undernourished (%) 43 2007 HIV prevalence (% of population ages 15–49) 14 2008 HIV antiretroviral therapy coverage (%) 51 2007 Tuberculosis incidence (per 100,000) 468 2008

Tuberculosis treatment success rate (% of registered cases) 88 2008 Malaria cases (per 1,000) 358 2007

Government expenditure on health (% of total government expenditure) 11 2008

Government expenditure on health per capita (international dollars, USD) 26 2006

Total health expenditure per capita (constant 2005 international dollar, USD) 80 2008

Out-­‐‑of-­‐‑pocket health expenditure (% of private expenditure on health) 75 2008

External resources for health (% of total expenditure on health) 50 2008 Physician density (per 10,000) 1 2006

Number of hospital beds (per 10,000) 2 2008

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Exhibit 4a Malaria Program Scale-Up: Coverage and Burden Reduction

Source: Malaria Control and Evaluation Partnership in Africa. Scaling Up for Impact through Comprehensive Program Improvement. Seattle; 2007.

Exhibit 4b Scale-up for Impact: Principle of the “Three Ones”

One national plan o Multiyear strategic plan o Three-­‐‑year implementation plan o Annual action plan o Business plan for human resources, supply chain management, etc.

One coordination mechanism for implementation

o Financial and human resource support o System support for administration, partnering, etc. o Intervention support

One monitoring and evaluation system o Monitor coverage and use o Document action o Track impact on illness, anemia, death o Identify gaps for next planning cycle

Source: Malaria Control and Evaluation Partnership in Africa. Scaling up for Impact through Comprehensive

Program Improvement. Seattle; 2007.

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Exhibit 5 Evolution of National Malaria Control Strategic Plan Targets in Zambia

Parameter National Malaria Control Strategic Plan 2000–2005

National Malaria Control Strategic Plan 2006–2011

Guiding principles RBM principles RBM principles and scale-­‐‑up for impact concept

ITN coverage target 60% of households with ³ 1 ITN >80% of households with average of 3 ITN/households

IRS coverage target Not defined >85% coverage of eligible households in 15 districts

IPTp coverage target 90% of pregnant women using IPTp >80% of pregnant women receiving 2 doses IPTp

Target for ITN use in pregnant women

50% of pregnant women sleeping under ITN

80% of pregnant women sleeping under ITN or in a house sprayed with IRS

Target for ITN use in children <5 years of age

60% of children <5 years of age sleeping under ITN

80% of children <5 years of age sleeping under ITN or in a house with IRS

Target of PECM (prompt and effective clinical management)

60% of sick persons have access to PECM

80% of sick person treated with effective antimalarial within 24 hours of onset

Source: Adapted from: Steketee, RW, Sipilanyamb, N, Chimumbw, J, et al. National Malaria Control and

Scaling Up for Impact: The Zambia Experience through 2006. American Journal of Tropical Medicine and Hygiene. 2008; 79(1):45–52.

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Exhibit 6 NMCC Resource Allocation in 2008 (Estimated/Budgeted Values)

Source: Adapted from Ministry of Health Zambia. 2008 National Malaria Control Action Plan: Actions for Scale-Up for Impact on Malaria in Zambia. Lusaka; 2007.

Insecticide-­‐‑treated nets 53%

Case management 19%

Operational research 2%

IEC/BCC 4%

Emergency/epidemic activities

2%

Monitoring and evaluation

4%

Program management

1%

Entomological activities

1%

Indoor residual spraying 14%

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Exhibit 7 National Malaria Control Program Estimated 2008 Budget: Part 1 Note: DDT refers to dichloro-diphenyl-trichloroethane.

Activity Budget Insecticide Treated Nets $32,061,426

Mass distribution (incl. 3.5 million LLINs) $26,101,723 Malaria in Pregnancy Campaign (incl. 490,000 LLINs) $4,009,059 Equity Programme (vulnerable populations) $270,628 Retreatment of nets $1,339,503 Technical meetings and seminars $23,776 Zambia Business Coalition against Malaria workshops/meetings $16,568 Support for Provincial Health Offices $4,893 Community Malaria Booster Response strengthening $295,276 Indoor Residual Spraying $8,583,000 National-­‐‑level IRS coordination $74,000

Implement IRS in 36 districts (incl. 1245 spray pumps, 32,500 insecticides, 2,500 sets of personal protective equipment) $7,827,000 Geocoding and mapping houses $30,000 IRS IEC/BCC Materials $152,000 Environmental safeguards $500,000

