INTL 340

-health is gov't and global responsibility
-community participation
-intersectoral action
-health for all
-health affected by social/economic dev.
challenge: too broad/how to measure

physical, emotional and social well being, not just merely an absence of disease

fund research, make policies, UN agency of health, coordinates programs

global equity for all
-back to Alma Ata principles
-community level participation
-greater access to drugs and technologies
-strengthened health programs
-addressing social determinants of health

community participation key factor to scaling up
-political will
-social activism to push for action
-global expansion of aids treatment and delivering ART's to patients
-drugs being delivered as public goods
-observing patients take treatment

-haitians blamed for disease, and its culture practices "black magic"
-impacts poor unevenly, overcoming stigma
-using ARV therapy
-risk factors: homosexuality, IV drug use, transfusions, hemophilia
-global response of understanding homosexuality and its culture
-putting millions of $$ into programs

-homosexuality as risk groups
-blaming on Haitians and their cultural practices

-shifts in focus on AIDS
-poverty, civil war, political/economic systems
-non compliance because patients were resistant to drugs
-DOT program: observed patients take medication, follow up with patients, social support. Expensive, big commitment of time and resources.
-DOTS-Plus program for MDRTB patients

it's the historical shift from communicable to non communicable disease. Assumes linear relationship but it's not because new communicable diseases have come out

making a private market

:cuts on government spending which cut on health programs. Raised prices on medications and health care, less people could get treatment. Rise in infectious disease

-global health as a field of knowledge and practice
-Private businesses and universities seeing a potential profit from research and innovation
-becoming an industry

-making sense of infectious diseases
-story of how disease is spread and how it came about
-makes transmission routes visible
-from victim to agents

-taking culture into account for definition and perception of illnesses
-social&cultural contexts structure illness
-meanings of illness differ cross-culturally

-community based approach
-trained community health workers to assess and treat mental disorders
-mental health service integrated into primary health care
-debates in field: standard set of disease categories based on underlying physiological&neurobiological changes
-treatments should be neurochemical (pharmacy drugs)

-US one of wealthiest countries
-rank 30th in life expectancy
-more babies die here their 1st year in life than Sylvania, cyprus and other countries
-income inequality, stress, racism, contribute to bad health

achievements:
12.6 mil deaths under five in 1990 to 6.6 million in 2012

-investigated social determinants of health, specifically the cardiovascular disease prevalence and mortality rates
-longitudinal overtime epidemic studies
-population- british civil servants
-study relationship between occupation and health
-Whitehall 1 (1967: 18,000 men)
-Whitehall 2 (1985 10,000 men and women)
-followed panels of subjects over decades
-lower you are on the occupational hierarchy, worse the health

-refers to the fact inequalities in population health status are related to inequalities in social status. This study advances and tests a model of the relationships between what we term primary and secondary determinants of the social gradient in health.

For example, if you look at under-5 mortality rates by levels of household wealth you see that within counties the relation between socioeconomic level and health is graded. The poorest have the highest under-5 mortality rates, and people in the second highest quintile of household wealth have higher mortality in their offspring than those in the highest quintile. This is the social gradient in health.

the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.
examples-
biology and genetics ex- sex and age
indivi. behavior- ex alcohol use, unprotected sex
social environment- ex- discrimination, gender

cross sectional relationship between life expectancy and real per capita income

states that an individual's attitude to consumption and saving is dictated more by his income in relation to others than by abstract standard of living; the percentage of income consumed by an individual depends on his percentile position within the income distribution.

Secondly it hypothesises that the present consumption is not influenced merely by present levels of absolute and relative income, but also by levels of consumption attained in previous period. It is difficult for a family to reduce a level of consumption once attained. The aggregate ratio of consumption to income is assumed to depend on the level of present income relative to past peak income.

argued from 1955 that the population growth of the UK post- 1700 was due to economic conditions rather than improved medicine and public health

measure of inequality of a distribution. It is defined as a ration with values between 0 and 1. the numerator is the area between the Lorenz curve of the distribution and the uniform distribution line. the denominator is the area under the uniform distribution line.

Africa, Americas, South East Asia, Europe, Eastern Mediterranean, Western Pacific

fostering health security, health systems development, data collection and distribution, measures impact of health problem on a region, etc.

true

False

True

True

False

True

True

False

False

True

1. Liberalization
2. Stabilization
3. Privitization

Neoliberalism

Americas, Africa, Europe, South-East Asia, West Pacific, Eastern Mediterranean

"health, which is a state of complete physical, mental and social well being, and not merely the absence of disease or infirmity"
The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.
The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.

GDP vs Life Expectancy

Income inequality (distribution) impacts health of all populations - esp. in middle income and affluent nations
states that an individual's consumption and saving is dictated more by his income in relation to standard of living. Percent of income by an individual depends on his percentile position within the income distribution.
Possible Mechanisms:
Access to opportunities
Social comparison; social support, cohesion
Public participation, collective efficacy, social capital
"Social meanings of deprivation" (Wilkinson p.42)
Inability to achieve social role/status & mental
health consequences
Less investment in public infrastructures
"Competitive spending"
Stress & psychosocial pathways

the structural determinants and conditions in which people are born, grow, live, work and age. They include factors like socioeconomic status, education, the physical environment, employment, and social support networks, as well as access to health care
Examples:
Racism; social exclusion; gender equity; stress of discrimination
Socioeconomic status; income and income distribution (inequality)
Education
Job and income security; working conditions (stress); sense of control, empowerment, fairness (at work and in life)
Food (in)security
Housing conditions (safety and security); neighborhood; community design (open spaces, recreation, etc.)
Social support networks; sense of belonging, engagement, involvement
Sense that one's life meets social values and standards

Relationship b/w social position measured as occupational level of British civil servants (predictor variable) and the morbidity rates of these workers due to cardiovascular disease (outcome variable)
Workers with "lower class" occupations had higher rates of mortality due to CVD compared to executive employees
Longitudinal model
Controlled for individual health behaviors and health care access

Infant Mortality Rates
Low Birth Weight
Life Expectancy
DALYs: measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or early death

Global shift from communicable disease to chronic disease
Anthropological position
Original settling of humans in community settings
Industrialization
Globalization
Reemergence of communicable disease
Critiques
Moving from "diseases of the poor" to "affluent" chronic diseases

Declines in death rates from infectious diseases are due primarily to improvements in living standards rather than medical advancements

neoliberal policies have contributed to the loss of access to health care and have contributed to deepen the problem of the commodification of basic human necessities and this has life-and-death implications for vulnerable populations
tendency for the poor not to access treatment
Cuts in Health Budgets (through SAPs) and introduction of user fees
limiting them to the poor who cannot afford to pay for the services. That increases the gap between rich and poor and weakens public services and the health system.
Reduction of what is understood by "the common good" by limiting health care to the control of certain diseases while excluding the social determinants of health
Privatisation of healthcare services and the autonomy of hospital management
Privatisation of health services increases inequity of access by favouring those who can afford to pay for health care.
Commercialization of Health care. A market for health care, medical equipment and medicines is being developed
World Bank & IMF promoted SAP (Structural Adjustment Programs) which reduce government health spending
SAP- World Bank gives money to implement certain infrastructures to assist in development but on the conditions that that nation restructure its economic, political, and social sectors to neoliberal policies
Stabilization, Privatization, and Liberalization

Under USSR control, there was lots of funding for healthcare and social programs. After the collapse, there was an increase in poverty and malnourishment and decreased access to medications and care.
Under USSR system, medication was free and disadvantaged populations had access.
Lowered quality of life such as crowded conditions led to higher rates of infectious diseases
Many blamed bloodletting and swaddling for health outcomes, rather than the collapse of the healthcare system
^ Is this "competing claims of causality" ?? I believe so. <-Yes, but for the competing claims of causality we mainly discussed patient noncompliance and whether they just didn't take their meds (patient's fault) or didn't have the appropriate access to comply with medication schedules (health system's fault)

Countries did not have a large reserve or access to medication (crisis)
Government couldn't provide medication
Solution was user fees
Led by UNICEF and WHO
Said that they would bring medicine but that they were going to charge for it
People couldn't afford it, though

was to implement strategies (User Fees) designed to increase the availability of essential drugs and other healthcare services for Sub-Saharan Africans.

