Stephen Bezruchka, MD, MPH

Department of Global Health & Health Services

School of Public Health

University of Washington

Health as a SOCIETAL RIGHT

AgendaFirst two sessions

– Spirit Level– Rationing of health care

Health as a societal right?

Determinants of Health in Rich Countries

Global Health today

A theory of Global Health

AgendaFirst two sessions

– Spirit Level– Rationing of health care

Health as a societal right?

Determinants of Health in Rich Countries

Global Health today

A theory of Global Health

UNFAMILIAR IDEAS– Intergenerational

transmission of health– Biology underlying

inequality

(first paragraph) "There is no known biological reason why every population should not be as healthy as the best."

So Far…..

Health as a SOCIETAL RIGHT

Societal right?

SOCIETAL RIGHT

MEDLINE:

Religious racism

Equity, food security and health equity in the Asia Pacific Region

Ruptures, rights and repair: the political economy of trauma in Haiti

SOCIETAL RIGHT ..

Social Right..

Human right

"rights are context bound"

EARTH/GLOBAL RIGHTS

GLOBAL HEALTH

Spatial-temporal spectrum of human health around the globe– cut across political and cultural units– very little non-national data exist

Human health measured by mortality indicators– IMR, life expectancy,

• healthy life expectancy, disability adjusted life expectancy– Quality of life and well-being related to mortality

World systems analysis

Japan 82.2 Denmark Palestine Thailand Tajikistan UgandaSwitzerland Cuba Colombia Peru India 63.6 Mali Australia United States Lithuania Egypt Kazakhstan Burkina FasoSweden Portugal Bulgaria Nicaragua Pakistan EthiopiaCanada Korea, Lebanon Morocco Bangladesh KenyaItaly Czech Republic Saudi Arabia Turkey Turkmenistan South Africa Israel Uruguay China 71.9 Belarus Nepal TanzaniaSpain Mexico Armenia Moldova, Yemen Côte d'IvoireNorway Croatia Jordan Honduras Myanmar CameroonFrance Panama Romania Guatemala Ghana NigerNew Zealand Argentina Algeria Dominican Republic Cambodia RwandaAustria Poland Paraguay Indonesia Sudan BurundiBelgium Ecuador El Salvador Kyrgyzstan Senegal ChadGermany Slovakia Brazil Azerbaijan PNG Congo (DR)Singapore Bosnia Herzegovina Viet Nam Uzbekistan Madagascar NigeriaFinland Sri Lanka Philippines Ukraine Lao Eq GuineaNetherlands Macedonia, Iran, Russian Federation Togo MozambiqueUnited Kingdom Albania Georgia Bolivia 64.4 Eritrea AngolaGreece Libya Benin Sierra LeoneCosta Rica Syria Guinea MalawiUAE Tunisia Mauritania CARChile Malaysia Djibouti ZambiaIreland Hungary Congo Zimbabwe

Venezuela 73 Haiti Swaziland 31

LIFE EXPECTANCY RANGE

Health Olympics 2004 UNDP HDR 2006

9.2 YEARS 8.3 YEARS 32 YEARS

1629 million 2693 million 2256 million

2007/09Gap 40years

1990/93Gap 37

GLOBALHEALTH

Your thoughts on global health disparities?

RICH COUNTRIES

How healthy is the US?Health Olympics

Number one Gold 1-5 _______6-10 _______11-15 _______

16-20 _______21-25 _______26-30 _______31+ _______

United Nations Human Development Report 2009

HEALTH OLYMPICS 2007

5

15

10

2520

30

WHO 2009

Health Olympics Age 50 (2006)

Japan

Austra

lia

Switzer

land

Andorra

France

Italy

Icel

and

Spain

Canad

a

New Z

eala

ndIs

rael

Sweden

Norway

Austria

Cypru

s

Greec

e

Germ

any

Nether

lands

Belgiu

m

Finla

nd

Irela

nd

Portugal

Costa

Rica

United K

ingdom

Mal

ta

United S

tate

s

Korea,

Rep

.

