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Introduction to Global Health and Social Determinants of Health

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Annelise Miller

on 15 January 2013

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Transcript of Introduction to Global Health and Social Determinants of Health

Annelise Miller, B.A.&Sc., MDCM Candidate (2015) Introduction: Determinants of Health and the Global Burden of Disease WHO Definition of Health "Global Health" vs "International Health"? Determinants of Health What is "Global Health"? “Global health [...] places a priority on improving health and achieving equity in health for all people worldwide.[...] [It] involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care"

Global health "problems, issues, and concerns [...] transcend national boundaries, and may be influenced by circumstances or experiences in other countries, [and as such, they] are best addressed by cooperative actions and solutions" What is a health "determinant"? “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” 1. Constitution of World Health Organization, April 7, 1948. http://www.who.int/about. adapted from material by:

Alison Doucet, MD, Department of Family Medicine, McGill University
Christina Clausen, RN, MSc.(A), School of Nursing, McGill University Is achieving such a state of health so straight forward? Another way to think of it:
Health is a state of being that allows a person to go about all of their occupational activities (life, work, personal) and achieve their life goals. Goals By the end of this interactive module, you should be able to ...

Understand the meanings and usages of the terms "global health", "developing countries", "third world"

Identify the various (non-medical) factors that influence human health at home and abroad

Reflect upon trends in the global burden of disease and how it is evaluated

Critically appraise the causes of global health challenges

Reflect upon how global health issues abroad relate to health challenges at home in Canada, in particular in areas of resource scarcity as well as in vulnerable populations. 2 3 Global health problems have geographic breadth and may be quite complex. Understanding their etiologies and finding solutions requires a multidisciplinary approach!

Examples: pandemics (e.g. SARS, Influenza A H1N1), famines (especially when caused or influenced by transnational conflict/politics), etc. "Global Health" = health problems/issues/challenges with a broad geographic scope.
Global health focuses on a multidisciplinary and partnership-based approach that emphasizes commonalities rather than differences.


"International Health" = practices, policies and systems surrounding health in countries other than one's own.
The term focuses more on differences, rather than similarities, and is often used in the context of discussing foreign aid (unilateral), rather than collective action (bilateral). Language in Global Health "Third World", "Developing", "North vs South", and other terminologies are used in discussions to differentiate poorer from richer countries. Of course not!

There are factors that influence human health and well-being beyond the biomedical components! 1 2. Koplan JP, Bond CT, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK, Wasserheit JN. Towards a common definition of global health. The Lancet. 2009; 373 (9679): 1993-1995.

3. Institute of Medicine (1997). Definition. "http://www.treatthepeople.com/mihi/index"
The term "Global Health" is now replacing "International Health", so as to reflect the evolution of aid to be more collaborative rather than unilateral, wherein both countries assist each other to better understand the health challenges and together develop solutions. "Third World country": Cold War Era term denoting countries that were neither Capitalist (First World) or Communist (Second World).
! pejorative, alludes to such countries as being third-rate. No longer politically correct.


"Developing country": More commonly used term; however, denotes a linear/mobile trajectory and may not reflect static or declining economies.
! may imply inferiority as related to "developed countries". Also assumes "development" according to the "Western" economic model.


"North vs South": Differentiation of richer ("North") countries from poorer ("South") countries.
! Controversial because it is not necessarily geographically true (Australia and New Zealand are "South" but not poor, for instance)


Alternatives:
"Low income" vs "middle income" vs "high income" countries
"Majority world" or "two-thirds world" reflecting population distribution
Indices such as human development index (HDI), life expectancy, happiness index, DALYs All of these terminologies have their own caveats and a history. It is important to be aware of the connotations and discourses surrounding their use. Global Burden of Disease BUT... How do we measure health and disease? Direct epidemiological data Life expectancy
Mortality
Morbidity
Infant mortality rate
Disease prevalence
Disease incidence All of these statistics can give us an idea as to the different facets of population health! DALYs! Global Burden of Disease DALYs = Disability adjusted life-years A DALY is a way of quantifying the burden of disease from morbidity and mortality.

One DALY = one year lost of "healthy" life.

The sum of all DALYs across the population is a way of measuring the burden of disease in a population. In other words, the sum of DALYs lets us examine the gap between the current health status and the "ideal" health status of a population (i.e. everyone reaches life expectancy)

Of course, no statistic is perfect, and neither is the DALY, but it is another way to explore the burden of disease Where:

YLL= NxL
= number of deaths (N) x life expectancy (L). YLL is calculated for age, sex and cause of death

YLD= Ix DWx L
= incidence of the disease during a given period (I) x disability weight (DW) x duration of illness until death (L) Disability Weight (DW) is assigned to a disease/condition to reflect its impact on functionality and productivity, where 0 is perfect health and 1 is death. Mathematically, the DALY for a disease or condition is the sum of Years of Life Lost (YLL) from premature mortality and the Years Lost due to Disability (YLD).

