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