introduction to global health dr yoga nathan senior lecturer in public health gems ul
TRANSCRIPT
Introduction to Global Introduction to Global HealthHealth
Dr Yoga NathanDr Yoga Nathan
Senior Lecturer in Public HealthSenior Lecturer in Public HealthGEMS ULGEMS UL
Learning ObjectiveLearning Objective
To understand To understand the link between water, the link between water, sanitation and health from a global sanitation and health from a global perspective.perspective.
To understand the environmental, To understand the environmental, social, economic and political factors social, economic and political factors playing a role in cholera. playing a role in cholera.
DefinitionDefinition
What is What is global healthglobal health??
• Health problems, issues, and concerns Health problems, issues, and concerns that transcend national boundaries, that transcend national boundaries, which may be influenced by which may be influenced by circumstances or experiences in other circumstances or experiences in other countries, and which are best addressed countries, and which are best addressed by cooperative actions and solutions by cooperative actions and solutions (Institute Of Medicine, USA- 1997)(Institute Of Medicine, USA- 1997)
Global Health IssuesGlobal Health Issues
Refers to any health issue that concerns Refers to any health issue that concerns many countries or is affected by many countries or is affected by transnational determinants such as:transnational determinants such as:• Climate changeClimate change• UrbanisationUrbanisation• Malnutrition – under or over nutritionMalnutrition – under or over nutrition
Or solutions such as:Or solutions such as:• Polio eradicationPolio eradication• Containment of avian influenzaContainment of avian influenza• Approaches to tobacco controlApproaches to tobacco control
Historical Development of TermHistorical Development of Term Public HealthPublic Health: Developed as a discipline in the mid : Developed as a discipline in the mid
1919thth century in UK, Europe and US. Concerned more century in UK, Europe and US. Concerned more with national issues.with national issues.• Data and evidence to support action, focus on populations, Data and evidence to support action, focus on populations,
social justice and equity, emphasis on preventions vs cure.social justice and equity, emphasis on preventions vs cure.
International HealthInternational Health: Developed during past : Developed during past decades, came to be more concerned with decades, came to be more concerned with • the diseases (e.g. tropical diseases) and the diseases (e.g. tropical diseases) and • conditions (war, natural disasters) of middle and low income conditions (war, natural disasters) of middle and low income
countries. countries. • Tended to denote a one way flow of ‘good ideas’.Tended to denote a one way flow of ‘good ideas’.
Global Health:Global Health: More recent in its origin and More recent in its origin and emphasises a greater scope of health problems and emphasises a greater scope of health problems and solutions solutions • that transcend national boundariesthat transcend national boundaries• requiring greater inter-disciplinary approachrequiring greater inter-disciplinary approach
Disciplines involved in Global Disciplines involved in Global HealthHealth
Social sciencesSocial sciences Behavioural sciencesBehavioural sciences LawLaw EconomicsEconomics HistoryHistory EngineeringEngineering Biomedical sciencesBiomedical sciences Environmental sciencesEnvironmental sciences
Communicable Diseases and Risk Communicable Diseases and Risk FactorsFactors
Infectious diseases are communicableInfectious diseases are communicable
But.. But..