Chile

Panam

a

Cuba

Denm

ark

30.0

30.5

31.0

31.5

32.0

32.5

33.0

33.5

34.0

34.5

35.0

10

20

5

15

25

30

year

s

GETTING TO RETIREMENT

Mu

nn

ell 2

004

FALLING BEHIND

INFANT MORTALITY

SCF State of the World's Mothers 2004

In Phillips County,Arkansas, the birth rate among teenage girls in 2000 was 127 births per 1,000 women aged 15 to 19 - a rate higher than in 94 developing countries.

A fifth of 20-yr old women who gave birthin the US gave birth did so in their teens

TEEN BIRTHS

0 2 4 6 8 10 12

Japan

France

Germany

Spain

Greece

UK

Czech Republic

Portugal

Belgium

Hungary

Italy

Denmark

Netherlans

Australia

Poland

Canada

Korea

New Zealand

USA

*Austria, Finland, Ireland, Norway, Sweden and Switzerland had fewer than 20 deaths reported and therefore rates were not calculated.

Youth violence Olympics—Homicide rates among youth aged 10-29 (most recent year available) from the World Health Organizations’ World Report on Violence and Health, 2002*

YOUTH HOMICIDE

MEDICAL STUDENTS

DON'T KNOW POPULATION

HEALTH

1st & 4th yr US medical student knowledge of Population Health

(2002)Question First Year

INCORRECTFourth Year

INCORRECT

US has higher life expectancy than any other nation?

28.3% 34.4%

US has lower infant mortality than any other nation?

40.6% 30.2%

Agrawal et. al. (2005)

Population Health Concepts

Health has been improving most of the last century

Health improvements are not shared equally

Poorer people have poorer healthEarly life is most critical period for

health

Where is our health?

Female Life Expectancy by County 1990 C. Murray, Harvard, 1998

Female Life Expectancy70.0 to 77.1

77.1 to 78.1

78.1 to 78.6

78.6 to 79.1

79.1 to 79.6

79.6 to 80.1

80.1 to 80.8

80.8 to 90.0

Life Expectancy

CLOSER TO HOME

Cascadia2002NW Env Wa

Sightline

Population Health Concepts

Health has been improving most of the last century

Health improvements are not shared equally

Poorer people have poorer healthEarly life is most critical period for

health

Health and Social Problems are not Related to Average Income in Rich Countries

Index of: • Life expectancy• Math & Literacy • Infant mortality• Homicides• Imprisonment• Teenage births • Trust• Obesity• Mental illness – incl.

drug & alcohol addiction

• Social mobility

Source: Wilkinson & Pickett, The Spirit Level (2009) www.equalitytrust.org.uk

Index of: • Life expectancy• Math & Literacy • Infant mortality• Homicides• Imprisonment• Teenage births • Trust• Obesity• Mental illness – incl.

drug & alcohol addiction

• Social mobility

Health and Social Problems are Worse in More Unequal Countries

Source: Wilkinson & Pickett, The Spirit Level (2009) www.equalitytrust.org.uk

Davidson's textbook of Medicine 2006, pg 97

"Recent research suggests that uneven distribution of wealth is a more important determinant of health than the absolute level of wealth as measured by the GDP;

Countries that have a narrower or more even distribution of wealth enjoy longer life expectancies than countries with similar or higher GDPs but wider distributions of wealth.

The mechanism is not understood."

Population Health Concepts

Health has been improving most of the last century

Health improvements are not shared equally

Poorer people have poorer healthEarly life is most critical period for

health

womb with a view

Newsweek September 27, 1999

EARLY LIFE

pathway

latent

cumulative

Life begins atConception Ends at Birth

The daughterIs the motherOf the woman

CONCEPTION

Epigenetics

Do POORER PeopleHave POORER PROTOPLASM?

