Gunilla Krantz MD, ProfessorInstitute of Medicine /Epidemiology and Social Medicine, EPSOSahlgrenska AcademyUniversity of GothenburgE-mail: [email protected]
www.epso.gu.se
What is Global Health
This session will…
• Give a short background to Global Health as a topic in science; • Introduce global public health principles;• Introduce public health history in short; • Discuss social determinants of health and other key concepts within
Global Health!
Trends in global health…In the past 20-40 years:• Extreme poverty has been reduced by…..% in 20 years,• 50• Average number of years at school is for boys….., for girls…..?• 8 years 7 years• Average number of children /family is….?• 2,4• Average life expectancy is …. years?• 71,5 (males 68,3, females 72,6)• How many people have no access to electricity in the world? …....• 1.2 billion/+325.000 every day• How many people do not have access to clean water?..... • 780 million• How many people lack access to improved sanitation?........• 2,5 billion• There are today 2 billion children in the world 0-15 years. How many will it be in 2100? • 2 billion• How many of the world’s children have been immunised against a disease at 1 year of age? • 80%• Infant mortality rates have declined • Birth rates have gone down • Communicable disease mortality/morbidity has declined• World’s population growth also slowed down!
Wlth h id i f th /l i t i
The globalised world’sproblems…
• 1.2 billion people still live in extreme poverty (<1,90 USD/person and day, estimated in 2015, based on prices from 2011),MPI (Multidimensional Poverty Index) includes lack of basic needsand not only income, 1.5 billion people are in this situation (UNDP),
• Environmental issues, climate change and global emissions are not treated seriously by the global society
• The socio-economic inequalities within countries is a biggerproblem than between rich and poor countries/regions - leading to civil unrest, criminality, violence, extreme poverty
• The global financial system is unreliable, unemployment rates arehigh, salaries low…
• Chronic diseases is a huge threat to population health almost all over the world….
Poverty is the most serious threat to health…
• WHY…???
Poverty is the most serious threat to health…
• Poverty leads to malnourishment, diarrhoeal diseases and other infectious diseases with poor access to healthservices….
• Worst affected are the children and pregnant women; • In the most poor and war stricken countries, infant
mortality rates are hundreds of times higher than in Sweden/other high income countries;
• Reduction of maternal mortality (MDG 5) slowest progress;• Average life expectancy among the poor is far below the
level of those belonging to higher socio-economic groupsin the same country;
• Despite this, only a small proportion of the funding for health research is spent on poverty alleviation!
What is poverty about?Absolute and relative poverty
Absolute and relative poverty
• What is it about?• Absolute ?
• the poverty level is defined (<1,9 USD/person/day)
• Relative ? • the poverty level is decided by comparing with others, i.e proportion of people
with less than 50% of the median income is a common way of estimating this!
Poverty means Inequality in Health
Unequal distribution of wealth and health!i.e. people of different socio-economic groups (class), ethnicgroups, sex, sexual orientation, religion and/or with disabilities face different health developments due to:
Unequal access to resources! (jobs, education, money, social networks, health care services…)
Discrimination! Human Rights aspects…The right to health
Intersectionality! Sociological theory on how multiple forms of discrimination interact, classical model of oppression (social class, race/ethnicity, gender, religion, nationality, sexual orientation, disability)
Health inequalities in Sweden!
Average life expectancy in Gothenburg
• Within Gothenburg, the difference in average life expectancy is 9 years between people living in Angered as compared to moreaffluent parts of Gothenburg!
• COPD is a commonly occurring disease in Angered – but it is seldom diagnosed as people do not seek health care…
• Socio-economic conditions is the most important reason for difference in average life expectancy; (Education, employmentpossibilities, income…).
Health inequalities:Maternal mortality Tanzania and Peru
Maternal mortality in Tanzania and Peru• 700/100.000 live born among the poorest segment of the
population in Tanzania and in Peru; • 290-398/100.000 is the average in the population in
Tanzania; 100/100.000 i Peru; The better educated the mother is, the more likely she will have a skilled birth attendant: No basic education: 42%; Primary school: 65% Higher education: 99%
In Sweden 4-5/100.000 in the entire population
• UNICEF data
The Oxfam report 2016• 8 people in the world posess as much as wealth as
the poorest 50% of the world’s population, whichtranslates into 3,8 bill people!
