World Health Organization Topic Guide

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LETTER FROM THE DAIS Dear Delegates, Hey everyone, and welcome to the World Health Organization! I’m Vivek, one of the Chairs for this year’s committee. I’m currently a sophomore in Trumbull College, majoring in the History of

Hello Wendy andborn I, along withinEmily, am your seniorbut staffer Science,everyone!

Medicine, My and name Public is Health.

I was and raised San Diego, California am grateful YMUN 39’s Yale Commission thefor Status Women.

Currently, I’malways a sophomore at Yale, to have called my secondon home theseof past two years (though I’m missing the majoring in Psychology with a Neuroscience track with plans to go to graduate school.

California sun!).

My interest in global health first began two summers ago while I was working as a teacher and

Outside of the classroom and YMUN, I am also Bangalore, part of Yale’s Mock team, a mentor medical volunteer in a rural village orphanage outside India.

SinceTrial coming to Yale, I have in WYSE (Women Youth Each a mentoring group for several local middle luckily been able to and further this Supporting passion. During myOther), time here, I have been able to take global school girls, and I am running a non-profit, Codi’s Hats. health courses and am also currently involved in Yale’s Unite for Sight Chapter and the Yale Journal of Public Health. I am also interested in exploring global health technologies and infectious disease With thework ever-evolving advocacy while here atpolicies Yale. on reproductive health rights and women’s rights, I’m exWe have a great planned for this session and I’m lookingmay forward to out. watching cited to see theagenda different stances andyear’s cultural clashes thatreally the topics bring I look you all in to action.

Mental andrespond infectious are both major contributors forward seeing howhealth you all indiseases the committee.

See you soon! to the overall global burden of disease. This weekend, you aren’t high school students with an upcoming AP Monday.

-Biology Wendyexam Cai,on Yale ‘15 You are health ministers, doctors, and global health experts dealing with real and complex issues in health. Best of luck!

-Vivek Vishwanath, Yale’16 Hi guys! I’m Emily, and I will also be working as one of the directors for CSW. A Northern California native, I’m currently a sophomore at Yale invivek.vishwanath@yale.edu Branford College, majoring in Hello everyone, Economics with a possible double major in East Asian Studies. After graduation, I hope My name and I am extremely to beasenior staffing this year’s WHO to live and workisinDennis ChinaWang for several years beforeexcited pursuing graduate degree, possibly in committeeor at law.

YMUN. I am a senior in Calhoun College here at Yale, majoring in Molecular business Biophysics & Biochemistry and Global Affairs. I am also studying Epidemiology of Microbial Diseasesnot with a Global Health or Concentration at the Yale School PublicasHealth (will in graduate with When going to classes preparing for YMUN, I alsoofserve a mentor ReadySetmy MPH an in 2015!).

I am originally fromcollege Fairfax, counseling Virginia, andservices I hope totowork in Washington, D.C. Launch, organization providing low-income students, in government or health work before applying to medical school.

This past summer, I spent time participate in Danceworks, a dance group at Yale, and I serve on the alumni fundraising workingfor at my the WHO in Geneva, Switzerland, so I cannot wait to recreate thatsoftball. experience here in board high school.

I also enjoy cooking, baking, and playing New Haven. In summers before that, I have worked in labs at George Mason University, the NIH, thewait Yale Stem Center. also have lived in Rwanda forhave a summer, working with Spark this year.

Iand can’t to hear yourIthoughts on the topics we prepared for committee MicroGrants doingremain monitoring anddebated evaluation on health and international At Yale, Women’s rights a hotly topic globally, and I know development. you all are going to I’m a Master’s Aide at my residential college, the Secretary-General for YMUN-China, and I write come up with informed, innovative solutions to these pressing problems. Please don’t hesfor thetoYale Scientific addition, I love to travel and have visited Canada, the UK, Czech itate email eitherMagazine.

Wendy orInme with any questions or concerns.

Republic, Austria, China, Korea, and India, just to name a few! luck with - Emily Good Harris, Yale ‘15your research and I will see you all in New Haven in January!

-Dennis Wang, Yale ‘14 dennis.wang@yale.edu All the best, All the best, Wendy Cai (wendy.cai@yale.edu) Vivek Vishwanath (vivek.vishwanath@yale.edu) Emily Harris (emily.harris@yale.edu) Dennis Wang (dennis.wang@yale.edu)

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TABLE OF CONTENTS History of the Committee Mental Health Topic History Current Situation Questions to Consider Combating Tuberculosis in Vulnerable Populations Topic History Current Situation Questions to Consider Role of the Committee Structure of the Committee Suggestions for Further Research Footnotes

5 7 11 21 22 24 35 36 37 38 39

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History of the Committee The World Health Organization is a specialized United Nations agency, created in 1946 to discuss and combat issues concerning international public health. It is a global body of leadership that directs and aids in research, provides policy recommendations based on empirical data, and sets global health standards. Its constitution states that its objective is “the attainment by all people of the highest possible level of health.” WHO was the first specialized agency in the United Nations to which every member nation subscribed. Its constitution was ratified in 1948, and its first leaders were Andrija Stampar, a Croatian medical scholar, and G. Brock Chisholm, a Canadian First World War veteran. WHO was preceded by the Health Organization, an agency of the short-lived League of Nations.i The first primary objective of WHO at the time when it was founded was to eradicate malaria, tuberculosis, and sexually transmitted infections, as well as to improve maternal and child health in compromised and vulnerable areas. The agency’s initial efforts included a mass tuberculosis vaccination drive in 1950 and a malaria eradication drive in 1955. Later, WHO began to coordinate its efforts with other international organizations, including the United Nations Development Program (UNDP), the World Bank, and the Food and Agriculture Organization (FAO). The agency also began to broaden its perspective when it enacted a resolution on Disability Prevention and Rehabilitation in 1976. 2 One of WHO’s earliest and most prominent victories was the eradication of the only known human disease to be completely eliminated –

smallpox. In 1967, some 15 million cases of smallpox (an incurable and often deadly disease) were occurring in more than 30 endemic countries.

This prompted the launching of the Intensified Smallpox Eradication Programme, which initially aimed to curb the spread of the disease through mass vaccination.

Though the agency’s theoretical goal was to vaccinate 100% of the population, a regional outbreak in Nigeria provided insight into a novel and more feasible strategy. Using a new technique of surveillance and containment, vaccinating vulnerable populations and isolating infected individuals, the transmission chain of smallpox could be broken even if less than half the population received the vaccination. In this way, WHO-led efforts managed to halt the spread of smallpox and officially released a statement in 1979 announcing global eradication of the disease.

Thereby the process of institutional memory and local adaptation became essential to WHO’s progress and development, setting the stage for many other global health-related achievements. 3 Other historical operations of WHO included a list of “essential medicines” compiled in 1977, which forms the basis of national drug policy in both developed and developing countries. This also means that governments of sovereign states refer to WHO for guidelines regarding national health expenditures. In 1989, the agency began an global program to combat HIV/AIDS, followed up by UNAIDS in 1996 to coordinate comprehensive global action regarding the AIDS epidemic. In 1988, the Global Polio Eradication Initiative was established. 4

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Though international progress in medical technology and health policy has led to shifts in WHO’s focus, its general objectives remain the same, as outlined its Constitution: to act as a directing and coordinating global authority on health matters; to assist governments in strengthening health services; to promote the improvement of nutrition, sanitation, and hygiene; to collaborate with scientific and professional groups that contribute to the advancement of health; and to make recommendations regarding health policy. 5

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Mental Health Topic History The history of global mental health is a history of oppression, misunderstanding, and injustice. The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”ii While multilateral agencies, governments, and NGOs have worked to address issues of physical and social well-being over the past several years, much remains to be done to improve mental well-being. In fact, mental disorders have been misunderstood and mistreated for centuries.

Religious and spiritual explanations dominated perceptions and treatments of mental disorders until the early 17th century, when secular explanations finally began to gain acceptance.

Madness eventually came to be seen as a physical state, but medical practitioners at the time viewed mental illnesses as self-inflicted emotional states or punishments. The mentally ill were in turn confined to public jails or asylums, and treated as a subhuman species.

Abuse of the mentally ill was largely overlooked until 18th century humanitarian concerns led to more moral treatments. These reforms were not sustainable in the long term, however, due to financial constraints, continued misunderstandings, and a lack of cost-effective treatments for the mentally ill. In addition, moral treatments were not always replicated globally, and many mentally ill patients continued to be physically abused in poor living conditions.

After the Second World War, there was as great deal of international emphasis on setting standards for human rights and human rights violations.

Accompanying this movement was an increased push for bettering the treatment of the mentally ill. The poor living conditions, physical abuse, and inadequate treatment of the mentally ill in asylums was seen as a crime and governments were criticized for not taking the proper measures to care for their mentally ill citizens. The human rights movements led to a reduction in mental hospitals and an increase in community mental health services.

This process, known as deinstitutionalization, led to the closure of several psychiatric hospitals around the world and more community-based care.iii Community-based mental health services included a range of services including mental care, psychosocial rehabilitation, and housing and employment schemes for the mentally ill.

Shifting Perspectives In the 1970s, several anthropological and medical studies on mental disorders finally led to a consensus that mental illnesses affected people in all cultures and were not merely “imagined” or “self-inflicted” health conditions. While developed countries continued to maintain strong mental hospital systems, the developing world continues to struggle with issues of coverage, quality care, and efficiency. A few developing countries have integrated psychiatric services into general care networks and improved basic psychiatric hospital services. In the majority of these countries, however, psychiatric services are scattered and suffer from a lack of trained personnel and treatments to cover their patients. In addition, mental illnesses continue to be misunderstood

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throughout the world. Unfortunately, this has attached a great deal of stigma and embarrassment to mental disorders, preventing many from seeking care.iv Stigma and a growing treatment gap feed off one another, with up to three of four affected persons in low and middle-income countries (LMICs) failing to receive the treatments they need. v Mental health has historically received less funding and attention from the global health community, but it is nevertheless as important, if not more important than, physical and social well-being. In fact, the World Health Organization has long maintained that there is no health without mental health.

Mental Health and Development Over the past two decades, an increasing number of studies have also shown a correlation between mental illnesses and poor socioeconomic situations. These studies were compiled and analyzed in the 2001 WHO report Mental Health: New Understanding, New Hope and updated in 2009 and 2010 to include more recent reviews on poverty and common mental disorders. vi Along with a novel desire to fully understand the causes and circumstances behind mental illnesses came WHO’s first official mental

health program, known as the Mental Health Gap Action Programme (mhGAP) in 2008. Launched specifically to produce guidelines for managing mental, neurological, and substance abuse disorders, mhGAP conducted numerous studies that outlined eight groups of primary conditions that required global attention. These conditions were: depression, schizophrenia, other psychotic disorders (e.g. bipolar disorder), suicide prevention, epilepsy, substance abuse, dementia, and mental disorders in children. vii Compiling its findings, mhGAP published a guide known as the mhGAP-Intervention Guide (mhGAP-IG) in 2010.

