Global Burden of TB

It is the leading infectious cause of adult mortality in the world, with up to 1/3 of the global population infected (half of which will not be diagnosed. 6% growth rate in new infections annually -- disease is spreading

• most cases occur in the developing world as do most of the deaths
• disease and death hits 14-54 year olds (very broad range)
• TB kills more women than all other of the maternal deaths combined
• costs 12 billion dollars a year

1. HIV/AIDS
2. Multi drug resistant strains of TB
3. Lapse of TB control programs
4. Structural factors (especially poverty)

• HIV/AIDS leads to more vulnerability: 1/3 of people globally with HIV/AIDS are infected with TB and in Sub-Saharan Africa, up to 70% of HIV/AIDS patients have TB
• TB accelerates the replication of HIV and leads to the replication of HIV and the onset of AIDS : it is a major cause of death for HIV/AIDS patients
• HIV positive patients need to be tested and treated for TB

TB and Poverty

Poverty causes and is therefore linked to TB:

(9)

1. Malnutrition
2. overcrowding
3. poor sanitation
4. inadequate health care
5. low education
6. unstable housing
7. unstable employment
8. social marginalization
9. co-morbidity with other disease

Vaccination for children

Treatment is done by taking two or three different types of antibiotics

DOTS (Direct Observed Therapy Shortcourse)

5 steps

1. governement support
2. case detection by sputum smear when symptomatic patient enters health clinic
3. standardized treatments lasting 6-8 months for those testing postive on the sputum smear. They must be directly observed for the first two months
4. regular and unterupted supply of the anti-TB drugs
5. standardizing and reporting system that allows for assement and outreach for the patient and the TB control program

First established a National Tuberculosis Program (NTP) in the 1960's with very poor results. Very few patients finished their treatment as there was a short supply of drugs, support, staff, diagnosis tools and patient follow up. In 1993 RNTCP was established to implemented the WHO DOTS program. The goal was to cure 85% and reach 70%.

They evaluated the intergration of DOTS into different clinics (with controls).

Those with RNTCP were often stuck waiting on lines and just handed drugs to take elsewhere in the clinic. The cure rate was around 70% with a drop out rate between 6-11%

More than half of the patients opted out or were excluded from the DOTS program:

the patients either found the logistics too complicated or the provider refused because they did not want those who were less able to comply to their treatment method to spoil their results.

Social marginalization and poverty were key factors in exclusion

Multi-Drug Resistant TB CAUSED BY

(5)

1. Erratic drug ingestion
2. Omission of one or more of the perscribed agents
3. Suboptimal dosage
4. poor drug absorption
5. Insufficient number of active agents in a regimen

Treatment of Mutli-Drug resistant TB

(4)

1. 18-24 months of treatment
2. second line drugs which are much harsher than the first course
3. $200,000 dollars per person
4. efficacy of treatment is only slightly more than 50% of patients HIV NEGATIVE

What predicts compliance to TB treatment? 

3 factors

1. Free and convinient treatment 
2. access to supplemental food and income 
3. those least likely to comply are those least able to 

Lecture 8B - Health and Development 

1. Single
2. Double 
3. Maternal (includes double)
4. Paternal (includes double) 

It determines how you give out resources and services 

NOTE: Human rights groups push for childhood being determined as U 18

• 75% not actually orphans
• High fertility
• high migration 
• provide labor to families without children 
• This works as long as money is flowing from children to adults
• Caldwell's Theory of Wealth flows 
• Farming out of kids for labor
• Purposive vs. crisis fostering
• Crisis fostering is part of Social Immunity 

Because there is a delay between initial infection and death from AIDS there is a lag in orphanhood. As a result we can expect a huge jump in AIDS orphans after this delay is caught up. 

PREDICT: 25 million orphans 

At this time, fostering is no longer as benificial or feasible. 

Already there is a jump in the rise of orphanages

1/500 is you have sex once with an infected person

transmission occurrs within 4 months of infection. 

