Global Health 340

a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity - Preamble to the WHO constitution

"Health problems, issues, and concerns that transcend
national boundaries, may be influenced by
circumstances or experiences in other countries, and
are best addressed by cooperative actions and
solutions"
--Institute of Medicine 1997, p.2

• High birth and death rates
• Death from infectious diseases and nutritional deficiencies

• Low birth and death rates
• Death from chronic and lifestyle diseases

• Low birth rates and increasing death rates
• Increase in deaths from new and re-emerging infectious diseases
• Rapid spread due to globalization

• The industrial revolution and the emergence of epidemiology: cholera
• Entanglements between colonial medicine and interwar international
health: yellow fever
• Hookworm: the Rockefeller Foundation's International Health Board
• "Rural hygiene": the League of Nations Health Organization

Common thread: conflict between social/economic emphasis and
technical solutions

• Dr. John Snow: cholera in London
• Dr. William C. Gorgas & Dr. Carlos Finlay: yellow fever in Cuba
• Rockefeller Foundation
• League of Nations Health Organization (LNHO): rural LMICs

• Bacterial infection of small
intestines
• Transmitted through
contaminated water

Year 1854

targeting "upstream" causes of
illness, not individuals

"Tiger mosquito"
• Day active
• Viral diseases: Yellow fever, dengue,
chikungunya, Zika

• Crepuscular (morning/evening active)
• Parasitic diseases: Malaria,
filariasis (roundworms)

• Draining water
• Screening or oiling water sources
• Quarantining people with YF in screened enclosures
• Fumigating

- Major victory for tropical medicine
- Strategy applied elsewhere

• The idea that the US success must be exported internationally
• Science existed about Aedes mosquito (thanks to Cuban knowledge)
• A major concern for colonizers, though locals were largely immune
• Eradication was a political act
• Success in Havana and Panama was applied elsewhere
• American Method was not translatable everywhere

• Charismatic leaders bounced between colonial medicine posts and international-health programs
• Critical shift in the 1930s toward recognizing the social and economic determinants of health (around Great Depression)
• But this was controversial
• Technical solutions dominated
• Rarely were local communities taken seriously as holding valuable knowledge and solutions (expats were revered)
• Individual donors played powerful roles in directing global health priorities for over a century

1. Idea of tropical medicine as its own field, reinforced by public health workers who struggled to distinguish themselves from general physicians
2. Overcoming yellow fever reinforced the belief in US's scientific and technical expertise
3. Myth of US imperialism improving lives in colonies through scientific and technical expertise

1. The Rockefeller foundation's International Health Board (IHB)
2. The League of Nations Health Organization (LNHO)

• Over 80 countries, multiple diseases

• Strategies for hookworm control in British colonies:
—Mapping large populations
—Collecting and testing stools for infection
—Treating with highly toxic medicine
— Sometimes treating entire populations

• NOT addressing sanitation

• Few were tested, and all were treated if high rates
• Reduced need for sanitation efforts
• Quick technical fix with potential high reward
• Constructing latrines, wearing shoes, + improving sanitation
were perceived as too costly and time intensive
• Emphasis on treatment over prevention eventually
undermined IHB's ability to eradicate hookworm; IHB
wrapped up hookworm programs by 1920s

Took over IHB's Yellow Fever Commission in 1915
- Peru
- Mexico
- Ecuador

• Funded graduate schools of public health in the US and Europe
• Promoted links between colonial medicine and new int'l-health orgs
• Trained Americans to work abroad
• Trained international students to lead efforts at home
• Education focused on biomedical intervention plus bacteriology and parasitology

• Rockefeller-funded
• Interwar years
• Malaria
• Tuberculosis
• "Rural hygiene"—focus on social determinants
• Led by Ludwik Rajchman

Inspired by Italy's bonifica integrale program under Mussolini

• Holistic approach:
• Protecting humans with treatment and prevention
• Also controlling mosquitos and their habitats
• Collaboration with committees on rural hygiene, housing, labor, maternal and child welfare, and nutrition
— Linking social and economic issues with health

• Technical solutions
• "quick fixes" in interest of military and territorial protection
• De-emphasis on long-term solutions
• Staffed by US public health officials who gained experience in colonies and military

• Social medicine
• Long-term fixes based on infrastructure and sanitation improvements
• Emphasis on long-term solutions
• Staffed by British and other European officials who gained experience in colonial medicine

Commitment to "bring about the fullest collaboration between all nations in the economic field with the object of securing, for all, improved labor standards, economic advancement, and social security."

