Health systems, social cohesion and exclusions as determinants of health –

understanding the disease burden (HIV/AIDS, EBOLA, ZIKA, MALARIA)

Janine White

12th Annual Meeting of African Science Academies (AMASA)6-8 November 2016

Communicable diseases: a significant global disease burden

In 2012, communicable, maternal, neonatal and nutrition conditions collectively were responsible for 23% of global deaths (2)

Communicable disease –spread from person to

person (1)

contact with blood and

bodily fluids

breathing in an airborne

virus

by being bitten by an

insect

Zika virus Ebola virus disease

HIV/AIDS Malaria

Source: The Independent, 2016

Mapping the Zika virus

The disease burden: Ebola virus disease

Source: World Health Organization, 2016

Source: World Health Organization, 2014

The disease burden: HIV/AIDS

HIV deaths decreased slightly from 1.7 million (3.2%) deaths in 2000 to 1.5 million (2.7%) deaths in 2012.

Tuberculosis, while no longer among the 10 leading causes of death in 2012, was still among the 15 leading causes, killing over 900 000 people in 2012

The disease burden: Malaria

Source: Nature, 2012

The social determinants of health (SDOH): a multifaceted approach to communicable diseases

• Social determinants of health “create conditions for the transmission of communicable diseases” (3)

• Preventing and controlling communicable (& other) diseases requires:– broad and integrated

interventions (4), and

– a multi-faceted approach (5)

The social determinants of health (SDOH): health systems/ infrastructure; social cohesion and

social exclusionhealth systems/ infrastructure

Why do health systems matter?

Upstream determinants

• Downstream determinants (6)

Why do health systems matter?

Health systems that fail to address the social determinants of health perpetuate inequity (6)

Why do health systems matter? The Cuban experience

CubaModest infrastructure

investment

&

strong public health strategy (7)

control of infectious diseases

reduction in infant mortality

progress in control of chronic diseases

establishment of a research and

biotechnology industry (7)

Health systems & infrastructure as a social determinant of Ebola virus disease

Guinea Liberia Sierra Leone

Human resources and infrastructure

Number of physicians (per 1,000 people in 2010)

0.1 0.01 0.02

Improved sanitation (Total, Rural, Urban)

19%, 11%, 33% 17%, 6%, 28% 13%, 7%, 23%

Improved water source (% of population without access in 2012)

25% 25% 40%

During an outbreak, an adequate public health systems will be able to:

rapidly identify cases, trace contacts, and isolate infected and exposed patients (8)

Guinea, Liberia & Sierra Leone ranked lowest in global development & further lack essential public health infrastructure, such as an adequate health workforce (8)The crisis has further destroyed

already minimal healthcare systems, hospitals have closed and scarce medical staff have died in the epidemic (9)

is defined as the willingness of

members of a society to

cooperate with each other in

order to survive and prosper

(10)

Social cohesion

Social cohesion as a social determinant of health

Social cohesion

Optimal functioning of communities through social cohesion and

organization in social networks (10)

Social relationships are

increasingly associated with

greater individual-level risk (11)

Social networks can spread (or

reduce) transmission of communicable

disease (10)

Sex workers, social cohesion and HIV/AIDS

• Sex workers risk of HIV infection is exacerbated by:– social and structural factors,

– inequitable laws and policies,

– police brutality, and

– lack of non-discriminatory healthcare services (12)

• Community empowerment - an effective tool for reducing HIV-related risk; enacting social- and structural-level changes (12)

Avahan Initiative, India - an HIV prevention intervention

Principles of social cohesion to reduce HIV infection by including sex workers in the programme.

Other interventions included:

– peer education,

– sex-worker friendly health services,

– formation of organizations led by and with sex workers to facilitate program ownership (12)

Social exclusion as a social determinant of health

• Men, women and children who are discriminated against often end up excluded from society, the economy and political participation (13)

• Discrimination in public institutions - legal system or the education and health services, as well as in the household and in the community (13)

• Social exclusionary processes -social, political, economic and cultural dimensions (14)

• Leads to health inequalities (14)

• Social exclusion deprives people of choices and opportunities (13)

Social exclusion as a social determinant of malaria

• The malaria burden is highest in least developed countries with the lowest human development, and within disadvantaged populations (15)

• Social exclusionary practices based on ethnicity may lead to poor access to malaria prevention and treatment (16)

• Barriers to access can also create mistrust in public services and influences norms and attitudes and frequently leads to higher rates of malaria infection (17)

• Panama - 85 percent of the malaria cases occur in the indigenous population, who constitute only 10 percent of the country’s population (18)