Changes in orphanhood:

Used to be because of 

________ but now it is because of ______

Number of Orphans in sub-Saharan Africa:

1. Total 
2. Due to AIDS
3. Expected to rise to 
4. Double orphans

1. There are 48.3 million orphans in Sub-Saharan Africa
• 12% of children 
   
2. 12 million are from AIDS 
    
3. Expcted to rise to 25 million to due AIDS when the delay in death occurrs 
    
4. About 8 millionare double orphans  -- a large proportion of this is due to AIDS

Impacts of Orphanhood on Children

(5)

1. Parental illness and death
2. changes in caregiver -- Health: who cares for you matters
3. changes in caregiver -- Education: impacts your edu
4. psycho-social impact: don't get enough attention
5. vulnerability over the lifecourse: impacts you negatively 

Parental Illness and death

What is the Double Jeopardy?

Why is paternal illness and death so bad? 

(3)

1. Double jeopardy
2. Parental illness is very harmful and many children die before their parents due to lack of care 
3. Maternal Death increases child mortality threefold

• lack of breastfeeding has a huge impact 

Shows the relationship between education and health in foster vs. own children.

Compared in 1992 and 1999

Foster children were pretty much equal if not better than own children in 1992 but there is a drastic shift and in 1999 for health especially foster children are now at a disadvantage when they used to have the advantage

Low enrollement and investment in educaton is not related to poverty but rather to closeness to the caregiver. The more distantly related to the caregiver, the less likely to be in school. 

HAMILTON'S RULE: Closeness of biological ties governs altruism. 

Children that were orphans demonstrated twice as much anxiety and 2 times as much depression, anger and disruptive behavior. 

In addition, children that were orphans were almost 6 times as likely to answer yes to the question: "Do you wish to die?"

Almost 6 times as likely to think that their lives would be bad. 

Children who lose their parents do tend to "lose their childhoods" and engage in "risky" adult behavior.

When comparing vulnerable children, the orphans were more likely to experience teen pregnancies, STIs and contract HIV. 

Policy Interventions for Children 

Conflicts,issues and problems

1. 40% of countries with HIV epidemics lack policies for orphans
2. Disagreement on whether or not to target poverty of orphans -- contentious issue. But then also, where do you cut the povert line off? 
3. Household vs institutional care
4. Emphasize Mother to Child tranmission or Protect Whole Families? 

• need to protect the whole family because even if the child is not affected with HIV, their health suffers if their parent is sick 

# of deaths under 1 year during a specified period 

------------------------------------------------------------ x 1000

# of live births occuring during the same time period

# of deaths  U5 years old during a specified time

------------------------------------------------------------ x 1000

# of live births occuring during the same time 

Number of Child deaths under 5 

in 1999

in 2008

Where do they occur? 

1999: 10.4 million

2008 : 8.8 million

98% occur in developing countries 

Solutions are cheap and could be made widely available! 

Africa contains 10 % of the population but account for 1/2 the child deaths 

Asia is 40% of the population and represents another large portion of child deaths

.1% of child deaths from the developed countries 

West and Central Africa and South Asia are the areas with the highest proportion of child deaths (UNICEF)

1. End of the Cold War
2. SAPs -- the article blames most of it on this
3. AIDS
4. Plateauing  

MDG 4: Reduce the number of childhood deaths under 5 by 2/3 by 2015

What does it look like? 

Sub-Saharan Africa does not look like it will at all despite the fact that it would be very cheap to make drastic changes to the mortality rate there. It woud also be a lot easier. 

Major causes of infant mortality 

(6)

1. Acute respiratory infection (ARI) (Pneumonia) 
2. Diarrhea 
3. Measles
4. Malaria
5. Perinatal (usually kills wihtin the first month)
6. Other (accidents, congenital disorders etc...)

Malnutrition plays a MAJOR role in 50% of these deaths

Make these diseases deathly when the child is malnourished 

Women's Education and Mortality

What does one year of education for the mother correspond to in terms of decline in under 5's mortality

Can see that if GDP had remained at the 1970 levels, child mortality would only be very slghtly higher whereas if the maternal EDU levels were where they were in the 1970's, the child mortality rate would have been very much higher. 

With both GDP and maternal EDU at levels from the 1970, mortality would have been at its highest. 

See that child mortality decreases steadily along the wealth gradient. Being in the richest versus the poorest gradient cuts mortality in half

Yet, the difference between women that had recieved only primary edu or none at all and women who had recieved secondary or higher education had also halved the number of child mortality rates. 

Wealth and education are obviously correlated -- wealthy tend to have more education. 