Pharmaceuticalization
Benefits:
All drugs were free to those who had AIDS/HIV
Cheaper than hospitalization and treatment if symptoms worsen
Decrease DALYs
Widely available
Supplementary programs (massage, therapy etc.)

Limitations:
Focal point became drug production & not building health infrastructure
Avoids thinking about social determinants of health
No prevention
Not a lot of follow-up
Limitations of "magic bullet approach)
the "neoliberalization of AIDS response,"
Individuals are viewed as ultimately responsible for their health
Citizens are viewed as "consumers" of health services
When AIDS programs cease to be inclusive, encourages non-compliance
Limit of "magic bullet approach"
administration of a specific drug to cure or ameliorate (make something bad better) a given disease or condition--doesn't factor in the underlying reasons people are getting sick
"Triple cocktail"

Actors: multilateral aid, bilateral aid, non-governmental, philanthropic, debt forgiveness
Priorities: pulling countries out of poverty → improving health overall
Commitments: 0.7% of gross national incomes from countries
Challenges: countries are not meeting 0.7

Taking something that was successful and implementing it on a national or international level (process of reaching larger numbers of a target audience in a broader geographic area by institutionalizing effective programmes.)

What factors contribute to the global rise in TB in the contemporary period? Discuss HIV/TB comorbidity.
Multi-Drug Resistant TB
Treating it aggressively, non-compliance from patients
Treatment Period (6-12 months)
Directly observed treatment (DOT) takes a long time and is really expensive
Requires a certain diet to be paired with treatment (not accessible to all communities, and hard to monitor)
Prevalence of co-infection with HIV
Attacks immune system to make people more susceptible to TB
One of the leading final causes of death for people with HIV
Social and Economic Development affecting access to health care
Poorer communities have limited access to healthier foods
Poorer housing developments and infrastructure
Social position and income inequality
Refugee immigration issues (living in close quarters and spreading it through migration)
Rural communities have limited access to health care clinics and treatment
Market oriented approach to public policy making changes how resources are distributed - not need based but where the most financial gain can be made
People started traveling around more with globalization, so more people were exposed to more diseases
Rise of AIDS/HIV made people more susceptible to catching infectious diseases because their immune systems were weak
Main points:
Rise of HIV/AIDS: massive populations with compromised immune systems increased the incidence of opportunistic infections
Globalization (increased trade and travel) exposed people to more infectious diseases and foreign pathogens
The rise of antibiotic resistance due to patient non-compliance (although Yarris contested the concept of antibiotic resistance as the "patient's fault," and emphasized the importance of access to health care)
AIDS/HIV
Pharmaceuticalization of AIDS treatment in Brazil
Method: Combines local-level ethnography with interviews with policy-makers and power-brokers in AIDS treatment
Interested both in the political economy of AIDS treatment and in the local networks of care and exclusion that follow the implementation of Brazil's ARV treatment policy
Mid 1990's Brazil begins national production of ARV's
Pharmaceutical companies reacted by suing and claiming intellectual property rights
Brazil negotiated for first line ARV's from pharmaceutical companies
Brazil becomes global leader and model for poor countries
Neoliberalism of AIDS
Individuals responsible for their own health
Citizens are viewed as consumers of health services
Who's left out?
Structural factors (violence) makes some people "better AID's patients
PROBLEM: when AID's programs cease to be inclusive and address structural determinants of "non-compliance)
"Right to health" was group privatized
" will to live"
"Magic bullet Approach" (Biehl)

UN set up in Ghana, no known cases there
Liberia affected, had just gotten out of a civil war, infrastructure & health system in bad shape
Started by food infected at funeral, everyone washed hands in well water, government negligence and selfish interests
Mistrust of government hurt everyone, extended the problem
SLOW international response, did not know until almost 6 months later in the news
Community burial traditions clashed with protocol
Miscommunication, "if there is no cure, what is the point"
Tensions between global offices and regional office and UN
Internal budget cuts, layoffs
What is Ebola?
Poster: showed people what it was
No jargon
Signs/symptoms
Fever > 102 = suspect Ebola
Try to get to hospital as fast as possible
Liberia came out of war in 2003
Structure/amenities down
Not trying to rebuild
Healthcare systems down
No electricity
Not a lot of doctors
Health system doesn't have enough funding -> doctors leave to get more funds
Sierra Leone, Guinea, Liberia = affected by the Ebola outbreak
Outbreak Dec. 2013 in Guinea
People easily move across borders
March 2014: WHO declares Ebola
August 2014: Ebola is a public health epidemic
Same signs of malaria
WHO
Tensions between global office and regional office and UN
Internal-budget cuts, layoffs including epidemic control; control of budget
UNMEER by UN security agency
Parallel activities UN/WHO
Tensions between state and international organizations; hiring state employees
Multilateral orgs-structural adjustment programs
Given
Declare state of emergency: complicated, affects economy
But need certain level of support
National/local response
Existing structures not effective-health provide by intl humanitarian orgs
Quarantine: community level and individual level (perception of control)
Effects: violence, memories of conflict, mistrust, human rights abuses
Coordinating lead role
Community self-mobilization within this gap
Use of volunteer groups and community leaders
When the person is dead, viral load is the highest
Questions and concerns
Messaging
Ebola is deadly and has no cure
This message did not work
Ebola is real
"ebola must go" signs
Early detection and treatment can save lives
How can someone work with infection but not get infected themselves?
Science, public health do not have all of the answers
Most information was sent out through radios-most common form of communication
Bushmeat is main source of protein, problematic
Ebola is a disease of love and care
The people close to you get infected next
Organizations on poster: UNICEF, Phil (??)
ITU = holding units

