Global Health: Challenges and Responses Midterm

the state of health worldwide, a set of problems and solutions for illness and death global relevance, aspiration for a world of healthy people, and interdisciplinary (methods and tolls from two or more disciplines/fields)

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

Physical (absence of disease and positive well-being), mental (absence of disease and positive well-being, and social well-being (ex: ensuring basic human needs are met)

spirituality, access to care and primary health providers, pharmaceutical development and regulations, disease management, old age and disease, disabilities

Location: Local, community, region, country, international, worldwide

Problems global in scope; urbanization, climate change, and health disparities

global spread, and can affect the health of everyone worldwide

partly a product of globalization, and will require global solutions; a country can reduce transmission, but its not a long term solution; requires global cooperation

driving burdens of disease; "syndemic" of CDs and NCDs

centered on white, wealthy, Europeans and North Americans traveling to the tropics, "tropical diseases" as they affected primarily white travelers, practice of medicine an dpublic health grounded in colonial empires and colonial mentality

Post WWII international diplomacy, characterized by high income countries sending people and resources to low and middle income countries, Cold War-era security focus

Scientific research: researchers from high-resource settings leading studies and programs in low-resource settings, multisite and multinational research, training, education, becoming more collaborative across sites and partnership-oriented rather than agenda-imposing, especially in the 2010s

Collaborative, multinational research, leadership by research teams from LMICs, Global health leadership from African continent, South and Southeast Asia, Agenda setting by individuals and institutions who know their own needs best

future developments: critical global health studies, planetary health: people rather than diseases, connectivity and wholeness, sustainability

Climate crisis, health in conflict zone, reducing health inequities, medicines: expanding access, reducing resistance, stopping infectious diseases

worsens malnutrition and promotes the spread of infections

forced migration leading to millions of people without access to health care and basic service; disease outbreaks requiring the highest level of WHO response occurred in countries with protracted

Improve child and maternal care, nutrition, gender equality, mental health, access to water and sanitationImprove governance of public and private health services. WHO also calls for more allocation of GDP to primary health services

Provide health care, resolve protracted conflictsWHO deploys mobile medical teams, uses disease detection and warning systems, conducts vaccination campaigns, and distributes medicines. Ultimately, political solutions are needed to resolve protracted conflicts.

how long, on average, a newborn can expect to live; if current death rates do not change; heavily weighted by infant and child mortality

ex: a life expectancy does not mean people are expected to live to 35

infectious diseases (45%), preterm birth and neonatal, congenital anomalies

73% (7 out of 10 deaths)

Healthy Average Life Expectancy = Life Expectancy - Years Lived With Disability

DALY = Years Lived with Disability + Years of Life Lost

one year of healthy life LOST due to premature death, disease, or disability

People with disabilities deserve respect
and recognition as a human right, DALYs may discount their lives, people with disabilities can be healthy
and can lead healthy lives

addresses health as determined by biological factors and individual behaviors; genetics, demographic characteristics, and individual behaviors

genetic composition; age, race, sex; diet, exercise, alcohol use and smoking; (un)protected sex; medical adherence

what YOU should do to be healthy

focused on an individual's physical and cognitive processes

can be reductive; reduces health to biological and physiological

"the circumstances in which people are born, grow up, live and age"; "systems that are put in place to deal with health, illness and well-being"

social, physical, and economic conditions and contexts in which one lives

social institutions, categories of identity, relationships, norms and practices of society

income, education, occupation; race, ethnicity, culture, gender, class; government policies, access to health care services; housing, infrastructure, urban/rural settings

zip code can capture education, income, environmental exposure, safety, infrastructure, county-level policies; life expectancy varies based on the place you live

have declined globally but remain high in low-resource:; occur from complications from delivery, unsafe abortions, severe bleeding, infections, high blood pressure during pregnancy,

poverty, malnourishment, distance to facilities, inadequate and poor quality services, lack of information, cultural beliefs and practices, age (adolescent pregnancies)

where women are least likely to have skilled attendance at delivery (midwife or trained health professional); within countries where the poorest and least educated women are

India; interstate and intrastate disparities (northern states have higher maternal mortality rates than souther states)

which women are dying OR causes and contributors to their deaths

the structures and decision-making processes that allow a state, organization, or group of people to conduct affairs; laws and standard that pertain to implementing these processes; formal and informal elements

UN conventions, treaties, decision-making processes, rules and standards

ex: UN Convention on the Rights of the Child

voluntary codes (multinational corporate codes); ways of shaping collective responses to issues of global significance (global responses to questions of financial stability, human rights, public health)

no agreed upon governing at the global level, no hierarchical political authority with jurisdiction over nation-states, challenging for societies to agree on and enforce rules, coordinate action, achieve policy coherence, and ensure accountability

national governments, UN systems (WHO, UN Children's Fund), multilateral development banks (World Bank), global health initatives (UNITAID, Global Fund), philanthropic organization (gates foundation), NGOs (doctors w/o Borders), private industry; professional associations; academic institutions

History of colonialism but also collaboration; Post- WWII, new efforts to establish peaceful relations among countries

forced as a UN agency; constitution of WHO adopted by the International Health Conference; currently 194 member states, across six regions

central decision-making body of the WHO; delegations from all WHO member states attend; focus on a specific health agenda prepared by the Executive Board

Is the WHO mandate too broad? organization too large and unwieldly to be effective? how do politics factor into health organization and operations.

partenerships (public-private partnerships, ppp)

CDC and Coca Cola for an obesitiy prevention program

Diseases that spread (transmitted, contagious) directly or indirectly from one person to another; In general, communicable diseases are infectious diseases

