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Threats to Global Health and Opportunities for Change: A New Global Health


The most recent phase of internationalization and globalization is characterized by the growing influence of non-governmental organizations that have had an impact on health. Key threats of strategic relevance for health, in addition to global warming, are the global divides in terms of demographic development and the burden of disease, social inequity, migration of populations, migration of health professionals, the inequitable terms of trade, and the consequences of the recent global monetary crisis. This paper addresses opportunities as set forth in the Millennium Development Goals, a revival of primary health care, and the necessary resetting of global aid in terms of international donor harmonization and national coordination, e.g., through a Sector Wide Approach (SWAp). We recommend: (1) A Global Code of Conduct for non-governmental organizations; (2) A renewed major effort of the United Nations community to achieve the Millennium Development Goals as planned; (3) Further development of the concept of SWAp’s to put the receiving governments into the “driver’s seat”. To this end, the achievement of the Paris/Accra criteria is essential, i.e., (4) To strengthen the linkage between governments and donors with a priority for primary health care services; and (5) To compensate the “sending” countries for basic investments in the upbringing and education of migrating professionals.


  1. 1.

    Basch, PF: Textbook of International Health. 2nd edition, Oxford University Press, New York and Oxford 1999: p.33.

  2. 2.

    Chadwick E. Report of the sanitary condition of the labouring population of Great Britain. A supplementary report on the results of a special inquiry into the practice of internment towns. London: Printed by R. Clowes & Sons for Her Majesty’s Stationery Office; 1843. Available from URL: or ChadwickClassic.pdf (Accessed 19 May, 2010).

  3. 3.

    Howard-Jones, N.: The scientific background on the international sanitary conferences, 1851–1938. Geneva: World Health Organization; 1975. Available from URL: (Accessed 30 March, 2010).

  4. 4.

    Sachs J. Report of the Commission on Macroeconomics and health: investing in health for economic development. Geneva: World Health Organization; 2001. Available from URL: 924154550X.pdf (Accessed 30 March, 2010).

  5. 5.

    World Health Organization. Declaration of Alma Ata, 1978. International Conference on Primary Care, Alma Ata, Russia, 1978. Available from URL: (Accessed 30 March, 2010).

  6. 6.

    US Census Bureau International Data Base (IDB). World population. Available from URL: (Accessed 25 April, 2010).

  7. 7.

    Kent MM, Haub C. Global demographic divide. Popul Bull. 2005;60:3–24. Available from URL: ide.pdf (Accessed 24 April, 2010).

  8. 8.

    Gwatkin DR, Shea Rutstein R, Johnson K, Suliman EA, Wagstaff A, Amouzou A. Socio-economic differences in health, nutrition, and population within developing countries. Second edition, Volumes I–III. Washington (DC): World Bank; 2007. Available from URL: INTPAH/Resources/IndicatorsOverview.pdf (Accessed 24 April, 2010).

  9. 9.

    Mathers CD, Lopez AD Murray CJL. The burden of disease and mortality by condition: data, methods, and results for 2001. In: Lopez AD, Mathers CD, Ezzati M, Jamison DT, editors. Global burden of disease and risk factors. Washington: IBRD; 2006. Available from URL: (Accessed 19 May, 2010).

  10. 10.

    National Institute of Allergy and Infectious Diseases: Emerging and re-emerging infectious diseases: List of NIAID Emerging and Re-emerging Diseases. Available from URL: (Updated December, 2009 and accessed 31 March, 2010).

  11. 11.

    Commission on Social Determinants in Health. Closing the gap in a generation: Health equity through action on the Social Determinants of Health. The Final Report of the WHO Commission on Social Determinants of Health. Geneva: World Health Organization; 2008. Available from URL: determinants eng.pdf (Accessed 24 April, 2010).

  12. 12.

    Mackenbach, JP, Meerding WJ, Kunst, AE. Economic implications of socioeconomic inequalities in health in the European Union. Luxembourg: Health and Consumer Protection Directorate General, European Commission; 2007. Available from URL: economics/documents/socioeco_inequalities_en.pdf (Accessed 24 April, 2010).

  13. 13.

    La Veist TA, Gaskin DJ, Richard P. The economic burden of health inequalities in the United States. Joint Center for Political and Economic Studies, 2009. Available from URL: health/the_economic_burden_of_health_inequalities_in_the_united_states (Accessed 24 April, 2010).

  14. 14.

    Cleland JG, van Ginneken JK. Maternal education and child survival in developing countries: the search for pathways of influence. Soc Sci Med. 1988; 27:1351–68.