Eradication programs
1958: WHO decided they would try and eradicate smallpox
proposed by USSR
US was not on board until 1965
They wanted the eradication of malaria to happen first
By 1972, smallpox was fully eradicated in Western/Central Africa
The primary objectives of these programs were measles eradication but US/CDC said they could not eliminate measles, but they could eliminate smallpox
Programs include:
Mass eradication: mass vaccinations and raising of awareness
Surveillance and containment: observe, look for cases of outbreak, vaccinate those areas --- worked well against smallpox
Led to them abandoning eradication of measles
Values driving the program
"Great Society Liberals"
Challenges:
Nomads did not live in villages and did not care about vaccinations
They proved to be uncooperative
Inappropriate equipment. Ex. Ford trucks instead of range rovers (culturally inappropriate), vaccination gun which malfunctioned frequently, etc.
CDC launches study of nomads to overcome this challenge in South Africa
1969: smallpox was fully eradicated
Led to enthusiasm about eradications everywhere except for in the US
Implications for contemporary GH:
INGOs would come into foreign areas to help them, however they would leave the second that things were under control
Rather than helping African countries build up their infrastructure so that if another outbreak of a disease happens they could control it themselves, western countries came, vaccinated against a disease, and left without following up on these communities.
The West did not help African countries know how to handle an outbreak themselves, only that they must rely on INGOs to come in and help
25% infected with smallpox died
WW2 smallpox did not exist in developed world
What happened to smallpox?
there's no cure just the protection offered
why does gov. still get invested into to
bio threat "bio threat"
Do we celebrate or become scared b/c it is eradicated
1967 smallpox all over 10 years later gone?
US supported malaria eradication before smallpox
Post eradication - enthusiasm
Eradication in West Africa
From the beginning the program was focused on smallpox AND measles <--primary objective
Most people were young were not doctors... really just wanted to help
"great society liberals" ---the 1960s into 70s style power of the gov. and resources often working with private industry can do good
All supplies needed to be made in America (dodge trucks, pedojet (vaccination gun)
There were lots of problems even with confident effort
with environments (couldn't get parts during Vietnam war)
the challenge of nomads; developed maps to follow where they were going
Surveillance and containment vs. mass vaccination
Observe and find where there might be small pox and vaccinate there instead of just trying to reach 80% of the population
1/2 way through year they switched to survey and contain method and they broke out of the curve
Selfish intent
Reject idea of eliminating virus... people say you never know it might come back so we need to keep the vials because who knows what we can learn from the virus
Why we should keep the virus is exactly why we needed to eradicate the disease
Act of arrogance to say we can outsmart the virus and always be ahead

Important points: Use of paid LHWs, work with public sector, address social determinants and inequalities, provide a 'preferential option' for the poor
Strengthen access to public health care, provide healthcare to the poor, building community partnerships
Rwanda: President got rid of all (I)NGOs unless they agreed to work under state led development goals. Wildly successful. goal->independent from aid by 2020, GDP quadrupled, health and development indicators improved, implemented mutuelle health insurance scheme in 2006
Important for GH intervention; expanding programs from local to national/international level [scaling up] , leveraging private resources to strengthen broader PHC and public sector health systems.

Utilitarianism:the doctrine that actions are right if they are useful or for the benefit of a majority, the greatest level health for the greatest number of people (utilitarianism can be a good starting point for setting priorities, but solely focusing on the benefit of the majority is what feeds blind spots and excludes populations): Mill and Benthem
Liberalism Cosmopolitanism - the ideology that all human beings belong to a single community, based on a shared morality; open to new behaviors or opinions and willing to disregard old traditions; broadening a person's general knowledge: Thomas Pogg
Capabilities approach- The Capability Approach is defined by its choice of focus upon the moral significance of individuals' capability of achieving the kind of lives they have reason to value. Thinkers: Sen and Nussbaum
A person's capability to live a good life is defined in terms of the set of valuable 'beings and doings' like being in good health or having loving relationships with others to which they have real access.
Health as a human right- alma ata principle, reiterated by Brazilian Minister of Health during free HIV/AIDS pharmaceuticals initiative.

social determinants of health
Examples: CEO of hospital, Lab Director & Janitor.
Janitor had higher blood pressure, compared to CEO. Living conditions of both individuals played a contributor in increased or decreased stress.

disparities b/w black and white women with low birth weight babies -- weathering hypothesis answers low birth weight and is proven to not be due to genetics as it has been controlled for such variable

1997 Brazil: ARV drugs available to all with HIV
Brazil manufactured their own ARV drugs, reduced cost by 70%
Noncompliance due to treatment schedule, lack of food, worsening side effects, etc.
Community health care worker passing out condoms and brochures about AIDS
Government funded health care system and brazilian produced ARVs saved Brazil from an HIV pandemic.
"It just takes a health minister who is committed to the free drugs program"

Regions: Americas, Africa, Europe, South-East Asia, West Pacific, Eastern Mediterranean

Roles:

Data:

"Health, which is a state of complete physical, mental and social well being, and not merely the absence of disease or infirmity"

The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.

The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.

GDP vs Life Expectancy

Income inequality (distribution) impacts health of all populations - esp. in middle income and affluent nations

R.I.H - states that an individual's consumption and saving is dictated more by his income in relation to standard of living. Percent of income by an individual depends on his percentile position within the income distribution.

Possible Mechanisms:
-Access to opportunities
-Social comparison; social support, cohesion
-Public participation, collective efficacy, social capital
-"Social meanings of deprivation" (Wilkinson p. 42)
-Inability to achieve social role/status & mental
-Health consequences
-Less investment in public infrastructures
-"Competitive spending"
-Stress & psychosocial pathways

The structural determinants and conditions in which people are born, grow, live, work and age. They include factors like socioeconomic status, education, the physical environment, employment, and social support networks, as well as access to health care

Examples:
-Racism; social exclusion; gender equity; stress of discrimination
-Socioeconomic status; income and income distribution (inequality)
-Education
-Job and income security; working conditions (stress); sense of control, empowerment, fairness (at work and in life)
-Food (in)security
-Housing conditions (safety and security); neighborhood; community design (open spaces, recreation, etc.)
-Social support networks; sense of belonging, engagement, involvement
-Sense that one's life meets social values and standards

Relationship between social position measured as occupational level of British civil servants (predictor variable) and the morbidity rates of these workers due to cardiovascular disease (outcome variable)

Workers with "lower class" occupations had higher rates of mortality due to CVD compared to executive employees

Longitudinal model

Controlled for individual health behaviors and health care access

Infant Mortality Rates

Low Birth Weight

Life Expectancy

DALYs: measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or early death

Global shift from communicable disease to chronic disease

Anthropological position
-Original settling of humans in community settings
-Industrialization
-Globalization
=Reemergence of communicable disease

Critiques
-Moving from "diseases of the poor" to "affluent" chronic diseases

Declines in death rates from infectious diseases are due primarily to improvements in living standards rather than medical advancements

Neoliberal policies have contributed to the loss of access to health care and have contributed to deepen the problem of the commodification of basic human necessities and this has life-and-death implications for vulnerable populations
-Tendency for the poor not to access treatment

Cuts in Health Budgets (through SAPs) and introduction of user fees
-Limiting them to the poor who cannot afford to pay for the services. That increases the gap between rich and poor and weakens public services and the health system.

Reduction of what is understood by "the common good" by limiting health care to the control of certain diseases while excluding the social determinants of health

Privatisation of healthcare services and the autonomy of hospital management
-Privatisation of health services increases inequity of access by favouring those who can afford to pay for health care.