Cuts the chance of death by half

** neonatal issues are beyond a mother's control but later on in life, a mother can impact her children's health**

Correlates and Predictors of Infant and Child Mortality

(10)

1. Low birth weight
2. maternal age (over 40 and under 20 is more dangerous)
3. birth interval 
4. Birth order and plurality (twins or triplets less healthy)
5. sex
6. breastfeeding
7. maternal education
8. Ethnicity and culture 
9. Economic and environmental conditions including health care
10. maternal health including HIV 

Need conceptual framework to understand all the factors 

MOSELY - CHEN  ANALYTIC FRAMEWORK 

Aims: 

(3)

1. What predicts when a child gets sick?
2. Combines both mortality and growth faltering/stunting
3. Uses a gradient of malnutrition with death being the highest grade 

Proximate determinants of the Mosely - Chen analytic framework

(5)

1. Maternal Factors
2. Environmental Contaminents
3. Injury
4. Nutrient Deficiency
5. Personal Illness control (treatment and prevention)

The five proximate determinants of the Mosely - Chan analytic framework are determined by socio-economic factors. These socio-economic factors are broken into 3 different parts:

1. Individual variables (edu, productivity, norms, beliefs, traditions)
2. household variables (income/wealth)
3. community variables (ecological, political, econ, health system)

1. Mother's education
2. Income / Wealth 

1. Improved socioeconomic status (Mosely-Chen socioeconomic determinants)
2. Health KNowledged (M-C Personal Illness control)
3. Modern attitudes towards health care (Person lllness control)
4. Female autonomy (M-C Personal Illness control)
5. Reproductive behaviors (Maternal factors) 

1) Improved Socio-economic status 

(3)

1. Women with more education are likely to have better paying jobs 
2. Women with more edu are more likely to have husbands with more education and better paying jobs 

2) Health Knowledge

(4)

1. Improved understanding about causation of disease
2. Improved prevention
3. Improve timely treatment 
4. Better understanding of healthmessages 

3) Health Attitudes

(3)

1. Shift towards modern medicine and away from traditional practices
2. Less fatalistic about disease and death
3. More likely to adopt innovative remedies

4) Greater Autonomy 

(4)

1. Women generally are the primary care givers -- earlier recognition of illness
2. Have greater decision making power on health matters 
3. they have more confidence in handling medical officials
4. more willing to travel alone 

Found that when birth interval was spaced by 2 or more years survival was greater 

Still found that educaton was the most influential factor changing women's perception of health and their ability to intervene. 

Policy Interventions to Improve Child Survival 

(5)

1. Reduction of high risk births
2. expanded program on immunization (EPI)
3. Oral rehydration therapy
4. Breastfeeding 
5. Health and nutritional statu of mothers

Anthropometric Measures

Definition and 3 requirements

These are tools used to measure nutritional status of children. They quantify growth deficits that are presumed to be associated with inadequate food consumption or infection/disease 

1. International or standard reference 
2. Simple indices 
3. Identification of poor status 

Need an international measure for what height should be at a given age. 

Use National Health Survey as a standard

International comparison shows little variation among different ethnic or racial groups among well nourished children

2) Simple Indices

(2)

1. wastng: deficit in tissue and fat mass for height (from lack of recent adequate food or infection)
   
   - look at : weight for height and current health status
    
2. Stunting: slowing of the skeletal growth due to poor environment, reoccuring infection, poor nutrient intake
• look at height for age
• longer term growth

Weight

--------------------

(height)squared

3) Cut-off points for poor status

(3)

1. Calculate Z-scores
2. Kids below 2 standard deviations from norm suffer from wasting or stunting
3. Kids below 3 standard deviations from norm suffer from severe wasting or stunting 

1. Macronutrients: carbs, proteins, fats and oils
2. Micronutrients : vitamines and minerals

Overarching factor: Poverty/Low Socioeconomic Status 

causes:

1. Limited access to food ----> Inadequate dietary intake

2. Limited access to improved water and sanitation ----> Infectious disease AND Inadequate Dietary intake

3.Limited access to health services ----> Infectious disease

Culminates in: Undernutrition, death and disability

1. Short stature leads to higher rates of obstructed labor which requires caesarean delivery
2. Low BMI in pregnancy leads to intrauterine growth restriction and low birth weight infants 

less than 37 weeks

(difficult to document)

less than 2500 grams

this number is easy to collect since it only depends on weight but it tells you less because low birth weight could be due to either small for gestational age or preterm birth

