Intro to Global Public Health Exam 1

-allows for a focus on interactions rather than relying solely on deterministic biological/social explanations

-intertwining reality of biological & social factors in health
-biological & social processes affect each other & thereby influence health & disease

-US took control of islands
-established military base
-concentrated poverty
-water shortages
-segregated from US
-discrimination-quality of life
-crowded environment
-power outages
-nuclear weapon testing
-lack of hygiene/sanitation
-urbanization = more infectious disease
-not enough $ to go to hospital
-limited access- doctors traveled to them
-malnourishment/ change in diet
-environment controls them
-compromised immune systems
-rate of TB = 23x US
-relocated =disrupts their lifestyle

Combining anthropology, sociology, history, political economy & other "resocializing disciplines" w/ fields like epidemiology, demography, clinical practice, molecular biology, & economics allows us to build a coherent new field that might better be termed "global health equity."

gross national product

gross domestic product

-Obscure local inequities such as those seen w/in a nation, state, district, city, or other local polity
-Substantial health outcomes b/w rich & poor households
-Social status such as mother's educational level correlates w/ health outcomes such as infant morality

-WHO health definition: a state of physical, mental, * social well-being
-Problem: Can definition of health capture subjective illness experiences of individuals in diff settings?

-Public health: focuses on health of populations
-Medicine: focuses on health of individuals

-Global health: encapsulate role of nonstate institutions (international NGOs, private philanthropists, & community-based organizations)
-International health: emphasized the nation-state as base unit of comparison & implied focus on relationships among states

Global health: not yet a discipline but rather a collection of problems
-focuses on particular set of groups/ problems

-Subtracting outstanding debts & liabilities from the cash value of currently owned assets (houses, land, cars, savings accounts, pension plans, stocks & other financial investments & businesses)
-Families w/ higher earnings tend to accumulate more assets
-Families w/ same income level may have dramatically diff levels of wealth

-Wealth b/c accumulated assets provide more complete info about person's cumulative lifetime economic resources - his/her lifetime earnings & inherited wealth
-Income only measured for single period of time = misleading picture of actual economic resources
-Income fluctuates yearly, due to unemployment, disability / retirement

b. Although there are substantial disparities between black Americans and white Americans in both income and wealth, the biggest disparity is in their income

1. Access to health-promoting goods & services
-Higher income & greater wealth = easier to pay for insurance premiums, deductibles, copayments & medicines
-Eat more nutritious food, stay physically active, live in safe homes & neighborhoods
2. Psychosocial effects linked with economic resources
-Stress from negative impact of financial hardships
-Varying degrees of control feel have over their working conditions
-Lower-paid workers facing higher demands while experiencing lower control
3. Cumulative effects over time and at critical periods
-Economic advantage & disadvantage over a person's lifetime
-Financial hardships, average income & changes in income over time affect range of health-related outcomes (physical & congnitive functioning, psychological well-being, diabetes & mortality)
-Certain critical periods of life (gestation, birth-5 yrs)

1. Safety net programs that make income go further: child care & housing subsidies, supplemental food assistance programs
-SNAP (formerly food stamps)
-WIC & school nutrition programs
-Free/ subsidized health insurance help low-income families more adequately cover basic necessities
2. Earned Income Tax Credit (EITC)
-Refunds federal taxes to low-income working families
-Shown to increase employment & lift around 4.4 million people out of poverty annually

Social gradient: the higher the socioeconomic level of the household the lower the mortality rate.
-child mortality = highest among poorest households
-adult mortality rates vary inversely w/ level of education (no education = higher mortality rate)
-low life expectancy w/ increased social inequalities

-Poverty = material deprivation- dirty water, poor nutrition, lack of quality medical care
-Fails to properly take into account relief of material deprivation not simply technical matter of providing clean water/ better medical care
-Who gets these resources = socially determined

-Dirty water, lack of calories & poor antenatal care cannot account for 20 year deficit in life expectancy of Australian Aboriginal & Torres Strait Islander peoples.
-Form of poverty takes & health consequences = diff when considering chronic disease & violent deaths
-Policies have not benefited disadvantaged people in poor countries

-The social conditions that give rise to high risk of non-communicable disease whether acting through unhealthy behaviors/ through the effects of impossibility stressful lives
i. Can't go into their population and tell them they should take better care of themselves
ii. That smoking & obesity were killing them
iii. Tell them they must drink in moderation?