Commercialization of Health care. A market for health care, medical equipment and medicines is being developed

World Bank & IMF promoted SAP (Structural Adjustment Programs) which reduce government health spending

SAP - World Bank gives money to implement certain infrastructures to assist in development but on the conditions that that nation restructure its economic, political, and social sectors to neoliberal policies
-Stabilization, Privatization, and Liberalization

Under USSR control, there was lots of funding for healthcare and social programs. After the collapse, there was an increase in poverty and malnourishment and decreased access to medications and care.

Under USSR system, medication was free and disadvantaged populations had access.

Lowered quality of life such as crowded conditions led to higher rates of infectious diseases

Many blamed bloodletting and swaddling for health outcomes, rather than the collapse of the healthcare system
-^ Is this "competing claims of causality" ?? I believe so. <- Yes, but for the competing claims of causality we mainly discussed patient noncompliance and whether they just didn't take their meds (patient's fault) or didn't have the appropriate access to comply with medication schedules (health system's fault)

Countries did not have a large reserve or access to medication (crisis)
-Government couldn't provide medication
Solution was user fees

Led by UNICEF and WHO
-Said that they would bring medicine but that they were going to charge for it
-People couldn't afford it, though

Bamako Initiative was to implement strategies (User Fees) designed to increase the availability of essential drugs and other healthcare services for Sub-Saharan Africans.

Pharmaceuticalization

Benefits:
-All drugs were free to those who had AIDS/HIV
-Cheaper than hospitalization and treatment if symptoms worsen
-Decrease DALYs
-Widely available
-Supplementary programs (massage, therapy etc.)

Limitations:
-Focal point became drug production & not building health infrastructure
-Avoids thinking about social determinants of health
-No prevention
-Not a lot of follow-up
-Limitations of "magic bullet approach)

The "neoliberalization of AIDS response,"
-Individuals are viewed as ultimately responsible for their health
-Citizens are viewed as "consumers" of health services
-When AIDS programs cease to be inclusive, encourages non-compliance

Limit of "magic bullet approach"
-Administration of a specific drug to cure or ameliorate (make something bad better) a given disease or condition--doesn't factor in the underlying reasons people are getting sick
-"Triple cocktail"

Actors: multilateral aid, bilateral aid, non-governmental, philanthropic, debt forgiveness

Priorities: pulling countries out of poverty → improving health overall

Commitments: 0.7% of gross national incomes from countries

Challenges: countries are not meeting 0.7

Taking something that was successful and implementing it on a national or international level (process of reaching larger numbers of a target audience in a broader geographic area by institutionalizing effective programmes.)

What factors contribute to the global rise in TB in the contemporary period? Discuss HIV/TB comorbidity.

-Multidrug Resistant TB

-Treating it aggressively, non-compliance from patients

-Treatment Period (6-12 months)

=Directly observed treatment (DOT) takes a long time and is really expensive

=Requires a certain diet to be paired with treatment (not accessible to all communities, and hard to monitor)

-Prevalence of co-infection with HIV

=Attacks immune system to make people more susceptible to TB

=One of the leading final causes of death for people with HIV

-Social and Economic Development affecting access to health care

=Poorer communities have limited access to healthier foods

=Poorer housing developments and infrastructure

=Social position and income inequality

=Refugee immigration issues (living in close quarters and spreading it through migration)

=Rural communities have limited access to health care clinics and treatment

Market oriented approach to public policy making changes how resources are distributed - not need based but where the most financial gain can be made

People started traveling around more with globalization, so more people were exposed to more diseases

Rise of AIDS/HIV made people more susceptible to catching infectious diseases because their immune systems were weak
-Main points:
=Rise of HIV/AIDS: massive populations with compromised immune systems increased the incidence of opportunistic infections

=Globalization (increased trade and travel) exposed people to more infectious diseases and foreign pathogens

=The rise of antibiotic resistance due to patient non-compliance (although Yarris contested the concept of antibiotic resistance as the "patient's fault," and emphasized the importance of access to health care)

AIDS/HIV
-Pharmaceuticalization of AIDS treatment in Brazil

=Method: Combines local-level ethnography with interviews with policy-makers and power-brokers in AIDS treatment

=Interested both in the political economy of AIDS treatment and in the local networks of care and exclusion that follow the implementation of Brazil's ARV treatment policy

*Mid 1990's Brazil begins national production of ARVs

=Pharmaceutical companies reacted by suing and claiming intellectual property rights

*Brazil negotiated for first line ARVs from pharmaceutical companies

=Brazil becomes global leader and model for poor countries

Neoliberalism of AIDS
-Individuals responsible for their own health

-Citizens are viewed as consumers of health services

-Who's left out?
=Structural factors (violence) makes some people "better AID's patients

=PROBLEM: when AID's programs cease to be inclusive and address structural determinants of "non-compliance)

="Right to health" was group privatized

=" Will to live"

="Magic bullet Approach" (Biehl)

UN set up in Ghana, no known cases there

Liberia affected, had just gotten out of a civil war, infrastructure & health system in bad shape

Started by food infected at funeral, everyone washed hands in well water, government negligence and selfish interests
-Mistrust of government hurt everyone, extended the problem

SLOW international response, did not know until almost 6 months later in the news
-Community burial traditions clashed with protocol

-Miscommunication, "if there is no cure, what is the point"

-Tensions between global offices and regional office and UN

-Internal budget cuts, layoffs

What is Ebola?
-Poster: showed people what it was

=No jargon

-Signs/symptoms

=Fever > 102 = suspect Ebola

=Try to get to hospital as fast as possible

Liberia came out of war in 2003

-Structure/amenities down

-Not trying to rebuild

-Healthcare systems down

-No electricity

-Not a lot of doctors

-Health system doesn't have enough funding -> doctors leave to get more funds

Sierra Leone, Guinea, Liberia = affected by the Ebola outbreak
-Outbreak Dec. 2013 in Guinea

-People easily move across borders

March 2014: WHO declares Ebola

August 2014: Ebola is a public health epidemic

Same signs of malaria

WHO
-Tensions between global office and regional office and UN

-Internal-budget cuts, layoffs including epidemic control; control of budget

UNMEER by UN security agency
-Parallel activities UN/WHO

-Tensions between state and international organizations; hiring state employees

Multilateral orgs-structural adjustment programs
Given
Declare state of emergency: complicated, affects economy
But need certain level of support
National/local response
Existing structures not effective - health provide by intl humanitarian orgs
Quarantine: community level and individual level (perception of control)
Effects: violence, memories of conflict, mistrust, human rights abuses
Coordinating lead role
Community self-mobilization within this gap
Use of volunteer groups and community leaders
When the person is dead, viral load is the highest
Questions and concerns
Messaging
Ebola is deadly and has no cure
This message did not work
Ebola is real
"Ebola must go" signs
Early detection and treatment can save lives
How can someone work with infection but not get infected themselves?
Science, public health do not have all of the answers
Most information was sent out through radios-most common form of communication
Bushmeat is main source of protein, problematic
Ebola is a disease of love and care
The people close to you get infected next
Organizations on poster: UNICEF, Phil (??)
ITU = holding units

Conference in the USSR in 1978
Primary Health Care
Repair inequalities in health
Community participation
Health as a fundamental human right
Health care/access for all by 2000
Intersectoral Action for Health
Needs to be in every area of society i.e. economic and social policies
Health is tied to social/economic development
Disarmament/Peace and Health
Stop spending so much money on the military and start paying for people's health care
Defined health, now the WHO's definition of health