Infant and yound child feeding recommendations 

(7)

1. early initiation of breastfeeding (within one hour of birth)
2. Exclusive breastfeeding birth to 6th month
3. continued breastfeeding two 2 years or more
4. Introduction of solid, semi-solid foods or soft foods from 6 months
5. minimum of four food groups for dietary diversity
6. meal frequency according to age (2-3 for 6-8 months, 3-4 from 9 months with 1-2 nutritious snacks as needed)
7. consumption of iron rich (flesh) or iron fortified foods

Complementary feeding is challenging 

2 major reasons 

1. Local foods pose a problem: 

      - low energy dense

      - low micronutrient dense

      -high phylate bings minerals 

      - little variety

      - seasonal hardship 

      - little no animal products

2. Feeding style

    - passive

    - not frequent enough

    - household distribution

    - poor hygiene 

Health Implications of malnutrition

(7)

1. Stunting
2. Wasting 
3. Anemia
4. Blindness (lack of Vitamin A)
5. Brain damage (iodine deficiency)
6. Vulnerability to infection
7. Death 

27% of all U5 children in developing countries are underweight

Including half of the children in South Asia

Child Health and Mortality: 

# of deaths and % of DALYs

(3)

1. 2.2 million deaths and 21% of DALYs due to stunting wasting and intrauterine growth restrictions
2. 1.4 million deaths and 10% of DALYs due to suboptimal breastfeeding 
3. 3.5 million deaths and 35% of DALYs due to maternal and child malnutrition

Is a type of malnutrition

effects about 20 million children worldwide 

associated with type 2 diabetes, hypertension, gallstones, asthma, back pain, arthritis, heart disease, stroke and some types of cancer

a family is a group of individuals affiliated by consanguinity, affinity or co-residents. 

Rely most on co-habitation definition

Extended vs nuclear

household vs family

matrilineal vs patrilineal 

opposite sex vs same sex 

cohabitation vs married 

intact vs blended 

monogomous vs polygamous

singly vs dual

Implications of family on child well-being -- NORTH AMERICAN EVIDENCE 

4 facts

- children of single parents :

poorer outcomes in edu, behavior and general health

- fewer investments made on children in blended families vs intact families 

- married men and women tend to be healthier and live longer than unmarried 

- lower levels of wealth among unmarried account for about 1/2 of these effects but still controling for wealth the effects of family structure remain

Polygamy vs monogamy and dual vs single parenthood in Sub-Saharan Africa 

High fertility

25-50% of unions in SSA

Benificial Effects of Polygamy on Children

(4)

Wealthier households

longer breastfeeding 

longer birth intervals and postpartum abstinence 

social and economic suport from co-wives

Harmful effects of Polygamy on Children 

(7)

1. Poorer per-capita
2. lower parental investment by fathers
3. selectivity of mothers (rural, less educated women tend to be in polygamous relationships)
4. Over crowding
5. Rivalry among co-wives
6. In polygamous societies, there are lower HIV rates but having concurrent partnership raises the risks of infection
7. Problem when there are urban and rural wives and they don't get the benifits of polygamy

Negative 

Children have higher risks of dying when born into a polygamous family 

First year of life there is no difference between monogomous and polygamous

Between 2 and 5 the risks are higher for polygynous kids because the social factors start to take effect 

pre-marital birth

divorce/widowhood before child turns 15

dying before the age of 5 with a single mother increases between 33-66 %

YET EDUCATION: no edu increases the probability of childmortality between 0 and 84%

Death of a womanfrom direct and indirect obstetric causes more than 42 days after but less than one year after the termination of a pregnancy 

Deaths resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes but was aggravatd b physiologic effects of pregnancy 

 # of deaths to women from pregnancy-related cases

----------------------------------------------------------------

# of live births 

expressed as a number over 100,000 live births

# of deaths to women from pregnancy during a specific period 

-----------------------------------------------------------------

# of women of reproductive age during specific time

Ask people about their adult sisters 

- can use small sample size

- ask four questions

- good for high fertility settings 

- long term retrospective period 

ask :

how many total numer of sisters did you have who reached the age of 15?

How many are still alive?

How many dead?

How many of these sisters died during childbirth, right after childbirth or while pregnant?