--Atlantic Charter, signed by President Roosevelt and Prime Minister Churchill in 1941 for a postwar
world, ending the British Empire, and replacing it with ideas of development
Photo%of%Atlantic%C

• Penicillin (post-war penicillin was 4X strength of earliest)
• Streptomycin (effective for curing TB)
• Vaccines: influenza, pneumococcal pneumonia, & plague
• X-ray machines

• 44 Allied nations
• A new world order focused on peace, free trade, financial stability and economic growth in developing countries
• Founded the World Bank and International Monetary Fund (IMF)

World Health Organization (WHO)
UNICEF
World Bank

- Led by WHO in the 1950s


• Tuberculosis, yaws, malaria, syphilis, smallpox, typhus
identified as critical global health problems
• Belief: the world could not wait for social and economic
development

• Variola virus
• Airborne
• Mortality rate 30%
• Longstanding vaccine (1796, Edward Jenner)
• Eradicated in 1980

• Plasmodium parasite
- falciparum
- vivax
- ovale
- malariae
- knowlesi

• Mosquito-borne
• No vaccine
• DDT-reliant

• Toxicity for mosquitoes and household pests for months
• Long acting pesticides reduced cost of vector control
• Anti-malaria campaigns using DDT showed new pesticide could eliminate need for other approaches to malaria
• Rockefeller's IHB promoted; eventually picked up by WHO

Yes and No

• No vaccine
• Multiple variants of Plasmodium
• Human and mosquito hosts
• DDT toxicity
• Lack of flexibility in program

Yes

• Vaccine with single dose
• Single variant of Variola
• Human-only host
• Relatively few side effects
• Flexibility in program

• WHO, UNICEF, Rockefeller
• 50% fertility decline between 1960s-80s
• Reflection of the "culture of technical assistance" enshrined in eradication campaigns (Packard)

• Health as a human right
• Need for universal healthcare provision
• "Health for all by the year 2000"
• Emphasis on primary healthcare as the mode for this to happen

- The idea that health services development should focus on providing essential health care at the village or neighborhood level
- Generated the need to build and staff thousands of primary healthcare centers all over the world
- Idea that communities should be active partners in these projects, without realistic understanding of constraints on time
- Inability to challenge structures of social inequality upheld by national governments

• Expats rarely left Kathmandu, relying on knowledge of Nepalese urban experts
• Saw "model villages" near major highways, not typical villages
• Didn't spend long in one place
• When healers were incorporated, were decoupled from religious roles

Growth monitoring
Oral rehydration
Breast feeding
Immunization

Female education
Family planning
Food supplementation

Comprehensive Primary Health Care
• Political mobilization proved very challenging.
And yet:
• Oriented toward goal of global health equity.
• Avoided many problems of top-down, vertical programs.
• Emphasized systems building

Selective Primary Health Care
• Easy support from donor community.
• Met NGO need for measurable, fast results.
And yet:
• Still a rather top-down, vertical program.
• Not participatory or engaging sectors outside health ministries.

• Colonial relationships transformed into "development" projects
•After European reconstruction, shift to developing countries
• Eradication campaigns consolidated US power and the emphasis on quick fixes (vs social reform)
•US power held in financial commitments, determined direction of international organizations—WHO, UNICEF, World Bank
• The primary healthcare movement in the 1970s was a moment of hope
•... but was quickly derailed by recession and structural adjustment programs and "interim solutions"

• Public awareness of global inequities
• Increasing emphasis on sustainability and cultural sensitivity
• Major influence of private donors
• Public-private partnerships

1. Increase vaccination rates
2. Capacity building for vaccination in LMICs
3. Predictable financing for vaccination campaigns
4. Stimulating research and development

Malaria eradication in the 21st century?
• 2007 meeting at Microsoft in Seattle (Gates Foundation hosted)
• In attendance:
- 3 ministers of health of African countries
- UNICEF
- WHO
- World Bank
- Private foundation heads (e.g., Gates)
- Major NGO heads (e.g., Global Fund to Fight AIDS, Tuberculosis, and Malaria)
- Corporations and pharma companies (e.g., Exxon, Sanofi-Avenits, Novartis, etc)


Technologies for global health improvement:
• Vitamin A supplementation
• Insecticide-treated bed nets
• Antiretroviral drugs
• Male circumcision
• Childhood immunization
• Polio vaccination

"...have potential to save lives—millions at a time. But they should
not be seen as solutions in their own right, or as substitutes for
building effective health systems and addressing the underlying
structural causes of ill health in society. Yet increasingly, over the
course of the twenty-first century, these technologies have become
just that."

1. Eradicate extreme poverty and hunger
2. Achieve universal primary health
3. Promote gender equality and empower women
4. Reduce child mortality
5. Improve Maternal Health
6. Combat HIV/AIDS, Malaria, and other diseases
7. Ensure Environmental sustainability
8. Global Partnership for development

Plumpy Nut

• Health worker training
• Antenatal care
• Family planning

• Vaccines
• Medications
• Mostly technical solutions

60% of global deaths

From the millennium developmental goals:
1. Child mortality
2. Maternal health
3. The big 3: HIV, TB, Malaria

From the Farmer chapter and the history we've been learning about:
4. Neglected tropical diseases
5. Noncommunicable diseases
6. Health systems strengthening