INFLAMMATION

Ranjit et. al. 2007

MESA US Cohort

<$20k

$20-50k

$≥50k

Ranjit et. al. 2007

MESA US Cohort

<$20k

$20-50k

$≥50k

Hegewald et. al. 2007

Hegewald et. al. 2007

Intergenerational Stress Prenatal psychosocial

stress Pregnancy stress:

divorce, breakup, paternity denial, marital infidelity, death of partner, parent, child, illness in other (cancer, MI, stroke), financial problems (loss of house by flooding, husband unemployed, foreclosure, MVA, unmarried (father not accepted by family), political refugee

Cytokine production in women offspring (34 subjects and 28 comparison) mean age 24, healthy

(Entringer et.al. 2008)

Activationin vitro phytohemaglutinin (PHA) induced cytokine production

Efficacy not tested

Production: no difference

Entringer et. al. 2008IFN interferon

PSCG

IMMUNE SYSTEM TESTING of lymphocytes:

PS = Prenatal Stress

CHRONICDISEASE RISK

Disease approach

Birth DEATH

CHRONICDISEASE RISK

Health Care and Risk factor approach

Birth DEATH

"As dramatic and consequential as medical care is for individual cases and for specific conditions, much evidence suggests that such care is not and probably never has beenthe major determinant of levels or changes in population health." Pg 4.

OTHER COUNTRIES

There walk the earth now both the richest people who ever lived and the poorest. Clark 2007

WORLD INCOME TRENDS LAST 3000 YEARS

There walk the earth now both the richest people who ever lived and the poorest. Clark 2007

Smits & Monden 2009

Distribution of length of life for males in Niger, Brazil and Japan in 2000

BIG PICTUREDETERMINANTS OF HEALTH

communities, SOCIETIES, global

BASIC NEEDS (food, water, shelter)

Nature of caring and sharing relationships or

quality of SOCIETAL relationships

health care

Population Health Concepts

Health declined with development of agriculture

“Agriculture has long been regarded as an improvement in the human condition: Once Homo sapiens made the transition from foraging to farming in the Neolithic, health and nutrition improved, longevity increased, and work load declined. Recent study of archaeological human remains worldwide by biological anthropologists has shown this characterization of the shift from hunting and gathering to agriculture to be incorrect. Contrary to earlier models, the adoption of agriculture involved an overall decline in oral and general health.” (Larsen, C. S. (1995). "Biological changes in human populations with agriculture." Annual Review of Anthropology)

Health Declined with agriculture

Sub-SaharanAfrica

Russia

Present (1990) (1900) 1000 10000 100,000

Y e a r s b e f o r e p r e s e n t ( l o g s c a l e )

Japan

USA

Rome

Paleolithic

20

30

50

60

70

80

40

Life Expectancy Trends: Paleolithic On

Hassan 1981

Countries ranking in healthWHY?

Theory of Global Health1. Where they ranked when the race

started

2. When did health begin to improve

3. Mix of factors influencing health improvements

GLOBAL HEALTHHISTORY

World health by colonial troop

mortality

Curtin 1968

Curtin 1968

Curtin 1998

Curtin 1998

Curtin 1989

World health before health started improving?

End of Euro-Colonialism

End of Cold War

Global Economic Collapse

1960s 1990s 2010s

HEALTH HISTORY TRANSITIONS

Euro-Colonialism

TropicalMedicine

Internationalhealth

GLOBALHEALTH

?Populationhealth

MilitaryMedicine

1500s

Easterlin 1999

When did health start improving?

Hundreds of years ago:Life Expectancy increased

after childhood

CHILDHOOD"The history of childhood is a

nightmare from which we have only recently begun to awaken. The further back in history one goes the lower the level of child care, and the more likely children are to be killed, abandoned, beaten, terrorized and sexually abused."

