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BIOE 301 Lecture Two:BIOE 301 Lecture Two:
Health Problems in the Health Problems in the Developed and Developed and
Developing World: Ages Developing World: Ages 0-40-4
Louise OrganLouise Organ
1.11.071.11.07
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Review of Lecture OneReview of Lecture One
Course goalsCourse goals Four main questions we aim to Four main questions we aim to
addressaddress Technology assessmentTechnology assessment Introduction to world healthIntroduction to world health Health data and usesHealth data and uses
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World Health Organization: WHOWorld Health Organization: WHO
Established by charter of the UN after Established by charter of the UN after World War IIWorld War II
Headquartered in GenevaHeadquartered in Geneva Mission:Mission:
• ““Attainment by all peoples of the highest Attainment by all peoples of the highest possible level of health”possible level of health”
Website:Website:• http://http://www.who.intwww.who.int/en//en/
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Functions of the WHOFunctions of the WHO Services to governments:Services to governments:
• Epidemiologic intelligenceEpidemiologic intelligence• International standardization of vaccinesInternational standardization of vaccines• Reports of expert committeesReports of expert committees• Data on world health problemsData on world health problems
Member countries must provide Member countries must provide certain info in regular reportscertain info in regular reports• Disease outbreaksDisease outbreaks• Health of populationHealth of population• Steps to improve healthSteps to improve health
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Lecture TwoLecture Two
Health problems in developed and Health problems in developed and developing world: ages 0-4developing world: ages 0-4• Unit 1-What are the major health Unit 1-What are the major health
problems worldwide?problems worldwide?• Differences between developed and Differences between developed and
developing worddeveloping word• Understand disease/condition causes, Understand disease/condition causes,
treatments, and preventiontreatments, and prevention
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World Mortality Rates (2002)World Mortality Rates (2002)
6.4%7.8%
85.8%
Developed Countries
9.5%
40.1%
50.4%
Developing Countries
Group 1 = communicable diseases, maternal/perinatal conditions, malnutritionGroup 2 = Non-communicable diseases (cardiovascular, cancer, mental disorders)Group 3 = Injuries
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Infant and Child MortalityInfant and Child Mortality 8 UN Millennium Development Goals 8 UN Millennium Development Goals
(MGDs)(MGDs)• Goal 4: Reduce Child Mortality Goal 4: Reduce Child Mortality • Reduce by two-thirds, between 1990 Reduce by two-thirds, between 1990
and 2015, the under-five mortality rate and 2015, the under-five mortality rate WHO World Health Report 2005: WHO World Health Report 2005:
Make Every Mother and Child CountMake Every Mother and Child Count• Almost 11 million children under five will Almost 11 million children under five will
die in 2005 from causes that are largely die in 2005 from causes that are largely preventablepreventable
• 4 million babies who will not survive the 4 million babies who will not survive the first month of life first month of life
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Causes of Child MortalityCauses of Child MortalityWHO 2005 World Health ReportWHO 2005 World Health Report
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Causes of Child Mortality by RegionCauses of Child Mortality by Region
WHO 2005 World Health ReportWHO 2005 World Health Report
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Leading causes of mortality: ages 0-4Leading causes of mortality: ages 0-4 Developing worldDeveloping world
1.1. Perinatal conditionsPerinatal conditions
2.2. Lower respiratory infectionsLower respiratory infections
3.3. Diarrheal diseasesDiarrheal diseases
4.4. MalariaMalaria Developed worldDeveloped world
1.1. Perinatal conditionsPerinatal conditions
2.2. Congenital anomaliesCongenital anomalies
3.3. Lower respiratory infectionsLower respiratory infections
4.4. Unintentional injuriesUnintentional injuries
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Perinatal ConditionsPerinatal Conditions