a. Social functioning & meeting human needs
b. Focus on material conditions & control of infectious disease
c. Understand circumstances in which people live & work are as important for communicable & non-communicable disease
d. Create social conditions that will ensure good health for the entire population
e. Looking at rich countries & implementing what they are to improve health

a. Incomplete explanation of differences in mortality among countries or among subgroups w/in countries.
b. Little correlation b/w gross national product per person & life expectancy

-No raising income is not the best way to achieve greater health because there are many examples of relatively poor pop. w/ similar incomes but strikingly diff heath records.
--Action in place to relieve poverty not only having desired effect on avg incomes but also on income distribution & on poorest ppl

1. Children who experience discrimination have higher rates of depression, ADHD, & other behavioral problems.
2. Black women whom experience discrimination more frequently are more likely to develop breast cancer.

-Interpersonal discrimination: harassment, "micro-aggressions" / anticipation of prejudice
i. Rise in anti-Arab sentiment after 9/11
1. Women w/ Arabic names had increased risk of preterm birth & low-birth weight babies
-Structural discrimination: social & economic polices that systematically put certain groups at a disadvantage.
i. In Arkansas, unemployment rate for blacks = 3.6x higher than for whites; in Delaware, employed at similar rates.

-policymaking
-social factors
-physical factors
-health services
-behaviors
-biology & genetics

-social arrangements that put individuals & populations in harm's way
-embedded in political & economic organization of our social world
-cause injury to people

1. Health knowledge and behaviors
-diet, exercise, smoking
2. Jobs/income
-having job
-working conditions: exposure to hazards, stress
-work related resources: health insurance, sick leave, paid vacation
3. Social and psychological factors
-personal control
-social standing
-social networks

Exposure to hazards
Control/demand imbalance
Stress

No building codes so buildings fell and crushed victims
No reliable sanitation system so cholera & other diarrheal diseases spread
No reliable water sources
No resources for emergency planning
No comprehensive health system (so clinics/hospitals in other parts of Haiti couldn't fill the gap) No reliable distribution system (roads, trucks, airport runways, means of communicating)

False
-Access to health care does not explain the whole relationship between wealth and health

1. Accumulated wealth
2. Neighborhood socioeconomic characteristics at a given level of income.
3. Chronic stress related to perceived and experienced discrimination may impact health

-Although first-generation Latinos in the U.S. in general are poorer, have lower levels of education, and are less likely to have health insurance, they have lower adult and infant mortality rates than that of non-Hispanic whites
-Researchers' hypotheses. Recent immigrants may:
-be inherently healthier (able to face the challenge of immigrating) -have healthier behaviors
-have stronger social networks
-have other sources of psychological resilience than U.S.-born
-come from places which have specific healthier practices (such as breastfeeding or not smoking)

1. Health
2. Education
3. Living standard

Conditional cash transfers
-"Co-responsibility" between the government and the recipients
-Previously, even though health care for the poor was free, many did
not take advantage of it
Health:
• Children under age 5 had a 12% lower incidence of illness
• Reduced stunting among kids age 1-3 yrs
• Adults had 19% fewer days of difficulty with daily activities
• Adults over 50 had 17% fewer days incapacitated, 22% fewer days in bed, 19% fewer days of difficulty with daily activities.
• 18% decrease in iron-deficiency anemia
Education:
• 11-14% increase in secondary school enrollment for girls • 5-8% increase for boys

-Civil registration: counting/keeping track every person in the country
1. Monitor long term & short term demographic changes
2. Give up to date population counts
-Vital statistics: results from civil registration
1. Collecting cause of death, births
2. Can help with health policies

-Benefits:
1. Human rights & help w/ economic development
2. Vital statistics on births & deaths = reliable data for cause of death, provide crucial info for policy, planning & evaluation in all sectors of development
3. Establish & protect identities, citizenship & property rights
1. Provide access to state services/entitlements, defense against exploitation
4. Official development assistance
1. Policies & programs
2. Tax payers
-Risks:
1. Be used to do harm to individuals & vulnerable minorities
2. Governing authorities control movement & liberty of sections of population

1. No, investing now will pay off in the future.
2. Cost dived by # of ppl benefitting from info generated, cost becomes negligible
3. Vital statistics only expensive if obtained & nvr used

