As part of our commitment to the communication of global health research, PLOSBLOGS is pleased to host this Q&A with the three final candidates for WHO Director General. In three previous guest posts appearing on this blog, a supporter of each candidate outlined their views of the candidate’s primary qualifications and offered reasons for their endorsements. In this last post before the DG election, which takes place on May 22-30, the candidates are asked to address critical issues in global health, with their unedited answers provided. We thank the post’s authors, global health researchers & authors, Anne-Emanuelle Birn, Yogan Pillay, and Timothy H. Holtz, for bringing this work to our readers.
Lastly, please note, the opinions expressed in this post belong solely to its authors and their interviewees and do not necessarily reflect the views of PLOS or the PLOS journals.
By AE Birn, YG Pillay, TH Holtz  (See author bios below this post)
In just a few weeks, the World Health Assembly will be electing the next Director-General of the World Health Organization (WHO), replacing Dr. Margaret Chan, of China, who has served in this role since 2007. This is the first time the Director-General will be directly elected by member countries rather than by the WHO’s Executive Board.
Given WHO’s overall aim as laid out in its Constitution: “…the attainment by all peoples of the highest possible level of health,” and the funding shortfalls experienced by WHO since the 1980s and especially for the past two decades (since member state dues have been frozen)—plus the uncertainty of US global health and development funding under the Trump administration—the Director-General’s election is extremely important.
In her letter chronicling her 10 years as Director-General, Dr. Chan leaves this global health legacy to her successor: “The challenges facing health in the 21st century are unprecedented in their complexity and universal in their impact. Under the pressures of demographic aging, rapid urbanization, and the globalized marketing of unhealthy products, chronic noncommunicable diseases have overtaken infectious diseases as the leading killers worldwide.”
Dr. Chan’s list, however, ignores the deeper challenges that characterize health conditions in the contemporary world order, including: “preventable disease, disability, and premature death related to poor living and working conditions, limited health care access, discrimination, and, ultimately, the gross inequities across population groups due to highly skewed distribution of wealth, power, and resources among the world’s over 7.5 billion people.” ] The vital concerns include: how will Chan’s successor respond to these and other serious challenges to health as a “fundamental human right”; and what role will WHO play in attaining “health for all,” as articulated in the 1978 Declaration of Alma-Ata?
While there have been profiles and interviews of the candidates in such leading venues as the Lancet and the New York Times, these pieces have not covered the most crucial political economy issues facing the organization and the range of actors involved in global health, and, most importantly, how these issues affect the health of the public.
As co-authors of Oxford University Press’s just-published Textbook of Global Health (4th edition), we have drawn from the book’s critical political economy of health framing (that is, how health and disease are produced and influenced by political, economic, and social structures [practices, institutions, and policies] and social [class, race, and gender] interrelations) to pose a series of direct questions to the three candidates: Dr. Sania Nishtar (SN), of Pakistan; Dr. David Nabarro (DN), of the United Kingdom; and Dr. Tedros Adhanom Ghebreyesus (TAG), of Ethiopia.
We present their unedited responses to help WHA members and their constituencies decide which candidate is best placed to lead WHO to fulfill its constitutional mandate to work for the highest attainable level of health for all people ~ and thus who is most fit for this very important position.
How seriously will you take the societal determinants of health and what specific actions will you lead in this regard?
SN: Social policy, macroeconomic management, and governance effectiveness matter deeply for health. The strongest determinants of a nations’ health status are the levels of per-capita income and maternal education. The social and environmental determinants of health play a critical role in addressing inequities and achieving the desired health outcomes.
As Director-General, I would recognize that WHO couldn’t, by itself, address all these issues. In many important areas, WHO’s goals are dependent on action entirely outside of the health sector. Girls’ education, women’s economic empowerment, and reproductive rights are particularly critical for improving health, globally. Furthermore, the achievement of universal health coverage necessities a major change in employment, and economic and social policies.
Over the last decade, WHO has called for reduction of health inequalities in practically every document adopted at the World Health Assembly, and not least by repeatedly calling for countries to address the social determinants of health. The paradox of this issue is that it lies at the core of WHO’s mandate, yet lies farthest from the sphere of its direct influence. The redistribution of income, access to education, the provision of safe and decent work, and participatory governance are not elements within WHO’s direct influence. WHO needs therefore to re-examine its work in three areas.