Perhaps the most poignant finding from its studies was the very obvious disparity in human resources. While countries like the United States have 50,000 certified psychiatrists to serve a population of roughly 300 million, India has a mere 4,000 to serve a population of 1.2 billion. A “brain drain” in human resources has long been acknowledged as a barrier to care in low and middle-income countries. Nevertheless, its direct impact on healthcare is not felt as significantly in any other sector of healthcare. Thus, mhGAP’s findings also pointed towards task shifting: the practice of training health workers to recognize and deliver interventions for specific mental disorders.

This practice has not only involved training

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primary care physicians, but also training community health workers in rural and peri-urban areas to recognize the symptoms of specific mental illnesses.viii Moving Forward Yet another significant step forward was the creation of the Movement for Global Mental Health. A coalition of organizations and individuals dedicated to promoting global mental health and reducing the disparities in care, the movement has brought together various parties and created a network for advocacy and cooperation. As of July 2011, the organization consisted of 1700 individuals and 94 institutional members. The rise of several NGOs and coalitions is a promising sign for reducing the treatment gap, but much still remains to be done.ix The last three decades have not only witnessed a rise in attention for mental health, but major advances in drug and social interventions as well. With the introduction of chlorpromazine in 1955, several other antipsychotic drugs entered the market, though with a wide variety of neuromuscular side effects. These side effects deterred several patients from taking the drugs regularly until 1973, when four or five novel antipsychotic drugs were introduced without the side effects of earlier drugs.

Psychosocial treatments also underwent significant advancements beginning in the late 1970s. Cognitive-behavioral therapies aiming to change faulty thinking patterns proved to be successful in the treatment of depression, anxiety states, phobias, and obsessive-compulsive disorder.

Though WHO reports and NGO work has increasingly focused on addressing the significant

disparities in mental healthcare, it still remains a low priority in most LMICs. Developing countries currently facing a variety of health issues often give priority to infectious diseases and reproductive, maternal, and child health.

Stigma and Gender in Mental Health In addition, mental illnesses have a long history of stigma attached to them. Despite the numerous advancements that have led to more humane care for the mentally ill, many in both developed and developing countries consider mental health problems to be the result of personal flaws. Compounding these perceptions is the lasting notion that mental illnesses are associated with religious or spiritual curses. Understanding the cultural backgrounds of these perceptions, then, is crucial to the treatment of mental health. The historical approaches countries have taken to treating mental disorders vary, but all have been influenced by cultural perceptions of race, religion, and tradition.x In 1999 and 2001, the U.S. Surgeon General and the World Health Organization, respectively, cited stigma as a key barrier to successful treatments.xi Over the course of the past thirty years, numerous studies have developed plausible theories on how stigma plays a role in the mental health space. Papers published in 1999 most directly pointed to a self-perpetuating cycle, in which societal perceptions on mental health are internalized by the mentally ill, who then continue the cycle by being afraid to reach out for care.

Gender was consistently found to also contribute to mental health. A patient’s gender can influence how likely they are to seek treatment, especially in countries facing tremendous sexual

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discrimination. Across various countries, studies also showed that men and women tend to express emotions differently and are more susceptible to different mental illnesses. Women, for example, are more likely to be diagnosed with anxiety or depression. Men, on the other hand, are more susceptible to substance abuse or antisocial disorders.

Comprehensive Mental Health Action Plan The 66th World Health Assembly consisting of Ministers of Health of 194 Member States adopted WHO’s Comprehensive Mental Health Action Plan 2013-2020 on 27th May 2013.

The action plan intends to build on mhGAP’s foundation, acting as a guide for national mental health plans. The plan consists of a basic framework of suggested actions for member states.

In addition, it outlines six cross-cutting principles and approaches for mental healthcare to improve in all resource settings. Proposed actions include the development of better laws and policies, as well as the expansion of integrated mental health services.

While drafting the proposal, greater attention was given to human rights and empowerment of people with mental disabilities.

The 2013 plan also has set practical goals for member nations. These goals include, for example, a 10% reduction in suicide rates in countries by 2020. The Action Plan was a collaborative effort, involving both member states and other stakeholders in civil society. It is hoped that this new plan will lead to tangible and significant developments in global mental healthcare by 2020.xii

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Current Situation Though an integral part of well-being and health, mental health and its associated conditions have long been undervalued in the global health space. Mental health conditions affect over 450 million people globally and people living with mental illnesses often face a wide variety of social problems, including stigma, violence, and a lack of opportunities.xiii WHO’s most recent findings estimate that 151 million people suffer from schizophrenia, 40 million suffer from epilepsy, 125 million people are affected by substance abuse disorders, and 24 million suffer from Alzheimer and other dementias.

In addition, approximately 844,000 people die by suicide each year. Of these victims, the World Health Organization estimates that 90% suffer from some kind of mental illness, most commonly depression or substance abuse. Mental illnesses are thus a major risk factor for suicide. xivRecent studies have also shown that major depressive disorder contributes almost as much (3.2%) to the burden of disease in low-income countries as malaria does (4.0%).

According to 2010 WHO reports, in the past several years, mental illnesses have become the leading cause of DALYs (see Appendix) worldwide and now account for nearly 25% of all Years of Life Lived with Disability (YLDs) worldwide. Mental illnesses account for 14% of the total global burden of disease (GBD), and depression alone accounts for 4.3% of the GBD. xv People in low and middleincome countries (LMICs) with mental health conditions, such as schizophrenia, major depressive disorder, drug addictions, and intellectual impairments don’t suffer only from their mental illnesses. Rather, these mental health conditions also result in a stream of social problems, such as

stigmatization and exclusion from society.xvi

Determinants of Mental Health Mental health is defined as a state of wellbeing in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. Multiple social, psychological, and biological factors determine the mental health of an individual at any point in time. While individual attributes matter, so do social, cultural, political, economic, and environmental factors like living conditions, working standards, and community structures.

Now a leading cause of YLDs, mental disorders also put individuals at disproportionately higher risks for disability and mortality. Persons with major depression and schizophrenia, for example, are 40-60% more likely to die prematurely than the general population. One possible explanation for this is the lack of attention given to other conditions (e.g. cancers, diabetes, HIV, etc.) patients with mental illnesses may have.xvii Suicide

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also becomes an important concern when dealing with mentally ill patients. Not only is suicide the second most common cause of death among young people worldwide, but it also is not given enough attention in vulnerable populations, like those living with mental illnesses.

Mental disorders are linked in a vicious cycle with other diseases such as HIV/AIDS and non-communicable diseases like diabetes and cardiovascular disease. One proven example of this cycle is depression’s link to myocardial infarction (heart attack) and diabetes. People living with a major depressive disorder are in fact predisposed to both myocardial infarctions and diabetes. In turn, both of these conditions also increase the likelihood of worsening an individual’s state of depression.

This cycle is also impacted by social factors, like low socioeconomic status, alcohol use, and stress.

While the health impact of these disorders has been noted previously, it is also worth mentioning the economic impact of mental illnesses. A recent study has estimated that the cumulative global impact of mental disorders in terms of lost economic output will amount to US $16.3 billion between 2011 and 2030.xviii Given the tremendous health and economic

tolls of mental conditions, it is unfortunate that so little has been done to create sustainable systems of mental healthcare. Moving forward, global mental health must be seen as a priority, receiving as much attention as initiatives to improve social and physical well-being.

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A Vulnerable Group People living with mental conditions are subject to a wide variety of societal factors that make them a vulnerable group. These factors include: stigma, violence, exclusion from participating fully in society, reduced access to health/social services, lack of educational opportunities, exclusion from income generation, and increased disability/premature death.

Stigma, Violence, and Abuse Stigma and discrimination have long been one of the largest barriers to mental healthcare.

Many mentally ill patients are either too embarrassed or too afraid to seek treatment in low and middle-income countries due to the tremendous misconceptions that surround mental illness. Historically, mental health conditions have been seen as personal weaknesses or conditions caused by spirits or supernatural entities. These beliefs frequently lead to treatments that only exacerbate mental illnesses. Such treatments include institutionalization in psychiatric hospitals or prisons. The mentally ill are also seen as a lazy, violent, unintelligent group around the world, but these misconceptions are not only false, but extremely dangerous as well. Nevertheless, examples of stigma are omnipresent. In Afghanistan, mental health conditions are commonly thought to be caused by witchcraft or the “evil eye.� In Oman, both doctors and the general public associate certain stereotypical facial features with the mentally ill. xix Globally, the mentally ill have also been marginalized as a violent group. Studies in highincome countries have revealed that mentally ill

patients are more likely to be victims of violence than they are to be perpetrators themselves. In the United Kingdom, a recent study found that patients with severe mental illnesses (SMI) were 3-7 times more likely to be violently attacked and twice as likely to experience household crimes than the general public. These findings reveal that the mentally ill are a vulnerable population who are repeatedly taken advantage of and misunderstood.

Closing the treatment gap for mental illnesses, then, will also need to involve movements to end stigma and promote awareness and acceptance.

Numerous historical studies have shown that patients with mental illnesses are capable of leading normal lives with community support and proper psychiatric treatment programs.xx

Social Justice and Exclusion from Society In many countries, people with mental illnesses are restricted from being fully involved in society. Many are denied of their civil and political rights under the false assumption that the mentally ill are incapable of taking care of themselves or making independent decisions. Not only are many denied the right to vote, but there also exist few judicial mechanisms to deal with the grievances of the mentally ill or crimes committed against them.

In fact, a recent analysis of election laws in 63 countries showed that only four countries- Canada,

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Ireland, Sweden, and Italy- did not restrict the political freedom of their mentally ill citizens in any way. xxi To add to this fundamental discriminatory principle, the mentally ill are often seen as incapable of making their own health or economic decisions.

In many countries, basic human rights including informed consent, confidentiality, and privacy are violated frequently. Furthermore, decision-making power is conferred to family members, leaving the mentally ill further restricted.

People with mental health conditions also are restricted from marrying and having a family in some countries. Unfortunately, fewer than 20% of countries have mental health service user organizations to connect the mentally ill with policy initiatives. While patients with HIV/AIDS have had moderate success in voicing their opinions, the mentally ill have no voice in the majority of countries around the world.

Denied of their basic political rights, people with mental health conditions also suffer from the inability to reach their true potential. In many low and middle-income countries, the mentally ill are institutionalized in facilities that do not provide modified educational curriculum. Education has long been recognized as a building block for self-

advancement and economic development. With this basic opportunity denied, many people living with mental conditions are disadvantaged from the beginning. For those who do attend school, they face tremendous levels of ridicule and rejection from their peers. In addition, without a specialized curriculum, the mentally ill face high dropout rates and a higher chance of failure. Given that approximately one in five children suffers from a mental health condition, failing to improve social services for the mentally ill puts 20% of the world’s adult population at risk for poor educational and employment performance.

Vulnerability and Mental Health As mentally ill patients continue to face stigma and marginalization, they develop lasting self-esteem issues and reduced motivation. Violent or abusive encounters can make mental health conditions like depression and anxiety even worse.