Entomology $800,400 Conduct entomological surveys $61,200 Vector susceptibility and resistance surveys $54,000 Evaluation of new insecticides/larvicides as alternatives to DDT $54,000 Operationalise Malaria Decision Support System $120,000 Larval source management $336,000 Environmental safeguards $125,000 Meetings and supervision $50,200 Prompt and Effective Case Management (PECM) $11,137,502

Malaria diagnosis for all health facilities (incl. 2 million RDTs and training 30 new microscopists) $2,554,720

Drug logistics management (incl. 3.8 million doses of Coartem®, 400,000 x 3 doses SP) $6,213,490 Home management for malaria (w/ ACTs and RDTs) $391,000 Improvement of case management with ACTs in private sector $24,000 FANC (for malaria in pregnancy) $1,737,500 Severe malaria management $167,262 Monitoring and supervision $49,530

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Exhibit 7 (cont’d) National Malaria Control Program Estimated 2008 Budget: Part 2

Activity Budget Operations Research $986,178 Conferences / research (incl. drug efficacy trials) IEC/BCC Advocacy Plan (Large funding) $2,219,000 Launch communication strategy $30,000 BCC capacity building $386,500 IEC materials $230,000 BCC proposals $272,000 Advocacy and coordination meetings $138,000 Community mobilization (incl. radio and television shows) $437,000 Media and radio efforts $169,500 Promotional events $390,000 Engage traditional healers $64,000 Engage private sector $102,000 Monitoring and Evaluation Activities (Big funding gaps) $2,183,500 National M&E coordination $57,000

Programmatic and district performance monitoring (incl. support to sentinel districts) $885,500 Evaluation and reporting (incl. 2008 MIS) $1,177,000 M&E capacity development (incl. staff trainings) $64,000 Program Management $877,507

Organization, alignment, coordination (incl. meetings with provinces, districts, partners, other ministries) $32,738 Policy, program planning, and design $30,973 Human resource management (incl. some NMCC salaries) $130,778 Financial management $285,857 Program implementation $38,005 Infrastructure and equipment $262,915 Commemoration of national days $10,715 Institutional capacity development $85,526 Emergency Planning Activities $982,000 Emergency and malaria epidemic preparedness plan $497,000 Malaria early warning systems plan $275,000 Establish emergency fund $210,000 TOTAL ESTIMATED COST $59,830,513

Source: Adapted from Ministry of Health Zambia. 2008 National Malaria Control Action Plan: Actions for

Scale-Up for Impact on Malaria in Zambia. Lusaka: 2007.

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Exhibit 8 National Malaria Control Program Partners and Key Involvement

Partner Type Main Role/Involvement Japanese International Cooperation Agency

Bilateral ITN distribution

President’s Malaria Initiative Bilateral Funds, technical support

Zambia Malaria Foundation Community based organization IEC, ITN distribution

John Snow International Consulting Supply chain management improvement

Global Fund Donor Funds (ACTs, diagnostics, IEC, IRS, ITN distribution, M&E health systems strengthening)

Child Health Unit Government ITN distribution, case management, IEC

Ministry of Defense Government ITN distribution (transport)

Ministry of Education Government IEC, ITN distribution

Reproductive Health Unit Government Malaria in Pregnancy, ITN distribution ZANIS Government IEC Health Communication Partnership Implementing (funded by PMI) IEC

Health Systems Strengthening Partnership

Implementing (funded by PMI) IRS

Society for Family Health Implementing (funded by PMI) ITN distribution (antenatal, <5)

JIPHEGO International NGO Malaria in Pregnancy

Malaria Consortium International NGO IEC, M&E

Malaria Control and Evaluation Partnership in Africa

International NGO Funds, IEC, ITNs, M&E, advocacy, technical support

RAPIDS International NGO ITN distribution (equity channel)

House of Chiefs Local authority IEC, ITN distribution

Zambia Business Coalition Against Malaria

Local collaboration IEC

Roll Back Malaria Multilateral Advocacy, technical support

UNICEF Multilateral Funds, ACTs, IEC, ITN distribution, technical support

WHO Multilateral Technical support, M&E

World Bank Multilateral Funds (IEC, ITN distribution, IRS, health systems strengthening)

Barclay’s Bank Private ITN distribution (mass distribution)

Konkola Copper Mines Private IRS, ITN distribution

Churches Health Association of Zambia

Religious organization ITN distribution, case management, Malaria in Pregnancy

Research Triangle Institute Research Center Operational research

Tropical Diseases Research Centre (TDRC)

Research Center Operational research

University of Zambia (UNZA) Research Center Operational research

Note: List of partners and main involvement is not fully comprehensive. Source: Compiled by case writers from program documents and interviews.