1. Improve trans regional health
2. Stop plagues that disrupted commerce

1. Rightness of European imperial project & evidence of the frailty of "savage" bodies compared to European ones
1. Inferior
2. Disparity in infectious disease mortality
1. Hardened into racial hierarchies based on embodied and seemingly unalterable biological characteristics
1. Racial discrimination
3. High mortality rates = colonization was right
1. Europeans intentionally introduced diseases

1. Malaria - huge disease for Europeans
2. Tropical fever
3. Support the military before broadening to include European-born administrators & civilians
4. Protect heath of laboring populations & colonists themselves

1. Statistics gave belief black body was better suited for labor in hot climates than white body
2. In addition, darker bodies described by colonial administrators a vectors of disease
1. "imperial hygiene" focused on "uncivilized" & "unclean" practices of nonwhite subjects whose "primitive" state made them a menace to civilized world
1. imperial hygiene = bringing indigenous ppl's health up to white people's hygiene.

1. No
3. Missionary work
4. WHO attempts @ eradicating Malaria
5. Immunizations needed to travel - not b/c we think they are diseased, but b/c we haven't been exposed & more likely to get
6. Ebola
1. Been in Africa for a long time
2. Didn't care until came to US
7. Zika Virus

1. "tropical medicine": one could control the damaging economic effects of epidemic disease by fighting its nonhuman vectors w/o providing direct curative services to native populations
1. refers to latitudes
2. possibility of tropical colonization by white races
3. Wanted to eradicate insects themselves
2. "germ theory": direct causes of 99% of diseases = germs
1. kill them simply matter of knowledge & application of knowledge
2. introduced a nonhuman target for disease control efforts
3. introduced a new vector - "healthy carrier" = hygienic practices as important to disease control as traditional measures
1. Mary Mallon/ "Typhoid Mary" - Irish cook infected at least 53 ppl w/ typhoid fever in first two decades of 20th century
2. Branded a threat to society & incarcerated last 23 years of her life
3. Colonial subjects blamed for causing disease among white populations
1. U.S military occupation of Philippines
2. Blamed Filipinos for cholera epidemics b/c American soldiers died (200,000 ppl)
3. U.S. Army Public Health Force declared a "cholera war"
1. Administered drugs, imposed quarantines, seized & cremated afflicted bodies
5. African's didn't know what Western time is
1. Take at 10 o'clock, what do you mean 10 o'clock?
2. AIDS treatment was "too difficult" or "too complex" in the very continent most afflicted by the disease
6. Malaria: decided easiest to fight vector
1. Didn't think about socioeconomic issues causing Malaria to be more prevalent

-Missionary medicine: engaged more directly w/ local populations
1. Believed that indigenous religions & social systems = backward, immoral & unclean
2. Western civilization & Christianity = solution to illness & pathway to salvation
3. Focused on individuals
1. Personal illness, personal hygiene & personal sin
4. Used to spread Christianity & convert patients
-Colonial medicine: limit extent to which African communities (especially in rural areas) were disrupted by Western culture & lifestyle
1. Focused on populations

1. Panama Canal - eliminating yellow fever
1. Convention: how disease can impact international trade?
1. Didn't impact health, but money
2. PAHO = south American wing of WHO
1. Rockefeller - focus in international health = eradication & prevention of infectious disease, funded PAHO
1. Sought to use biomedical interventions
2. Build sturdier & more cost effective public health systems
1. Mosquito nets
2. Vaccines (technical fix)
3. Sought to modernize "traditions", backward & "non-western" cultures
1. Colonization
4. Concerned w/ populations rather individuals
5. Campaigns = forceful
6. Little community involvement
2. Apply one size fits all prevention & treatment techniques

1. Given limited resources, administrators of development projects forced to choose b/w immediate provision of services & long term investment in infrastructure
1. Pick and choose where funding should go for public health
2. Quick fix or long term infrastructure (pushing our ideas, values)
1. More expensive for quick fix
2. Socialization for scarcity
3. Perpetuates asymmetry in military, power

1. Left w/ incomplete infrastructures
2. Very small national budgets based almost entirely on export crops
3. Enormous fiscal responsibilities to their populations
4. Embarked on ambitious development projects
1. Success of projects depended on global commodity prices
5. Health systems, education & infrastructure development suffered b/c natural disasters, declines in export prices & access to credit, political pressures & heavy handed postcolonial policies