so are elements of western lifestyles:so are elements of western lifestyles:• Dietary changesDietary changes• Lack of physical activityLack of physical activity• Reliance on automobile transportReliance on automobile transport• SmokingSmoking• StressStress• UrbanisationUrbanisation
It’s the Real ThingIt’s the Real Thing
Key Concepts in Relation to Global Key Concepts in Relation to Global HealthHealth
1.1. The determinants of healthThe determinants of health
2.2. The measurement of health statusThe measurement of health status
3.3. The importance of culture to healthThe importance of culture to health
4.4. The global burden of diseaseThe global burden of disease
5.5. The key risk factors for various The key risk factors for various health problemshealth problems
6.6. The organisation and function of The organisation and function of health systemshealth systems
1. Determinants of Health1. Determinants of Health Genetic make upGenetic make up AgeAge GenderGender Lifestyle choicesLifestyle choices Community influencesCommunity influences Income statusIncome status Geographical locationGeographical location CultureCulture Environmental factorsEnvironmental factors Work conditionsWork conditions EducationEducation Access to health Access to health servicesservices
Source: Dahlgren G. and Whitehead M. 1991
Determinants of Health Determinants of Health
PLUS MORE GENERAL FACTORS PLUS MORE GENERAL FACTORS SUCH AS:SUCH AS:
POLITICAL STABILITYPOLITICAL STABILITY CIVIL RIGHTSCIVIL RIGHTS ENVIRONMENTAL DEGRADATIONENVIRONMENTAL DEGRADATION POPULATION GROWTH/PRESSUREPOPULATION GROWTH/PRESSURE URBANISATIONURBANISATION DEVELOPMENT OF COUNTRY OF DEVELOPMENT OF COUNTRY OF
RESIDENCERESIDENCE
Multi-sectoral Dimension of the Multi-sectoral Dimension of the Determinants of HealthDeterminants of Health
Malnutrition – Malnutrition – • more susceptible to disease and less likely to more susceptible to disease and less likely to
recoverrecover Cooking with wood and coal – Cooking with wood and coal –
• lung diseaseslung diseases Poor sanitation – Poor sanitation –
• more more intestinal infectionsintestinal infections Poor life circumstances – Poor life circumstances –
• commercial sex work and STIs, HIV/AIDScommercial sex work and STIs, HIV/AIDS Advertising tobacco and alcohol –Advertising tobacco and alcohol –
• addiction and related diseasesaddiction and related diseases Rapid growth in vehicular traffic often with Rapid growth in vehicular traffic often with
untrained drivers on unsafe roads- untrained drivers on unsafe roads- • road traffic accidents road traffic accidents
2. The Measurement of Health Status I2. The Measurement of Health Status I Cause of deathCause of death
• Obtained from death certification but limited Obtained from death certification but limited because of incomplete coveragebecause of incomplete coverage
Life expectancy at birthLife expectancy at birth• The average number of years a new-borns The average number of years a new-borns
baby could expect to live if current trends in baby could expect to live if current trends in mortality were to continue for the rest of the mortality were to continue for the rest of the new-born's lifenew-born's life
Maternal mortality rateMaternal mortality rate• The number of women who die as a result of The number of women who die as a result of
childbirth and pregnancy related complications childbirth and pregnancy related complications per 100,000 live births in a given yearper 100,000 live births in a given year
The Measurement of Health Status IIThe Measurement of Health Status II Infant mortality rateInfant mortality rate
• The number of deaths in infants under 1 year The number of deaths in infants under 1 year per 1,000 live births for a given yearper 1,000 live births for a given year
Neonatal mortality rateNeonatal mortality rate• The number of deaths among infants under 28 The number of deaths among infants under 28
days in a given year per 1,000 live births in days in a given year per 1,000 live births in that yearthat year
Child mortality rateChild mortality rate• The probability that a new-born will die before The probability that a new-born will die before
reaching the age of five years, expressed as a reaching the age of five years, expressed as a number per 1,000 live birthsnumber per 1,000 live births
