Chapter One contains an assessment of the global health situation, with some important and unexpected findings. Over the last 50 years, average life expectancy at birth has increased globally by almost 20 years, from 46.5 years in 1950--1955 to 65.2 years in 2002. The large life expectancy gap between developed and developing countries in the 1950s has changed to a gap between the very poorest developing countries and all other countries.
Of the 57 million deaths in 2002, 10.5 million were among children of less than five years of age, and more than 98% of these were in developing countries. Globally, considerable progress has been made since 1970 when over 17 million child deaths occurred. In 14 African countries, however, current levels of child mortality are higher than they were in 1990. Overall, 35% of Africa's children are at higher risk of death today than they were 10 years ago. The leading causes of death in children are perinatal conditions, lower respiratory tract infections, diarrhoeal diseases and malaria, with malnutrition contributing to them all. In sub-Saharan Africa, HIV/AIDS was responsible for an estimated 332 000 child deaths in 2002. Across the world, children are at higher risk of dying if they are poor and malnourished, and the gaps in mortality between the haves and the have-nots are widening.
The state of adult health at the beginning of the 21st century is characterized by two major trends: slowing of gains and widening health gaps; and the increasing complexity of the burden of disease. The most disturbing sign of deteriorating adult health is that advances in adult survival in Africa have been reversed so drastically that, in parts of sub-Saharan Africa, current adult mortality rates today exceed those of 30 years ago. The greatest impact has been in Botswana, Lesotho, Swaziland and Zimbabwe, where HIV/AIDS has reduced life expectancies of men and women by more than 20 years.
The fragile state of adult health in the face of social, economic and political instability is apparent elsewhere. Male mortality in some countries in eastern Europe has increased substantially. Globally, most countries are already facing the double burden of communicable and noncommunicable diseases. Almost half of the disease burden in high-mortality regions of the world is now attributable to noncommunicable diseases. Population ageing and changes in the distributions of risk factors have accelerated these epidemics in most developing countries. Injuries, both intentional and unintentional, are on the increase, primarily among young adults.
Chapter Two traces the origins of the Millennium Development Goals and charts the progress so far towards achieving them. These goals represent commitments by governments worldwide to do more to reduce poverty and hunger and to tackle ill-health, gender inequality, lack of education, access to clean water and environmental degradation. Three of the eight goals are directly health-related; all of the others have important indirect effects on health.
The Millennium Development Goals place health at the heart of development. This chapter warns that without significantly strengthened commitments from both wealthy and developing countries, the goals will not be met globally, and outcomes in some of the poorest countries will remain far below the achievements hoped for.
Chapter Three reviews major trends in the HIV epidemic and examines successes and failures in the struggle against the world's most devastating infectious disease, before discussing goals for the coming years. These include narrowing the AIDS outcome gap by providing three million people in developing countries with combination antiretroviral (ARV) therapy by the end of 2005 (known as the "3 by 5" target). Although robust HIV prevention and care constitute a complex health intervention, such interventions are not only feasible in resource-poor settings, but are precisely what is needed.
The chapter shows the often stark division between AIDS prevention and care, which in the developing world has meant that, for most people living with HIV, there is simply no decent medical care available at all. But it also provides examples, such as Brazil, where prevention and care have been successfully integrated. The chapter acknowledges that there is still a great deal to be done if the target of three million people on ARV therapy by 2005 is to be met. For this reason, WHO has formally declared inadequate access to ARV therapy to be a global health emergency, and has set in place a number of initiatives to respond accordingly and to progress towards the ultimate goal of universal access to ARV therapy.
Chapter Four is the encouraging story of how a major, ancient disease can be conquered. As a result of the Global Polio Eradication Initiative, one of the largest public health efforts in history, the number of children paralysed by this devastating disease every year has fallen from over 350 000 in 1988 to about 1900 in 2003; the number of countries in which the disease is endemic has fallen from over 125 to seven. This chapter records the expected last days of polio, one of the oldest known diseases, as the campaign to eradicate it nears its end. The vision of a polio-free world is within reach, although formidable obstacles remain.
The successes to date are the result of a unique partnership forged between governments, international agencies, humanitarian organizations and the private sector. Through this partnership, over 10 million volunteers immunized 575 million children against polio in nearly 100 of the lowest-income countries in the world in the year 2001 alone. The most visible element of the polio eradication initiative has been the National Immunization Days, which require immunizing every child under five years of age (nearly 20% of a country's population) over a period of 1--3 days, several times a year for a number of years in a row. In many countries, the scale and logistic complexity of these activities were even greater than those of campaigns undertaken during the height of the smallpox eradication effort.
To capitalize on progress so far, substantial effort is now required to interrupt the final chains of polio transmission, certify that achievement, and minimize the risk of polio being reintroduced in the future. The ultimate success of the eradication effort, however, is still not guaranteed; it now rests with a very small number of endemic areas, where all of the children must be immunized, and with donors who must close the chronic financing gap for these activities.
Chapter Five, on SARS, is a tale of how a completely new disease can emerge with major international implications for health, economy and trade. Its rapid containment is one of the success stories of public health in recent years and represents a major victory for public health collaboration.