- Firstly, I would call on technical units, at the global, regional and country offices to develop the framework of an equity status report that could be used to assess progress in health equity over time and use that report to drive our cooperation strategies and plans with countries that comply.
- Secondly, we must use social determinants as a direct entry point for addressing health inequity. The Global Commission on Social Determinants of Health examined a number of determinants that are directly within WHO’s core mandate and influence: health systems, gender, early childhood development, and priority public health conditions. I would give these four determinants priority in terms of reduction of inequalities.
- Finally, WHO must lead by example. We must report frankly about the efforts being made, share successes, shortcomings, and lessons learned, in an effort to urge peers to adopt a similar approach to the determinants within their mandate.
DN: The people of our world face a daunting series of challenges to their health. These include growing threats of non-communicable diseases, the health impacts of climate change, environmental pollution and unplanned urbanization; the mounting toll of death and disability on our roads; the persistent challenge of hunger for some and over-nutrition for others; poor people unable to access effective medicines, the scandalous neglect of mental health; the blight on communities caused by the traffic in narcotics; the plight of migrants; the victims of human traffickers; the many who live in fear are forced leave their homes by conflict and adversity; and the market and systems failures that underpin Anti-Microbial Resistance (AMR). Health services face new demands that result from changing norms in society, increasing public expectations and populations living longer.
These challenges have two characteristics in common. First, they are all encompassed in the 2030 Agenda for Sustainable Development, something that I have worked very closely on, playing a leading role in the implementation of the Sustainable Development Goals (SDGs). Second, they highlight the reality that the attainment of good health will always depend on a combination of good science and the right policy choices. The latter includes a focus on inclusion and equity, with no-one left behind, which is something I personally am committed to and have demonstrated throughout my career.
Good health is a person’s most precious asset. Ministers of Health lead government efforts that act on the economic, social, political and environmental determinants of ill-health. They need to take deliberate action to influence choices in other policy arenas in order to promote and protect health.
The SDGs within the 2030 agenda provide a renewed incentive for active inter-sectoral efforts to tackle social determinants of ill-health. Areas of particular relevance, in which governance can have a positive impact on health, include Anti-Microbial Resistance, the health of ageing populations, trade and intellectual property, sustainable energy, income inequality, migration, food security, and sustainable consumption and production. While much of the attention on governance for health has focused on global outcomes, the SDG declaration points to the importance of governance for health at local, national and regional levels.
As Director General of WHO I will build on the solid foundation provided by the SDGs. I will pursue a practical agenda with a consistent focus on key outcomes. My approach will be based on the themes of “health in all policies” and “multi-sectoral action plans.” I will seek emphasis on successful implementation of the 2030 Agenda within different population groups, by encouraging health professionals everywhere to work with personnel from all the sectors that determine health outcomes, and to engage appropriately in the implementation of policies across government and society.
WHO has a major role to play in monitoring progress against the goals and targets in the SDGs that relate to health and well-being. Given the nature and breadth of the 2030 Agenda, a range of stakeholders will use the Goals and Targets to monitor progress, using inputs from the public provided via their smartphones and presenting reports of progress though social media. In future the SDGs, in addition to being used by national authorities to monitor progress, may well feature in national debates about positions on inequality of income or of access to health care, on the condition of migrants, on access to medicines and on other factors that impact on people’s health.
TAG: I will take the social determinants of health very seriously if elected Director-General of the World Health Organization, because without acknowledging and addressing these issues, we won’t solve health challenges at their roots. I will specifically address these first by working at all levels to break the silos down between our development objectives. At the international level, I will work to position WHO as a leader in building strong partnerships across UN organizations. I will engage key regional and sub-regional groups to build the political leadership necessary to create multi-sectoral approaches. At the country level, I will also advocate for strong commitments to health not only from Health Ministries, but also Finance, Social and Planning, among others.
Where programs have been effective at addressing the social determinants of health, the WHO can draw out evidence-based best practices and ensure they are shared regionally and globally. Lastly, as I have throughout my career, I will focus especially on the needs of vulnerable groups and those disproportionately affected by the social determinants of health. These include migrant, displaced and disabled individuals, people living in rural, urban slum, and low-income areas and other marginalized populations.
How will you ensure that non-state actors do not capture the WHO and thereby neuter the role of UN member states in decision-making?