1. UN after WWII grouped them all together
2. PAHO = south American wing of WHO
3. PAHO, the OIHP, the League of nations health committee drafted the constitution for a unified global health body
4. WHO = universal membership & decentralization
1. Global superpower

1. Socialization for scarcity- the assumption that resources for poverty reduction & international health initiatives will be in perpetually short supply would come to be the dominant logic of international health, whether acknowledged or not
1. Not enough to go around for everyone
2. Don't have enough $ to do everything, need to choose b/w diff approaches
2. Cost of draining all mosquito breeding sites
1. Advocate vector control encourage drainage of potential mosquito breeding sites
2. Use of insecticides in homes & fields
3. Widespread distribution of insecticide treated bed nets
3. Vector control can take place even in areas w/o robust health services & full cooperation of at risk populations is not required
1. What we chose
4. Malaria will never be effectively controlled w/o transformation of living conditions
5. Best way to protect humans from illness?

1. Technological tools could be so effective
2. Development of new antibiotics & pesticide DDT
3. Top down - fund program to eradicate malaria in world, belief in vector control
1. DDT used in WWII
4. Vertical - disease specific approach
1. Preferred by political leaders in US & other western powers
5. Every home in malaria-stricken regions sprayed @ least once a year until disease eradicated
6. Spraying team obstacles:
1. Accessing remote areas
2. Earning cooperation of residents
3. Anticipating possible reintroduction of parasite from neighboring regions
4. Paying sky rocketing costs of personnel & supplies
7. By mid 1960's mosquitoes & malaria parasite demonstrated resistance
1. Started to look expensive to eradicate now
8. Small pox:
1. Focused on
1. Large scale vaccination & surveillance & containment
1. Strong reporting infrastructure
2. When case discovered, isolate sick, quarantine those come in contact w/ infected, ensure vaccination of whole community, disinfect all surfaces contaminated w/ virus
3. Required large # of health works, but not professionals
1. Trained quickly
4. Small pox is easily identifiable, symptoms appear quickly, transmission = easily tracked, vaccine effective & easy to administer
5. Forced vaccinations

1. Mortality rates started to decline before treatment available
1. Improved sanitation/living conditions
2. Improved standards of living leads to reduced exposure to disease
3. Advancement in nutrition
4. Show steep decline before biomedical interventions were available

a. Cancer
b. Diabetes
c. Chronic obstructive pulmonary disease
d. Mental health conditions

a. Outdated & counterproductive
b. Begins w/ 'non' may be considered a 'non-issue' or 'non-starter'
i. Propagates confusion
ii. No sense of urgency
iii. Deflects attention from effective system-wide interventions
c. Still world's biggest killer

a. Evidence mounting that some NCD'S are partly/ wholly communicable
i. Can spread through social networks, viruses, built environment, cultural & economic conditions, food deserts (areas short of fresh fruit, veggies) & intergenerational transmission (diabetes & obesity)

a. Misnomer implied causes are individual rather than societal
i. Efforts focused on individual behavior have little overall effect if social & policy environments do not change parallel
b. System-wide socioeconomic drivers = difficult to change
c. Blame poor people for making poor decisions
d. Other power economic interests besides regulatory changes in tobacco, alcohol, & food policy

Prevalence:
• The # of people suffering from a certain health condition at a certain time
Incidence:
• The # of people diagnosed with a health condition over a specific period of time.

• Mortality - death
• Morbidity - the condition of being diseased

DALY = YLL + YLD
YLL = Years of Lost Life (due to mortality)
YLD = Years Lost to Disability (due to injury & illness)

• Setting health care priorities
• Setting research priorities
• Identifying disadvantaged groups for health interventions
• Allowing better evaluation of health interventions
• Understanding transnational burden of disease
• Allocating resources for interventions based on cost-effectiveness • Combines morbidity and mortality into one measure

• Has led to more evidence-based health practice
• More attention has been paid to neglected diseases and populations

1. Reduces the subjective and multifaceted experience of ill-health into an objective index
2. Does not deal with the social suffering by those not diseased (family, community)
3. Does not account for how suffering varies across time and space
4. Minimizes differences in suffering in different contexts
5. In past: Sex-specific life expectancy calculation could downplay deaths of males (now using same life expectancy for male and females)
6. In past: Age-weighting: the relative value of a healthy life increases from birth to age 25 and then declines slowly to old age. (no longer age- weighting)
7. Mental health separate from physical health
Biggest critique:
Health care as a human right
vs.
Health care based on cost effectiveness