DALY = YLL+YLD Examples: AIDS cases not on ART = 0.505
S. pneumoniae meningitis= 0.615
Pharyngitis (upper respiratory tract infection)=0.070 4. World Health Organization (WHO). Health Statistics and Health Information. http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/
5. WHO. Global Burden of Disease Update 2004: Disability Weights for Diseases and Conditions. http://www.who.int/healthinfo/global_burden_disease/GBD2004_DisabilityWeights.pdf 5 4 4 Global Burden of Disease Realities Indirect health indicators (less indicative
of particular problems, but overall health
or particular trends):
Social development
Poverty
Literacy rate
etc. An alternate, slightly novel
metric... What about measuring the specific impact of a given disease (which may be endemic or highly prevalent)?

None of these statistics quite approximate the impact of early mortality or morbidity on social functioning or on families... in order words, how can we capture the BURDEN of a disease on an individual, family or society? Health inequities and inequalities Inequality vs. Inequity: Definitions

Health "inequities" are AVOIDABLE inequalities between groups of people.
An inequity implies injustice and preventability, whereas an inequality is a qualitative or quantitative disparity in outcomes between groups The health inequities exist within countries and between countries are the direct result of the social, economic, political, and physical environments in which people live For instance:
The infant mortality rate in Iceland is 2/1000 live births, as compared to 120/1000 live births in Mozambique

Maternal mortality rates (during or shortly after pregnancy) are 1 in 17,400 in Sweden as compared to 1 in 8 in Afghanistan

The prevalence of Type 2 Diabetes Mellitus in reserve-dwelling First Nations individuals in Canada is 17.2% as compared to the 6.8% in the general Canadian population (2009) 7. WHO. Key Concepts- Social determinants of Health. http://www.who.int/social_determinants/thecommission/finalreport/key_concepts/en/index.html

8. Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective. http://www.phac-aspc.gc.ca/cd-mc/publications/diabetes-diabete/facts-figures-faits-chiffres-2011/highlights-saillants-eng.php#chp1 8 7 7 7 Social Determinants
of Health: Themes As we can see (and as you are all aware), health outcomes are not equally distributed amongst nations and within nations. Women and gender equity: Employment and income: Physical Environment: Themes Globalization: Early childhood development: Access to water/sanitation: Indoor and outdoor air quality: Transportation infrastructure: Urbanization and housing: A determinant is a primary risk factor that is causally associated with a problem Social (and political) determinants of health affect mental and social well being, which in turn can have effects on physical health; political oppression or discrimination influences mental health, for instance and may lead to psychiatric illness, chronic stress, or in the case of political violence, PTSD. Low socioeconomic status affects access to food, housing and resources, and may result in malnutrition or increased disease burden. The physical environment can directly influence health (e.g. poor air quality leading to respiratory disease) or may interact with social and political factors to influence physical health. Rapid urbanization may influence housing for instance; the physical environment may also influence transportation and thus access to health services The association may not be direct or clear. Most determinants of health are rather complex (as you are well aware!) and not as simple as, per se, contact with an infectious agent. The root behind health inequalities and health inequities lies in the determinants of health for a given population. Trends in the burden of disease vary widely across the world (and across time!) and are difficult to summarize briefly!