Period from 22 weeks of pregnancy Period from 22 weeks of pregnancy through the first week of lifethrough the first week of life
2.5 million children die from perinatal 2.5 million children die from perinatal conditionsconditions
> 500,000 women die as a > 500,000 women die as a consequence of pregnancy and consequence of pregnancy and childbirthchildbirth• Leading cause of death for women of Leading cause of death for women of
childbearing age in developing countrieschildbearing age in developing countries
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Perinatal ConditionsPerinatal Conditions
3.3 million stillborn 3.3 million stillborn infants per yearinfants per year
Likely underestimates Likely underestimates as vital registration as vital registration rates and practices varyrates and practices vary• Countries with the Countries with the
highest mortality rates highest mortality rates tend to also have the tend to also have the lowest rates of vital lowest rates of vital registrationregistration
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Common Perinatal Conditions Common Perinatal Conditions
Premature deliveryPremature delivery Low birth weightLow birth weight Birth asphyxiaBirth asphyxia
• Entangled umbilical Entangled umbilical cordcord
• Breech birthBreech birth
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Common Perinatal Conditions Common Perinatal Conditions Birth traumaBirth trauma
• Mechanical forces encountered during Mechanical forces encountered during decent through the pelvic regiondecent through the pelvic region
• DALYDALY InfectionsInfections
• Umbilical cordUmbilical cord Non-sterile instrumentsNon-sterile instruments
• Organisms in the maternal genital tractOrganisms in the maternal genital tract• PATH kitPATH kit
http://www.path.org/http://www.path.org/
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World Health Report: 1995 vs. 2005World Health Report: 1995 vs. 2005
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37% Mortality Due to Neonatal 37% Mortality Due to Neonatal CausesCauses
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Challenges to Reducing Perinatal Challenges to Reducing Perinatal ConditionsConditions
Lack of skilled birth attendants Lack of skilled birth attendants
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Challenges to Reducing Perinatal Challenges to Reducing Perinatal ConditionsConditions
No adequate way to predetermine No adequate way to predetermine difficult birthsdifficult births
Cultural isolationCultural isolation• ““Birth” may not be celebrated until after Birth” may not be celebrated until after
perinatal period is overperinatal period is over Vital registration ratesVital registration rates Isolation may be positiveIsolation may be positive Delaying medical care can be negativeDelaying medical care can be negative
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Lower Respiratory InfectionsLower Respiratory Infections
#2 in developing world & #3 in #2 in developing world & #3 in developeddeveloped
1 million children per year1 million children per year PneumoniaPneumonia
• Lung infectionsLung infections• Fever, cough, chest pain, weaknessFever, cough, chest pain, weakness
Until 1936 pneumonia was the Until 1936 pneumonia was the leading cause of death in the USleading cause of death in the US
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Causes of PneumoniaCauses of Pneumonia A group of infectionsA group of infections
• Viruses, bacteria, and fungiViruses, bacteria, and fungi 50% bacterial50% bacterial
• Streptococcus pneumoniaeStreptococcus pneumoniae, , Haemophilus Haemophilus influenzaeinfluenzae, , Staphlococcus aureusStaphlococcus aureus, and , and pertussis (whooping cough)pertussis (whooping cough)
50% viral50% viral• SARSSARS• InfluenzaInfluenza• MeaslesMeasles
Coinfection is an increasing concernCoinfection is an increasing concern
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Pneumonia: PhysiopathologyPneumonia: Physiopathology Bacteria or virus invades lungsBacteria or virus invades lungs Immune response causes fluid and Immune response causes fluid and
puspus Filled alveoli have limited gas Filled alveoli have limited gas
exchangeexchange
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Identifying PneumoniaIdentifying Pneumonia Etiology affects treatment Etiology affects treatment Chest X-raysChest X-rays Blood testsBlood tests Examine Examine
sputum/secretionssputum/secretions Direct Fluorescence Assay (DFA)Direct Fluorescence Assay (DFA)