3. Culture and Health3. Culture and Health Culture:Culture:
• The predominating attitudes and behaviour The predominating attitudes and behaviour that characterise the functioning of a group or that characterise the functioning of a group or organisationorganisation
Traditional health systemsTraditional health systems Beliefs about health Beliefs about health
• e.g. epilepsy – a disorder of neuronal e.g. epilepsy – a disorder of neuronal depolarisation vs a form of possession/bad depolarisation vs a form of possession/bad omen sent by the ancestorsomen sent by the ancestors
• Psychoses – ancestral problems requiring the Psychoses – ancestral problems requiring the assistance of traditional healer/spiritualistassistance of traditional healer/spiritualist
Influence of culture of healthInfluence of culture of health• Diversity, marginalisation and vulnerability due Diversity, marginalisation and vulnerability due
to race, gender and ethnicityto race, gender and ethnicity
4. The global burden of disease4. The global burden of disease Predicted changes in burden of disease Predicted changes in burden of disease
from communicable to non-communicable from communicable to non-communicable between 2004 and 2030between 2004 and 2030• Reductions in malaria, diarrhoeal diseases, Reductions in malaria, diarrhoeal diseases, TB TB
and HIV/AIDSand HIV/AIDS• Increase in cardiovascular deaths, COPD, road Increase in cardiovascular deaths, COPD, road
traffic accidents and diabetes mellitustraffic accidents and diabetes mellitus
Ageing populations in middle and low Ageing populations in middle and low income countriesincome countries
Socioeconomic growth with increased car Socioeconomic growth with increased car ownershipownership
Based on a ‘business as usual’ assumptionBased on a ‘business as usual’ assumption
High Fertility/High MortalityHigh Fertility/High Mortality
Source: US Census Bureau, Population Report
Declining Mortality/High FertilityDeclining Mortality/High Fertility
Source: US Census Bureau, Population Report
Reduced Fertility/Reduced MortalityReduced Fertility/Reduced Mortality
Source: US Census Bureau, Population Report
5. Key Risk Factors for Various 5. Key Risk Factors for Various Health ConditionsHealth Conditions
Tobacco useTobacco use – – • related to the top ten causes of mortality world related to the top ten causes of mortality world
wide wide Poor sanitation and access to clean water-Poor sanitation and access to clean water-
• related to high levels of diarrhoeal/water related to high levels of diarrhoeal/water borne diseases borne diseases
Low condom useLow condom use – – • HIV/AIDS, sexually transmitted infectionsHIV/AIDS, sexually transmitted infections
Malnutrition Malnutrition – – • Under-nutrition (increased susceptibility to Under-nutrition (increased susceptibility to
infectious diseases) and over-nutrition infectious diseases) and over-nutrition responsible for cardiovascular diseases, responsible for cardiovascular diseases, cancers, obesity etc.cancers, obesity etc.
6. The Organisation and Function 6. The Organisation and Function of Health Systemsof Health Systems
A health system A health system • comprises all organizations, institutions and comprises all organizations, institutions and
resources devoted to producing actions resources devoted to producing actions whose primary intent is to improve health whose primary intent is to improve health (WHO)(WHO)
Most national health systems Most national health systems consist:consist:• public, private, public, private, • traditional and informal sectors:traditional and informal sectors:
Source: W.H.O. Statistics
Source: WHO statistics 2008
Trends in Global Deaths 2002-30Trends in Global Deaths 2002-30
Source: World Health Statistics 2007
COMPARATIVE DATA (1)COMPARATIVE DATA (1)
IRELANDIRELANDDEVELOPING DEVELOPING COUNTRIESCOUNTRIES
INFANT MORTALITY INFANT MORTALITY 7 7 100-190100-190RATERATE
UNDER 5 MORTALITY UNDER 5 MORTALITY 10 10 175-300175-300RATERATE
MATERNAL MORTALITY MATERNAL MORTALITY 2 2 600-1600600-1600RATERATE
LIFE EXPECTANCY LIFE EXPECTANCY F - 82 F - 82 F < 50F < 50 M - 77M - 77 M < 50 M < 50
but may but may be be
= or > F= or > F
COMPARATIVE DATA (2)COMPARATIVE DATA (2)
IRELANDIRELANDDEVELOPING DEVELOPING COUNTRIESCOUNTRIES
POPULATION GROWTH POPULATION GROWTH 0.3% 0.3% 3%+ 3%+RATERATE