Instead, we invite you to please peruse the interactive figures at the Institute for Health Metrics and Evaluation (IHME) at the University of Washington. http://www.healthmetricsandevaluation.org/gbd/visualizations/regional Please peruse the various figures, and play with the different variables! It's pretty cool, and is also practice for better understanding health metrics such as DALYs and YLDs. 1. Leading Causes and Risks Region Heat Map
http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-2010-leading-causes-and-risks-region-heat-map 2. Healthy Years Lost vs Life Expectancy
http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-2010-healthy-years-lost-vs-life-expectancy With particular emphasis on... BUT... What's the difference? For more reading: Global Health Education Consortium: http://globalhealtheducation.org/Pages/GlobalvsInt.aspx If you would like to read the full set of publications regarding this ground breaking research, it can be found on the website for The Lancet. "Global Burden of Disease Study 2010". Published in The Lancet, Dec 13, 2012. http://www.thelancet.com/themed/global-burden-of-disease A short film summarizing the social determinants of health, and following 3 projects that seek to equalize them What about here, in Canada? All of what we have discussed is applicable at home, not just abroad! Additional resources: 1. WHO and PAHO Global Learning Device on Social Determinants
http://dds-dispositivoglobal.ops.org.ar/curso/cursoeng/unidad1.html Acknowledgements: Many thanks to Dr. Alison Doucet and Cristina Clausen for the use of their powerpoint as reference, as well as to the 2013 IPGHC committee for their revisions and comments. Disclaimer: any audiovisual materials and hyperlinks used in this presentation are for educational purposes only and have been cited where applicable. No copyright infringement is intended. demographic migration from rural to urban populations and the expansion of city size. Such changes often occur without the provision of enough and adequate housing, resulting in sprawling slums and overcrowding. Substandard housing quality including poor sanitation, inadequate heating/cooling, poor ventilation, lack of access to electricity, urban crowding. includes the quality and distribution of roads and the access to vehicles of quality, the availability and cost (and safety) of transit. Impact on access to health care and the transportation of food and supplies Outdoor/urban air pollution and smog from vehicles, industrial emissions. Indoor air pollution from cooking and heating stoves/fires contribute gases (carbon monoxide, VOCs, radon), particulates, microbes, mould, asbestos, etc... includes a transportation infrastructure that is safe and well-maintained, the presence of vehicle certification and driver testing, the provision of safe crossings and pedestrian intersections, adequate law-enforcement for reinforcement of safety protocols, and minimization of motor vehicle and pedestrian-vehicle accidents. Road safety: Physical Environment: Themes (cont'd) Food security: Food security is a measure of a household's ability to access essential nutrition. This includes access to a food supply that is safe, affordable, easily acquired, and varied enough to provide all essential nutrients. Violence: including domestic, structural/political, and organized violence (war, terrorism, genocide, territorial/resource conflict), etc... Global climate change: including more frequent and severe natural disasters/extreme weather events, the impact of droughts and floods, changes in the food supply, changes in the incidence and areas of vector borne disease, etc... includes access to potable water for drinking and cooking, proper infrastructure and facilities for waste collection, decontamination and storage/disposal Education Social exclusion, discrimination and cultural norms/behaviours Political marginalization and/or conflict Access to health services Social Determinants of Health: Themes (cont'd) (could also be named "socioeconomic and political determinants of health") includes the physical, social/emotional, and language/cognitive aspects of development. Influenced by nutrition, family environment, education, safety, community support, etc. includes access to sufficient and fair employment, the type and location of job, proper remuneration, occupational exposure, possible exploitation, opportunities for growth and development, and the stress of relating to the threat of unemployment. includes differential exposures to health-harming factors (e.g. pollutants from indoor cooking), differential economic and political opportunity, sexual exploitation/abuse, particular health needs (e.g. access to gynaecological screening and obstetric services), differential access to education and knowledge includes the impact of trade liberalization, multinational corporations, and market-driven changes in consumption and production patterns on local economies and household income. includes discrimination and exclusion based on ethnicity, language, appearance, gender, sexual orientation. Also includes the sociocultural expectations of gender roles, economic, domestic and political activities and the codes of behaviour/conduct in certain settings (e.g. public market may not only be for trade of produce but alcohol consumption and the bartering and trading of sexual favours) Clear correlation between educational attainment, life expectancy, and overall health. Universal primary education is one of the Millenium Development Goals, however has yet to be attained (this says nothing of secondary education, which is a standard in the West). includes differences in political power, the opportunity for dissent and democratic participation, or the outright marginalization of minority groups (including women, immigrants, members of certain religious or ethnic groups) includes access to primary, secondary or tertiary services within a reasonable distance or delay, financial barriers to treatment, and sufficient support to comply with therapy or treatment modalities. The wealthiest 20% of neighbourhoods in Canada have a life expectancy that is 2 years longer than the poorest 20% of neighbourhoods

9% of Canadian households experience food insecurity, and this number rises dramatically in single-parent households, in Aboriginal communities, and recent immigrant communities.
Food insecure households are 80% more likely to report having diabetes, 60% more likely to report having hypertension, 70% more likely to report food allergies than food secure households

In 2009, the proportion of tenants spending more than 30% of their gross (pre-tax) income on housing (the definition of unaffordable housing in Canada) is 43% in Vancouver, 42% in Toronto, and 36% in Montreal.
The proportion spending more than 50% of their gross income is 22% in Vancouver, 20% in Toronto, and 18% in Montreal Canada has one of the highest levels of low-paying jobs (23%) and family poverty rates of all Western nations 9. Mikkohen J, Raphael D. 2010. The Canadian Facts. Toronto: York University School of Health Policy and Management. http://www.thecanadianfacts.org/The_Canadian_Facts.pdf 9 9 9 9 9 9 Thanks for reading! 2. http://www.healthmetricsandevaluation.org/gbd/visualizations/regional 3. http://www.who.int/research/en/
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