Addressing the social determinants of communicable diseases

• Social, medical, biological or environmental factors - all these factors are important (19-20)

• No one person or group can effectively address all communicable diseases (19)

• Multiple skill sets: knowledge of communicable disease; public health and SDOH and the ability to work with local communities, governments and non-governmental organizations (19)

References I

1. Alameda Country Public Health Department. Communicable disease [internet]. Accessed on the 1 November 2016. Available from http://www.acphd.org/communicable-disease.aspx

2. World Health Organization. The top ten causes of death [INTERNET]. 1 November 2015. http://www.who.int/mediacentre/factsheets/fs310/en/index2.html

3. Quinn SC, Kumar S. Health Inequalities and Infectious Disease Epidemics: A Challenge for Global Health Security. Biosecurity and Bioterrorism : Biodefense Strategy, Practice, and Science. 2014;12(5):263-273. doi:10.1089/bsp.2014.0032.

4. Butler-Jones D, Wong T. Infectious disease, social determinants and the need for intersectoral action. Can Comm Dis Rep 2016;42-Suppl 1:S18-20.

5. David, A.M., Mercado, S.P., Becker, D. et al. The Prevention and Control of HIV/AIDS, TB and Vector-borne Diseases in Informal Settlements: Challenges, Opportunities and Insights. J Urban Health (2007) 84: 65. doi:10.1007/s11524-007-9183-5

6. Health Equity Knowledge Network

7. Health in Cuba Richard S Cooper1* Joan F Kennelly2 and Pedro Ordun˜ ez-Garcia, International Journal of Epidemiology 2006;35:817–824 The Author 2006; all rights reserved. doi:10.1093/ije/dyl175

8. Gostin LO. Ebola: towards an International Health Systems Fund. The Lancet. Published Online September 4, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61345-3

9. Mitchell S. Accidents waiting to happen: the failure to address the social determinants of health [internet]. October 2014. Accessed on the 2 November 2016. Available at http://advocacyinternational.co.uk/advocacy/accidents-waiting-to-happen-the-failure-to-address-the-social-determinants-of-health

10. What Do We Know about Social Cohesion: The Research Perspective of the Federal Government's Social Cohesion Research Network Author(s): Dick Stanley Source: The Canadian Journal of Sociology / Cahiers canadiens de sociologie, Vol. 28, No. 1, Special Issue on Social Cohesion in Canada (Winter, 2003), pp. 5-17 Published by: Canadian Journal of Sociology Stable URL: http://www.jstor.org/stable/3341872 Accessed: 01-11-2016 08:18 UTC

References II

11. Zelner JL, Trostle J, Goldstick JE, Cevallos W, House JS, Eisenberg JNS. Social connectedness can inhibit disease transmission: Social organization, cohesion, village context and infection risk in rural Ecuador. American journal of public health. 2012;102(12):2233-2239. doi:10.2105/AJPH.2012.300795.

12. Baral S, Beyrer C, Muessig K, Poteat T, Wirtz AL, et al. (2012) Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis. The Lancet Infectious Diseases 12: 538–549. doi: 10.1016/s1473-3099(12)70066-x

13. Department for International Development. Reducing poverty by tackling social exclusion. DFID Policy Paper. September 2005.

14. Popay J, Escoral S, Hernandez M, Johnson H, Mathieson J, Rispel L. Understanding and tackling social exclusion. Final report to the World health Organisation’s Commission on Social Determinants of Health. Geneva; 2008

15. United Nations Development Programme. Multisectoral action framework for Malaria. Geneva; 2013

16. Cotter, C., Sturrock, H.J., Hsiang, M.S., Liu, J., Phillips, A.A., Hwang, J. et al. ‘The changing epidemiology of malaria elimination: new strategies for new challenges,’ Lancet, 2013, Apr 15

17. Worrall, E., Basu, S. and Hanson, K., ‘The relationship between socioeconomic status and malaria: a review of the literature,’ London School of Hygiene and Tropical Medicine, London, 2002

18. Feachem, R.G., Phillips A.A., Hwang, J., Cotter, C., Wielgosz, B., Greenwood, B.M. et al., ‘Shrinking the malaria map: progress and prospects,’ Lancet, 2010, Nov 6; 376(9752): 1566–78.

19. Butler-Jones D. Commentary in: Goel V, McIsaac W. Clinical general practice as a setting for health promotion. In: Poland BD, Green LW,. Rootman I, editors. Settings for health promotion: linking theory and practice. Thousand Oaks (CA): Sage; 2000.

20. Heymann J., Hertzman C, Barer ML, Evans RG. Healthier societies: From analysis to action. New York: Oxford University Press; 2006.

Thank you