HIV +ve RATEHIV +ve RATE 0.15% 0.15% 15%+15%+
AIDS CASESAIDS CASES 20/ 20/ 400/400/ 100,000 100,000
100,000100,000
GNP PER CAPITAGNP PER CAPITA $16,000 $16,000 <$200<$200
HEALTH EXPENDITUREHEALTH EXPENDITURE $1,600 $1,600 $1-$2$1-$2PER CAPITAPER CAPITA
HEALTH PATTERNSHEALTH PATTERNS
GENETIC FACTORSGENETIC FACTORS ENVIRONMENTAL FACTORSENVIRONMENTAL FACTORS LIFESTYLE FACTORSLIFESTYLE FACTORS
COMMUNICABLE vs NON-COMMUNICABLE COMMUNICABLE vs NON-COMMUNICABLE
DISEASESDISEASES DISEASES DISEASES
HEALTH PATTERNS IN HEALTH PATTERNS IN RESOURCE POOR COUNTRIESRESOURCE POOR COUNTRIES
INFECTIOUS/COMMUNICABLE DISEASES PREVALENT:INFECTIOUS/COMMUNICABLE DISEASES PREVALENT: VACCINE PREVENTABLE DISEASES, e.g. measlesVACCINE PREVENTABLE DISEASES, e.g. measles ACUTE RESPIRATORY INFECTIONS (ARI)ACUTE RESPIRATORY INFECTIONS (ARI) DIARRHOEAL DISEASES (cholera)DIARRHOEAL DISEASES (cholera) MALARIAMALARIA TBTB HEPATITISHEPATITIS HIV/AIDSHIV/AIDS
Plus: Plus: MALNUTRITION RELATED CONDITIONS:MALNUTRITION RELATED CONDITIONS: - CALORIE DEFICIENCIES- CALORIE DEFICIENCIES - MICRO-NUTRIENT DEFICIENCIES- MICRO-NUTRIENT DEFICIENCIES TRAUMA/ACCIDENTSTRAUMA/ACCIDENTS
Many of these diseases are treatableMany of these diseases are treatable
HEALTH PATTERNS IN HEALTH PATTERNS IN RESOURCE RICH COUNTRIESRESOURCE RICH COUNTRIES
NON-COMMUNICABLE DISEASES PREVALENT:NON-COMMUNICABLE DISEASES PREVALENT: Causes of death (all ages):Causes of death (all ages): 40% Circulatory diseases, e.g. heart disease, 40% Circulatory diseases, e.g. heart disease,
strokes, etc.strokes, etc. 25% Cancers25% Cancers 16% Respiratory diseases16% Respiratory diseases 5% Injuries and Poisonings5% Injuries and Poisonings 0.6% Infectious diseases0.6% Infectious diseases
Premature mortality (<65):Premature mortality (<65): 25% 25% Circulatory diseasesCirculatory diseases 33% Cancers33% Cancers 16% 16% Injuries (RTAs/Suicides) and PoisoningsInjuries (RTAs/Suicides) and Poisonings 1% Infectious diseases1% Infectious diseases
Many of these deaths are related to lifestyle factors Many of these deaths are related to lifestyle factors and are preventableand are preventable
HEALTH PATTERNS IN RESOURCE HEALTH PATTERNS IN RESOURCE RICH COUNTRIESRICH COUNTRIES
Lifestyle factors affecting physical Lifestyle factors affecting physical and mental health:and mental health:
Smoking – one third of cancer deaths Smoking – one third of cancer deaths related to smokingrelated to smoking
DrinkingDrinking Healthy eating/nutritionHealthy eating/nutrition Physical activityPhysical activity Substance abuseSubstance abuse
Cholera 1800sCholera 1800s
Cholera: the DiseaseCholera: the Disease
Entry: oralEntry: oral ColonizationColonization: small : small
intestineintestine Symptoms: Symptoms:
nausea, diarrhea, nausea, diarrhea, muscle cramps, muscle cramps, shockshock
Infants with Infants with choleracholera
First Cholera PandemicFirst Cholera Pandemic
Second Cholera PandemicSecond Cholera Pandemic
John Snow and the Pump HandleJohn Snow and the Pump Handle
John Snow is credited by John Snow is credited by many with developing many with developing the modern field of the modern field of epidemiologyepidemiology
John Snow and cholera in John Snow and cholera in 1854 London 1854 London http://www.ph.ucla.edu/http://www.ph.ucla.edu/epi/snow.htmlepi/snow.html
London in the 1850’sLondon in the 1850’s• Germ theory of disease Germ theory of disease
not widely accepted not widely accepted
People lived in very People lived in very crowded conditions crowded conditions with water and privies with water and privies in yard (NY 1864: 900 in yard (NY 1864: 900 people in 2 buildings people in 2 buildings 180’ deep x 5 stories 180’ deep x 5 stories – 1 pump a block – 1 pump a block away, privy in yard)away, privy in yard)
John Snow’s ObservationsJohn Snow’s Observations People with cholera developed People with cholera developed
immediate digestive problems: cramps, immediate digestive problems: cramps, vomiting, diarrheavomiting, diarrhea
Face, feet, hands shriveled and turned Face, feet, hands shriveled and turned blue; died in less than a dayblue; died in less than a day
Probably spread by vomiting and Probably spread by vomiting and diarrheadiarrhea
Comparison of pump location with Comparison of pump location with cholera deaths, first 3 days of epidemic cholera deaths, first 3 days of epidemic in 1854in 1854