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Exhibit 9 National Planning Process

Source: Ministry of Health Zambia. 2008 National Malaria Control Action Plan: Actions for Scale-Up for

Impact on Malaria in Zambia. Lusaka; 2007. Exhibit 10 Main Sources of ITNs in 2007

Source Quantity of Nets Procured Global Fund 1, 082, 000 World Bank 1, 080, 000 President’s Malaria Initiative /PEPFAR/RAPIDS 505, 000 Japanese International Cooperation Agency 392, 500 USAID/ Society for Family Health 322, 348 UNICEF 16, 500 Malaria Control and Evaluation Partnership in Africa 18, 000 TOTAL 3, 416, 348 Source: Ministry of Health Zambia. 2008 National Malaria Control Action Plan: Actions for Scale-Up for

Impact on Malaria in Zambia. Lusaka: 2007.

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Exhibit 11 Trends in Malaria Mortality in Zambia, 2001–2007

Reported Malaria Deaths, 2001-2007

Reported Malaria Deaths and All-cause Deaths, 2001–2007

Year 2001 2002 2003 2004 2005 2006 2007 Reported malaria deaths, all ages 9369 9021 9178 8289 7737 6484 NA Reported malaria deaths, <5 years 5498 4717 4653 4008 3470 3342 3783

All-­‐‑cause deaths, all ages 35,358 39,482 39,117 38,466 38,740 35,541 NA All-­‐‑cause deaths, <5 years 16,680 16,377 15,459 13,569 12,796 12,469 13,842

Source: Adapted from World Health Organization. World Malaria Report 2008. Geneva: 2008.

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Exhibit 12 Progress in Malaria Control Interventions

Indicator

DHS 2002 (%)

MIS 2006 (%)

MIS 2008 (%)

            Mosquito  Net  Coverage  and  Use  

Households with at least 1 net 27.2 50.1 71.5

Households with at least 1 ITN 13.6 44.4 62.3

Children <5 years who slept under net 16.3 26.6 47.5

Children <5 years who slept under ITN 6.5 22.8 41.1

Malaria in Pregnancy Campaign Pregnant women who slept under net 17.4 23.9 45.5

Pregnant women who slept under ITN 7.9 21.1 43.3

Pregnant women who took any antimalarial drug 35.8 76.9 88.1

Pregnant women who took at least 2 doses of IPT NA 61.9 66.1

            Prompt,  Effective  Case  Management  for  Fever/Malaria  Among  Children  <5  years  

Children who reported fever in 2 weeks preceding survey 43.3 29.2 28.1

Febrile children who took any antimalarial drug 51.9 57.3 43.3

Febrile children who took any antimalarial drug in 24 hours 36.8 37 28.9

Febrile children who took ACT in 24 hours NA 12.7 8.2 Febrile children who sought treatment from facility/provider in 24 hours NA 4.5 64.0

Malaria Parasite Prevalence and Anemia in Children <5 years

Children with malaria parasites NA 21.8 10.2

Children with severe anemia (hemoglobin <8g/dL) NA 13.3 4.3 Sources: Chipimo M, Banda R. Demographic Health Survey, Chapter 10: Malaria. 2002.

Ministry of Health Zambia; Zambia National Malaria Indicator Survey 2006. Lusaka: MOH; 2006. Ministry of Health Zambia; Zambia National Malaria Indicator Survey 2008. Lusaka: MOH; 2008.

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References

  1. Economist Intelligence Unit. Zambia: Country Profile 2007. 2007. 2. The World Bank Group. World Development Indicators Online, Zambia, 2007. http://ddp-­‐‑

ext.worldbank.org. Accessed December 13, 2008. 3. Packard RM. The making of a tropical disease: A short history of malaria. Baltimore: The Johns Hopkins

University Press; 2007. 4. CIA World Factbook. Zambia Country Facts. https://www.cia.gov/library/publications/the-­‐‑world-­‐‑

factbook/geos/za.html. Accessed 07/13/08. 5. Ministry of Health Zambia. National Health Strategic Plan 2006-­‐‑2010. In: MOH, ed. Lusaka; 2005. 6. Ministry of Health Zambia. Strategic Plan for Rolling Back Malaria in Zambia, 2001-­‐‑2005. Lusaka:

MOH; 2001. 7. Yadav P. Analysis of the Public, Private, and Mission Sector Supply Chains for Essential Drugs in

Zambia.; 2007. 8. President’ʹs Malaria Initiative. Malaria Operational Plan Zambia FY 2008. USAID; 2007. 9. Ministry of Health Zambia. Zambia National Malaria Indicator Survey 2006. Lusaka: MOH; 2006. 10. Ministry of Health Zambia. 2008 National Malaria Control Action Plan: Actions for Scale-­‐‑Up for

Impact on Malaria in Zambia. Lusaka; 2007. 11. Steketee RW, Sipilanyambe N, Chimumbwa J, et al. National Malaria Control and Scaling Up for

Impact: The Zambia Experience through 2006. American Journal of Tropical Medicine and Hygiene. 2008; 79(1):45–52.

  1. Sipilanyambe N, Simon JL, Chanda P, Olumese P, Snow RW, Hamer DH. From chloroquine to artemether-­‐‑lumefantrine: the process of drug policy change in Zambia. Malaria Journal. Vol 7; 2008.
  2. MACEPA. Scaling up for impact through comprehensive program improvement. Seattle; 2007. 14. Ministry of Health Zambia. A Road Map for Impact on Malaria in Zambia, a 6-­‐‑Year Strategic Plan,

2006–2011. In: MOH, ed. Lusaka; 2005. 15. MACEPA. Strengthening systems for distributing insecticide-­‐‑treated mosquito nets in Zambia.

Seattle; 2007. 16. Ministry of Health Zambia. Zambia National Malaria Indicator Survey 2008. Lusaka: MOH; 2008. 17. Chipimo M, Banda R. Demographic Health Survey, Chapter 10: Malaria. 2002. 18. Chanda P, Masiye F, Chita MB, et al. A cost-­‐‑effectiveness analysis of artemether lumefantrine for

treatment of uncomplicated malaria in Zambia. Malaria Journal. 2007; 6(21). 19. National Malaria Control Centre. National Malaria Control Programme 2007 Annual Report.

Lusaka: Ministry of Health Zambia; 2007. 20. Ministry of Health Zambia. Framework to Strengthen Routine Monitoring of Malaria Activities

Under the World Bank Funded Booster Project. Lusaka: MOH; 2006. 21. World Health Organization. World Malaria Report 2008. Geneva; 2008. 22. Ministry of Health Zambia. “ʺRemarkable Figures”ʺ Demonstrate That Zambia Is Winning Its Fight

Against Malaria. Press Release. Lusaka; September 22, 2008.

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Carry out a literature review of peer-reviewed journals

Carry out a literature review of peer-reviewed journals

5

The Impact of the Globalization of Infectious Disease on Today’s Public Health Agenda

Instructions of the assignment:

Referring to the example of the Case Study on the malaria control efforts in Zambia, prepare a 2-page (single-spaced) brief for use by a public broadcasting news reporter on the impact of the globalization of infectious disease on today’s public health agenda. Included in your discussion should be evidence-based information (literature review) reflecting the foundational competency and the SLO stated below. Conduct a literature review of peer-reviewed journals and appropriate government documents.

MPH 19: Communicate audience-appropriate public health content, both in writing and through oral presentation.

SLO4: Synthesize the inter-relatedness of the public health disciplines and the ways in which these disciplines connect with a community or population group around a public health event.

Use the following articles to write this paper in addition to extra sources, please.

https://www.ncbi.nlm.nih.gov/books/NBK56591/
https://www.healthypeople.gov/2020/topics-objectives/topic/global-health
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1299207/
https://www.sciencedirect.com/science/article/pii/S147149221500207X

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Task Data Breach

Task Data Breach

Data Breach

Find an article regarding a recent data breach. In APA format write a 1 to 2 page paper on the incident. Be sure to

Find out about the company such as how long have they been in business?

Did they have an incident response plan or team?

What was the outcome?

Who was affected?

What would you have done?

Be sure to properly cite your references both in text and at the end.

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Discuss remaining usability problems in the interface

Discuss remaining usability problems in the interface

Introduction
Purpose

Your goal is to create a design for a software interface. You can choose one of the suggested projects and you can experience the scope of the design process from brainstorming ideas and gathering information about users’ needs to storyboarding, prototyping, and finally, testing and refining your product. As you work on the software interface, you will demonstrate your ability to apply fundamental Human-Computer Interaction principles to interface analysis, design, and implementation.

Deliverables

This project should follow the main steps of the first three phases and presentation. Details description and diagrams should be included in each phase.