SARS is a newly identified human infection caused by a coronavirus unlike any other known human or animal virus in its family. Transmission occurs mainly from person to person during face-to-face exposure to infected respiratory droplets expelled during coughing or sneezing. The overall case--fatality ratio, with the fate of most cases now known, approaches 11% but is much higher in the elderly. The international outbreak eventually caused more than 8000 cases and 900 deaths in 30 countries.
Seven key lessons emerge from the SARS epidemic and will help shape the future of infectious disease control. First and most compelling is the need to report, promptly and openly, cases of any disease with the potential for international spread. Second, timely global alerts can prevent imported cases from igniting big outbreaks in new areas, provided the public health infrastructure is in place and an appropriately rapid response occurs. Third, travel recommendations, including screening measures at airports, help to contain the international spread of a rapidly emerging infection.
Fourth, the world's scientists, clinicians and public health experts, aided by electronic communications, can collaborate to generate rapidly the scientific basis for control measures. Fifth, weaknesses in health systems, especially in infection control practices, play a key role in permitting emerging infections to spread. Sixth, an outbreak can be contained even without a curative drug or a vaccine if existing interventions are tailored to the circumstances and backed by political commitment. Finally, risk communication about new and emerging infections is a great challenge, and it is vital to ensure that the most accurate information is successfully and unambiguously communicated to the public.
Chapter Six, in contrast, describes the impact on developing countries of the stealthy but rapidly evolving epidemics of noncommunicable diseases and injuries, particularly cardiovascular disease (CVD), the global tobacco epidemic, and the "hidden epidemics" -- direct and indirect -- resulting from the growth in road traffic.
Today, the burden of deaths and disability in developing countries caused by non- communicable diseases outweighs that imposed by long-standing communicable diseases. In examining the impact of the combination of these two categories, this chapter proposes a "double response" involving the integration of prevention and control of communicable and noncommunicable diseases within a comprehensive health care system based on primary health care.
Ironically, rates of CVD are now in decline in the industrialized countries first associated with them, although not all population groups have benefited. But from that irony stems hope: the decline is largely a result of the successes of primary prevention and, to a lesser extent, treatment. What has worked in the richer nations can be just as effective in their poorer counterparts, although particular attention is needed to ensure that the benefits flow to the entire population. There is now abundant evidence to initiate effective actions at national and global levels to promote and protect cardiovascular health through population-based measures that focus on the main risk factors shared by all noncommunicable diseases. The application of existing knowledge has the potential to make a major, rapid and cost-effective contribution to the prevention and control of the epidemics of noncommunicable diseases.
The consumption of cigarettes and other tobacco products and exposure to tobacco smoke are the world's leading preventable cause of death, responsible for about 5 million deaths in 2003, mostly in poor countries and poor populations. The toll will double in 20 years unless known and effective interventions are urgently and widely adopted. The recognition that globalization of the tobacco epidemic can undermine even the best national control programme led to the adoption by 192 Member States at the World Health Assembly in May 2003 of the WHO Framework Convention on Tobacco Control (WHO FCTC).
The opening of the Convention for signature and ratification provides an unprecedented opportunity for countries to strengthen national tobacco control capacity. Success in controlling the tobacco epidemic requires continuing political engagement and additional resources at both global and national levels. The resulting improvement in health, especially of poor populations, will be a major public health achievement.
Chapter Six concludes with an assessment of the rising toll of road deaths and injuries and emphasizes the indirect, but equally important, effects of the growth in road traffic. More than 20 million people are severely injured or killed on the world's roads each year. The social and economic burden falls most heavily on developing countries and will grow significantly heavier still in these countries because of the rapid increase in the number of vehicles on their roads. Existing knowledge must be converted into successful interventions for developing countries, taking account of each country's unique road safety circumstances. More generally, cross-sectoral collaboration can improve public health and make more efficient use of the resources of the health, environment and transport sectors.
Chapter Seven emphasizes that health systems must be strengthened to meet the formidable challenges described in earlier chapters. Without significant health systems strengthening, many countries will make little headway towards the Millennium Development Goals, the "3 by 5" target, and other health objectives. The chapter proposes an approach to scaling up health systems based on the core principles of primary health care formulated in the 1978 Declaration of Alma-Ata: universal access and coverage on the basis of need; health equity as part of development oriented to social justice; community participation in defining and implementing health agendas; and intersectoral approaches to health. While these principles remain valid, they must be reinterpreted in the light of dramatic changes in the health field during the past 25 years. The chapter clarifies the conceptual basis of the development of health systems that are led by primary health care, then explores how health systems based on primary health care principles can confront four major contemporary challenges: the global health workforce crisis; inadequate health information; lack of financial resources; and the stewardship challenge of implementing pro-equity health policies in a pluralistic environment.
The World Health Report 2003 closes by showing that reinforced cooperation with countries to scale up health systems is part of WHO's new way of working. Strengthening the Organization's presence and technical collaboration in countries is the best way for WHO to speed progress towards the global health community's most important goals: measurable health improvements for all, and aggressive strides to close equity gaps. Health inequalities scar the present and threaten the future. New forms of collaboration for comprehensive health systems development are needed to shape a world in which all people can enjoy the conditions of a healthy, dignified life. This report shows how WHO and its partners are drawing the lessons from recent achievements to press forward with this work.