In addition, by denying the mentally ill of social and healthcare services, society exacerbates existing conditions and makes the mentally ill feel more and more like a marginalized, excluded part of society.

The cycle that develops in this process is extremely dangerous, thrusting the mentally ill into poverty and poorer overall health.

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Socioeconomic Status Though poverty has long been thought to be associated with mental illnesses, only recently have studies found tangible evidence of the relationship between poverty and socioeconomic inequalities with depression and other mental illnesses. In studies conducted in the United Kingdom, there is substantial evidence linking low standards of living to the prevalence of depression.

A community study in Indonesia also found strong associations between depression and the presence of amenities like electricity and television. These findings were also confirmed by a survey of 3,870 persons in Chile linking depression to severe socioeconomic difficulties. xxii Poverty exposes individuals to dangerous work environments, stressful lives, and a complete lack of stability. These individuals also have fewer resources to cope with these additional stressors, leading to long-term problems including poor health, increased mortality, substance abuse, school failure, and crime.

Though about half of mental disorders begin before the age of 14, regions with the highest populations of children under the age 19 have the poorest mental health resources. Studies have found that most low and middle-income countries have only one child psychiatrist available for every 1 to 4 million people. Poverty, then, can play a critical role in exacerbating mental health conditions in children.

People with mental health conditions sometimes are unable to find work because of the symptoms of their illnesses. Without adequate opportunities to work, they find themselves deeper and deeper in poverty. In such instances,

individuals may seek medical treatment.

Nevertheless, if these treatments are too expensive or ineffective, people with mental health conditions not only do not get better, but also have now fallen even deeper below the poverty line.

Reversely, people living in poverty lack the ability to maintain a basic standard of living, leading to a long-term loss in educational and employment opportunities.xxiii Such losses leave the poor living in slums and unsanitary conditions without access to clean water or proper healthcare services. In such environments, depression is considered a norm and seeking treatment is considered shameful. Thus, these added stresses may cause individuals living in poverty to develop severe mental illnesses.

Illustrative Examples of Poverty and Mental Health Farmer Suicide in India In 2011, suicide rates among Indian farmers were 47% higher than they were for the general population. These astonishing results may be explained by the failure of seasonal monsoons since the mid-1990s. With low harvests and low incomes, poor subsistence farmers have been unable to make ends meet. Without the credit to get bank loans, farmers have turned to loan sharks who place exorbitant interest rates on their loans.

As their crops continue to fail, farmers are faced with more and more debt and the possibility of becoming bonded labor for moneylenders until their debts are paid. Given such an ultimatum, many farmers instead have turned to suicide. This example clearly illustrates the ongoing negative cycle between poverty and mental illnesses.xxiv

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Lack of Human Resources in Zambia In 2001, Zambia’s Health Minister, Mutale Mumba, cited significant reductions in human resources as the main problem behind access to mental health services for the poor. Health infrastructures and equipment were in a “deplorable state” with very little access to psychotropic drugs. With very limited mental health resources available, the poorest in Zambia had no chance whatsoever of obtaining the necessary drugs they needed. Those who sought informal care also were unlikely to see positive results. This cast a great deal of Zambia’s poor population deeper into poverty without having gotten even slightly better. xxv Mental Health Resource Availability Despite a renewed push for better mental healthcare, between 76% and 85% of people with severe mental disorders in LMICs currently do not receive any treatment whatsoever for their conditions. A corresponding 35% to 50% of patients in high-income countries also receive no treatment.

Such a widespread lack of treatment can be explained by global expenditures on mental health.

Annual spending on mental health is currently less than US $2 per person. An even more astonishing

figure is the amount spent in low-income countries: less than US $.25 per person each year. In addition, 67% of this funding goes towards stand-alone mental hospitals instead of community-based services even though these hospitals have been associated with poorer health outcomes.

Community-based care, on the other hand, is the only plausible and sustainable option found to generate positive health outcomes. Integrating mental health into primary care would not only better use existing funding, but would also improve quality and access to care.

Compounding funding and access problems is the issue of human resource erosion.

The number of specialized mental health workers in LMICs does not at all meet the growing need for psychiatric care. WHO reports from 2013 indicate that almost half the world lives in regions with one psychiatrist to serve over 200,000 people.

Legislation to cover the mentally ill in LMICs is also grossly insufficient, with only 36% of people being covered by mental health legislation in their respective countries.

The underlying problems behind mental health care then, are not in the actual treatments themselves. They instead are manifested in issues of access to and quality of mental healthcare. Few

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organizations and civil society movements target the mentally ill in LMICs. Recent reports have observed that only 49% of low-income countries even possess organized movements for the mentally ill, as opposed to 83% of high-income countries. xxvi Mental health has historically received less attention in the medical world, but nowhere is this disparity more blatantly obvious than in the availability of medicines to treat mental health conditions. As opposed to medicines and treatments available for infectious diseases or noncommunicable diseases (NCDs), the availability of antipsychotic drugs and psychosocial treatments is significantly low. Without trained healthcare professionals to administer the proper treatments or medications, the drugs themselves are becoming increasingly scarce.

Cost-Efficiency

A dominant topic of discussion in all global health settings is the issue of cost-efficiency.

Therefore, it is important to understand the cost behind medical treatments for mental health conditions to make any progress whatsoever.

Studies have shown that new drugs and community-based models of therapy cost significantly less than first expected. Community-

based service models for schizophrenia and bipolar disorder are much less expensive than hospitalbased care. According to the second edition of Disease Control Priorities in Developing Countries, “the total cost per capita of community-based outpatient treatment with first-generation antipsychotic or mood-stabilizing drugs, including all patient-level resource needs as well as infrastructural support, ranged from US$0.40 to US$0.50 in Sub-Saharan Africa and South Asia to US$1.20 to US$1.90 in Latin America and the Caribbean and in Europe and Central Asia.� xxvii Further cost-effective analyses show that the most effective means of closing the current treatment gap for severe mental disorders and psychosis would be a combination of drug and behavioral therapies. More specifically, a combination of anti-psychotic/mood-stabilizing drugs and psychosocial behavioral therapies in a community-based model seem to have the most potential to create lasting, cost-effective change.

The cost-effectiveness ratio of such treatment would be below US $2,000 in Sub-Saharan Africa (SSA) and South Asia, and less than US $5,000 in Latin America and the Caribbean. These figures would avert 500 DALYs (see Appendix) per US $1 million spent in SSA and South Asia and 200 DALYs in Latin America and the Caribbean. As mental disorders currently are a leading cause of YLDs (and consequently, DALYS), these treatments could have tangible and practical impacts on mental health.

In regards to less severe and more common mental disorders (like depression and anxiety), cost-effective treatments must focus on integrating mental health into primary care. Currently, the most cost-effective treatments for depression are

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the scaled-up use of older antidepressants (US $30 for six months of treatment). Newer antidepressant drugs (SSRIs) can cost up to US $150 combined with psychotherapy. Nevertheless, as patents are removed and generic SSRIs begin to be produced, SSRIs may become a large-scale viable option in LMICs. xxviii Nations must also work to address the tremendous lack of human resources. One viable, cost-effective option may be to integrate mental health treatments and diagnoses into primary care.

By training primary care practitioners to recognize, diagnose, and treat basic mental disorders, countries can greatly expand their mental healthcare coverage at a minimal cost. Training rural community health workers to diagnose conditions like depression and administer antidepressants are also possible solutions for LMICs. Mental health has long been undervalued in the global health space, but by recognizing it as a key component of health and establishing policies and guides for nations to follow, the World Health Organization aims to not only significantly expand mental healthcare coverage, but also implement lasting transformations in quality of care.

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Bloc Positions Africa Mental health policies have been adopted in half of all African countries. In addition, legislation protecting the mentally ill is prevalent in almost 80% of African countries, with national mental health programs also in place.

Nevertheless, African nations continue to grapple with funding allocations for mental health. Outof-pocket payments comprise a significant proportion of total spending on mental health.

Political turmoil and stigma have prevented many from seeking medical treatment for mental illnesses. Nevertheless, with new drug and treatment policies in place, African countries have begun to view mental health as a more of a priority.

Americas The countries of the Americas have enjoyed long partnerships with the Pan American Health Organization to promote mental health care in the region. The Americas possess an unusually high percentage of integrated mental health care, with 94% of primary care facilities offering treatment for mental illnesses as well.

Despite rapid advances in policies and the understanding and treatment of mental illnesses, there still remains work to be done in terms of closing the treatment gap. Millions of patients suffering from disorders like schizophrenia and epilepsy lack basic access to mental health facilities. Countries of the Americas have made it their priority to restructure their health systems to include more community-based, accessible care options for the mentally ill.

Eastern Mediterranean The Middle East has long been committed to providing the minimum necessary mental health care for all, and has made significant progress in doing so. Though many countries in the Middle East are plagued by religious conflicts, war, sanctions, and refugee crises, the region has recognized the value of integrating mental health in existing health systems in the past 15 years. The region faces high levels of depression, epilepsy, and anxiety (possibly brought about by years of turmoil and religious/cultural conflicts). Notable progress has been made in countries like Bahrain, Cyprus, and Saudi Arabia, which all posses primary healthcare systems with integrated mental healthcare. Countries such as Egypt and Jordan have also sought to implement mental healthcare projects in select areas. Given the high level of turmoil in some parts of this region, mental healthcare has increasingly been seen as pertinent and necessary for emergencies, humanitarian crises, and daily life.

Europe With 96.1% of primary care facilities integrating mental healthcare, European countries have given a great deal of attention to mental illnesses in the wake of rapid social transitions. As in other regions, however, many European countries still spend less than 3% of their health budgets on mental health (though mental health costs easily can make up half of all total health expenditures). More than 50% of all patients in some Eastern European countries remain in mental hospitals and significant minority groups are living with the dual burden of poverty and

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mental illness.

WHO/EURO (see Appendix) has been working with European countries for the past century to conduct research and improve mental health.policies. Given that 40% of member states have no government-sanctioned mental healthcare plan, these studies are proving useful in setting novel policies for the region and its people living with mental conditions South-East Asia The South-East Asia bloc faces a tremendous mental health burden. Though 63.6% of countries in the region have some mental health legislation in place, out-of-pocket spending on mental health expenditures is still significantly high at 30%. This means that a significant proportion of people living with mental health conditions in this region are unable to afford care.

Several countries still follow psychiatric hospital models, and only recently have NGOs, multilateral agencies, and governments focused on introducing community-based models of care. There also still exist significant barriers to care, including availability, stigma, and affordability of medications. All three must be addressed when implementing novel governmental policies for mental health.

Western Pacific Though the Western Pacific Region bears a significant burden of mental disorders, only 60% of countries have designed mental health policies.

Nevertheless, many countries have adopted two strategic directions to improve mental health.