SN: Under my leadership, WHO will promote strategic engagement with non-state actors, while firewalling normative functions. We must implement WHO’s Framework of Engagement with Non-State Actors (FENSA) in earnest both efficiently and effectively to tap into the resources non-state actors can offer—while enforcing all procedures of FENSA to build safeguards against undue influences, which can undermine public confidence and create a reputational risk.
WHO has a dual role—on the one hand it is the world’s norms and standard-setting body in health and as such, as rightly mentioned in the question, its relevant work needs to be firewalled from all kinds of influences. On the other hand, WHO is also meant to exercise effective stewardship in relation to health emergencies and assist countries with the implementation of the SDGs in a context where there is an explicit mandate to engage civil society and the private sector. In this era of the SDGs as WHO’s work becomes more inter-sectorial, engagement with Non-State Actors (NSAs, a collective name used for Non-governmental organizations, private sector, academic and philanthropic organizations) becomes an imperative. Member States have agreed on the rules of engagement with NSAs during the 69th WHA by approving the Framework of Engagement with Non-State Actors (FENSA). Under my leadership, WHO will promote strategic engagement with NSAs, efficiently and effectively, while enforcing all procedures of FENSA to build safeguards against undue influences, which can undermine public confidence and create a reputational risk. I believe transparency in all areas of WHO work is one of the most important safeguards in this connection—which is precisely why I have placed it number one in my 10 pledges. It is a hedge against many risks and reputational challenges the organization can face in the coming years. As DG I would regard and practice transparency as my most important policy tool.
DN: The Member States of WHO set the organization’s policies and priorities. They expect WHO to be responsible for providing strategic leadership for all engaged in the pursuit of the health outcomes that are incorporated in the 2030 Agenda. To do this WHO needs to understand more about the perspectives of the multiple actors that influence health outcomes.
These include civil society networks, individual NGOs, professional associations, the media, think tanks, national and transnational corporations, individual activists and informal communities. All these actors have the capacity to influence decision making and as a result of digital and social media advances can now be better heard. Given this reality it is important that WHO’s governors – the Member States – make the final determination of policies and priorities for global health.
WHO has a particularly important role as it sets the standards that are used to determine the optimal health status of people and the levels of health care that they should be able to access. Given the importance of this role, the technical capability and impartiality of WHO’s Secretariat must be able to call on the best independent expertise and be protected from vested interests. I am committed to rigorous processes for ensuring the independence of WHO’s standard-setting as well as for identifying and managing any conflict of interest. Multi-stakeholder working is on the increase and is likely to have increasing significance within international efforts to support sustainable development. Hence the need for safe spaces to exist so that all parties can interact without intimidation. The spaces should be specially designed to enable participation by those who might lack the power they need to ensure that their voices are heard and presence is felt. I have substantial experience of partnering and fostering movements and appreciate the careful balance that is required to benefit from (a) the work of multiple stakeholders, (b) the independence of WHO’s technical functions and (c) the vital role of Member States in determining the Organization’s policies and priorities.
I will encourage all in WHO to use their professional skills to broker agreement between actors and to and avoid deadlock when interests diverge. This capacity to broker will be made available at all levels of government and will help states to honour international agreements in ways that benefit the health of people. Information about progress in relation to the goals and targets in the 2030 Agenda helps governments to assess their performance; and enables others to champion different aspects of the right to health.
TAG: The growing number of non-state actors around the World Health Organization provides both an opportunity and a challenge. The opportunity lies in bringing diverse perspectives and skills to bear on some of the world’s greatest health challenges through partnership and collaboration. However, WHO is the global leader for developing norms, standards and guidelines. This normative work must be firewalled from the wide variety of non-state actors that today need to be engaged in the programmatic work in order to fully address health issues. Having this in mind, WHO’s Framework for Engagement of Non-State Actors (FENSA) is a welcome step toward strengthening partnerships between WHO and non-state actors, including civil society. If elected, I will work toward FENSA’s full implementation in pursuit of effective partnership with all stakeholders. In addition, where we do form partnerships, we must operate on the principle of complementarity, but not be afraid to challenge partners, for example to ensure that their work is evidence-based and responsive to countries’ needs.
What specific novel policies will you propose to improve health equity and strengthen health outcomes in LMICs?