1. Vital statistics (civil registration): birth registration and cause of death
2. Census data (questions: how many ppl live here, rent/own, name, age, sex, race)
3. Population surveys
4. Health service records (ICD-10 coding of health issues, Reportable diseases (to health department))

• Infectious diseases (Group 1)*
• Noncommunicable diseases (Group 2) • Accidents and injuries (Group 3)
* Now the GBD calls this "communicable, maternal, neonatal, and nutritional"

Looking historically at the countries that are now high income:
• Before 1900, they had high death rates, high birth rates, and slow population growth
• Around 1900, mortality decreased in these countries
• Hygiene, nutrition, housing improve; infectious diseases less of a burden
• As mortality declined, population increased...
• ...and share of population that is young increased
• Eventually fertility also decreased
• Births and deaths more equal, so
population growth slows
• Share of population that is older increased
Stage 1: Least Economically Developed Countries (LEDCs)
High birth rates due to:
• No contraception
• Couples have many babies to
compensate for the high death rate
caused by poor health care
• Large families need to work on the land
to contribute to family income
• Children look after old
• Religious reasons
High death rates due to:
• Poor medical facilities • Disease
• Poor nutrition
• High Infant mortality
Stages 2-3: Newly Industrialized Countries (NICs)
High/decreasing birth rates due to: • People are used to having many
children. Takes time for culture to
change
• Changing status of women
Decreasing death rate due to:
• As an economy develops, money
becomes available for better health
care
• Housing improves • Better childcare
Stage 4: Most Economically Developed Countries (MEDCs)
Low birth rate due to:
• Children are expensive
• People know their children are going
to survive so they can keep their
families small
• Widely available contraceptives • Changing status of women
Low death rate due to:
• Better health care
• Better standard of living
Stage 5: ???
- Birth rates getting below replacement levels in some countries, and populations declining
- E.g. Germany, Sweden, Japan

DTM:
• Theory is based on evaluation of data from mostly European societies that went through the industrial revolution.
• Model assumes that the fall in the death rate in Stage 2 was due to industrialization
• Timescale and curve may not apply to all countries
• Industrialized countries that grew due to emigration/settler colonialism (US, Canada, Australia) did not go through the first stages of the model
ETM:
• Epidemiologic Transition model (ETM) is subject to similar critiques as the Demographic Transition model (because the ETM takes the DTM as its starting point)
• The ETM holds for high-income countries, as demonstrated by increasing obesity rates are leading to more NCDs
• BUT in low and middle-income countries, the transition is "protracted"
• High communicable AND noncommunicable diseases, at the same time

• Many countries are experiencing the "double burden" of high rates of Group 1 diseases and Group 2 diseases at the same time
• Group 1 - communicable/infectious, perinatal, maternal, and nutritional • Group 2 - non-communicable
• Sometimes these different groups of diseases are occurring in different populations within the same country
• The affluent are more likely to have a high burden of non-communicable diseases
• The poor are more likely to have a high burden of diseases of extreme poverty
• Having high rates of both types can be taxing on the health system

• Focuses on the causes of death within the demographic transition, and how those have changed over time
1.
2. 3.
High and fluctuating mortality related to poor health conditions, epidemics, famine • Initially, deaths mostly from Group 1 diseases (Diseases of extreme poverty)
Then, progressive declines in mortality as epidemics become less frequent
Finally, further declines in mortality, increases in life expectancy, and the predominance of non-communicable diseases.
• Historical shift in cause of death during economic development
What about injuries and accidents (group 3)?
• Stays roughly the same (according to the theory)

• The pace at which different countries go through the transition differs
• Not all infectious diseases declined with development
• There is some evidence that specific injuries and accidents decline with increasing development, but others have increased

• #1 - Investing in "vertical" programs, not in health systems
• #2 - Targeting specific infectious diseases not chronic diseases • #3 - Method was through technical fixes
• #4 - Decisions made without local input

The unanticipated consequences can be due to:
• Immediacy of the problem
• Misunderstanding of language and culture - knowledge asymmetries • Thinking what worked elsewhere will work in another context
• Institutional values blinding one from thinking about other impacts