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GLOBAL HEALTH AND ITS DETERMINANTS
Roberto De Vogli
Department of Epidemiology and Public Health, University
College London
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Theory and Evidence
Ideas
THEORY
Inductive Deductive
Reasoning Reasoning
EVIDENCE
Reality
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Scientific Evidence?
Data speak by themselves
vs.
If you torture the data long enough, they will
eventually confess everything!
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Lies, Damn Lies and Statistics
There are three kinds
of lies: lies, damned
lies and statistics
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It is easy to lie with statistics,
butit is even easier to lie without them
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The important thing
is not to stop
questioning
A. Einstein
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In Africa they didn't know what 'food' meant.
In Eastern Europe they didn't know what 'honest' meant.
In China they didn't know what 'opinion' meant.
In the Middle East they didn't know what 'solution' meant.
In South America they didn't know what 'please' meant. In Western Europe they didn't know what give' meant.
And in the USA they didn't know what 'the rest of the world' meant.
UN Food Shortage Worldwide Survey.UN Food Shortage Worldwide Survey.
The only question asked was:The only question asked was:
Would you please give your honest opinion about solutions toWould you please give your honest opinion about solutions to
the food shortage in the rest of the world?the food shortage in the rest of the world?
The survey was a huge failure....The survey was a huge failure....
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Outline
A. What are the major categories of globalhealth determinants?
B. What are the most important?
C. What are their relative contributions indetermining global health?
D. Exercise
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Outline
A. What are the major categories of globalhealth determinants?
B. What are the most important?
C. What are their relative contributions indetermining global health?
D. Exercise
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Meta-theories of Health Determinants
Nutrition (Mc Keown, 1976)
Public health technology (Preston, 1976)
Economic growth - poverty reduction (Preston, 1976)
Sanitation, hygiene and clean water
Education, autonomy of women and maternal and childservices (Caldwell, 1986)
Income Inequality (Wilkinson, 1992)
Health behaviors (Mc Ginnis, 1993)
Medical treatment (Bunker, 1994)
Gene expression (Venter, 2001)
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Frameworks of Health Determinants (I)
Disease HealthCare
Cure, care
OtherFactors
Clinical Epidemiology
Healthcare Evaluation
Health Services Research, etc.Source: Evans and Stoddart, 1994.
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HEALTH CARE
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OECD, 2005. Health at a glance
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Source: Ontario Cancer Registry 1999
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Frameworks of Health Determinants (II)
DiseaseHealth
Care
Cure, care
Other
Factors
Lifestyle Environment Biology
Source: Evans and Stoddart, 1994.Clinical Epidemiology
Healthcare Evaluation
Health Services Research, etc.
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BEHAVIOURS
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Smoking and Lung Cancer: animal studies
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and human studies
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ENVIRONMENT
(PHYSICAL AND SOCIAL)
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Fig 1 Neighbourhood specific homicide rates (per 100 000 population per year) in relation
to male life expectancy at birth (with effects of homicide mortality removed) for 77 communityareas of Chicago, 1988-93
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BIOLOGY
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STRESS AND ITS BIOLOGICAL TRANSLATION
Stress is posited to get under the skin
via different biological pathways
including the hypothalamic-pituitary-
adrenal (HPA) system
People may differ in terms of
psychological, biological and
behavioural response to stressors
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Frameworks of Health Determinants (III)
Wellbeing Prosperity
Individual
Responses:
Behavior
Biology
Social
Environment
Physical
Environment
Genetic
Endowment
Health
&
FunctionDisease
Health
Care
Source: Evans and Stoddart, 1994.
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Outline
A. What are the major categories of globalhealth determinants?
B. What are the most important?
C. What are their relative contributions indetermining global health?
D. Exercise
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Kunst A 1998.
Fig. 1. Probability of men in non-manual and manual classes dying between the ages 45 and 65.
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Figure 3. Under-5 mortality rates by socioeconomic quintile of the household for selectedcountries based on data taken from the World Bank.
Victora et al. Lancet 2003;362:233-41
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Source: Davey-Smith (1996) Age adjusted mortality of 300 685 white American men by median family
income of zip code areas in the United States. AJPH 1996;86:497-504.
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1. The sport of choice for the urban poor is
BASKETBALL.
2. The sport of choice for maintenance level employees
is BOWLING.
3.The sport of choice for front-line workers isFOOTBALL.
4. The sport of choice for supervisors is BASEBALL.
5. The sport of choice for middle management is TENNIS.
6. The sport of choice for corporate officers is GOLF.
Socioeconomic status and sport of choice
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Figure Life expectancy among males and females in India compared with United States, mid-1990
from Sen (2002)
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Inequality and health worlwide
Babones (2007) Social Sciences
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Source: De Vogli R, Mistry R, Gnesotto R and Cornia GA (2005) Has the relation between income
inequality and life expectancy disappeared? J Epidemiology and Community Health
Income inequality and life expectancy among wealthy nations
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Fig. 1. Mortality in working age men by proportion of income belonging to the less well off half of households, US states
(1990) and Canadian provinces (1991). Mortality standardised to Canadian population in 1991.State abbreviations: LA-Louisiana; MS-Mississippi; AL-Alabama; SC-South Carolina; FL-Florida; TX-Texas; CA-California; AR-Arkansas;
NH-New Hampshire; MN-Minnesota. Province abbreviations: QC-Quebec; NS-Nova Scotia; NB-New Brunswick; ND-Newfoundland;
PE-Prince Edward Island; ON-Ontario; AB-Alberta; BC-British Columbia; MB-Manitoba; SK-Saskatchewan
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Outline
A. What are the major categories of globalhealth determinants?
B. What are the most important?
C. What are their relative contributions indetermining global health?
D. Exercise
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WHO (2002). GLOBAL RISK FACTORS. High-mortality, developing REGIONS=subregions in D and E mortality strata. Lower-mortality, developing
REGIONS=AMR-B, EMR-B, SEAR-B, and WPR-B subregions. Developed REGIONS=AMR-A, EUR, and WPR-A. The figure shows the estimate d
mortality and disease burden for each risk factor considered individually. These risks act in part through other risks and act jointly with other risks.
Consequently, the burden due to groups of risk factors will usually be less than the sum of individual risks.
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WHO (2002).
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Relative Influence of Health Determinants
Societal/social
characteristics
Total Ecology
Genes & Biology
Health Behaviors
Health Care
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Now I can see the real picture