DeMause The History of Childhood 1974

Leigh & Jencks 2007

Factors influencing health improvements

Colonizing country or not

Type of colonialism experienced

Societal and political policies

Economic issues: rapid growth or not

Cultural factors

Global Health Determinants

Where countries were in the health olympics starting blocks

Colonial history 3 groups:

1 few Europeans settled (PEASANT COLONIES) – societies were peasant colonies with Europeans as

administrators or tax collectors or exploiters• plantations dominated economy in some places

– Europeans didn't stay in power after independence– Outcomes depended on how much Europeans

helped local elites to plunder– India, Nigeria, Sri Lanka

Global Health DeterminantsWhere countries were in the health olympics starting blocks

Colonial history:

2 Europeans settled as a minority (SETTLER COLONIES) – Tended to expropriate land and resources– Used indigenous peoples labor, imported slaves

• Plantations, mining in Americas• Locals often not allowed to own land

– After independence Europeans remained in power• Colonial system prevailed with elite exploitation

– South Africa, Zimbabwe, Latin America

Global Health DeterminantsWhere countries were in the health olympics starting blocks

Colonial history:

3 Europeans settled as a majority (NEW EUROPE COLONIES) – Wiped out local peoples– Adopted systems similar to homeland Europe– Where there was more slavery, there was a greater

hierarchy and worse health outcomes

Wilkinson & Pickett 2009 Spirit Level

Health Outcomes Map 2000 (Hegyvary, Berry, & Murua, Journal of Public Health Policy, 2008)

Life Expectancy

Ch

ild M

ort

alit

y (

log

sc

ale

)

How do child mortality and life expectancy vary throughout the world?

1

2

3

PRECOLONIAL INSTITUTIONS

affect

Colonial

Postcolonial AFRICAN GOVERNMENTS

PRECOLONIAL: – Centralized (politically not fragmented) ethnic

groups where chiefs accountable to traditional authority • Can modernize better• Less tyranny, disorder halting modernization

PRECOLONIAL CENTRALIZATION: – In modern era, benefits public goods provision in

stratified more than in egalitarian gorups– High Geographic Spillover: roads, immunization

benefits both stratified & egalalitarian groups– Education, IMR benefits stratified but not egalitarian

(where already have less local tyranny)

Precolonial African Centralization and IMR decline

Gennaioli et al. 2007

Precolonial African Centralization and paved roads

Gennaioli et al. 2007

Precolonial African Centralization and adult literacy

Gennaioli et al. 2007

Health Determinants of nationsWhere countries were in the health olympics starting blocks History of poor health affects cohort & subsequent

generationsHow well they provided basic needs (food)How much they support early lifeHow much they support ALL (social welfare systems)Sense of community, social capitalCulture, values, ethos Political systems: especially redistributive policies

– "educated, capable, and demanding public" (Caldwell 1986)

Economic growth (up to ~1850 ↑living standards), then whether rapid & shared or not, if not shared, can worsen health

Hierarchy details: economic, social Access to health carePublic health programs

GLOBAL HEALTH

Spatial-temporal spectrum of human health around the globe– cut across political and cultural units– very little non-national data exist

Human health measured by mortality indicators– IMR, life expectancy,

• healthy life expectancy, disability adjusted life expectancy– Quality of life and well-being related to mortality

World systems analysis

BIG PICTUREDETERMINANTS OF HEALTHcommunities, nations, global

BASIC NEEDS

Nature of caring and sharing relationships or

quality of social relationships

health care

Life course

Life course approach

Timely intervention

CHRONICDISEASE RISK

CONCEPTION DEATH

Trans-generational

PRIMORDIAL PREVENTIONHEALTH approach

Timely intervention

CHRONICDISEASE RISK

Conception DEATH

EARLY LIFE LASTS MANY LIFETIMES

Factors influencing health improvements

Colonizing country or not

Type of colonialism experienced

Societal and political policies

Economic issues: rapid growth or not

Cultural factors

Health Determinants of nationsWhere countries were in the health olympics starting blocks

Provided basic needs (food) Forager-Hunters, UK (WWII)How much they support early life SWEDENHow much they support ALL (societal welfare systems)

CUBASense of community, social capital OKINAWACulture, values, ethos JAPANPolitical systems: especially redistributive policies NORDIC,

KERALA, USA

– "educated, capable, and demanding public"

Economic growth (up to ~1850 ↑living standards), then whether rapid & shared or not, if not shared, can worsen health

Hierarchy details: economic, societal Access to health care, Public health programs

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(last paragraph) "The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social. Medicine and politicscannot and should not be kept apart."

(first paragraph) "There is no known biological reason why every population should not be as healthy as the best."