Diseases that result from an infection; Bacteria, fungi, viruses, parasites; Biologic agents that are pathogenic (cause disease); Enter the body, sustain themselves, reproduce, and colonize the body, causing disease

Diseases that are not transmitted from person-to-personIn general, noncommunicable diseases are often chronic (long duration) diseases, marked by slow progression; can be relatively acute or have low 5-year survival rates

spread through bodily fluids; high case fatality rate; "zoonotic pathogen"

preads between animals and humans; unpredictable and intermittent outbreaks

poverty; humanitarian crises; weak health infrastructure

Avg. family earnings less than $1 per day in 2014; Chronic malnutrition; Hunting/foraging deeper in forest, closer contact with animal reservoirs; lack of basic infrastructure - electricity, reliable roadways; People traveling to neighboring towns and cities for work

Civil wars in Sierra Leone and Liberia; Refugees in resource-strained areas

Lack of health infrastructure for supplies (PPE); No labs for testing and disease identification; Health worker staff underpaid, unpaid, manage constant shortages

•No identification or tracking available for first 3 months- Doctors without Borders - brought lab samples to Lyon, France, March 2014
•After lab identification, still no scalable way to test and identify cases
•Without testing and tracing, people continued to move, spreading disease
•No testing to identify and trace infected individuals
•Health workers lack personal protective equipment (PPE) and, without
testing, knowledge to take precautions (e.g. isolate patients, PPE)
•Health workers suffer high mortalitystigma
•Health centers often lacked IV fluids for rehydration and other supplies
•Health centers become "places to die," people avoid
•Family members exposed at home
•Family burials - transmit the virus after death
•Continued lack of laboratory services to test and track infected persons,
amplifies viral spread

•Cooperation - health workers work within own communities to educate about spread•Global response - WHO declared state of emergency•Resources directed for health workers, testing, and tracing support• WHO, NGOs, other donors•Resources directed for PPE and other medical supplies•Government policies and cooperation (e.g. school closures)

2018-2020 Democratic Republic of Congo; occurred in an active conflict zone

• DRC and WHO trained thousands of health workers (16,000 frontline responders and 1,500 WHO workers deployed)
• Testing and tracing (200,00 samples)• Treatment and vaccination (300,000 people vaccinated), care for survivors
• Community engagement• Donor support, UN partner agencies, NGOs, research networks, Global Outbreak Alert and Response Network

established 5 key NCDs
•Cardiovascular disease
•Diabetes
•Cancer
•COPD
•Mental health

5 key risk factors
•Smoking
•Alcohol
•Inactivity
•Unhealthy diet
•Air pollution

•NCDs considered diseases of industrialization and economic development- Wealth, abundance, overnutrition,
•NCDs often increase with older age (especially < 55 years)
•Development aid minimal for NCDs
•Within high-income countries, premature deaths cluster in low SES areas

•Non-communicable diseases produce and perpetuate poverty
•High productivity losses and healthcare costs
•Can strain economies with limited healthcare systems, undermine social and economic development, and affect health security and stability

•Leading cause of death globally
•India comprises disproportionate share of world's heart disease burden
•Early onset of disease
•Half of heart attacks in Indian men occur before the age of 50
•Onset about 10 years later (60) in women
•How should governments and global health address this cause? How have they addressed it in the past?
•Delayed recognition of heart disease for first part of 20th century
•When Indian Prime Minister Nehru died of a heart attack (in 1964), strengthened assumptions that heart disease as diseases of affluence, not the poor
•India became a leader in developing heart transplants and cardiac care—but with a cost
- World class care available to wealthy elites, but lack of basic services for all
- High cost of expensive surgeries make them inaccessible
•Some countries with high rates of heart disease (such as India, US) have developed health care systems that can exacerbate disparities

•Rural areas
•Economies affected by fragility, conflict, and violence •Specific countries :Higher densities of extremely pooroIn Sub-Saharan Africa, half of the poor live in 5 countries oNigeria, Democratic Republic of Congo, Tanzania, Ethiopia, and Madagascar
•High flood risk areas

•Access to nutrients-pre-birth throughout life course
•Exposures to environmental risk factors (air pollution, employment)
•Exposure to "obesogenic" environments (poor nutritional quality)
•Exposure to violence (conflict, migration, other stressors, affects diet and physical activity)
•Access to sanitary water and other public health infrastructures
•Access to medical care, prevention, and treatment
•Different NCDs and causes of NCDs need different frameworks
•NCDs produce and perpetuate poverty •Non-communicable diseases create long-term suffering and sometimes progressive illness
•Productivity losses, including job loss (unemployment)
•High healthcare costs
•Inability to access health care exacerbates symptoms of diseaseàfurther productivity and potential income losses
•Can strain economies with limited healthcare systems, undermine social and economic development, and affect health security and stability

challenges to homeostasis is a challenge to capacity load

Syndemic: two or more diseases that cluster together, exacerbate one another, and interact with social and economic inequalities
•Term developed by biological anthropologists (e.g., Merrill Singer, mid-1990s)•Response to idea of diseases as discrete entities•Includes the effect of social conditions such as poverty, stress, structural violence on health
•Precautions for Covid-19 (indoors, less exercise, isolation) exacerbate NCDs in the most vulnerableoWorst health at baseline, more stringent precautionsoFewer diagnoses, management for isolated and vulnerableoPeople with fewest resources have greatest risk of losses•Results from and contributes to persistent SES inequalities

•Rising life expectancy
•Childhood mortality
•Shifting burdens of disease toward noncommunicable diseases (NCDs)

•Life expectancy
•Healthy average life expectancy (HALE)
•Disability-adjusted life years (DALYs)