  15. 15.

    UNICEF. State of the World’s Children 2004. UNICEF, New York. Available from URL: (Accessed 19 May, 2010).

  16. 16.

    Health in Israel, 2001. Jerusalem: State of Israel Ministry of Health; 2001.

  17. 17.

    Health in Israel, 2005. Jerusalem: State of Israel Ministry of Health; 2005. Available from URL: &catid=653&pageid=3607 (Accessed 25 April, 2010).

  18. 18.

    Quality indicators for community health in Israel. Public report for 2005–2007. Jerusalem: State of Israel Ministry of Health. Available from URL: (Accessed 24 April, 2010).

  19. 19.

    Hart JT. The inverse care law. Lancet. 1971;297:405–12.

  20. 20.

    Sequist TD, Fitzmaurice GM, Marshall R, Shaykevich S, Safran DG, Ayanian JG. Physician performance and racial disparities in diabetes mellitus care. Arch Intern Med. 2008;168(11):1145–51.

  21. 21.

    Epstein L. (editor) Culturally appropriate health care by culturally competent health professionals. International Workshop Report. Jerusalem: Israel National Institute for Health Policy and Health Services Research; 2008. Available from URL: dfea47b5583fd61f2.pdf (Accessed 24 April, 2010).

  22. 22.

    UNHCR. 2008 Global Trends: Refugees, Asylum-seekers, Returnees, Internally Displaced and Stateless Persons. Country Data Sheets, 16 June 2009. UNHCR. Available from URL: or (Accessed 19 May, 2010).

  23. 23.

    Department of Social and Economic Affairs, Population Division. Trends in total migrant stock: the 2005 revision. New York: United Nations; 2005. Available from URL: UN_Migrant_Stock_Documentation_2005.pdf (Accessed 24 April, 2010).

  24. 24.

    World Bank. Migration and remittances data: migration and development brief 5: Revisions to remittance trends, 2007. Available from URL: Brief5.pdf (Accessed 30 March, 2010).

  25. 25.

    National Center for Geographic Information and Analysis. The global demography project. Available from URL: (Accessed 30 March, 2010).

  26. 26.

    Seeger JR. Research on urban health — the priorities and approaches. In: Harpham T. and Tanner M., editors: Urban health in developing countries. Progress and prospects. London: Earthscan; 1995. pp. 64–81.

  27. 27.

    Gurgand M. Book review: Zhang M. China’s poor regions rural-urban migration, poverty, economic reform and urbanization: London: Routledge/Curzon; 2003 China Perspectives. 2006; September–October: no.67. Available from URL: (Accessed 23 April, 2010).

  28. 28.

    Ravallion M, Chen S, Sangraula P. New evidence on the urbanization of global poverty. Popul Devel Rev. 2007; 33:41:557–701. Available from URL: (Accessed 24 April, 2010).

  29. 29.

    Cornelius-Taylor B, Handajani YS, Jordan S, Köhler G, Korff R, Laaser U, et al. Urbanisation and public health: a review of the scientific literature. In: Strohmeier KPG, Köhler G, Laaser U, editors. Urban violence and health: determinants and management. A Study in Jakarta, Karachi and Conurbation Ruhrgebiet. Lage: Hans Jacobs-Verlag; 2001: 31–77. Available from URL: (Accessed 24 April, 2010).

  30. 30.

    World Federation of Public Health Associations. Resolution. Ethical restrictions on international recruitment of health professionals from low-income countries. Geneva: World Federation of Public Health Associations; 2005. Available from URL: (Accessed 24 April, 2010).

  31. 31.

    Mejia A. Migration of physicians and nurses: a world wide picture. Bull World Health Organ. 2004;82:8. Reprinted with permission of International J. Epidemiol. Available from URL: 626.pdf (Accessed 25 April, 2010).

  32. 32.

    World Bank. High level forum on the MDGs. Addressing Africa’s health workforce crisis: an avenue for action. Abuja, December 2004. Available from URL: 20Abuja.pdf (Accessed 9 April, 2010).

  33. 33.

    Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M, et al. Human resources for health: overcoming the crisis. Lancet. 2004, 364:1984–90. Available from URL: 0140-6736(04)17482-5/fulltext (Accessed 30 March, 2010).

  34. 34.

    United Nations. The universal declaration of human rights. Available from URL: (Accessed 30 March, 2010).

  35. 35.

    Friedman E. An action plan to prevent brain drain: building equitable health systems in Africa. Boston MA: June, 2004. Available from URL: pdf (Accessed 30 March, 2010).

  36. 36.