Studies in the region have focused on a wide variety of mental health issues, from alcohol abuse to high-risk groups. Countries in the Western Pacific Region have also implemented projects to reduce stigma and raise awareness. The region also is committed to following the framework established by WHO’s Comprehensive Mental Health Action Plan 2013-2020. xxix

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Questions to Consider 1. It has long been known that the global health community has overlooked mental health. Mental health funding allocations total to only 1% of the world’s total health budget. Nevertheless, the World Health Organization firmly holds that there is no health without mental health. Despite the tremendous urgency behind closing the mental healthcare treatment gap, countries also have a number of other issues on their health agendas. How can WHO and its member nations reach practical compromises in terms of mental health budgets? What process must be undertaken to both address mental health issues and create a lasting system of holistic healthcare?

2. An important topic in mental healthcare is the range of barriers to care. People living with mental health conditions face a great deal of stigma and often are unable to access care due to a lack of human resources or exorbitant treatment prices. What can be done to overcome these complex barriers to care that appear to be simple on the surface? How can the World Health Organization create new partnerships and build on existing connections to increase awareness of mental health conditions?

3. Are there better ways of setting up sustainable healthcare systems? What steps must be taken to ensure that mental health becomes a regular part of primary healthcare? Community health workers have often been seen as a solution to addressing the tremendous disparities in mental healthcare. Is this a long-term solution? Or are there other alternatives to the lack of human resources for mental healthcare?

4. To what extent should the World Health Organization be involved in member nations’ mental health policies? How can WHO best serve its member states and set guidelines for the proper establishment and implementation of mental health legislation?

5. With the introduction of WHO’s Comprehensive Mental Health Action Plan 2013-2020, how can the World Health Organization take member states’ renewed commitment to mental health and deliver tangible results?

How can WHO ensure that treaties that have been signed are actually implemented? Are there other tangible means of measuring mental health outcomes in health systems?

WHO 22 TOPIC II.

Combating Tuberculosis in Vulnerable Populations Topic History Tuberculosis has a long history with mankind. From ancient Indian and Chinese texts to the Old Testament, the diseases makes multiple appearances throughout history. With curative prescriptions ranging from herbal concoctions to the ‘royal touch’, mankind struggled to deal with the disease until the 19th century.

The infectiousness of the disease made it particularly dangerous and several explanations were developed for the causes of the disease.

During medieval times, it was feared as the handiwork of the demon and sufferers were often ostracized. The struggle to understand the disease continued as philosophers, medicine-men, intellectuals, astronomers and alchemists continued to weigh in on the causes of the disease. Italian scholar Girolamo Fracastoro first aired the idea of a Tuberculosis virus in the early 1500s. He also theorized that the disease spread through direct contact with bodily fluids of the infected.

Breakthroughs in the 19th century led to the discovery of the true cause of the disease and

subsequent research into effective cures. After the initial rejection of Benjamin Marten’s theory that the disease was spread by microscopic beings, the idea finally became accepted when Robert Koch proved it to be true.

Figure 1: The tuberculosis bacteria Source: npr.org On the 20th of April 1882, Koch published an article that claimed that Mycobacteria were responsible for all kinds of TB. A medical cure for the disease was not discovered until 1944, when streptomycin was isolated. This was the first

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antibiotic to work against TB. After an initial successful fight against the scourge of TB, the world faced another serious challenge in the form of drug-resistant strains of the disease, especially multi-drug resistant tuberculosis (MDR-TB).

Estimated incidence of the disease in 2009

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Current Situation

The incidence of MDR-TB cases amongst all TB cases in 2008.

Tuberculosis is the second leading cause of death by a single communicable disease, after HIV/AIDS.xxx Target 6.C of the Millennium Development Goals, to halt and begin to reverse the incidence of malaria and other major diseases by 2015, was achieved by 2013 for tuberculosis.xxxi The Stop TB target, to reduce prevalence and deaths

due to TB by 50% compared with a baseline of 1990, will be achieved by 2015 in some countries and regions, but not others, especially in the AFRO regionxxxii. The post-2015 goal, to eliminate TB as a public health problem (defined as <1 case per million population), will not be achieved in most countries by 2050.xxxiii As mentioned in the 2013

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MDG Report, “successful treatment of tuberculosis is exceeding global targets, but more work lies ahead.”xxxiv Work is needed to improve existing case finding and treatment strategies, and to develop new diagnostic technologies, drugs, and vaccines for the prevention and treatment of TB. Progress is unequal, but all countries have a role to play in the global fight against tuberculosis, and all countries can improve on reducing the incidence of tuberculosis, which fell at a rate of only 2.2% from 2011-2012, by targeting at-risk populations.xxxv People living with HIV/AIDS (PLHIV) and patients with MDR-TB are two focuses of current TB effortsxxxvi, as they contribute to a growing percentage of the burden of TB. Other poor and vulnerable populations, however, have yet to be formally addressed in many places. This document discusses the current state of data collection, management, and analysis at the subnational level, and, drawing from examples, the ways in which the use of subnational data by NTPs can be improved.

The tuberculosis epidemic turned around at the global level in 2006, but some countries will not reach the MDG or Stop TB targets by 2015 and are not on track to reach the goal of zero deaths outlined in the post-2015 strategy. Globally, onethird of tuberculosis cases go undetected, and in all countries, poor and vulnerable populations shoulder the greatest burden of tuberculosis. They are especially susceptible to contracting active tuberculosis and face barriers to accessing healthcare due to their location, co-morbidities, and the multiple manifestations of poverty (including malnutrition and crowded housing) and

marginalization, ultimately leading to poor outcomes.

Global efforts to combat tuberculosis in vulnerable populations are generally limited to people living with HIV/AIDS. WHO has also produced guidelines in some higher risk contexts, including prison and refugee populations, but these guidelines are primarily focused on clinical interventions rather than prevention and control.

National tuberculosis programs are improving basic health and information systems to collect more complete case notifications and to improve treatment outcomes in generalized epidemics, but the post-2015 End TB Strategy acknowledges that “In most high-prevalence settings, mapping at-risk populations and providing priority attention to the most affected remain to be undertaken.”xxxvii A more targeted and integrated approach at the national level using subnational data and mapping of social determinants to address the tuberculosis epidemic in vulnerable populations is a key part of the post-2015 strategy. The strategy recommends that the global strategy be adapted at the country level using local evidence, and that interventions be prioritized based on knowledge of epidemiology and understanding of context in vulnerable populations. There is also increasing interest among donors and partners to respond to hotspots of disease and vulnerability. For example, this is one of the strategic priorities of The Global Fund.

An understanding of the socioeconomic and environmental determinants of tuberculosis will guide future efforts to minimize the burden of the disease and to maximize the impact of

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interventions to address tuberculosis and its determinants, as well as identify potential synergies with other organizations and programs at the international and national levels.

TB cases by WHO region in 2009.

There is not one tuberculosis epidemic, but many tuberculosis epidemics which vary from country to country. No two tuberculosis epidemics are the same, and no two strategies should be, but general principles from the monitoring of the Millennium Development Goals, from the HIV community, and from other projects made possible by new GIS technologies to assess poverty and social determinants can be used to develop more targeted strategies for different contexts. Existing sources of subnational data, including routine tuberculosis reporting, household surveys, national censuses, and prevalence surveys, will be especially useful.

WHO in 2005 published a document on Addressing poverty in TB control which tried to answer the questions â&#x20AC;&#x153;Who are the poor and vulnerable populations? Which situations and groups require special consideration?â&#x20AC;? but included the disclaimer that the document was not a guideline, and could be developed further with more experience and evidence. As 2015 approaches, it is appropriate to revisit those questions, and to expand on them.xxxviii Vulnerable population A vulnerable population is any group of people in which the incidence, prevalence, or mortality of TB is significantly higher than in the general population due to biological, environmental, social, or economic factors. This paper focuses on community-level vulnerable populations with potential community-level interventions.

The following list is ordered based on qualitative notions of risk and vulnerable populations and not the quality or quantity of data.

Relative risks are generally not available except for comorbidities and biological or individual-level risk factors, where systematic reviews have been completed at the global levelxxxix. They are rarely available for socioeconomic or environmental

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(ecological) risk factors (except in prisons and refugee populations), which are highly variable from country to country, and need to be assessed through systematic reviews of various sources at the country level to establish priorities. The list below includes both individual-level and ecological risk factors, but all are groups that individuals may identify with and that come together in geographical areas, prisons, hospitals, etc., and that may be targeted by interventions. Governments may have their own definitions (poverty lines, for example), as vulnerable populations are different in different countries.

To assess national priorities in fighting tuberculosis, attributable fractions can be calculated using relative risks and size estimates of vulnerable populations. Global estimates are problematic. For example, tuberculosis transmission in prisons accounts for 25% of the burden and cases in some countries, but significantly less in others. Both relative risks and population sizes vary from country to country. Data analyses will need to be completed at the national level in coordination with academic institutions and government agencies to calculate relative risks, but better size estimates of vulnerable populations may already be available from existing sources (see prisoners and military), at the national and even in some cases at the subnational level, and can easily be shared at the country level.

Geographical areas Some geographically defined subpopulations with high incidences or high prevalences of tuberculosis place the people living there at high risk for becoming infected with tuberculosis. In these areas, the people may be

poor, may be living in crowded conditions, or may have poor access to healthcare, other socioeconomic and environmental characteristics strongly associated with location. Geographical areas can provide a descriptive understanding of the location of tuberculosis hotspots, but the underlying drivers may include other determinants of vulnerability such as high concentrations of susceptible populations including indigenous peoples, people living with HIV/AIDS, or miners. Geographical areas are often defined by administrative divisions (ex. provinces, districts).

Poverty Poverty, like geographical areas, alone does not predispose individuals for tuberculosis. Being poor, however, means that an individual is more likely to be undernourished, to live with large households in crowded conditions, and to work in mines and other jobs where they may be exposed to environmental risk factors. Whether the poor themselves have these risk factors, or engage in risk behaviors such as drinking, smoking, or drug use, simply living in a geographic area in close proximity with other poor people who may be more likely to be infected with tuberculosis means that they are also at higher risk. Maps of poverty by administrative division already exist in many countries. As poverty is one of the most frequently cited risk factors for tuberculosis, a so-called â&#x20AC;&#x153;disease of povertyâ&#x20AC;? that disproportionately affects the poor, the impact of socioeconomic status deserves greater consideration as an indirect underlying cause of tuberculosis transmission.

Tuberculosis incidence is also noted to drop in areas where poverty is reduced. The World Bank defines poverty as â&#x20AC;&#x153;living on less than 2 dollars a

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day at 2005 international prices,” and extreme poverty as “living on less than 1.25 dollars a day at 2005 international prices.” Other social definitions based on lack of basic needs also exist.