Shorter reference period, larger sample size and more detailed questions asked. 

For sisters that are dead: 

- was she pregnant?

- did she die in childbirth ?

-did she die within 2 months of childbirth?

Occurs disproportionately in developing countries (99%)

90% occur in asia and africa 

child mortality U5 doubled if mother dies 

1 in 7,300 chance of death in the developed world

1 in 73 chance in developing world 

Why do women die? 

(7)

Unsafe abortions

severe bleeding 

infection

obstructed labor 

other direct causes 

indirect causes 

eclampsia

1. deciding to seek care
2. reaching and finding a medical facility 
3. receiving adequate and appropriate treatment 

- decision making power

-status of women

-perceptions of the illness

-physical distance from the facility

-previous experience at the facility and percieved quality of care

-socio-cultural barriers

 - distribution of health facilities

- travel time from home to the facility

- availability and cost of transport

- conditions of roads and geographical obstacles 

adequacy of referral system

lack of supplies and equipment

lack of trained health professionals

availability of trained personnel 

Emergency Obstetric Care (EOC)

Basic

- give meds

- remval of the placenta 

removal of retained tissue

- assistance with vaginal delivery

-provision of newborn care

EOC 

Comprehensive

- all basic services 

- c-section

- safe blood transfusion

- emergency care for sick newborns

EOC 

International guidelines

National Mother mortality Study done because recognized high maternal mortality --- 1992

Many interventions

NMMS redid study found a drop of 50% of maternal deaths 

What Egypt case study maternal death reduction attributed to

(5)

increased hospital births 

skilled attendants at birth

antenatal care coverage

contraceptive use

decrease in fertility 

increased to 80% of births attended by skilled person

higher contraceptive use

higher literacy for women -- lessening of gap between men and women 

antenatal care increased

If lower socio-economic status have:

lower edu

lower earnings 

poorer housing conditions

lower health insurance

less access to health services

discrimination

less political protection

Would assume Mexican immigrants to be between US and Mexican mortality rate 

What is it?

Mexican Immigrants are found to have: 

4

- higher birthweight babies 

- less obeisity, better adult health status 

-lower infant and child mortality 

- lower adult mortality 

- found AFrican Americans did worst 

almost as bad as those in developing countries 

- foreign born hispanic population is best `

higher chance of infant mortality 

- some stats were not significant 

longer in the US, the more chances of being obesese.

By 15 years only a slightly less chance of being overweight in ill health 

1- selection bias : paradox doesn't exist because we selectively chose healthy immigrants 

healthy people are more likely to immigrate, if you are sick you go home, there is no point to immigrate if you are sick 

2- The Acculturation Hypothesis 

The Acculturation Hypothesis 

Recent immigrants are :

(5)

1. less likely to smoke
2. drink less alcohol
3. lower rates of teenage pregnancy (better maternal risk profiles)
4. Live with extended families and therefore have better social networks 
5. eat more nutritious foods 

Selection Bias 

3

Salmon Hypothesis (you go home if you are sick) 

poorer registration or under registration of infant or adult immigrant deaths 

Healthy immigrant Theory

Testing the Salmon Hypothesis 

What do you compare?

3

those that cannot return (Cuba)

Those whose deaths even if they return home will be recording in US stats (Puerto Rico)

Compare US born Latinos 

Still found that immigrants have better rates of mortality

there is still no argument against healthy immigrant effect 

The Epidemiological Paradox in Canada 

Objectives of Canada's Immigration Policy

4

enacted in 1978

- promotion of Canada's demographic, economic, social and cultural goals

- family reunion

- nondiscrimination

- refugee obligation

Less severe than in the US

Immigrants tend to live in poverty but suffer less emotional problems and retain cultural heritage 

x number of people per square kilometer

number of residents

precentage of population not reliant on agriculture 

provision of public services and utlities available

There is no universal definition as it differs from country to country 

Urbanization

3

growth in the proportion of a population living in urban areas 

level of urbanization is reported as the percentage of the total population living inurban areas 

the rate of urbanization is the rate at which it grows

Trends in Urbanization: Global urbanization

number of people urban

mega cities def

half world population

mega cities = 10 million residents or more 

there are 26 mega cities globally 

rise in urban poor 

asia has the highest urbanization levels 

steady decrease in smaller settlements (but they are still high) and rise in urban settlements 

What impacts Urbanization?