    World Federation of Public Health Associations. Available from URL: (Accessed 25 April, 2010).

  37. 37.

    Whelan A, Arkles R, Dewdney J, Zwi A. International movement of skilled health professionals: ethical policy challenges for developed nations, Harvard Health Policy Review. 2004;5:2. Available from URL: (Accessed 23 April, 2010).

  38. 38.

    Mensah K, Mackintosh M, Henry L. The ‘skills drain’ of health professionals from the developing world: a framework for policy formulation. London: Medact; February 2005. Available from URL: 20drain/Mensah%20et%20al.%202005.pdf (Accessed 31 March, 2010).

  39. 39.

    World Health Organization. International recruitment of health personnel: draft global code of practice. Report by the Secretariat. Geneva: World Health Organization; 2008. Available from URL: pdf_files/EB124/B124_13-en.pdf (Accessed 31 March, 2010).

  40. 40.

    Shaffer E. World Federation Public Health Associations. Global trade and public health. World FPHA position paper. J Public Health Policy. 2007;28:141–6. Available from URL: submission_ph_int_world_fed_2007.pdf (Accessed 25 April, 2010).

  41. 41.

    General Agreement on Trade in Services (GATS). Objectives, coverage and disciplines. Geneva: World Trade Organization. 2009. Available from URL: (Accessed 29 March, 2010).

  42. 42.

    Banoob SN. Minimizing the health impacts of the global financial crisis. J Public Health Pol. 2009;30/2: 243–7.

  43. 43.

    Lin JY. The impact of the financial crisis on developing countries. World Bank Res Dig. 2009;3:7–8. Available from URL: Oct_31_JustinLin_KDI_remarks.pdf (Accessed 23 April, 2010).

  44. 44.

    Buvnic M. The global financial crisis: assessing vulnerability for women and children, identifying policy responses. World Bank. February 2009. Available from URL: (Accessed 23 April, 2010).

  45. 45.

    Bhutta ZA, Bawany FA, Feroze A, Rizvi E. Impact of the food and economic crisis on child health and nutrition. December 2008 — draft working paper prepared for the UNICEF Conference, East Asia and Pacific Islands Singapore 2009. Available from URL: Health_Nutrition_ZB.pdf (Accessed 29 March, 2010).

  46. 46.

    World Health Organization: The Partnership for Maternal Newborn and Child Health. Financial crisis and global health: report of a high level consultation. Geneva: World Health Organization; 2009. Available from URL: (Accessed 25 April, 2010).

  47. 47.

    World Federation of Public Health Associations. International debt relief. Available from URL: 20Debt%20Relief.pdf (Accessed 25 April, 2010).

  48. 48.

    United Nations. The Millennium Development Goals report 2009. New York: United Nations; 2009. Available from URL: millenniumgoals/pdf/MDG%20Report%202009%20ENG.pdf (Accessed 1 April, 2010).

  49. 49.

    Bourguignon F, Bénassy-Quéré A, Dercon S, Estache A, Gunning JW, Ravi Kanbur R, et al. Millennium Development Goals at midpoint: where do we stand and where do we need to go? Brussels and Luxembourg: European Commission; 2008. mdg_paper_final_20080916_en.pdf (Accessed 1 April, 2010).

  50. 50.

    United Nations General Assembly. Resolution A 55/2: United Nations Millennium Declaration. Available from URL: millenniumgoals/pdf/MDG%20Report%202009%20ENG.pdf (Accessed 30 March, 2010).

  51. 51.

    International Conference Dedicated to the 30th Anniversary of the Alma Ata Declaration on Primary Health Care. Almaty, Kazakhstan. Available from URL: html (Accessed 17 November, 2009).

  52. 52.

    World Health Organization. World health report 2008: primary health care now more than ever. Geneva: World Health Organization; 2008. Available from URL: (Accessed 1 April, 2010).

  53. 53.

    Tarimo E, Webster EG. Primary health care concepts and challenges in a changing world: Alma-Ata revisited. Geneva: World Health Organization; 1994.

  54. 54.

    World Health Organization. Primary health care 21: everybody’s business. Report of an international meeting to celebrate 20 years after Alma-Ata, Almaty, Kazakhstan, 27–28 November, 1998. Geneva: World Health Organization; 2000. Available from URL: hq/2000/WHO_EIP_OSD_00.7pdf (Accessed 23 April, 2010).

  55. 55.

    Avsall JE. The Alma-Ata declaration: 20 years of impact on the European Region of WHO. In: Primary health care 21: everybody’s business. Geneva: World Health Organization; 2000. Available from URL: (Accessed 23 April, 2010).