"State of complete physical, mental, and social well being, and not merely the absence of disease or infirmity."
Africa, Americas, South East Asia, Europe, East Mediterranean, West Pacific
Disease trends, mortality rates well-being, and not merely the absence of disease or infirmity as a funda
Mainly do research and provide it to governments to incite them to act

Comprehensive: health tied to development, prioritizes health promotion and prevention
Overall health targeted, lots of public health initiatives
Selective primary: cost effectiveness= key concern, Rockefeller Foundation, categorical funding, disease specific, top-town

James Grant
selective/targeted public health care program, GOBI=cost effective interventions
Immunization rates up, oral rehydration use up
12 mil children save globally, less than $10 per child

As social position decreases, health worsens
As social inequality grows, health overall worsens
Stress on low income families with poor working conditions can affect health in a negative way because the stress starts affecting your health

Strengths - large samples, clear indicators of social position, measures broad range of conditions, controls for access to medical care and health "risk" behaviors, carried out over long period of time
Design - panel, longitudinal
Impact - Influenced people's acceptance of the social determinants of health. Demonstrates that in fact, when controlling for lifestyle factors and other indicators, the social gradient of health is evident insofar that people with higher social standing (in terms of work credentials) were able to obtain better health outcomes when compared to those who had the same access to care, but worse social standing. That is, class indeed has an effect on health outcomes and not merely an outcome based on genetics or individual lifestyle .

Not just ABSOLUTE material deprivation (poverty) but relative deprivation
Health and social position on same "gradient"
Dose response effect; each increase in social status has a positive effect on health

Income and income distribution
Childhood development
Food security
Social exclusion ( racism, gender)
Access to health services
Education, job, income security
Social support

A. Public health:
Focuses on populations
Community-based, participatory, health promotion, social and environmental interventions, policy changes
Aim to prevent disease
B. Medicine:
Focused on individuals
Clinical care of the patient
Medical interventions, pharmaceutical agents, delivered through hospitals and clinics (by professionals)
Aim to cure disease

Antibiotic resistance ("superbugs")
Climate change
Increasing human population
Globalization (increase of air travel, diseases quickly spreading, etc)
Vaccine compliance

Infectious disease/communicable: transmittable to host by an outside source (vectors, body fluids, etc)
chronic/noncommunicable: conditions "within" host, usually due to degeneration (aging)

"health, which is a state of complete physical, mental and social well being, and not merely the absence of disease or infirmity"
The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.
The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.

Taking something that was successful and implementing it on a national or international level (process of reaching larger numbers of a target audience in a broader geographic area by institutionalizing effective programmes.)

Main points:
Rise of HIV/AIDS: massive populations with compromised immune systems increased the incidence of opportunistic infections
Globalization (increased trade and travel) exposed people to more infectious diseases and foreign pathogens
The rise of antibiotic resistance due to patient non-compliance (although Yarris contested the concept of antibiotic resistance as the "patient's fault," and emphasized the importance of access to health care)

The Capability Approach is defined by its choice of focus upon the moral significance of individuals' capability of achieving the kind of lives they have reason to value.

pushed by international lenders on debtor nations; mechanisms of neoliberal economic "reforms"

British civil servants, aged 40-64 •Study of the relationship between occupation
and health
Whitehall I (1967; 18,000 men) •Whitehall II (1985; 10,000 men & women)

Africa
The Americas
South East Asia
Europe
Eastern Mediterranean
Western Pacific

we have to work across sectors together to reach goals, if public health is a govt. responsibility then we have to work together across agencies/departments/ministries ... we must collaborate

• Structural adjustment policies: pushed by international lenders on debtor nations; mechanisms of neoliberal economic "reforms"
• Require "austerity": cuts to govt (public sector) spending—including education, health, social programs—reductions to public sector wages and pensions dismantling/weakening unions, etc.
• Provoke popular/civil society response/protest
➢ SAPS are the mechanism of structurally adjusting economies along neoliberal lines

Always shows us the relationship between 2 variables, GDP as a measure of national development, and LE as a very crude measure of health. The curve is very steep from absolute nothingness to about 5,000

Predictor variable: social position (measured as occupational category)
outcome variable: CVD morbidity (heart disease, stroke, pulmonary disease, etc.) and mortality (death rates)

Large samples
Clear indicators of social position
Measures a broad range of conditions
Control for access to medical care
Control for health "risk" behaviors

The reason that this occupational category/job rank that exists in the British civil service is a strength because sometimes measuring social positions is "a muddy set of waters" in the US social class doesn't have the same kind of meaning—harder to find class indicators

Responds to the conditions people have at work ex. Can they take a day off, arrive late, are they being bossed around... these are all associated with these different job categories

Whitehall 1: higher risk of death due to CVD for men in lower occupational grades
Men in lower job classes had higher risk of negative health behaviors
Even after controlling for these behaviors, risk of death for men of low social status was higher
➢ Strong and convincing data mattered a lot to convince the public and policy makers to do something about what they found
➢ Health is not entirely under our individual control, even if we exercise for 30 minutes a day, eat right, and don't smoke, your health can still be worse because of worse socioeconomic class

Disability adjusted life year
YLL+YDL
-years of life lost to premature mortality+ years of life lost to disability

used to track the global burden of disease

Tries to understand the burden/impact of disease/illness beyond just mortality but in some kind of way that accounts for disability

The DALY is a health gap measure, combines impact of premature death, disability and morbidity

Measures gap between current health status and an ideal situation where entire population lives to advanced age, free of disease and disability

Previous to the DALY, mental health was not on the global health agenda. But then we started detecting the burden of mental health and how it impacted social and economic productivity in people and nations
Not necessarily dying from depression etc. but they are highly impacted in other ways

1 DALY can be thought of as 1 healthy year of life lost (HYLL), the sum of DALY's is the burden of disease for that condition

Shift in global burden of disease from communicable (infectious) to non-communicable (chronic) conditions
shift from diseases of poverty to diseases of affluence

Epidemiological transition theory says → that in human history we would see a shift away from infectious diseases towards chronic conditions due to improvements in the types of things McKeown was interested in i.e. environmental factors
Infectious diseases are really diseases of poverty, once we see increased living standards, we see a decline of the spread of infectious diseases.