Suggested planning

For a thoughtful progress of the project and knowing that you will give a presentation of your work by week 13, you are advised to follow this planning:

a. Phase I: week 9

b. Phase II: week 10

c. Phase III: week 11

d. Phase IV: week 12

Phase One:
2 Marks

Learning Outcome(s):

LO1

You need to determine the idea and it must be useful. Here is a list of suggested project idea that you can choose from:

· Cinema Booking

· Finding Doctors

· ….(Instructors can add other ideas}

Then, you need to write a brief description of your idea, including the following main points:

  1. Title of your project
  2. Introduction to the interactive system (software interface) to be developed
  3. Why is it interesting?
  4. Main users affected
  5. Identify and describe at least 6 tasks for your system. Each task should include a goal, description and subtasks (if any). Also, write a task scenario for each of the tasks you have identified.

Phase Two:
3 Marks

Learning Outcome(s):

LO1, LO3

A high-fi prototype shows the main elements of a user interface connected and working together using a software tool. Its purpose is to get a quick, clear and precise look of the final interface. It, also, provides both designer and user with the ability to interact with the system and check some of its functions. A high-fi prototype enables designers to identify usability issues such as confusing paths, bad terminology, layout problems, and missing feedback.

Your task, in this phase of the project, is develop a Hi-Fi prototype for your software interface. Please note that your prototype does not need to be as extensive, 5-7 interfaces to show the main functions will be sufficient. Your prototype should allow people to navigate from screen to screen, recover from errors, and change their choices. Don’t try to show every possible action or detail. Focus on the main interactions.

1- Using any prototyping tool, create a High Fidelity prototype for your software interface. Here is a list of prototyping tools that you can choose from:

· InVision

· Microsoft PowerApps

· Marvel

· Ionic creator

2- Write a description of each of the interfaces (include screenshots) explaining the following:

a. The purpose of the interface.

b. The main functions in the interface.

c. The previous and next status of main actions.

d. The layout of the interface(screenshot).

3- Write a design rationale trying to justify your choices of design. You may support your answer by referring to any guidelines, principles or theories that you have learned from IT201.

Phase Three:
3 Marks

Learning Outcome(s):

LO3,LO5

1- You will conduct a heuristic evaluation of your prototype with expert users. Your classmates in this course would make great expert reviewers. You should use Jakob Nielsen’s Ten Usability Heuristics or another set of heuristics approved by your professor.

a. Allow at least 3 expert users to use the high-fi prototype.

b. The purpose of the heuristics is to guide your expert users and help them find as many different types of usability issues as possible.

c. Instruct your experts to describe each issue noted as specifically as possible. Allow the expert to explore the interface and follow any paths.

2- Make sure to practice with your prototype so that you can operate it effectively and not waste time. Doing several practice runs or walkthroughs will help you identify missing pieces and dead ends.

3- It would be a good idea to do this testing in groups. One person can be the expert tester while another works the prototype and the others take notes. Then, everyone can switch roles until all participants have been experts and had a chance to test their designs.

4- Review the feedback you got from your reviewers.

5- Write a summary of the prototype testing results describing what worked and what did not. In addition to a list of specific changes you want to make to your interface. This summary must include;

a. Average subjective satisfaction of reviewers

b. Number and details of terms/metaphors unfamiliar to reviewers

c. Number and details of action sequences considered confusing lengthy by reviewers

d. Number and details of inputs/outputs not understood by reviewers

And you can add any further items of interest from review activity.

Phase Four:
1 Mark

Learning Outcome(s):

LO1, LO3. LO5

Prepare a presentation of your project idea describing all of the following:

1- Problem: Introduce the idea of project you chose, including problems you are trying to solve, the target users, and a list of the tasks.

2- Design: Describe the final design of your interface, including any redesign you did after the usability testing with screenshots. Indicate important design decisions and discuss the design alternatives that you considered.

3- Reviewer Testing: Describe briefly your user test. Describe how the users did the test. What are the tasks they performed? Any useful suggestion or feedback from the users during the usability test.

4- Evolution: Describe how your implemented interface makes the system better from perspective of usability and user satisfaction. List all improvements experienced by reviewers or other sources who evaluated your interface.

5- Conclusion: Discuss remaining usability problems in the interface and what are the solutions to solve it. and discuss the conclusion and any future improvements you can suggest about interface of your selected system.

You will present this in front of your class during week 13, your instructor will provide you with the time/date for your presentation.

End of project report

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