Urban and rural Urban and rural areas are usually defined by national governments based on population density. Because individuals living in urban areas tend to be wealthier and to have better access to healthcare than individuals living in rural areas, tuberculosis prevalence is generally lower in urban areas than in rural areas. When tuberculosis prevalence in urban areas is disaggregated by geographical areas, however, peri-urban environments often have the highest prevalences of tuberculosis. Peri-urban settings are poorer than the average urban area, may have large slum populations living in a crowded area, or homeless populations with very limited access to healthcare (as defined in developed countries).xl Other diseases may also be prevalent in these settings, along with undernutrition and a host of other problems. Rural areas have lower case-notification rates than peri-urban areas, and remote areas (a subcategory of rural areas defined by long time or distance to the closest health center), with little or

no access to healthcare, have the lowest casenotification rates, possibly due to low case detection rates while the true incidences may still be high.

Population density, the real driver of transmission in urban settings, is mapped in many countries using census data or remote sensing, and urbanrural disaggregation is one of the most common in annual tuberculosis reports.

Undernourished people

Source: PerimcultureProject.com Defined by the World Food Programme as “people whose food intake does not include enough calories (energy) to meet minimum physiological needs,” undernourished people have weaker immune systems, and as a result may be more likely to convert from latent to active tuberculosis.

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Undernutrition may be associated with other direct or indirect risk factors for tuberculosis including poverty or comorbidities, and can be considered both a direct biological or indirect socioeconomic risk factor for tuberculosis.

Undernutrition is closely related but not the same as malnutrition, stunting, or wasting. Malnutrition carries a relative risk of active tuberculosis of 3.2, and one of the highest population-attributable fractions at 27%, due to the high prevalence of malnutrition as a risk factor.

Prisoners, prison staff, and other detainees including pre-trial detention A political term defined differently in different countries, this category includes all individuals who involuntarily and by law are restricted in their freedom to move or choose their own living conditions, as well as the people who care for them, in prisons and detention centers.

Prisons are hotbeds for tuberculosis transmission in many countries as the convergence of many people, including the poor, drug users, and people from marginalized populations, already susceptible to tuberculosis, as a place where those people are concentrated, exposed, and infected in overpopulated facilities, and as a source for infected individuals to be sent back into the community.

Depending on the country, prisoners may have better or worse access to healthcare, including diagnosis and treatment.xli See also TB in Russian prisonsxlii.

Healthcare workers People in healthcare settings are routinely in close contact with patients with compromised

immune systems and those infected with tuberculosis, and are exposed on a regular basis.

Hospitals, in particular, have higher concentrations of people infected with tuberculosis compared to the general population, and depending on the conditions and preventive measures, may be effective transmission hotspots for tuberculosis.

Community health workers and informal healthcare workers, however, are also at risk.

Military and police People living in crowded military facilities and exposed to many other people for long periods of time, are at risk for tuberculosis for many of the same reasons that prisoners are at risk. In many cases, military and police-officials also provide medical services as part of their duties in conflict zones which brings them in contact with high-risk zones.

Ethnic minorities, indigenous, tribal populations Ethnic minorities, religious minorities, indigenous peoples, tribal populations, and other populations marginalized for their backgrounds may be at higher risk for tuberculosis because they

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may on average be poorer than the general population, may live in crowded or unhygienic conditions, and may have worse access to healthcare leading to later case identification and worse outcomes. It is also possible that some groups are more biologically susceptible to developing active tuberculosis. Definitions are highly context-specific, and legal status varies from country to country. Local knowledge is absolutely essential to an understanding of the unique challenges faced by these populations.

Miners, workers exposed to silica, other businesses with occupational exposures People who are occupationally exposed to silica or have been diagnosed with silicosis or other lung diseases are biologically at higher risk for tuberculosis. Aside from workplace exposures, miners and workers in certain other industries, such as garment factories, may be at risk due to poor living conditions.

Sex workers are another example of a group that may be at higher risk for contracting tuberculosis due to higher HIV prevalence, incarceration, poverty, or simply bad hygiene. They may also suffer worse outcomes as a result of having worse access to healthcare.

Migrants Migrants from high burden to low burden settings are only especially important for lowburden countries such as the United States, which are focused entirely on risk groups, and where more than half of cases are often imported. Refugeesxliii, asylum seekers, generally displaced populationsxliv and economic migrants are especially vulnerable groups.

In some countries, cross-border populations with uncertain citizenship statuses (e.g on the Indian-Bangladeshi border) and nomadic populations are also associated with high risk due to their lower social status.

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Comorbidity Individuals whose immune system has been compromised, particularly those living with HIV/AIDS, are biologically at higher risk for developing active tuberculosis from latent tuberculosis, which is normally controlled by the immune system. HIV is one of the strongest risk factors for developing active tuberculosis, and about 25% of HIV deaths are attributable to opportunistic infection by tuberculosis. People infected with HIV have a relative risk of 26.7 for developing active tuberculosis, and HIV infection has a global population-attributable fraction of 19%.xlv People living with HIV/AIDS are the single vulnerable population on which the most has been done in terms of tuberculosis screening and treatment. People with diabetes have a relative risk of 3.1 for developing active TB (PAF=6%). Other comorbidities that may predispose an individual for active TB include chronic renal failure and chronic respiratory disease.

Behavior Alcohol use (40g/day) is associated with a relative risk of 2.9 for active TB (PAF=13%) and active smoking with a relative risk of 2.6 (PAF=23%). Injection drug use, common in prison populations and sex workers, is a risk factor for HIV and therefore also a risk factor for tuberculosis.

Though behaviors such as alcohol use, active smoking, and injection drug use are individual-level risk factors, they are often associated with poverty, comorbidities, and other determinants of tuberculosis at the community level.

IDUs and sex workers are at higher risk for TB due to higher HIV prevalence, being in prison,

poverty, etc. TB rates possibly higher even in HIVand non-prison IDUs and sex workers because they don’t take care of themselves. Sex workers and drug users are highly stigmatized, highly vulnerable, but not regularly tracked. Absence of data at country level may suggest that even with data, countries are not prepared to act on sex workers and drug users.

Though there is little data on sex workers and TB, sex workers should always be considered as an indirect risk factor, and included in the coordination with TB/HIV. The mechanism is not clear, whether drug use leads to TB through increased prevalence of HIV or other social mechanisms and non-causal associations. Some work has already been done.

Household contacts, close contacts Defined by the WHO as follows: Household contact: “A person who shared the same enclosed living space for one or more nights or for frequent or extended periods during the day with the index case during the 3 months before commencement of the current treatment episode” Close contact: “A person who is not in the household but shared an enclosed space, such as a social gathering place, workplace or facility, for extended periods during the day with the index case during the 3 months before commencement of the current treatment episode”xlvi These individuals are vulnerable due to constant exposure to people infected with tuberculosis. They may also have many of the same risk factors as the infected individuals with whom they are in contact, such as poverty, malnutrition, or HIV. Gender

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Though tuberculosis is more common in men, women may have less access to healthcare and thus suffer delayed access to diagnosis and poorer treatment outcomes. Whether or not this is true, or the opposite is true, depends on the country.

Age Tuberculosis is more common in workingage individuals, but young people and elderly people are vulnerable because like women, they have significantly less control over their healthcare decisions in some settings. Demographic shift may affect TB dynamics at the community level, and is something that deserves conscious consideration.

Mental health Very little data exists on the relationship between mental health and tuberculosis, but the mentally ill may be susceptible because they little control over their own health, because they are highly stigmatized in many countries, and because they often live in congregate healthcare settings like mental health institutions, similar to prisoners or healthcare workers.

Further discussion of the underlying causes of vulnerability are discussed in peer-reviewed papers and the WHO recommendations on Addressing poverty in TB control and Systematic screening for active tuberculosis.

Risk factors and social determinants The biological and social understanding of TB is better now than ever before. Evidence in the published literature and meta-analyses suggest that crowding, undernutrition, HIV, silicosis, smoking, diabetes mellitus, undernutrition, alcohol abuse, indoor air pollution, mental illness, illicit drug use, chronic helminth infection, and other diseases are risk factors for TB.xlvii The prevalence of these risk factors varies in different regions, countries, and parts of countries, as do their relative importance in different contexts.

Some risk populations are geographic, others are everywhere. Different locations for screening. This is a practical consideration, also different across settings, to be taken into account when planning interventions.

Lessons from HIV and malaria To date, relatively few studies have examined the subnational distribution of TB, a generalized epidemic in many countries, compared to the other two of the Big Three diseases, HIV, which is more focalized in vulnerable populations, and malaria, a vector-borne illness which demonstrates high spatial and temporal variability.

Further knowledge in this area is essential to improve case-finding, treatment outcomes and cost-effectiveness.

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HIV and malaria data, though perhaps weaker in quality, are better disaggregated and mapped than tuberculosis data. HIV is an example of a disease where this kind of mapping was done for IDUs and MSM. HIV is all about risk groups. Sex workers, one important risk group, are also relevant to TB. Many of the vulnerable populations for one disease, like HIV, are often vulnerable populations for others as well because of the underlying social determinants, and so work that has been done in HIV can be applied to TB as well. In this case, HIV risk groups are indirect TB risk groups almost by definition because HIV itself is a biological risk factor for TB. In PLHIV, a noted and well-documented risk group for TB, “nine percent (7-12%) of all new TB cases in adults (aged 15-49 years) were attributable to HIV infection, but the proportion was much greater in the WHO African Region (31%) and some industrialized countries, notably the United States (26%).”xlviii This highlights the need to formally characterize, or “know,” the epidemic in each country. Final strategies will depend on these priorities as well as costeffectiveness, and practicality.

As mentioned above, subnational data is more frequently reported for diseases like HIV and malaria. Where systems are already in place, HIV subnational reporting can be used as a model for TB programs, and integrated in a horizontal system where possible as health systems are strengthened and available to risk populations. The existing synergies between TB and HIV can be strengthened to increase cross-over in prevention, diagnosis, and treatment.

TB, on the other hand, has been criticized for being too biomedical. Of course, TB is not a purely biological disease, but also one that is driven by social determinants, with vulnerable populations disproportionately affected. There have been recent efforts to humanize TB, but despite or perhaps because of a history spanning hundreds of years, human rights and the equity perspective in TB lag behind those in HIV, which is unfortunate given that TB is entirely treatable, if not always preventable.

Malaria is largely driven by geographic determinants, and some historians including Jared Diamond claim that malaria is a mechanism by which geography shapes history. The Malaria Atlas Projectxlix is a good resource for understanding some of the work in malaria, but there are many more examples in the peer-reviewed literature.

UNAIDS and Know Your Epidemic On 15 April 2008, UNAIDS published its 2007 Annual Report on “Knowing your epidemic.”

The report highlighted, “The major elements of methodological improvements in 2007 included greater understanding of HIV epidemiology through population-based surveys, extension of sentinel surveillance to more sites, and adjustments to mathematical models from better understanding of the natural history of untreated HIV infections inlow- and middle-income countries.”l Discussion of population-based surveys and infections in lowand middle-income countries continue to dominate discussions about tuberculosis today.