• Collect sample and separate cellsCollect sample and separate cells• Fix cells onto slide and immerse in Fix cells onto slide and immerse in
alcoholalcohol• Apply solution containing antibodiesApply solution containing antibodies• Apply second antibody coupled to Apply second antibody coupled to
fluorescent dyefluorescent dye• View with fluorescent microscopeView with fluorescent microscope
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Pneumonia: TreatmentPneumonia: Treatment Viral Viral
• Usually resolves on its ownUsually resolves on its own• Severe cases: oxygen and antiviral drugsSevere cases: oxygen and antiviral drugs
BacterialBacterial• Treat with antibioticsTreat with antibiotics
Because the etiologies are hard to detect Because the etiologies are hard to detect WHO recommends antibiotics for all WHO recommends antibiotics for all children with pneumoniachildren with pneumonia• Proven to reduce mortality in developing worldProven to reduce mortality in developing world• May also foster the development of resistant May also foster the development of resistant
strainsstrains
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Diarrheal DiseaseDiarrheal Disease
#3 in developing world#3 in developing world Gastrointestinal disorders Gastrointestinal disorders
characterized by frequent, watery characterized by frequent, watery stoolsstools
Bacterial infectionBacterial infection• Escherichia coliEscherichia coli• Vibrio choleraeVibrio cholerae
Viral infectionViral infection• RotavirusRotavirus
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Diarrheal Disease: CholeraDiarrheal Disease: Cholera
Spread by water or food Spread by water or food contaminated with bacteriacontaminated with bacteria
Often a result of inadequate Often a result of inadequate sewage and water treatmentsewage and water treatment
Outbreaks were Outbreaks were common, historically, common, historically, and remain a concernand remain a concern• Rwandan refugeesRwandan refugees
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Diarrheal Disease is often a result Diarrheal Disease is often a result of unsafe water sourcesof unsafe water sources
Access to Safe Water (2000)Access to Safe Water (2000)
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Diarrheal DiseaseDiarrheal Disease
Normally, 98% of the water intake from Normally, 98% of the water intake from food or liquid is reabsorbed by epithelial food or liquid is reabsorbed by epithelial cells in the lower digestive tractcells in the lower digestive tract
Diarrheal disease rapidly leads to extreme Diarrheal disease rapidly leads to extreme dehydration and deathdehydration and death
The loss of body fluid leads to dangerously The loss of body fluid leads to dangerously low blood pressurelow blood pressure
10% loss of volume is sufficient to cause 10% loss of volume is sufficient to cause deathdeath
Treatment must effectively and efficiently Treatment must effectively and efficiently replace fluidsreplace fluids
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Diarrheal Disease: PhysiopathologyDiarrheal Disease: Physiopathology
Epithelial cells line the entire GI tractEpithelial cells line the entire GI tract Different regions have varying specific Different regions have varying specific
mechanisms but all work to reabsorb mechanisms but all work to reabsorb osmotically active nutrients and salts osmotically active nutrients and salts
To maintain osmotic balance, water To maintain osmotic balance, water follows and is eventually reabsorbed into follows and is eventually reabsorbed into the blood vesselsthe blood vessels
Toxins produced by bacteria inhibit sodium Toxins produced by bacteria inhibit sodium uptake from the lumen and cause uptake from the lumen and cause epithelial cells to secret chloride into the epithelial cells to secret chloride into the lumen lumen • Double whammy!Double whammy!
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Oral Rehydration Therapy (ORT)Oral Rehydration Therapy (ORT) A simple, inexpensive mixture of A simple, inexpensive mixture of
water, salt, and sugarwater, salt, and sugar• 1 liter boiled water, 1 tsp. salt, 8 tsps. 1 liter boiled water, 1 tsp. salt, 8 tsps.
sugarsugar Developed in 1960s and responsible Developed in 1960s and responsible
for a dramatic decrease in the for a dramatic decrease in the mortality rates of diarrheal diseasesmortality rates of diarrheal diseases
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Why Does ORT Work?Why Does ORT Work?