A long term shift in mortality and disease patterns whereby pandemics of infection are gradually displaced by degeneration and manmade diseases as the main causes of morbidity and mortality

Marks a fundamental change in main determinants of health... the point in economic development at which the vast majority... gained access to the basic material necessities of life.

medical advances
public health interventions

➢ First epi transition: rise in infectious diseases accompanying Neolithic period, settlements
➢ Second epi transition: Industrialization: rise in chronic disease combined with increase in public health infrastructure→ infectious diseases decline
➢ Third epi transition (1980's)-globalization and neoliberal restructuring→ infectious disease reemergence

A danger in following the health transition model too closely, because then people aren't prepared for infectious disease outbreaks

was trying to help explain the decline of infectious disease mortality

argues that declines in death rates to infectious diseases are due primarily to improvements in living standards
Global burden of disease—infectious diseases were leading to greater levels of population mortality or death

McKeown argued that it would be better to invest in increased environmental standards and other public health interventions
counter argument: HIV/AIDS

Public health intervention does more to the reduction of infectious diseases, then medical technology

the cumulative wear and tear on the body's systems owing to repeated adaptation to stressors.
measures the weathering hypothesis

Mulitlateral
•WHO, UNICEF, UN, etc.
•Multiple govt./states involved in intervention

Bilateral
•Govt. to govt.
•Nongovernmental

Philanthropic
•Gates foundation
•Critiqued for being too dominant since they can set global health priorities as they are still NGO's

Overseas development assistance

Their official target is that countries invest .7% of gross national income (of their federal budget) on foreign aid

Only 5 countries met the target in 2012, U.S. spends .2% of gross national income on foreign aid

Trying to take something that has proven affective ex. Reducing # of HIV cases, and taking that from one setting, site, or local to another, national or international level

Replicating programs with demonstrated success, designing sustainable interventions, securing resources for long term
Replication is part of scaling up, you would only want to replicate once you've seen proven success

Leveraging (private) resources for targeted health initiatives to strengthen broader PHC and public sector health systems

Expanding access to healthcare and needed social determinants of health on a population level

One critique of scaling up is that it raises the question of the extent to which one intervention could work in other cultures/societies
o Culture matters, so in scaling up we have to think about how culture matters ex. Kinds of beliefs of infant swaddling or breastfeeding if we're trying to expand a child nutrition program
o Cultural difference is not an impediment to scaling up, it just has to be considered

Challenges: economic, administrative, political
ex. question of political will... Brazil ministry of health was willing to take flack and heat for what he was doing

CDC's SMP program
o SMP eliminated smallpox from West and Central Africa by May of 1970
o Overall strategy was surveillance and containment, which focused on isolating outbreaks, rather than vaccinating the entire population.
o 19 countries participated in the SMP

CDC valued youthful enthusiasm and flexibility as well as administrative and management skills. Valued these over advanced medical training.
o The people who organized the program wisely realized that smallpox was not so much a medical problem as a management and logistics problem.

The manual emphasized adaptation and modification to fit the needs of the country in question

SMP's planners established a goal of 80% or greater vaccination coverage to create "herd immunity" in which the reservoir of potential hosts would decrease to the point that smallpox could no longer spread.

poor relations between the US and Guinea over the government's association with the soviet Union delayed SMP activates by a year

environmental conditions also caused trouble with other American tools ex. dodge trucks

ped-o-jet vaccination gun
they were believed to achieve a level of speed and efficiency that would make the program's goal—smallpox eradication within 5 years, possible. These devices promised a near revolutionary change in concepts of mass vaccination often proved incapable of the job in the field, dirt would infiltrate the device damaging the inner walls.
¼ of all ped-o-jets became inoperable, causing a slowdown in operations

Cold war

The SMP staff relied on locals for solutions to as well as information about environmental challenges

problems with migration of African groups
The study of the movements of nomadic peoples to produce a campaign strategy aimed at vaccinating those nomadic groups who are thought to play a major role in smallpox transmission.

Compared with the SMP's preferred method of mass vaccination, surveillance-containment represented something new and remarkably effective. The smallpox eradication teams pursuing nomads in Mali immunized 2x as many people in the first half of 1968 as has been vaccinated in all of 2967

Surveillance containment worked against smallpox but it would not help with Africa's measles problem

John Stewart Mill
greatest good for the greatest #

Reinharts work on the SAP
-belief we can do good with the govt.
-we are all in one global community
-justice=fairness, fairness is a value we should consider when allocating resources

Aid or investment in global health and development should be targeted to increasing human capacity or flourishing

Hanna Erent
Alma Ata
regardless of membership in nation states humans have rights to health, freedom of movements, etc. and those rights are universal regardless of what nation state you belong to

INGO founded by Paul Farmer when he was a student at Harvard working in Haiti

-use of paid LHWs
-work with public sector
-address social determinants and inequalities of health
-provide a 'preferential option' for the poor
-strengthen access to public healthcare
-building community partnerships
-provide health care and education for the poor
-Working in the public sector
-Focusing on women and children
-Improving health care tech in rich and poor countries

Use community health workers who live in the communities and understand cultural dynamics, child-rearing practices, they understand the culture of the community.... Use these people as the outreach workers in any health initiative

The PIH model is to be where people are, not just in the capital city OR not just bringing in outsiders with professional degrees, we need to train and give resources to local people
It is important to pay these people, this shows value of their work and is also an anti-poverty strategy

When we do global health intervention, we have to build partnerships NOT just with private sectors and NGO's but orient our resources towards building public health infrastructure, partner with the ministry of health

A vital public sector is the best way to bring health care to the poor, while NGO's play a valuable role in short term goals, only public sector health can ensure and sustain long term health access

There is no public health without a public sector

Partnerships involve community members of all levels of assessment, not a top down approach but a horizontal one

• Goal: Aid independent by 2020
• PIH began work in Rwanda in 2005 (as IIMB)
• In 2006, ministry of health implements mutuelle health insurance scheme
• Results of development and health initiatives: GDP quadruples; many health and development indicators improve
➢ Vision 20/20, this is how its going to look in education, agriculture, our cities, and in health... these are the goals and this is how we're going to implement them in all different sectors of the government
➢ Rwanda govt. said to NGO's if you want to help us then ok but you have to follow our vision 20/20 set by our govt. and ministries
➢ INGO communities took this as a front
➢ Centralized development approach, social, human, economic development indicators show that this model worked
o Graduation rates improved
o Literacy rates improved
o GDP increased
o Dismantled the ethnic distinction
o Invest heavily in primary health care, maternal child health, access to HIV testing treatment and care
➢ Rwanda's redevelopment in the vision 20/20 plan included the large scale recruitment and use of community health workers

• University based INGO, started by Paul Farmer and colleagues at Harvard, working in Haiti
• History of underdevelopment (colonialism, dictatorship, neocolonialism, political violence, resource extraction, environmental damage)
• Structural violence: disease risk is shaped by poverty and structures of inequality
• In Haiti, weakened health care infrastructure and poor health and development indicators
➢ Haiti has a history of resource extraction, French colony, indirect colonial rule after their separation from France through dependency on loans of WB & IMF, foreign aid
➢ Resource extraction, environmental degradation
➢ A failed development water scheme in the 1950's grand infrastructure financed by USAID and WB
o Developed hydroelectric dam
o Empower rural villages in Haiti
o The dam and subsequent flooding displaced thousands of people in these rural villages, they were dependent on rural agriculture
o "Water refugees"
o Rural Haitians (and also displaced urban Haitians) Farmer argues that we cannot understand Haiti's vulnerability to AIDS in the 80's without understanding their underdevelopment or development in reverse
• Places blame on failed development projects and international agencies such as the IMF
o The reason HIV AIDS takes off on the highland is due to structural disenfranchising
o Places blame to institutions... created a cycle of debt and dependency

1978

costly, governments must be totally on board

economic difference between developed and developing countries causes a difference in health in these countries

developing countries cannot ever compete with developed countries due to their lack of resources

World Health Organization

"Health is a state of complete metal, physical, and social well-being and not merely the absence of disease or infirmity"

6- Europe, Africa, Americas, SE Asia, Western Pacific, Eastern Med.

goals priorities, frameworks for health programs, data

targets well-being as a whole

Focuses on one specific area, ex. UNICEF

James Grant- director from 80-95

GOBI for < $10 a child

-Americas
-Europe
-Africa
-south-east asia
-west-pacific
eastern-mediteranean

-Health: complete physical, mental, and social well being (not just absence of disease)
-existing gross inequality of health states between developed/developing countries and within countries is politically, socially, and economically unacceptable and common concern for all
-people have right/duty to participate in planning/implementing their health care

-income inequality impacts health of populations especially in middle income and affluent nations
-RIH: individual consumption and savings is dictated more by his income in relation to standard of living
-% of income by an individual depends on his percentile within income distribution

-structural determinants and conditions: born into, grow, live, work, and age include...
-socioeconomic status, education, physical environment, employment, and social support and accessibility to health care
ie: racism, etc.