The non-clinical factors that
impact a person's health

• WHO GETS WHAT RESOURCES IS SOCIALLY DETERMINED
• Focus on alleviating the burden of material deprivation alone fails to properly take into account that simply a technical matter of providing clean water or better medical care cannot dissipate inequalities.
• RECOGNIZING POVERTY AS A PROBLEM IS NOT ENOUGH
• International policies have not been pursued as if they had people's basic needs in mind.
• WE MUST LOOK TO THE CAUSES OF THE CAUSES

Paul Farmer:
- Structural violence
- Partners in health

Arthur Kleinman
- Illness narratives
- Social suffering

"Violence is defined as the cause of the difference between the potential and the actual, between what could have been and what is."
-Johan Galtung

"Structural violence is one way of describing social arrangements that put
individuals and populations in harm's way...The arrangements are structural
because they are embedded in the political and economic organization of our
social world; they are violent because they cause injury to people... neither
culture nor pure individual will is at fault; rather, historically given (and often
economically driven) processes and forces conspire to constrain individual
agency. Structural violence is visited upon all those whose social status denies
them access to the fruits of scientific and social progress."

• Disrupting families and communities of support
• Displacing populations and exposing them to risks of hunger, disease, trauma, permanent disability, and further violence (rape, torture, exploitation)
• Damaging the environment (as in scorched-earth actions or radioactive contamination from weapons production and use)
• Destroying infrastructures, means of livelihood, and life trajectories
• Limiting access to healthcare
• Disrupting health information systems and preventive care and treatment
• The stress of living with fear and uncertainty

Biomedical Model
Behavioral Model
Political Economy Approach

• Health and illness at individual level
• Health understood as absence of disease
• Curative
• Privilege technological fixes

• Health and illness as consequence of individual or household actions/beliefs
• Regulation or change of personal conduct and cultural attitudes through education, counseling, incentives
• Making (largely) individual choices

• Considers political, social, cultural and economic contexts in which illness and disease arise
• Health as a function of linked determinants that operate at multiple levels: individual, household, community, workplace, social class, nation, global
• Solution is better policy, gender equity, wealth redistribution etc.

The social conditions that give rise to high risk of non-communicable disease whether acting through unhealthy behaviors or through the effects of impossibly stressful lives.

- The Social Gradients
- Stress
- Early Life
- Social Exclusion
- Work
- Unemployment
- Social Support
- Addiction
- Food
- Transport

• Interpersonal: Clinical interactions
• Structural: Partners in Health (PIH)
• Social: Médecins Sans Frontières (MSF)

• Michael Marmot's landmark studies
• Examined the health of over 30,000 British Civil Service members
• 1967 Whitehall I: link between hierarchical status and CVD. The less senior in the employment hierarchy, the shorter the life expectancy
• 1985 Whitehall II: the major cause of stress-related illness: high job demands and low control

link between hierarchical status and CVD. The less senior in the employment hierarchy, the shorter the life expectancy

the major cause of stress-related illness: high job demands and low control

The study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the control of health problems.

The science that considers the demographic, the geographic, and the temporal distribution of exposures and outcomes, and the causative relations between them.

• Recognize an epidemic
• Understand an epidemic
• Stop an epidemic
• What is the role of technology in stopping an outbreak?

The aspect of epidemiology concerned with organizing and summarizing health-related data according to time, place, and person

Priorities:
- When was the population affected?
- Where was the population affected?
- Who was affected?

examines causal (etiologic) hypotheses regarding the association between exposures and health conditions

Priorities:
- How was the population affected?
- Why was the population affected?

• Who are the people getting sick?
• Demographic information (age, sex, occupation, etc)
• Factors that may have led to exposure (habits regarding boiling water, decisions about whether to immunize children, etc)

the first patient found in an epidemiological investigation

• Geographic distribution of contact between host and agent
• Did everyone infected eat at one restaurant?
• Drink from the same municipal water source?
• Live in the same neighborhood?

• Trends over time
• Long term (secular)
• Periodic (seasonal)
• Epidemic (acute)
— Sometimes there is lag time between infection and active disease

Endemic: present at all times in a population
Epidemic: higher than expected incidence of diseases

# of new cases per population: tells you
how quickly something is increasing or decreasing
during a time period

# of total cases per population: tells you
how widespread something is at a single point in time

morbidity: having a disease
mortality: dying from a disease

Disability-Adjusted Life Years

• Measures overall burden of disease ("years lost due to different diseases, taking into account how severe they are")
• One DALY represents the loss of one year of full health

Years of life lost + years lived with disability

Benefits
• Allows comparison of different conditions' severity
• Allows comparison of disease burden between countries or populations
• These comparisons can identify marginalized groups in need of resources, and/or neglected diseases
• Relatively easy to interpret for big global data projects with big audiences, like Murray's

Drawbacks
• Doesn't account for comorbidity—the overlap of more than one disease
• Missing data may be replaced with data from nearby but very different countries (e.g. South Africa standing in for all of SSA)
• Ignores individual variation in experience of symptoms
• Ignores suffering of social others (only focused on individual)
• Emphasizes cost-effectiveness rather than inherent value of human life

Exposure —> Disease

It assesses hypotheses about disease causation

undefined