SN: While the health sector alone cannot bring health equity in any country and must depend on a whole-of-society approach, WHO is uniquely placed for both technical and political activism in this regard. Since country needs differ substantially, I will strive to make WHO’s technical assistance country-tailored, taking advantage of its three-tier structure, especially WHO’s unique 150-country-strong footprint. I will also focus on strengthening WHO’s technical assistance to countries in terms of quantum, quality, and relevance. As the global community and countries look at a full (sometimes overwhelming) suite of interventions, WHO must promote the ones that are high “value for money,” and have the potential to maximize synergies across silos, align with a rights based approach and create impact in terms of gender equality and equity in outcomes.
In terms of specific policies, I will push for intersectoral approaches and ensure that WHO assists member states, where needed with appropriate tools: how to design, formulate, implement, manage, monitor and evaluate intersectoral approaches. Many middle-income countries have experience in establishing concrete intersectoral approaches and developing appropriate governance arrangements to enable their implementation. Within this context, I will promote south-south sharing to capitalize on sharing of experiences. I will push for intersectoral action not only at the level of governments but also within the UN system. Also, I will push for data disaggregation, at level, which is a starting point to promote equity. Furthermore, I will pay special attention to neglected diseases of the poor where the market does not have an incentive to invest to provide solutions; I believe such an approach can be hugely equity-promoting. Furthermore, I will be very vigilant towards humanitarian crises where inequity tends to widen the most.
And let us not forget that Universal Health Coverage, the central pillar in the SDGs is the most important way to address equity. Achieving this means building on previous commitments to Primary Health Care and including long-term social policy commitment, domestic resource allocation, and a move linking coverage for essential services to financial risk protection.
DN: The WHO exists to respond to the specific needs of the people in the different Member States. Over my 40 year career I have worked in over 50, mainly developing, countries and have a strong understanding of what is needed to improve health outcomes. When I am Director General I will want to see an increase in this focus on the specific needs of the people in different nations. I will expect to see more support given to national governments as they pursue their objectives for people’s health: this will mean excellent technical advice designed to advise on policy options and to fill gaps in national capacities. Health inequities are on the increase both between countries and within populations. Given the focus, in the 2030 Agenda, on leaving no-one behind, WHO’s contribution should be designed to ensure that the most vulnerable and those that are hardest to reach do have access to quality health services. This includes women and children particularly.
While in South East Asia in March, I found that people’s average life expectancy has risen by 3.5 years per decade since the year 2000. However, around 130 million people in the region still lack access to essential services, and more than 60 million people are pushed into poverty each year as a result of health care costs. These statistics underline the reality of inequities – a pattern that I have found in many regions.
For many governments the challenge is to find adequate public funds to enable the health sector to have sufficient resource for poor people to be able to access health care of appropriate quality. Governments throughout the world are challenged to increase revenues and to increase the proportion of this income spent on promoting better health and preventing illness. Frequently finance ministers in countries that are enjoying healthy rates of economic growth acknowledge the importance of investment in health as a way to improve people’s prosperity and economic growth. Yet, many of them continue to approve a volume of public sector health spending that – as a percentage of GDP – is far below the global average. Without sustained improvements in the level and distribution of health spending, people will continue to be at risk of having to make massive out-of-pocket expenditures when they fall ill.
The term “leave no-one behind” means just that. It sounds easy in theory but practice is more challenging. The most important requirement is information: average achievements for individual health-related variables disguise significant inequities that can only be revealed if the information is disaggregated. Statistics can tell us the numbers of people who do not receive specific services, but further investigation is needed to assess who these people are and why they are excluded.
The statistics should be deigned to reveal the issues that tend to be of concern to local health workers. They should reveal the extent to which those excluded are members of minority populations that suffer discrimination because of their ethnicity, gender and sexual orientation as well as other personal characteristics and beliefs. We have learned from programmes for people with HIV/AIDS that to be effective means reaching out to marginalized populations. We know too that those who are left behind when it comes to accessing health services are those who tend to live on the margins of society and thus miss out on other benefits, such as education. Even in countries where governments guarantee health care and financial protection for everyone, in practice there remains a minority who do not, cannot afford to, or choose not to claim their rights. This is particularly so for migrants, refugees or others that do not have the same rights as citizens.
Reducing inequity and improving health outcomes increasingly depends on financing by the national government – particularly in middle-income countries where the majority of the world’s absolute poor now live.