-IMR
-low birth weight
-LE
-DALYs

measures overall disease burden expressed as number years lost due to ill-health, disability, or early death

-global shift from communicable diseases to chronic disease
-anthropological position
*industrialization
*globalization... reemergence of communicable disease
CRITIQUES:
-moving from "disease of the poor" to "affluent" chronic diseases

-neoliberal policies have contributed to the loss of access to health care and have contributed to deepen the problem of commodification of basic human needs... has life/death implications for vulnerable populations (poor=no care)
-cuts in health budgets and create user fees
creating larger disparities

-World Bank and IMF promoted SAP (structural adjustment programs) which reduce government spending
-SAP- world bank gives money to implement certain infrastructures to assist in development but on the conditions that are outlines by the world bank or organization that's giving the loan

-under USSR control, there was lots of funding for healthcare and social programs but after the collapse, there was an increase in poverty and malnourished and decreased access to medications or medical care
-under USSR system, medication was free and disadvantaged populations had access
-Lowered quality of life such as crowded conditions led to higher rates of infectious diseases
-many blamed bloodletting and swaddling for health outcomes, rather than the collapse of the health care system

-countries did not have a large reserve or access to medication (crisis)
-government couldn't provide meds
-solution was user fees
-Led by UNICEF and WHO
-said they would bring medicine but that they would charge for it... people couldnt pay
-Bamako initiative was to implement strategies (user fees) designed to increase availability of essential drugs and other healthcare services for Sub-Saharan Africans

Pharmaceuticalization:
BENEFITS:
-all drugs were free for those with HIV/AIDS
-cheaper than hospitalization or treatment if symptoms worsened
-decreases DALY
-widely avaliable
-supplementary programs

-actors: multilateral aid, bilateral aid, non-governmental, philanthropic, debt forgiveness
-priorities: pulling countries out of poverty... improving health overall
-commitments: 0.7% GDP from countries
-Challenges: countries not meeting .7%

-taking something that was successful and implementing it on a national/ international level
-process of reaching larger numbers of a target audience in a wider geographic area by institutionalizing effective programs

-rise of HIV/AIDS: massive populations with compromised immune systems increased inc
Rise of HIV/AIDS: massive populations with compromised immune systems increased the incidence of opportunistic infections
Globalization (increased trade and travel) exposed people to more infectious diseases and foreign pathogens

-1958 WHO begins eradication
-1972 fully eradicated in west/central Africa
-25% infected die

-strengthen access to PH, provide care to poor, build community partnerships
-Rawanda: goal: independent from aid by 2020... GDP 4x, health/development improved, mutuelle health insurance scheme in 2006

-actions are right if they are useful of for benefit of majority
-greatest level of health for most people
-good starting point but can lead to blind spots and exclude other populations

-ideology that all people belong to a single community
-open to new behaviors or opinions and willing to disregard old traditions
-broaden person's general knowledge

-moral significance of individuals capability of achieving kind of lives they're reason to value
-persons capability to have good life defined in terms of "beings/doings"

-alma-ata principle
-reintegrated by Brazilian Minister of health during HIV/AIDS pharmaceutical initiative

Social determinants of health
-ie: CEO, lab director, janitor
Janitor = higher BP than CEO
-living conditions effected stress level

-disparities between black/white women and low birth weight babies
-weathering hypothesis answers low birth weight
-proven to not be due to genetics, racism

-1997 Brazil: ARV drugs available to all w/ HIV
-Brazil made own drugs, reducing cost by 70%

1. Health is a human right
2. Health is not the absence of a disease
3. Inequalities exist in health
4. Community participation in health
5. Primary health care

1. Set goals
2. Provide framework
3. Organize and mobilize resources for action
4. Shape agenda

1. Difficult to implement
2. Lacked resources and funds
3. Rise of neoliberalism
4. Tax cuts and decrease in social programs

Health is a state of complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity

1. Fund research, disease monitoring, and surveillance
2. Establishes goals for health in different regions

1. Americas
2. Europe
3. African
4. SE Asia
5. W. Pacific
6. Mediterranean

Growth monitoring, oral rehydration, breast feeding, and immunization

Oral rehydration therapy

1. Increase immunizations & use of ORT
2. Malnutrition rates reduced
3. Saved millions of children's lives

1. Essential health care based on practical methods
2. Made accessible to individuals and families in the community through their full participation
3. At a cost that the community and country can afford to maintain at every stage of their development

A longitudinal study of the relationship between occupational position and heart disease

1967 study of 18k men; outcome was higher risk of death due to CVD for men in lower occupational grades

1985 study of 10k men & women; for women, occupational position strongly correlated with morbidity and mortality

Inequalities in population health status are related to inequalities in social status

"The causes of the causes of ill health"; i.e. education or food security

1. Due to excess stress, the body begins to deteriorate or become unhealthy.
2. Racial inequality takes a cumulative toll on Black woman, increasing the chance they will have health problems at younger ages
3. Encourages women to have children at a younger age

Repeated adaptation to stressors; Geronimus finds that black women have highest allostatic load score--double oppression of being black and a woman

1. Population-based
2. Result of social conditions
3. Services are community-based and focus on health promotion
4. Best practices include societal and population-based interventions
5. Aim: Prevention

1. Individual-based
2. Focusses on disease, function of biology/pathology
3. Services are medical interventions by physicians, through clinics
4. Best practices include clinical care of patient
5. Aim: Cure

1. Looked at the role of three different factors on population health including; medical advances, reduced exposure to infectious disease, and nutritional improvements
2. Argues that death rates due to infectious disease are decreasing due to improved living conditions.