Giving sterile water or salt water Giving sterile water or salt water alone is not sufficientalone is not sufficient
Discovery of a sodium reabsorption Discovery of a sodium reabsorption mechanism that is coupled to mechanism that is coupled to glucose transportglucose transport• 1950s1950s• Unaffected by cholera toxinUnaffected by cholera toxin
In 1960s shown to result in a net In 1960s shown to result in a net reabsorption of water into the reabsorption of water into the bloodstreambloodstream
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Oral Rehydration TherapyOral Rehydration Therapy 1975 WHO and UNICEF standard1975 WHO and UNICEF standard
• 90 mM sodium90 mM sodium• 20 mM potassium20 mM potassium• 80 mM chloride80 mM chloride• 30 mM bicarbonate30 mM bicarbonate• 111 mM glucose111 mM glucose
Packet of ORT costs ~10 centsPacket of ORT costs ~10 cents ORT treats a symptom ORT treats a symptom
(dehydration) not the disease (dehydration) not the disease (or organism)(or organism)• The volume of diarrhea usually The volume of diarrhea usually
remains unchangedremains unchanged
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ORT use in the USORT use in the US Rarely usedRarely used More expensive and More expensive and
painful IV therapy is far painful IV therapy is far more commonmore common• Even when ORT is Even when ORT is
sufficient and acceptable sufficient and acceptable treatmenttreatment
Likely due to initial troubles with original Likely due to initial troubles with original formulations (50’s-60’s)formulations (50’s-60’s)• Elevated sodium levelsElevated sodium levels• Inaccurate mixingInaccurate mixing
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Diarrheal Disease in the USDiarrheal Disease in the US
Second leading cause of US pediatric Second leading cause of US pediatric emergency room visitsemergency room visits
E. coliE. coli• Spinach outbreak in Sept.-Oct. 2006Spinach outbreak in Sept.-Oct. 2006• Taco Bell outbreak in Nov.-Dec. 2006Taco Bell outbreak in Nov.-Dec. 2006
RotavirusRotavirus• Causes ~30% of diarrheal disease deathsCauses ~30% of diarrheal disease deaths• Ubiquitous and highly contagiousUbiquitous and highly contagious
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Rotavirus VaccineRotavirus Vaccine Almost every child will be infected with a Almost every child will be infected with a
rotavirusrotavirus• 50,000 child hospitalizations annually50,000 child hospitalizations annually
Vomiting also occurs, so ORT can be Vomiting also occurs, so ORT can be difficult although still effectivedifficult although still effective
RotaShield was FDA approved in 1998RotaShield was FDA approved in 1998• 80-100% effective80-100% effective• 1 in 12,000 have severe complication1 in 12,000 have severe complication• Vaccine was voluntarily withdrawn in 1999Vaccine was voluntarily withdrawn in 1999
Ethical concernsEthical concerns• Complications vs. potential lives savedComplications vs. potential lives saved• Mortality disparity in developed vs. developing Mortality disparity in developed vs. developing
worldworld
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MalariaMalaria #4 mortality rate of children under 5 in #4 mortality rate of children under 5 in
developing worlddeveloping world Spread by Spread by AnophelesAnopheles mosquitoes which mosquitoes which
carry a parasite that infects humanscarry a parasite that infects humans 300 million cases 300 million cases
annuallyannually African children: 1.6-African children: 1.6-
5.4 episodes/year5.4 episodes/year 1 million under the 1 million under the
age of 5 die each age of 5 die each yearyear
CDC/ James Gathany
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Malaria: PhysiopathologyMalaria: Physiopathology Mosquito transfers sporozoites which infect Mosquito transfers sporozoites which infect
and rupture liver cells releasing merozoitesand rupture liver cells releasing merozoites Invade RBCs and either repeat a similar Invade RBCs and either repeat a similar
cycle or form gametocytescycle or form gametocytes Gametocytes are Gametocytes are
free in bloodfree in blood Ingested during biteIngested during bite Reproduce in Reproduce in
mosquito to form mosquito to form new sporozoitesnew sporozoites
http://www.cdc.gov/malaria/biology/life_cycle.htm
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Malaria: PhysiopathologyMalaria: Physiopathology Blood stage is time of clinical Blood stage is time of clinical
manifestation and diagnosismanifestation and diagnosis Burst RBCs result in anemiaBurst RBCs result in anemia
• Is particularly dangerous for mother and childIs particularly dangerous for mother and child• Malaria can be transmitted across the placentaMalaria can be transmitted across the placenta
US Public Health Image Library Infected RBC Ruptured RBC Gametocyte
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Malaria: Drug TreatmentsMalaria: Drug Treatments
Chloroquine, sulfadoxine-Chloroquine, sulfadoxine-pyrimethamine, quininepyrimethamine, quinine
Relatively inexpensiveRelatively inexpensive• Cents/courseCents/course