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Tuberculosis is a very different disease from HIV, but they are similar in the challenges faced by control and prevention efforts, including weak data and a range of different epidemics. In a response published in The Lancet, two authors commented that “the move to “know your epidemic, know your response” is welcome, but must not become overcomplicated—broad brushstrokes are sufficient for decisive, intelligent action.” They go on to say that “The challenge is clear. For too long, AIDS activists, academics, and national and international institutions have given insufficient emphasis to aligning prevention priorities with epidemic transmission dynamics, compromising effective prevention with

mismatched or unfocused responses. And the AIDS community in its entirety has been slow to implement genuinely proven approaches at adequate scale. With the knowledge we already have, far more should have been, and can still be, done to curb HIV transmission globally.”li The same is true for TB today.

A strategic plan outlining the characteristics of different epidemics and appropriate priorities for fighting TB in those settings should be created, like the ones created for HIV some five years ago, with special attention to the successes and failures of those strategies in that time. New priorities should stress balance in the post-2015 strategy leading up to 2050.

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Questions to Consider 1.

How has tuberculosis affected your country in the past, and what kind of impact does it have now?

What lessons can be learned from your nationâ&#x20AC;&#x2122;s past experience (if any) with the disease?

2. What policies does your nation take to decrease the incidence of TB in your own nation and in nations around the world?

3. In your countryâ&#x20AC;&#x2122;s view, what is the most important aspect of TB prevention? Do you value certain TBreducing practices over others?

4. What is the role of the UN and the WHO in reducing TB incidence around the world? How much is the responsibility of regional organizations, and of the country itself?

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Role of the Committee Today the World Health organization has a budget of almost four billion US dollars and acts as the United Nationâ&#x20AC;&#x2122;s principal health advisory organ. WHO continuously monitors the global health landscape and assesses new trends in health. It is the leading authority on international health issues within the United Nations and sets standards and guidelines for health. WHO experts help countries to address their public health needs by conducting research and identifying promising practices in health. WHO also serves as a network for governments to jointly tackle global health problems. Currently, the organization has 193 member countries and two associate members.

As the most recognized player in the international health sphere, WHO provides health leadership and deals with health-related emergencies or initiatives that require joint effort. WHO sets a research agenda and creates publications on a wide range of health issues in order to disseminate critical knowledge. Furthermore, the organization sets reasonable goals and standards for public health, with means of monitoring the implementation of these standards. WHO also contributes to health by setting research-based, ethical policies.

Lastly, it serves in a supporting role by providing technical support to help nations around the world build holistic, quality, and sustainable health systems.

WHO 37

Structure of the Committee More than 7,000 people from over 150 countries work for WHO. The organization employs individuals from a wide variety of backgrounds, but is governed primarily by its World Health Assembly, which meets annually in Geneva.

The World Health Assembly approves WHO’s annual budget, sets policies for the organization, and elects a new Director-General every five years. WHO’s operations are also bolstered by a 34member Executive Board. Not only do member states send representatives, but they are also represented by six regional WHO committees.

For YMUN purposes, the chairs will act as both the executive board and Director-General. This simulated committee will follow the majority of standards set in the Rules of Procedure of the World Health Assembly with a few exceptions. Delegates will be added to a speakers list but will not be elected to any presiding roles in committee. The chairs will handle all such procedures. Basic General Assembly rules will also be honored, including “Right of Reply” and “Adjournment of Debate To submit your position papers and for all questions, please contact either member of the senior staff: !"#$%&!"'()*+*,(-&#"#$%.#"'()*+*,(/0*1$.$23& 4$++"'&5*+6-&2$++"'.)*+6/0*1$.$23

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Suggestions for Further Research •

WHO Official Site http://www.who.int/en/

•

World Bank: Health http://www.worldbank.org/en/topic/health

•

WHO Publications http://www.who.int/publications/en/

•

WHO Infectious Diseases Page http://www.who.int/topics/infectious_diseases/en/

•

World Health Organization Programme Budget http://whqlibdoc.who.int/pb/2012-2013/PB_2012%E2%80%932013_eng.pdf

•

Comprehensive Mental Health Action Plan 2013-2020 http://www.who.int/mental_health/en/index.html

•

Mental Health and Development http://www.who.int/mental_health/policy/mhtargeting/en/index.html

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NOTES ix In-depth study on all forms of violence against women. United Nations General Assembly. A/61/122/Add.1. 6 July 2006. <www.un.org/ga/search/view_doc.asp?symbol=A/61/122/ Add.1&Lang=E.> x Brownmiller, Susan. Against Our Wills: Men Woman and Rape, Bantam, NY,1974. xi xii xiii xiv Ibid. xv In-depth study on all forms of violence against women. United Nations General Assembly. A/61/122/Add.1. 6 July 2006. <www.un.org/ga/search/view_doc.asp?symbol=A/61/122/ Add.1&Lang=E.> xvi United Nations General Assembly, PROTOCOL TO PREVENT, SUPPRESS AND PUNISH TRAFFICKING IN PERSONS, ESPECIALLY WOMEN AND CHILDREN, SUPPLEMENTING THE UNITED NATIONS CONVENTION AGAINST TRANSNATIONAL ORGANIZED CRIME (2000). <http://www.uncjin.org/Documents/Conventions/dcatoc/final_documents_2/convention_%20traff_eng.pdf> xviiCree, V.E. “Confront Sex Trafficking:Lessons from History”. International Social Work (2008): 763-776 xviiiThe Protection Project. Accessed August 16, 2012. <http://www.protectionproject.org>. xix Ibid. xxUN General Assembly, Convention for the Suppression of the Traffic in Persons and of the Exploitation of the Prostitution of Others, 2 December 1949, A/RES/317 <http://www.unhcr.org/refworld/docid/3ae6b38e23.html> xxi Ibid. xxii i UN Women. "Commission on the Status of Women-Follow-up to Beijing and Beijing + 5." Welcome to the United Nations: It's Your World. Accessed May 28, 2012. http://www.un.org/womenwatch/daw/csw/.

Your World. Accessed May 28, 2012. http://www.un.org/womenwatch/daw/CSW60YRS/CSWbriefhistory.pdf.

"Convention on the Nationality of Married Women." Twin Cities - University of Minnesota. Accessed May 28, 2012. http://www1.umn.edu/humanrts/instree/w1cnmw.html.

"Choike - 1st World Conference on Women, Mexico 1975." Choike: A Portal on Southern Civil Societies Southern NGO Web Portal. Accessed May 28, 2012. http://www.choike.org/nuevo_eng/informes/1453.html.

"Convention on the Elimination of All Forms of Discrimination against Women." Welcome to the United Nations: It's Your World. Accessed May 28, 2012. http://www.un.org/womenwatch/daw/cedaw/.

Mu, Tuoyang. "Human Rights, An Endangered Concept: The United Nations and the Advancement of Human Rights." The University of North Carolina at Chapel Hill. Accessed May 28, 2012. http://www.unawesttriangle.org/hrc/Women's%20Human%20Rights%20Handout.pdf.

"International Women's Health Coalition - Commission on the Status of Women." International Women's Health Coalition - Home. Accessed May 28, 2012. http://www.iwhc.org/index.php?option=com_content&task=view&id=3554&Itemid=1232.

"The NGO Committee on the Status of Women, NY." NGO/CSW/NY. Accessed May 28, 2012. http://www.ngocsw.org/. ii United Nations. "Short History of the Commission on the Status of Women." Welcome to the United Nations: It's Martin, Jodie. "Women and Patriarchy in Nepal." Suite101.com. August 21, 2008. Accessed September 02, 2012. <http://suite101.com/article/patriarchy-in-nepal-a65341> Provost, Claire. "UN Women Justice Report: Get the Data." The Guardian. July 04, 2011. <http://www.guardian.co.uk/global-development/poverty-matters/2011/jul/06/un-women-legal-rights-data> Blanchfield, Luisa, and Rhoda Margesson. International Violence Against Women: U.S. Response and Policy Issues. Report no. 7-5700. July 26, 2011. <http://www.fas.org/sgp/crs/misc/RL34438.pdf> "Short History of the Commission on the Status of Women." <http://www.un.org/womenwatch/daw/CSW60YRS/CSWbriefhistory.pdf>

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xxiii Convention on the Elimination of All Forms of Discrimination Against Women. 1979 <www.un.org/ womenwatch/daw/cedaw/text/econvention.htm> xxiv Ibid. xxv“General Recommendation 19.” Stop Violence Against Women campaign. The Advocates for Human Rights. <www.stopvaw.org/General_Recommendation_19.html> xxvi xxvii “Fourth World Conference on Women (1995).” Department of Public Information. 23 May 1997. <www. un.org/geninfo/bp/women.html> xxviii “Women.” Global Issues. United Nations. xxix xxx xxxi xxxii Ibid. xxxiii xxxiv Blanchfield, Luisa, and Rhoda Margesson. International Violence Against Women: U.S. Response and Policy Issues.

Report no. 7-5700. July 26, 2011. <http://www.fas.org/sgp/crs/misc/RL34438.pdf> xxxv International Research and Training Institute for the Advancement of Women (INSTRAW). “Inventory of UN system activities to eliminate VAW.” xxxviUN Action Against Sexual Violence in Conflict (UN ACTION). “Inventory of UN system activities to eliminate VAW.” xxxvii xxxviiiU.S. Department of State. Trafficking in Persons Report 2012, 2012. xxxix Kimani, Mary. “Taking on violence against women in Africa.” Africa Renewal 21.2 (July 2007). <www.un.org/ecosocdev/geninfo/afrec//vol21no2/212-violence-aganist-women.html> xl Walter, Lynn, ed. Women’s Rights: a Global View. Greenwood Press, 2001. xli xlii UN Global Initiative to Fight Human Trafficking, comp. HUMAN TRAFFICKING:THE FACTS. N.p.: n.p., 2007. <http://www.unglobalcompact.org/docs/issues_doc/labour/Forced_labour/HUMAN_TRAFFICKING__THE_FACTS_-_final.pdf> xliii U.S. Department of State. Trafficking in Persons Report 2012, 2012. xliv Watts, Charlotte, and Cathy Zimmerman. "Violence against Women: Global Scope and Magnitude." The Lancet 359 (April 6, 2002): 1232-37 "The United States Should Not Ratify CEDAW." Concerned Women for America. May 10, 2007. Accessed September 02, 2012. <http://www.cwalac.org/article_492.shtml> "Aid Worker Diaries - Overcoming Violence in DR Congo: CARE Assists Survivors of Sexual Violence."

Overcoming Violence in DR Congo: CARE Assists Survivors of Sexual Violence. August 2012. <http://www.trust.org/alertnet/blogs/aid-worker-diaries/overcoming-violence-in-dr-congo-care-assists-survivorsof-sexual-violence.> CSW. "Conclusions of the Commission on the Status of Women on Critical Areas of Concern Identified in the Beijing Platform for Action." December 1998. <http://www.un.org/womenwatch/daw/csw/agreedconclusions/Agreed%20conclusions%2042nd%20session.pdf> "Commission on the Status of Women-Follow-up to Beijing." UN News Center. <http://www.un.org/womenwatch/daw/csw/critical.htm> "United Nations Millennium Development G xlv Ibid. xlvi Ibid. xlvii U.S. Department of State. Trafficking in Persons Report 2012, 2012. xlviii Ibid. xlix l Ibid. li World Health Organization. WHO multi-country study on women's health and domestic violence against women: summary report. N.p.: n.p., 2005 lii Ibid. liii Ibid. liv United Nations Department of Public Information DPI/1772/HR. Last modified February 1996.