Exclusion is to be prevented through good and accountable governance. This means having good quality, disaggregated information to facilitate effective planning. It also means a proactive effort to identify those likely to be excluded and to ensure they benefit – such as woman migrants. On data, everyone needs to be counted, often with the help of new Information and communications technology. On analysis, there is a need to know more about barriers to access on both the supply and demand side. On preparedness, an understanding of exclusion should be part of all health worker training. Ideally, performance-related payment for health sector action should be a reflection not just to overall performance, but equally to measurable reduction in inequalities.
TAG: If I am elected, my top priority will be achieving universal health care (UHC) that is equitable and affordable for all. I am convinced that UHC, with financial protection and strong primary health care linked to community engagement, is the key to give us a world where everyone can lead healthy and productive lives regardless of who they are or where they live. It can also help us address public health emergencies and give us a safer world because a strong health system becomes our first line of defense to detect, monitor and respond to health emergencies. Achieving universal health care, of course, is an ambitious goal, and it is one which will require strong country-level ownership. To get there, I will work to raise the issue of universal health care to the highest political levels, championing universal health care as essential for the political agenda of every nation and as a basic right of every individual. I will work to unlock earmarked funding and mobilize new resources to achieve these goals. And I will lead a WHO that looks to form deep partnerships with countries and regions to design and implement UHC approaches that are right for their unique contexts.
What specific plans do you have to counter the climate change denialists, given the wealth of data on the negative impact of climate change on health?
SN: From global news headlines about the rising threat of dengue, which is now endemic in 128 countries and threatening 4 billion people, to recent United Nations Environmental Program publication, that outlined a range of environmental threats to health, and how addressing environmental challenges can also protect and promote health, the scale of the problem is quite clear. Many measures to reduce greenhouse gas emissions result in near-term co-benefits to health e.g., from reduced air pollution, which is an important risk factor for a number of non-communicable diseases. Policies to increase resilience of populations to climate change, such as by enhancing food security and access to safe water, also yield benefits to health. Many health issues are directly linked to climate change, such as shifts in the distribution of tropical diseases and disease outbreaks.
Over two years, 2014-15, I served on the Planetary Health Commission and contributed to a report, which highlighted existing evidence to show how the health and well-being of future generations is being jeopardized by the unprecedented degradation of the planet’s natural systems.
My country, Pakistan, is particularly vulnerable to climate change and variability. In 2010, for example, floods affected 20 million people, incurring huge economic losses. As such, I have a close understanding of country level grass roots dynamics, and the threat faced by many countries such as the Small Island Developing States, or ocean states, that risk losing past development gains due to environmental challenges.
Droughts, floods, other extreme climate events (hurricanes, typhoons), and changes in disease vector distribution can also wreak havoc in many other countries. It is, therefore, critical to build linkages between SDG 3 and other goals relevant to health and sustainability.
WHO must facilitate access of vulnerable countries to the climate mitigation/adaptation funds. It must also play a stronger role, coordinating development and humanitarian and climate change-related work as it relates to the right to health for all, which is why this features as one of my Ten Pledges in relation to a New Vision for WHO.
DN: If the nations of our world are to succeed in responding to threats that have the potential to influence people in multiple locations, collective action – characterised by cooperation and solidarity among national governments – is critically important. This is the approach that is needed in response to changing climates, to outbreaks of infectious disease and to the emergence of anti-microbial resistance. To succeed we need to take a collaborative approach and work together in an effective manner. Evidence about the degree of climate change, of its impact on people’s health and livelihoods, is extensive. WHO and its partners have played a major role in collating this evidence. A key part of the evidence is the health benefits of national efforts to adapt to climate change – in areas such as food production, water management and disease control, among others. I will seek to ensure that this work in WHO retains solid financial and political support.
As an organization that represents the will of all Member States, and the concerns of populations most seriously affected by climate change, I will ensure that the organization participates appropriately in all future debates on how best to ensure resilience in the face of climate change.
Under my leadership WHO will work as a catalyst for change. Our future approach on climate and on AMR will be to promote specific actions – country-by-country, issue-by-issue. Progress and demonstrable results build confidence, confidence born of real change strengthens the hands of those who seek resources. All this will require new ways of working in public health action – keeping health concerns at the forefront, but engaging with a much wider range of bodies across government, civil society and the private sector.