Disease/health condition

Death

# of cases

# of new cases

Shift in global burden of disease from communicable (infectious) to non-communicable (chronic) conditions following human development

Uneven; development often causes chronic disease

Transmittable to host by outside sources

Conditions within host; usually due to degeneration

1. Climate Change
2. Poverty
3. Inequality

General healthcare for communities as a whole

Emphasis on decentralization of care

Community driven

Health care for selective people with a goal, and cost more (not effective); emphasis on disease specific eradication

Didn't focus on maternal care - only focused on fixing child health outcomes & not what might've led there

Taking the decisions out of the hands of the communities

primary health care
inequalities are unacceptable
community participation
social and economic development
intersectoral
health for all
global responsibility

healthcare for community as a whole

for selective people with an end goal

race "gets under the skin" to influence biology

wear and tear on the body
(Geronimus finds that black women have highest allostatic load score--double oppression of being black and a woman)

different experiences in life of women of color

Give every child the best start in life
Improve education and life-long learning
Create fair employment and jobs
Ensure a minimum income for a healthy standard of living
Build healthy and sustainable communities
Apply social determinants' approach to prevention

How society is organized impacts health "the causes of the causes of ill health"

the inequalities in population health status are related to inequalities in social status

identify the cause of a disease or risk factor to intervene to reduce morbidity and mortality from disease

GDP and life expectancy
-The longest life expectancy is found in the countries with the most wealth distribution.
-After 5,000 GDP health expectancy begins to level off???
-Levels off due to large disparities in wealth

Coefficient that varies between 0 (perfect equality) and 1 (perfect inequality). Closer to 0 means that the income distributions are more equal or egalitarian vice versa.

income inequality affects health
absolute social income and relative distribution of benefits in society matters as determinant of population health

-focus on population
-aims at prevention

-focuses on individuals
-aims at cure

what factors influence health the most
1. living standards
2. nutrition
3. medical advances

-Shift in global burden of disease from communicable (infectious) to non-communicable (chronic) conditions following human development
-ie TB to cardiovascular disease

-"A long-term shift in mortality and disease patterns whereby pandemics of infection are gradually displaced by degeneration and man made diseases as the a main cause of morbidity and mortality"

-in top 10 killers
-"disease of poverty"
-95% of all TB cases occurs in developing culture

Keeping track of number of cases

years of life lost due to premature mortality

years lost due to disability

rate of disease

rate of death

directly observed therapy for TB (observe patients taking pills)
not enough funding

did not take into account all of the factors that affect health outcomes in populations

1. Selective/Categorical - only targets one particular disease, doesn't focus on overall population but specific individuals. Has more funding.
2. Comprehensive - multilateral, holistic approach. Focuses on every aspect of health care, comes from Alma-Ata.

It takes every part of our government to improve overall health, not just leaving it to the DHHS.

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

-Establishes goals, priorities, frameworks for health programs and action.
-Funds research, disease monitoring and surveillance, response
-Makes epidemiological data available to researchers and practitioners
-Priorities: fostering health security, health systems development, partnerships, performance

Africa, North and South America, Southeast Asia, Europe, Eastern Mediterranean, and Western Pacific

1. Global health is a global effort (#9)
2. Health inequalities are really bad and therefore concern all countries (#2)

1. Cost - who is going to pay for and implement health care? No one quickly stepped up to pay for it.
2. Location - getting together people from all around the world is very difficult, then once everyone is together its even harder to reach an agreement on a plan that works for everyone.

Created by UNICEF director at the time, aimed to lower child mortality rates, especially in poor countries. Example of selective PHC.

GOBI: growth monitoring, oral rehydration, breast feeding, immunization
ORT: oral rehydration therapy

1. Estimated 12 million lives saved
2. Cost effective, cost less than $10/child
3. Immunization rates rose (reached 80% by 1990)

1. Disparities still existed between wealthy and poor
2. Wasn't enough focus on the mothers, families, and communities of the children
3. Other health concerns were ignored with all of the world's focus on child survival campaign

-Income and income distribution; social inequality
-Education; job and income security, employment and working conditions
-Early childhood development
-Food (in)security; housing conditions
-Social exclusion; racism; gender equity; rights
-Social support; community; participation
-Access to health services

How society is organized impacts health

-Studied the relationship between occupational position (predictor) and heart disease (outcome)
-Population: British civil servants aged 40-64
-Followed participants over decades

-Large samples
-Clear indicators of social position
-Measures a broad range of conditions
-Control for access to medical care
-Control for health "risk" behaviors

-Whitehall I: higher risk of death due to CVD for men in lower occupational grades. Men in lower job classes also had higher risk of negative health behaviors.
-Whitehall II: For women (like men), occupational position strongly correlated with morbidity and mortality.

Shows that inequalities in population health status are related to inequalities in social status

Says that black people experience early health deterioration as a consequence of the cumulative impact of repeated experience w/ social or economic adversity

Cumulative wear and tear on the body's systems due to repeated stress

1. Public Health - main goal is prevention, focuses on population. Disease = social condition and policy.
2. Medicine - main goal is to cure, focuses on individuals. Disease = based on biology.

Curve showing the relationship between GDP per capita and life expectancy. As GDP increases, life expectancy increases. However, around 5,000 GDP, the curve levels off and life expectancy stops increasing.

-Income inequality effects health
-It is not just absolute social income or individual income, but relative distribution of the benefits of economic development in society that matters as a determinant of population health
-Income inequality impacts health of populations, especially in middle income and affluent nations

-0 to 1
-Measures income inequality
-Closer to 0 means less inequality; closer to 1 means more inequality
-Helps us see distribution of wealth/inequality

-Researched the role of three factors influencing population health:
1. Medical advances
2. Reduced exposure to infectious agents
3. Nutritional improvements
-Argues that declines in death rates to infectious diseases are due primarily to improvements in general living standards

-Shift in global burden of disease from communicable (infectious) to non-communicable (chronic) conditions following human development
-Diseases of poverty -> diseases of affluence
-Due to rising living standards and economic development

-The transition is uneven
-There are many places where people are experiencing both types of diseases

-Reemergence of TB in New York and Peru
-Neoliberalist movement -> collapse of infrastructure and loss of funding for preventative programs/clinics-Clinics closed and social programs were lost so people weren't getting the treatment they needed
-TB = disease of poverty
-Peru (1970s/80s): suffered economic crash, shift in policies towards privatization. People became poorer and TB reemerged

-Determining associations between characteristic of the environment ("exposure", "risk factor") and health/disease/illness
-Use research to inform health and social policy to reduce morbidity and mortality

-Prevalence: # of existing cases of a disease in a population at a point in time
(# of cases in a population at point in time) divided by (# of individuals in population at point in time)

-Incidence: # of new cases in a period of time
(# of new cases in period of time) divided by (# size of population in time period)

-Child Mortality Rate
-Under 5/Child Mortality Rate: death to children in first five years (0-5) per 1,000

-Infant Mortality Rate
-Death to infants in first year (0-1)
-Infant mortality rates = # of deaths per 1,000 live births in a population

WHO documented a ___ increase in obese and overweight individuals from 2009 - 2015.

___ of overweight children become overweight adults.

____ of food advertising is marketed toward children.

Soda purchases increased by _____ from 1985 - 2014.

Leading causes of disease in 2013 - heart disease:_____, cancer:______, LRI:_________

____ of Americans in poverty in 2015.

____ of white people in poverty compared to ___ of black people in poverty.

Male suicides: ________/100,000 vs Female suicides: ________/ 100,000

Death from accidents (male): ____/100000
Death from accidents (female): _____/100000

All humans share _____ amount of DNA. (Inclusion Chapter 10)

____ are all lumped into "white' americans racial category.

In 2014, _______ million were on welfare for at least a month. _____ of those were working households.

Life expectancy for black males in the US is ____.

Infant mortality rate for white people:___
Infant mortality rate for black people:___