WHO 41 <http://www.un.org/rights/dpi1772e.htm.> lv lvi lvii Watts, Charlotte, and Cathy Zimmerman. "Violence against Women: Global Scope and Magnitude." The Lancet 359 (April 6, 2002): 1232-37 lviii Ibid. lix Ibid. lxRatushenko, Gennadly, http://www.who.int/features/factfiles/violence/violence_facts/en/index9.html lxi Steiner, et al. Human Rights in Context, Harvard Law Press, 2007. lxii “Eliminating Female Genital Mutilation: An Interagency Statement,” World Health Organization, 2008, p. 4. lxiii “Culture of Discrimination: A Fact Sheet on Honor Killings,” Amnesty International, July 25, 2005. lxiv Ibid. lxv lxvi lxvii “Declarations, Reservations, and Objections to CEDAW.” Division for the Advancement of Women:Department of Economic and Social Affairs. <www.un.org/womenwatch/daw/cedaw/reservations- country.htm>. lxviii “Women and Rights in Latin America;In Mobilizing for Human Rights in Latin America”. Kumarian Press, 2007. lxix Kimani, Mary. “Taking on violence against women in Africa.” Africa Renewal 21.2 (July 2007). <www.un.org/ecosocdev/geninfo/afrec//vol21no2/212-violence-aganist-women.html>. lxx Ibid. lxxi Cook, Rebecca J., ed. Human Rights of Women: National and international perspectives. University of Pennsylvania Press: 1994. lxxii Ibid. lxxiii Walter, Lynn, ed. Women’s Rights: a Global View. Greenwood Press, 2001. lxxiv “Declarations, Reservations, and Objections to CEDAW.” Division for the Advancement of Women:Department of Economic and Social Affairs. <www.un.org/womenwatch/daw/cedaw/reservationscountry.htm>. lxxv lxxvi Blake, John. "Muslim women uncover myths about the hijab." CNN. < http://articles.cnn.com/2009-0812/us/generation.islam.hijab_1_hijab-muslim-women-muslim-americans?_s=PM:US.> lxxvii “Declarations, Reservations, and Objections to CEDAW.” Division for the Advancement of Women:Department of Economic and Social Affairs. <www.un.org/womenwatch/daw/cedaw/reservations- country.htm>. lxxviii “Russian Federation.” Stop Violence Against Women. The Advocates for Human Rights. <www.stopvaw.org/Russian_Federation.html>. lxxix UN Office on Drugs and Crime. Trafficking in Persons; Analysis on Europe. Vienna, 2009.<http://www.unodc.org/documents/human-trafficking/Trafficking_in_Persons_in_Europe_09.pdf > lxxx "Thousands Abandon Female Genital Mutilation in Africa." BET.com. February 8, 2012. Accessed September 02, "WHO | Reproductive health." http://www.who.int/topics/reproductive_health/en/.

"WHO | About us." Accessed September 10, 2012. http://www.who.int/reproductivehealth/about_us/en/index.html.

Collier, Aine. The Humble Little Condom: A History. Amherst, N.Y.: Prometheus Books, 2007.

"Ireland’s Sexual and Reproductive Health History | Irish Family Planning Association." Irish Family Planning Association. Accessed September 10, 2012. http://www.ifpa.ie/Media-Info/History-of-Sexual-Health-in-Ireland.

"WHO | Contraceptive Prevalence." Accessed September 12, 2012. http://www.who.int/reproductivehealth/topics/monitoring/contraceptive_prevalence.pdf "Annual Report of the Tariff Commission for the 2005-06." Tariff Commission, Ministry of Commerce & Industry, Government of India. Accessed September 12, 2012. http://tc.nic.in/areports/annualreport-2005-06.pdf.

"Ibis Reproductive Health." Ibis Reproductive Health. Accessed September 11, 2012. http://www.ibisreproductivehealth.org/where/unitedstates.cfm.

"Surveillance SummaryAbortion Surveillance: Preliminary Analysis, 1979-1980 --United States." Centers for Disease Control and Prevention. Accessed September 10, 2012. http://www.cdc.gov/mmwr/preview/mmwrhtml/00001243.htm.

"Abortion Surveillance --- United States, 2007." Centers for Disease Control and Prevention. Accessed September 11, 2012. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6001a1.htm?s_cid=ss6001a1_w.

"RH Reality Check: Nepal Advances As U.S. Backslides on Women's Rights | Center for Reproductive Rights."

Center for Reproductive Rights. Accessed September 12, 2012. http://reproductiverights.org/en/feature/rh-realitycheck-nepal-advances-as-us-backslides-on-womens-rights.

"Reproductive Rights in Nepal." Center for Reproductive Rights. Accessed September 13, 2012. http://reproductiverights.org/sites/crr.civicactions.net/files/documents/RR%20in%20Nepal%20Factsheet%20FIN

WHO 42 AL.pdf "India and Poland Urged to Improve Reproductive Rights | Center for Reproductive Rights." Center for Reproductive Rights. http://reproductiverights.org/en/press-room/india-and-poland-urged-to-improvereproductive-rights.

"Progress on Accountability for Maternal Health Care and Mortality in Bihar, India | Center for Reproductive Rights." Center for Reproductive Rights. Accessed August 20, 2012. http://reproductiverights xciii xciv Sunil, T.S., and Vijayan Pillai. "Women’s Reproductive Health in Yemen." Cambria Press. Accessed August 8, 2012. http:// www.cambriapress.com/cambriapress.cfm?template=4&bid=361.

"Choike - Sexual and reproductive rights." Choike: A Portal on Southern Civil Societies - Southern NGO Web Portal. Accessed August 8, 2012. http://www.choike.org/2009/eng/informes/1197.html.

Conde, Carlos H. "Philippines abortion crisis - The New York Times." The New York Times - Breaking News, World News & Multimedia. Accessed August 10, 2012. http://www.nytimes.com/2005/05/15/world/asia/15ihtphils.html.

"PHILIPPINES: Illegal abortions - the risks and the misery." IRIN Asia | humanitarian news and analysis.

Accessed August 8, 2012. http://www.irinnews.org/Report/84021/PHILIPPINES-Illegal-abortions-the-risks-andthe-misery.

"Forsaken Lives:The Harmful Impact of the Philippine Criminal Abortion Ban | Center for Reproductive Rights." Center for Reproductive Rights. Accessed August 6, 2012. http://reproductiverights.org/en/forsakenlives.

"The Roman Catholic Church in the Philippines | Helping women help themselves, their families and communities —Reproductive health —Family planning —Community health." Likhaan Center for Women's Health (Philippines) | Helping women help themselves, their families and communities —Reproductive health —Family planning —Community health. Accessed August 7, 2012. http://www.likhaan.org/content/roman-catholic-churchphilippines.

"Philippines: Senator Denounces Global Abortion Lobby | LifeNews.com." LifeNews.com - The Pro-Life News Source. Accessed August 14, 2012. http://www.lifenews.com/2012/08/23/philippines-senator-denounces-globalabortion-lobby/.

"Philippines: Pro-Abortion Groups Funding RH Bill Backers | LifeNews.com." LifeNews.com - The Pro-Life News Source. Accessed August 7, 2012. http://www.lifenews.com/2011/12/02/philippines-pro-abortion-groups-fundingrh-bill-backers/.

"Nepal Supreme Court: Abortion Is a Right | Center for Reproductive Rights." Center for Reproductive Rights.

Accessed August 7, 2012. http://reproductiverights.org/en/feature/nepal-supreme-court-abortion-is-a-right.

"Indian Activist Sues State for Neglecting Maternal Mortality | Center for Reproductive Rights." Center for Reproductive Rights. Accessed August 7, 2012. http://reproductiverights.org/en/document/indian-activist-suesstate-for-neglecting-maternal-mortality.

"Reproductive Rights of Women in Latin America and the Caribbean." The Human Rights Brief. Accessed August 4, 2012. http://hrbrief.org/2011/03/reproductive-rights-of-women-in-latin-america-and-the-caribbean/.

"Gender Equality Observatory." CEPAL. Accessed August 7, 2012. http://www.cepal.org/oig/noticias/noticias/3/47303/Fact_Sheet_5_reproductive_rights_EN.pdf.

"Latin America and the Caribbean." Ibis Reproductive Health. Accessed August 7, 2012. http://www.ibisreproductivehealth.org/where/latin.cfm.

"Polish Abortion Ban Defeated; Pro-Life Leaders Optimistic." The New American | Home. Accessed August 7, 2012. http://www.thenewamerican.com/world-news/europe/item/8837-polish-abortion-ban-defeated-pro-lifeleaders-optimistic.

"Poland Moves One Step Closer to Passing Abortion Law | Medindia." Medindia - Medical/Health Website.

Accessed August 6, 2012. http://www.medindia.net/news/Poland-Moves-One-Step-Closer-to-Passing-AbortionLaw-87174-1.htm.

"India and Poland Urged to Improve Reproductive Rights | Center for

WHO 43 Reproductive Rights." Center for Reproductive Rights. Accessed August 6, 2012. http://reproductiverights.org/en/press-room/india-and-polandurged-to-improve-reproductive-rights.

"Ibis Reproductive Health | Sub-Sahara Africa." Ibis Reproductive Health. Accessed August 8, 2012. x cxi cxii Giwa-Osagie OF et al. Aetiologic classification and sociomedical characteristics of infertility in 250 couples.

International Journal of Fertility , 1984, 29:104â&#x20AC;&#x201C;108. cxiii cxiv China's Quest for Reproductive Health: An Interview with Yu Xuejun - Population Reference Bureau." Home Population Reference Bureau. Accessed August 7, 2012. http://www.prb.org/Articles/2001/ChinasQuestforReproductiveHealthAnInterviewwithYuXuejun.aspx.

"How Universal is Access to Reproductive Health?." UNFPA - United Nations Population Fund. Accessed August 7, 2012. http://www.unfpa.org/webdav/site/global/shared/documents/publications/2010/universal_rh.pdf.

"Poor reproductive health among a group of socially damaged Middle East." Dove Medical Press - Open Access Publisher of Medical Journals. Accessed August 10, 2012. http://www.dovepress.com/poor-reproductive-healthamong-a-group-of-socially-damaged-middle-east-peer-reviewed-article-IJWH. "World Bank eLibrary Reproductive Health in the Middle East and North Africa." World Bank eLibrary home.

Accessed August 10, 2012. http://elibrary.worldbank.org/content/book/9780821349205.