  56. 56.

    Mahler H. Why Alma-Ata in 1978? In: Primary health care 21: everybody’s business. Geneva: World Health Organization; 2000. Available from URL: (Accessed 23 April, 2010).

  57. 57.

    Kark SL, Kark E. Promoting community health — from Pholela to Jerusalem. Johannesburg, South Africa: Witwatersrand University Press, 1999.

  58. 58.

    Mullan F, Epstein L. Community oriented primary care: new relevance in a changing world. Am. J. Public Health 2002;92:1748–1755. Available from URL: (Accessed 1 April, 2010).

  59. 59.

    Epstein L, Gofin J, Gofin R, Neumark Y. The Jerusalem experience: three decades of service, research, and training in community oriented primary care. A J Public Health. 2002;92:1717–21. Available from URL: (full text). (Accessed 1 April, 2010).

  60. 60.

    Rittenhouse DR, Shortell SM, Fisher ES. Primary care and accountable care — two essential elements of delivery system reform. N Engl J Med. 2009; 361:2301–3.

  61. 61.

    Shortell SM, Gillies R, Wu F. US innovations in healthcare delivery. Public Health Reviews 2010;32:190–212.

  62. 62.

    Tulchinsky TH, Varavikova EA. What is the “New Public Health”? Public Health Reviews 2010;32:25–53.

  63. 63.

    Bangdiwala SI, Fonn S, Tollman S, Okoye O. Workforce resources for health in developing countries. Public Health Reviews 2010;32:296–318.

  64. 64.

    United Nations. Report of the international conference on financing for development, Monterrey, Mexico. New York (NY): United Nations; 2002. Available from URL: CONF.198/11&Lang=E (Accessed 1 April, 2010).

  65. 65.

    Global Issues: ForeignAidNumbersinChartsandGraphs (Accessed 9 April, 2010).

  66. 66.

    Ravishankar N, Gubbins P, Cooley RJ, Leach-Kemon K, Michaud CM, Jamison, DT, et al. Financing of global health: tracking development assistance for health from 1990 to 2007. Lancet 2009;373:2113–24.

  67. 67.

    Bornhoft F, Knaup P. You are overtaxed. Der Spiegel 40/2008:42–44; 29 September, 2008. Available from URL: print/d-60666807.html (Accessed 9 April, 2010).

  68. 68.

    UN data Physician density per 10,000 population. East Timor physician coverage. Available from URL: inID%3AHSR02 (Accessed 9 April, 2010).

  69. 69.

    Deutscher E, Fyson S. Committing to effective aid: why can’t donors walk their talk? Outreach. February, 2009. (World Bank Group) Available from URL: (Accessed 9 April, 2010).

  70. 70.

    Council of Europe, Committee of experts on good governance in health systems (SP-GHC): Preliminary draft explanatory report. Strasbourg, 28 May, 2009.

  71. 71.

    Cassels A. A guide to sector-wide approaches for health development: Concepts, issues and working arrangements. Geneva: World Health Organization; 1997.

  72. 72.

    Brown A, Foster M, Norton A, Naschold F. The status of sector wide approaches. Overseas Development Institute, Working Paper 142: 2001.

  73. 73.

    HLSP Institute: Sector wide approaches: a resource document for UNFPA staff. London: HSLP; 2005. Available from URL: lib_pub_file/626_filename_swap-unfpa-resource-2005%20.pdf (Accessed 25 April, 2010).

  74. 74.

    Council of Europe, Committee of Ministers. Recommendations CM/ Rec (2010) 6 of the Committee of Ministers to member states on good governance in health systems. March 2010. Available from URL: ViewDoc.jsp?id=1608361&Site=CM&BackColorInternet=C3C3C3&Back ColorIntranet=EDB021&BackColorLogged=F5D383 (Accessed 25 April, 2020).

  75. 75.

    World Health Organization: Health Systems. Available from URL: (Accessed 9 April, 2010).

  76. 76.

    Borisch B. Global health initiatives and the new dichotomy in health systems. J of Public Health Policy: The federation’s pages 2010;31:100–109. Available from URL: 200954a.html (Accessed 24 April, 2010).

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Correspondence to Prof. Dr. med. Ulrich Laaser DTM&H, MPH.

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Laaser, U., Epstein, L. Threats to Global Health and Opportunities for Change: A New Global Health. Public Health Rev 32, 54–89 (2010).

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Key Words

  • global health
  • global divides
  • global opportunities
  • international health cooperation
  • Millennium Development Goals