Water Supply London 1850’sWater Supply London 1850’s
Cholera EpidemiologyCholera Epidemiology
Of 83 people, only 10 lived Of 83 people, only 10 lived closer to a different pump closer to a different pump than Broad Streetthan Broad Street
Of these 10, 5 preferred taste Of these 10, 5 preferred taste of Broad Street water and 3 of Broad Street water and 3 were children who went to were children who went to nearby schoolnearby school
Snow Index CaseSnow Index Case
Index caseIndex case is first person to is first person to become illbecome ill
40 Broad Street – husband and 40 Broad Street – husband and infant child became illinfant child became ill
Wife soaked diapers in pail and Wife soaked diapers in pail and emptied pail into cistern next to emptied pail into cistern next to pumppump
The Great ExperimentThe Great Experiment Two water companies supplied Two water companies supplied
central Londoncentral London Lambeth Company: water Lambeth Company: water
intake upstream of London intake upstream of London sewage outfall into Thamessewage outfall into Thames
Southwark & Vauxhall Southwark & Vauxhall Company: water intake Company: water intake downstream of sewage outfalldownstream of sewage outfall
The Great ExperimentThe Great Experiment Customers mixed in same Customers mixed in same
neighborhoodneighborhood Snow went door to door Snow went door to door
asking which water asking which water company served home company served home and compared locations and compared locations with cholera datawith cholera data
The Great ExperimentThe Great Experiment
# Houses # DeathsDeaths/
100,000
S and V 40,046 1263 315
Lambeth 26,107 98 37
Cholera EpidemiologyCholera Epidemiology Snow convinced Snow convinced
neighborhood council to let neighborhood council to let him remove handle from him remove handle from water pump on Broad Streetwater pump on Broad Street
The new cases declined The new cases declined dramaticallydramatically
Many on council not Many on council not convinced by his evidenceconvinced by his evidence
Cholera in the 1990sCholera in the 1990s
Epidemic in Peru beginning Epidemic in Peru beginning 19911991
From 1991-1994From 1991-1994•Cases 1,041,422Cases 1,041,422•Deaths 9,642 (0.9%)Deaths 9,642 (0.9%)
Originated at coast, spread Originated at coast, spread inlandinland
World Cholera 2000-01World Cholera 2000-01
Why Has Cholera Re-emerged?Why Has Cholera Re-emerged? Deteriorating sanitary facilities Deteriorating sanitary facilities
as larger population moves into as larger population moves into shanty townsshanty towns
Trujullo, Peru – fear of cancer Trujullo, Peru – fear of cancer from chlorination so water from chlorination so water untreateduntreated
Use of wastewater on cropsUse of wastewater on crops Africa – civil wars and drought Africa – civil wars and drought
caused migrations into campscaused migrations into camps
How Has Cholera Re-emerged?How Has Cholera Re-emerged? Simultaneous appearance Simultaneous appearance
along whole coast of Perualong whole coast of Peru Traveled in ship ballast?Traveled in ship ballast? Traveled in plankton from Traveled in plankton from
Asia?Asia? Always present in local Always present in local
zooplankton (copepods) but zooplankton (copepods) but dormant until triggered by ???dormant until triggered by ???
Copepod Carrying Copepod Carrying Vibrio Vibrio choleraecholerae
Global Health ReferencesGlobal Health References Skolnik R. Skolnik R. Essentials of Global HealthEssentials of Global Health. Jones & . Jones &
Bartlett Publishers, Sudbury MA 2008. Chapter 1Bartlett Publishers, Sudbury MA 2008. Chapter 1 Ed. Robert Beaglehole, 2003Ed. Robert Beaglehole, 2003. . Global Public Global Public
Health: A new era. Chapter 1Health: A new era. Chapter 1 Megan Landon. 2006. Megan Landon. 2006. Environment, Health Environment, Health
and Sustainable Developmentand Sustainable Development Bonder, B. Martin L. Miracle A. Bonder, B. Martin L. Miracle A. Culture in Culture in
Clinical CareClinical Care Koplan J et al, 2009.Koplan J et al, 2009. Towards a common Towards a common
definition of global health definition of global health The Lancet, Volume The Lancet, Volume 373, Issue 9679, Pages 1993-1995373, Issue 9679, Pages 1993-1995