2

- increase in Births -- more births than deaths (HIgher in latin america) 60%

- internal migration (highest in Africa) 40% responsible

Factors pulling people to cities from rural areas

4

employment

edu opportunities

higher standard of living and amenities

stimulation and excitement 

 - high unemployment 

natural disasters

political upheaval

food insecurity 

circular migration of men -- temporarily leave village for work in urban area

long term migration of men

circular family migration

permanent urban settlement 

Impacts of rapid urbanization 

4

- strain on infrastructure (drainage, clean water, sewage, waste removal, transportation, electricity)

- inadequate housing 

- food supply

- development of squatter settlements and urban slums 

Slum -- UN def

plus 5 shelter deprivations 

heavily populated urban area characterized by substandard housing and squalor and lacking in tenure security

one or more of the sheleter deprivations: 

- Lack of durable housing

- insufficient living area

- lack of access to clean water

inadequate sanitation

insecure tenure 

1 billion slum dwellers

1/3 of urban population globally 

- permanent or temporary housing

- usually on unwanted, dangerous land (flood plains, garbage dumps, close proximity to train tracks or industrial sites)

- lack of accessible roads 

unregulated and illegal 

Conditions in Urban slums 

6

extreme poverty

overcrowding

indoor and outdoor polution

substandard housing 

food insecurity

little or no public infrastructure 

Health Consequences of Urban Slums 

1) Infectious diseases  (measles , TB, Cholera, Dengue Fever)

2) Environmental Diseases (Respiratory health and diarrhea) 

3) Infant and child health (high infant mortality, respiratory disease stunting and wasting) 

4) Maternal Health (higher STDs, lower age of marriage and first birth, higher MM)

5) Mental Health 

- poverty and high rates of violence and murder and rape

- breakdown of tradition support networks

- depression, alchohol use drug use

- increased rates of suicide

Overall urba dwellers are better off because have better mortality and morbidity rates BUT this is NOT  true of the urban poor 

- comparable to rural and slightly worse of child indicators 

Urbanization and Health Factors

8

1. Double health burden (both communicable and lifestyle disease -- caught between the worst of both rural and urban environments)
2. Pollution
3. Lack of Sanitation
4. poor diet
5. increased smocking
6. urban violence
7. industrial and traffic incidents
8. lack of health care

Case study of Nairobi Slums 

Korogocho Slum

4thlargest Nairobi slum

30-35,000 people 

next to the largest dump

high dependency -- 1/3 pop under 15

40,000 

bordered by heavy industrial river that is very polluted, a train track and a busy highway

higher men to women 

lower dependency ratio

korogocho is more settled but still high circular migration, don't stay more than 3 years 

high migration of women in and out of the slum, net migration of women 

interviewed women: 3/4 had migrated from somewhere else in Kenya or east Africa married with kids 

complained of slum conditions 

process through which slum areas are formalized and incorporated into city by extending services and citizenship to slum dwellers. 

provide economic social institutional and community services available to other citizens:

legal land tenure physical infrastructure 

Increase GDP

Source of revenue 

source of foreign investment 

greater employment 

better access to more nutritious and diverse foods

increase tech transfer , including medical 

exposure to new disease

increased inequality

two tiered system of health

brain drain

infringe on public health provision

economic growth

inequality

General Agreement on Trade in Services (GATS)

4 modes of international trading in services

Mode 1: cross border supply: non-resident suppliers supply services across a border into the country

Mode 2 Consumption abroad: consumers or firms make use of a service in another country

Mode 3: commercial presence: a foreign company sets up subsidies or branches to provide service in another countr

Mode 4: Presence of natural persons: individuals travel from their home country to supply services in another country

175 million people living abroad 

88% of migrants to OECD have at least secondary edu 

60% have tertiary edu

1 in 10 teriary educated ppl from developing world now live in a high income country

Improved opportunities for edu ppl and their fams

knowledge transfer 

remittances 

loss of human capital 

loss of education investment 

shrinking of the middle class and potential political instability 

deficits in health and educational sectors 

Soil transmitted helminthiasis

schistosomiasis

lymphatic filariasis

blndind trachoma

onchoceriasis

changas disease

leishmaniasis

AIDS

TB 

Malaria