• 872 million people are extremly poor in the world, • Poverty is however reducing, everyone is foreseeing a
better life ….• But in India, with 1,25 billion people, 20% are
extremey poor, still 50-60% of the population have no access to a safe and private toilet (750 millions)...
What do such inequalities translate into?More crime, violations, conflicts, political action,
terrorist activites, radicalism...
What characterise Global Health as a scientific area ….
• Health and health development of populations, rather thanindividuals
• Multidisciplinarity; social anthropology, biology, child health, obstetrics& gynecology, infektious diseases, microbiology, care sciences, demography, health economics, epidemiology, policy and management, nutrition, psychiatry/psycology, sociology, ethno-geography, statistics, …
• Health inequalities….social determinants/life circumstances, poverty
• Concerned with healthproblems that do not respectnation borders!
What is Global Health about?
Inequity in Health:• Emerging infectious diseases (ex. Ebola)• Antibiotic resistance• Immunisation failure (mainly in conflict areas)
• Climate change and• Environmental disasters
• NCDs – chronic diseases• Diabetes ”epidemic”
• Human Rights violations, The Right to Health, Gender discrimination• Internal conflicts• Migration with a refugee situation
Threats to health that do not respect nation borders!The poorest suffer the most!
Global Health?Public Health?
International Health?T Tropical Medicine?
Global Health
• GH emphasise social and reasonable economic equity and reductionof health disparities; i.e. fairness!These are key themes in Global Health, but also in International Health and Public Health!
So what is the difference? Here follows the history…
1. Public Health 1800’s-1920’s….• Public Health: 1850’s; England, France, Germany, USA
William Farr - founder of epidemiology/biostatistics, herecorded births and deaths and found that ill-health was unevenlydistributed in cities, and less in rural areas Edwin Chadwick – water, sanitation, engaged in improving livingconditions for the poor,Louis Pasteur – microbiologist; rabies/anthrax vacc; pasteurization, Robert Koch – microbiologist, found TB bacillus and choleravibrione, Nobel Prize winner 1905 (TB)- later established the discipline Public Health, with otherscientists!
ILLUSTRATING PUBLIC HEALTH LANDMARKS….
The classical public health work:
of livingClean waterSanitationNutritious foodGood housing standard
The four pillars of classical public health work:
Broad Street PumpLondon, 1854
Dr.John Snow
1837 2000
Death rates/million inhab
1945 1955
Chemo-therapy
BCG Vacc.
England and WalesNordic countries…
1880
Tubercle bacillusidentified
2000
1500
1000
500
Tuberculosis mortality
1854
A Public Health Science definition…
Sir Donald Acheson:
• ”Public health is the science and art of preventing disease, promoting health and prolonging life through the organised effortsof society”
Sir Donald Acheson, 1998
“At home” focus, within country…
”Organised efforts of society”…
• If material and social inequalities produce health inequalitites…..then
• … research needs to investigate what political, economic, social and behavioural factors that can explain such inequalities and the link between them
• … and finally it is a state responsibility to develop and implement policies to reduce such inequalities –welfare policies and other mechanisms!
But what about individual’s own responsibility, for his/her health?
Principles of Public Health
• Focus on population groups rather than on individuals;• Prevention and promotion – immunisation, antenatal care
services, child health services; prerequisites for people tolive a healthy life;
• Treatment; i.e. how to treat common diseases in the population;
• Multisectoral and multiprofessional – medicine, epidemiology, biostatistics, behavioural sciences, economics, psychology, anthropolgy, sociology…;
• Social justice emphasised – social inequalities…;• Close collaboration with state authorities and communities
(”organised efforts of society”)
2. Tropical Medicine/International Health
• Trop Med in the 1870’s, Int Health in the 1910-20’s…• For decades, it was the term used for 1) health work abroad, 2) with a
geographical focus on low income countries with a content of 3) infectious and tropical diseases, water and sanitation, malnutrition, and maternal and childhealth (=CDs!).
• “relates to health practices, policies and systems...and stresses the differences between countries rather than their commonalities”
Global Health Education Consortium
”Them and not us”!