TAG: On this issue, we need to first start with the facts – that climate and environmental change are real and unfortunately are having and will continue to have a negative impact on health. That evidence-driven reality is why I included climate change as one of my five top priorities if elected to become Director-General. This is an issue I was fortunate to have been able to work on with Ethiopia’s late Prime Minister, Meles Zenawi, who was a vocal champion and wanted to ensure Ethiopia was a part of the solution, despite contributing nothing to the problem. Ethiopia now depends predominantly on renewable energy to reduce carbon emissions and is planting 7 billion seedlings a year to trap carbon. Within these efforts, I advocated for mitigation strategies in addition to adaptation strategies, so we can prevent further environmental and climate change.
The WHO also has an opportunity to be a part of the solution and should become a vocal advocate for mitigation strategies. It can champion global and regional coalitions which promote capacity building within countries around these strategies. It can advocate for increased financial allocations at the global, regional and national levels through active engagement with climate financing instruments, donors and national governments. It can work to strengthen country governments’ ability to understand and use climate services and information for health policy, planning and research. And it can promote sustainability within the health sector itself, championing the use of renewable energy sources.
While readers are invited to carry out their own comprehensive analysis, here we highlight just a few issues that we found most salient:
- None of the candidates discussed issues of social justice in their responses regarding the societal determinants of health (noting that human rights were the subject of a separate interview and publication). As well, while Dr. Nishtar stated that redistribution of income, safe work, and participatory governance were beyond WHO’s purview, Dr. Nabarro and Dr. Tedros did not address questions of the root origins of health inequities. None of the candidates mentioned the recommendations of the WHO Commission on Social Determinants of Health on global power asymmetries, specifically the need to “tackle the inequitable distribution of power, money, and resources.”
- In terms of the role of non-state actors in neutering public accountability at WHO, none of the candidates articulated the intrinsic differences in power and access between public-interest entities and corporate/philanthropic actors under the non-state actor rubric. All three seem to think FENSA will resolve the problems of private, undemocratic influence on WHO’s agenda, even as FENSA now legitimizesand increasesaccess of business associations and philanthropy in relation to WHO governing bodies. Likewise, the candidates did not discuss the importance of WHO’s integrity, independence and trustworthiness, nor did they refer to WHO’s vital role in advocating for the regulation of transnational corporations (as per follow-up on the Framework Convention on Tobacco Control and the International Code of Marketing of Breast-milk Substitutes, as well as ongoing efforts to push regulation in areas of Big Food, Big Soda, etc.)
- To improve health and health equity, all three candidates invoked Universal Health Coverage without specifying the role of public provision, comprehensive coverage, and equity in access, quality, and financing for health care systems. In relation to health equity and social determinants of health, all three candidates mentioned intersectoralism and social inclusion, partnerships, and WHO technical expertise, but again attention to the political context of these challenges was lacking. As well, all candidates took the SDGs as a given and as unproblematic in their construction. Specifically, they did not raise any of the limitations inherent to the SDGs, including that the SDGs themselves are not acknowledged as human rights (e.g., the right to health, the right to income security, etc.) and that the SDG platform serves as an open invitation to financing and agenda setting from the private sector and philanthropies as appropriate, albeit unaccountable and unrepresentative, partners to governments and public-interest NGOs.
- All three candidates underscored the need for WHO leadership to address climate change, based on scientific evidence, with Dr. Nishtar intertwining her understanding of local effects with involvement at the global level, Dr. Nabarro emphasizing WHO’s country-by-country catalyzing role, and Dr. Tedros highlighting local mitigation efforts in extremely low greenhouse gas contributing settings. What this means for the major fuel fossil combustion perpetrators—especially the United States—remains unsaid.
In sum, in order to address global health’s most fundamental challenges, each of the candidates for WHO Director-General ought to pay greater attention to, and act protagonistically around, the structural issues—global trade and financial governance arrangements and rules, patterns of wealth and ownership, production processes, imperialism, militarism, and class, race, and gender oppression—that shape ill health and health inequities both within societies and across the world.
 Birn, Professor of Critical Development Studies, University of Toronto, Canada; Pillay, Deputy Director- General, Department of Health, South Africa (writing in his personal capacity); Holtz, Adjunct Associate Professor of Global Health, Rollins School of Public Health, Emory University, Atlanta, USA.
 Anne-Emanuelle Birn, Yogan Pillay, and Timothy H. Holtz. Textbook of Global Health (4th edition). New York: Oxford University Press, 2017, p. xx.