"Child Marriage in the Middle East and North Africa - Population Reference Bureau." Home - Population Reference Bureau. Accessed June 17, 2012. http://www.prb.org/Articles/2010/menachildmarriage.aspx.

"Yemen's Child Marriages - Middle East - News." OnIslam.net. Accessed August 19, 2012. http://www.onislam.net/english/news/middle-east/456444-yemens-child-marriages.html.

Center for Reproductive Rights. "Dignity Denied." BlogHer | Life Well Said. Last modified October 15, 2010.

Accessed June 19, 2012. http://www.blogher.com/frame.php?url=http://reproductiverights.org/en/document/dignity-denied-downloadreport.

"Forced Sterilization: Oppressing Latin Americaâ&#x20AC;&#x2122;s Womb | BlogHer." BlogHer | Life Well Said. Last modified November 19, 2010. Accessed June 17, 2012. http://www.blogher.com/oppressing-latin-america%E2%80%99swomb.

"Regional Dialogue: Latin America." Global Commission on HIV and the Law. Last modified June 26, 2011.

Accessed July 20, 2012. http://www.hivlawcommission.org/index.php/lard-dialoguedocumentation?task=document.viewdoc&id=24.

"BBC NEWS | Americas | Chile introduces right to divorce." BBC News - Home. Last modified November 18, 2004. Accessed August 13, 2012. http://news.bbc.co.uk/2/hi/americas/4021427.stm.

Wang, Qingyun. "Premarital sex is common, survey finds." China Daily. Accessed April 10, 2012. http://www.chinadaily.com.cn/china/2012-04/10/content_15008509.htm.

"China's Quest for Reproductive Health: An Interview with Yu Xuejun - Population Reference Bureau." Home Population Reference Bureau. Accessed July 25, 2012. http://www.prb.org/Articles/2001/ChinasQuestforReproductiveHealthAnInterviewwithYuXuejun.aspx.

"No sex education please, we're Chinese - People's Daily Online." People's Daily Online - Home Page. Accessed July 20, 2012. http://english.peopledaily.com.cn/102780/7459948.html.

"China Sex Ed Dolls: Kindergarten Class Uses Realistic Dolls To Teach Sexual Education (PHOTOS, POLL)."

Breaking News and Opinion on The Huffington Post. Accessed July 9, 2012. http://www.huffingtonpost.com/2011/09/06/china-sex-ed-dolls_n_950636.html.

"Sex education causes stir in Chinese elementary schools - CNN." Featured Articles from CNN. Accessed August 7, 2012. http://articles.cnn.com/2011-09-09/world/china.sex.education_1_elementary-schools-textbook-healtheducation?_s=PM:WORLD. "International Women's Health Coalition - Young Adolescents' Sexual and Reproductive Health and Rights: South and Southeast Asia." International Women's Health Coalition - Home. Accessed August 13, 2012. http://www.iwhc.org/index.php?option=com_content&task=view&id=2697&Itemid=1162.

Elizabeth Eggleston, Jean Jackson and Karen Hardee. 1999. "Sexual attitudes and behavior among young

WHO 44 adolescents in Jamaica."

International Family Planning Perspectives 25(2):78-84 &

ii "Mental Health." WHO. N.p., n.d. Web. iii Koyanagi, Chris, and Judge David L. Bazelon Center for Mental Health Law. "Learning from History: Deinstitutionalization of People with Mental Illness as Precursor to Long-Term Care Reform." NAMI. The Henry J. Kaiser Family Foundation, Aug. 2007. Web. iv Promoting Mental Health." www.who.int. World Health Organization, n.d. Web. 2004. v “MENTAL HEALTH AND DEVELOPMENT: Targeting People with Mental Health Conditions as a Vulnerable Group." Http://whqlibdoc.who.int/publications/2010. World Health Organization, 2010. Web. vi Mental Health: New Understanding, New Hope. Geneva: World Health Organization, 2001. PDF. Available online at: http://www.who.int/whr/2001/en/whr01_en.pdf vii Scaling up Care for Mental, Neurological, and Substance Use Disorders. Geneva: World Health Organization, 2008.

PDF. Available Online at: http://whqlibdoc.who.int/publications/2008/9789241596206_eng.pdf viii MhGAP Intervention Guide. Geneva: World Health Organization, 2010. PDF. Available online at: http://whqlibdoc.who.int/publications/2010/9789241548069_eng.pdf ix "About the Movement | Movement for Global Mental Health." About the Movement | Movement for Global Mental Health. N.p., n.d. Web. 17 Oct. 2013. <http://www.globalmentalhealth.org/about>. x Disease Control Priorities in Developing Countries. Washington D.C.: The International Bank for Reconstruction and Development / The World Bank, 2006. PDF. xi Ahmedani, B.K. (2011). Mental health stigma: Society, individuals, and the profession. Journal of Social Work Values and Ethics, 8(2), 41-416. PMID: 22211117. xii "Mental Health Action Plan 2013-2020." (n.d.): n. pag. World Health Organization, 2013. Web. <http://apps.who.int/iris/bitstream/10665/89966/1/9789241506021_eng.pdf>. xiii “MENTAL HEALTH AND DEVELOPMENT: Targeting People with Mental Health Conditions as a Vulnerable Group." Http://whqlibdoc.who.int/publications/2010. World Health Organization, 2010. Web. xiv "Global Burden of Mental Disorders and the Need for a Comprehensive, Coordinated Response from Health and Social Sectors at the Country Level." World Health Organization, 1 Dec. 2011. Web. <http://apps.who.int/gb/ebwha/pdf_files/EB130/B130_9-en.pdf>. xv “MENTAL HEALTH AND DEVELOPMENT: Targeting People with Mental Health Conditions as a Vulnerable Group." Http://whqlibdoc.who.int/publications/2010. World Health Organization, 2010. Web. xvi Disease Control Priorities in Developing Countries. Washington D.C.: The International Bank for Reconstruction and Development / The World Bank, 2006. PDF.

WHO 45 xvii “Mental Health Action Plan 2013-2020." (n.d.): n. pag. World Health Organization, 2013. Web. <http://apps.who.int/iris/bitstream/10665/89966/1/9789241506021_eng.pdf>. xviii "Mental Health: Towards Economic and Social Inclusion." Commonwealth Secretariat, 2013. Web. <http://aamh.edu.au/__data/assets/pdf_file/0007/778777/PS12001_Mental_Health_Report.pdf>. xix “Mental Health and Development: Targeting People with Mental Health Conditions as a Vulnerable Group." Http://whqlibdoc.who.int/publications/2010. World Health Organization, 2010. Web. Page 9. xx Disease Control Priorities in Developing Countries. Washington D.C.: The International Bank for Reconstruction and Development / The World Bank, 2006. PDF. Neurological Diseases Chapter. xxi “Mental Health and Development: Targeting People with Mental Health Conditions as a Vulnerable Group." Http://whqlibdoc.who.int/publications/2010. World Health Organization, 2010. Web. Page 13.

xxii Evidence." Mental Health Atlas 2005. World Health Organization, 2013. Web. <http://www.who.int/mental_health/evidence/atlas/profiles_countries_c_d.pdf>. xxiii Mental Health and Development: Targeting People with Mental Health Conditions as a Vulnerable Group." Http://whqlibdoc.who.int/publications/2010. World Health Organization, 2010. Web. xxiv Guha, Jennifer, "Farmer Suicides in Maharashtra, India: Facts, Factors, and Possible Fixes" (2012). Honors Scholar Theses.Paper 235. http://digitalcommons.uconn.edu/srhonors_theses/235 xxv Mwape L, Mweemba P.. Strengthening the health system for mental health in Zambia (policy brief). Lusaka, Zambia: The Zambia Forum for Health Research, 2010. xxvi Mental Health and Development: Targeting People with Mental Health Conditions as a Vulnerable Group." Http://whqlibdoc.who.int/publications/2010. World Health Organization, 2010. Web. xxvii Disease Control Priorities in Developing Countries. Washington D.C.: The International Bank for Reconstruction and Development / The World Bank, 2006. PDF. Page 618. xxviii Disease Control Priorities in Developing Countries. Washington D.C.: The International Bank for Reconstruction and Development / The World Bank, 2006. PDF. Page 619. xxix Mental Health Action Plan 2013-2020." (n.d.): n. pag. World Health Organization, 2013. Web. <http://apps.who.int/iris/bitstream/10665/89966/1/9789241506021_eng.pdf>. xxx Institute for Health Metrics and Evaluation: http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd2010-change-leading-causes-and-risks-between-1990-and-2010 xxxi http://www.un.org/millenniumgoals/pdf/report-2013/mdg-report-2013-english.pdf xxxii Global Tuberculosis Report 2012, pages 18, 21 xxxiii http://www.who.int/tb/strategy/stop_tb_strategy/en/ xxxiv http://www.un.org/millenniumgoals/pdf/report-2013/mdg-report-2013-english.pdf, page 41 xxxv Global Tuberculosis Report 2012, page 1 xxxvi http://www.who.int/tb/strategy/stop_tb_strategy/en/ Word cloud with 300 words from the first draft of 31,471 words. This document is apparently about data on national and subnational poverty and tuberculosis vulnerable populations. xxxvii End Tuberculosis Strategy 2016-2035 draft. World Health Organization. Page 13, sections 1.5, 1.6, 1.10, 4.7, 6.13, 6.14, 8.5, 8.6. xxxviii Addressing poverty in TB control – options for national TB control programmes. World Health Organization. Page 10. xxxix Systematic screening for active tuberculosis: Principles and recommendations. World Health Organization. xl UN-HABITAT definition of slum household: a group of individuals living under the same roof in an urban area who lack one or more of the following: 1. Durable housing of a permanent nature that protects against extreme climate conditions. 2. Sufficient living space which means not more than three people sharing the same room. 3. Easy access to safe

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water in sufficient amounts at an affordable price. 4. Access to adequate sanitation in the form of a private or public toilet shared by a reasonable number of people. 5. Security of tenure that prevents forced evictions. xli Guidelines for control of tuberculosis in prisons. World Health Organization. Definition: “anyone held in criminal justice and correctional facilities during the investigation of a crime, anyone awaiting trial or conviction, and anyone who has been sentenced. It also refers to persons detained for reasons related to immigration or refugee status.” xlii http://www.who.int/bulletin/volumes/84/4/news30406/en/ xliii Tuberculosis care and control in refugee and displaced populations: An interagency field manual. World Health Organization. xliv UNHCR definition: A person who “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country…” xlv How health systems can address inequities in priority public health conditions: the example of tuberculosis. World Health Organization. xlvi Recommendations for investigating contacts of persons with infectious tuberculosis in low- and middle-income countries. World Health Organization. xlvii The Lime Book, page 286. xlviii http://www.who.int/hiv/events/artprevention/corbett_growing.pdf xlix Malaria Atlas Project http://www.map.ox.ac.uk/ l http://www.unaids.org/en/media/unaids/contentassets/dataimport/pub/report/2008/jc1535_annual_report07_en.pdf li http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2808%2960883-1/fulltext