Finally emerged…
Global Health 1990’s…
International Health 1910-20’s…Hygiene and Tropical Medicine 1870-…
Public Health 1850-….
’Them, not us’
’All of us’
’At home’
3. What is ’global’ in Global Health
It refers to the scope of problems and not to a certain location i.e. to problems not restricted to an area, country or region but problems that are transcending borders, relevant to many/all countries…
Climate change: floodings/tropical storms; urbanisation, global warming;Infectious diseases: HIV, influenza, Ebola, malaria, antibiotic resistance; Change of life style: lack of physical activity, obesity, tobacco use, alcohol use, poor nutrition; Mental ill-health due to deprivation, internal conflicts and violence…• ‘Global’ here refers to all being affected!
Global Health
Social and economic equity and reduction of healthdisparities are key themes in Global Health, but also in International Health and Public Health!
So what’s new???
Global Health, its development path:
• Societies recognise that the so called developed world may not have a monopoly on good ideas and …search across cultures for better approaches to the prevention and treatment of common diseases, healthy environments, and more efficient food production and distribution. ……a shift in philosophy and attitude that emphasise the mutuality of real partnership, a pooling of experience and knowledge, and a two-way flow between developed and developing countries. Global health thus aims to use the resources, knowledge, and experience of diverse societies to address health challenges throughout the world!
”All of us”
Comparison of global, international, and publichealth
Global health International health Public health
Geographicalreach
Focuses on issues that directly orindirectly affect health but that cantranscend national boundaries
Focuses on health issues ofcountries other than one’s own,especially those of low-income andmiddle-income
Focuses on issues that affect the health of thepopulation of a particular community orcountry
Level ofcooperation
Development and implementation ofsolutions often requires globalcooperation
Development and implementationof solutions usually requiresbinational cooperation
Development and implementation ofsolutions does not usually require globalcooperation
Individualsor populations
Embraces both prevention inpopulations and clinical care ofindividuals
Embraces both prevention inpopulations and clinical care ofindividuals
Mainly focused on prevention programmes forpopulations
Access tohealth
Health equity among nations and forall people is a major objective
Seeks to help people of othernations
Health equitywithin a nation orcommunity is a major objective
Range ofdisciplines
Highly interdisciplinary andmultidisciplinary within and beyondhealth sciences
Embraces a few disciplinesbut has not emphasisedmultidisciplinarity
Encourages multidisciplinary approaches,particularly within health sciences and withsocial sciences
Koplan JP, Bond TC et al. Towards a common definition of Global Health, Lancet 2009
A summarising definition
• Global health is an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide.
• Global health emphasize transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration;
• Global health is a synthesis of population based
prevention with individual-level clinical care.
Koplan JP, Bond TC et al. Towards a common definition of Global Health, Lancet 2009
How to improve overall living conditionsand thereby health?
•”The most important thing (for states) to do is toprovide basic health care, access to staple food, improved access to clean water/sanitation and higher literacy rates in women”
Hans Rosling, Prof in International Health, KI
Is he talkingabout SDH?
Why higherliteracy rates in women?
Social determinants of health (SDH)
• Social determinants of health are the political, economic and social conditions – and their distribution among the population – that influence individual and group differences in health status.
• These are society based risk factors found in one's living and working conditions (such as the distribution of income, jobs, social networks, health care services, wealth, influence, and power), rather than individual factors (such as behavioural factors or genetics) that influence the risk of disease or injury.
• Source: Juha Mikkonen; Dennis Raphael. "The Canadian Facts”
Theoretical framework for how to understand social determinants of health in a modern society
Source: Dahlgren and Whitehead, Policies and strategies to promote socialequity in health, 1991.
Gender
"The development of a society can be judged by the quality of its population's health, i.e. how fairly health is distributed across the social spectrum, and the degree of protection from disadvantage as a result of ill health"WHOCommission on Social Determinants of Health (2008)
Wha does it mean?
Sustainability issues and poverty?
Any reflections?
Our challenges in this course…
• To present bits and pieces of global health… knowledge, experience, attitudes, opportunities, threats, challenges…
• For you to pick up and develop into a whole, i.e. an understanding of howpoverty impacts on health, why some population suffer from infectiousdiseases while others don’t… why HIV is more common among womenthan men…