Malaria parasites now show resistanceMalaria parasites now show resistance• Chloroquine resistance in AfricaChloroquine resistance in Africa
New therapy development is slowNew therapy development is slow• Non-syntheticNon-synthetic• ExpensiveExpensive
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Malaria: PreventionMalaria: Prevention Insecticide treated netsInsecticide treated nets Cheap ~ $2Cheap ~ $2 Must be retreated, ~ 5 centsMust be retreated, ~ 5 cents Shown to reduce low birth weights by Shown to reduce low birth weights by
25%25% Proven to reduce mortality rate in Proven to reduce mortality rate in
young children by 20%young children by 20% April 25, 2007 is April 25, 2007 is
Malaria AwarenessMalaria Awareness
DayDay
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Leading causes of mortality: ages 0-4Leading causes of mortality: ages 0-4 Developing worldDeveloping world
1.1. Perinatal conditionsPerinatal conditions
2.2. Lower respiratory infectionsLower respiratory infections
3.3. Diarrheal diseasesDiarrheal diseases
4.4. MalariaMalaria Developed worldDeveloped world
1.1. Perinatal conditionsPerinatal conditions
2.2. Congenital anomaliesCongenital anomalies
3.3. Lower respiratory infectionsLower respiratory infections
4.4. Unintentional injuriesUnintentional injuries
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Congenital AbnormalitiesCongenital Abnormalities
2-3% of all children have birth defect2-3% of all children have birth defect 400,000 deaths annually400,000 deaths annually As general health increases, As general health increases,
congenital abnormalities rise as a congenital abnormalities rise as a cause of mortalitycause of mortality• #2 in developed world#2 in developed world
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Congenital Abnormalities: CausesCongenital Abnormalities: Causes
Can be roughly Can be roughly grouped into 3 grouped into 3 categoriescategories
Maternal age is Maternal age is a risk-factora risk-factor• Over 35Over 35• More common More common
in developed in developed worldworld
CauseCause ClassificationClassification ExampleExample
GeneticGenetic ChromosomalChromosomal Down Down syndromesyndrome
Single geneSingle gene Cystic Cystic fibrosisfibrosis
EnvironmentalEnvironmental Infectious Infectious diseasedisease
Congenital Congenital rubella rubella
syndromesyndrome
Maternal Maternal nutritional nutritional deficiencydeficiency(folic acid)(folic acid)
Neural tube Neural tube defectsdefects
ComplexComplex Congenital Congenital malformations malformations
involving involving single organ single organ
systemsystem
Congenital Congenital heart heart
diseasedisease
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Unintentional InjuriesUnintentional Injuries
Similarly, increased general health Similarly, increased general health results in a higher percentage of results in a higher percentage of injury fatalitiesinjury fatalities
15,000/year in developed and 15,000/year in developed and 273,000/year in developing (#9)273,000/year in developing (#9)
DrowningsDrownings Road traffic accidentsRoad traffic accidents
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MDG #4: Making progress?MDG #4: Making progress?
WHO World Health Report 2005: Make every mother and child count
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Reducing child mortality depends largely on Reducing child mortality depends largely on every mother and every child having the right every mother and every child having the right to access health care from pregnancy through to access health care from pregnancy through childbirth, the neonatal period, and childhoodchildbirth, the neonatal period, and childhood
MDG #4 : Making progress?MDG #4 : Making progress?
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How to Foster the Decline in Child How to Foster the Decline in Child Mortality?Mortality?
Complicated with multiple factors Complicated with multiple factors involvedinvolved• NutritionNutrition• Maternal healthMaternal health• Both viral and bacterial causes for Both viral and bacterial causes for
respiratory and diarrheal diseaserespiratory and diarrheal disease Encourage medical care while Encourage medical care while
discouraging overmedicatingdiscouraging overmedicating• Antibiotic resistanceAntibiotic resistance
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Summary of Lecture TwoSummary of Lecture TwoLeading causes of mortality: ages 0-4Leading causes of mortality: ages 0-4
Developing worldDeveloping world1.1.Perinatal conditionsPerinatal conditions2.2.Lower respiratory infectionsLower respiratory infections3.3.Diarrheal diseasesDiarrheal diseases4.4.MalariaMalaria
Developed worldDeveloped world1.1.Perinatal conditionsPerinatal conditions2.2.Congenital anomaliesCongenital anomalies3.3.Lower respiratory infectionsLower respiratory infections4.4.Unintentional injuriesUnintentional injuries
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Next Class and Questions?Next Class and Questions?
Homework 1 is Due on 1/16Homework 1 is Due on 1/16 Leading Causes of Mortality: ages 15-Leading Causes of Mortality: ages 15-
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