health societal right100122 web
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Stephen Bezruchka, MD, MPH
Department of Global Health & Health Services
School of Public Health
University of Washington
Health as a SOCIETAL RIGHT
AgendaFirst two sessions
– Spirit Level– Rationing of health care
Health as a societal right?
Determinants of Health in Rich Countries
Global Health today
A theory of Global Health
AgendaFirst two sessions
– Spirit Level– Rationing of health care
Health as a societal right?
Determinants of Health in Rich Countries
Global Health today
A theory of Global Health
UNFAMILIAR IDEAS– Intergenerational
transmission of health– Biology underlying
inequality
(first paragraph) "There is no known biological reason why every population should not be as healthy as the best."
So Far…..
Health as a SOCIETAL RIGHT
Societal right?
SOCIETAL RIGHT
MEDLINE:
Religious racism
Equity, food security and health equity in the Asia Pacific Region
Ruptures, rights and repair: the political economy of trauma in Haiti
SOCIETAL RIGHT ..
Social Right..
Human right
"rights are context bound"
EARTH/GLOBAL RIGHTS
GLOBAL HEALTH
Spatial-temporal spectrum of human health around the globe– cut across political and cultural units– very little non-national data exist
Human health measured by mortality indicators– IMR, life expectancy,
• healthy life expectancy, disability adjusted life expectancy– Quality of life and well-being related to mortality
World systems analysis
Japan 82.2 Denmark Palestine Thailand Tajikistan UgandaSwitzerland Cuba Colombia Peru India 63.6 Mali Australia United States Lithuania Egypt Kazakhstan Burkina FasoSweden Portugal Bulgaria Nicaragua Pakistan EthiopiaCanada Korea, Lebanon Morocco Bangladesh KenyaItaly Czech Republic Saudi Arabia Turkey Turkmenistan South Africa Israel Uruguay China 71.9 Belarus Nepal TanzaniaSpain Mexico Armenia Moldova, Yemen Côte d'IvoireNorway Croatia Jordan Honduras Myanmar CameroonFrance Panama Romania Guatemala Ghana NigerNew Zealand Argentina Algeria Dominican Republic Cambodia RwandaAustria Poland Paraguay Indonesia Sudan BurundiBelgium Ecuador El Salvador Kyrgyzstan Senegal ChadGermany Slovakia Brazil Azerbaijan PNG Congo (DR)Singapore Bosnia Herzegovina Viet Nam Uzbekistan Madagascar NigeriaFinland Sri Lanka Philippines Ukraine Lao Eq GuineaNetherlands Macedonia, Iran, Russian Federation Togo MozambiqueUnited Kingdom Albania Georgia Bolivia 64.4 Eritrea AngolaGreece Libya Benin Sierra LeoneCosta Rica Syria Guinea MalawiUAE Tunisia Mauritania CARChile Malaysia Djibouti ZambiaIreland Hungary Congo Zimbabwe
Venezuela 73 Haiti Swaziland 31
LIFE EXPECTANCY RANGE
Health Olympics 2004 UNDP HDR 2006
9.2 YEARS 8.3 YEARS 32 YEARS
1629 million 2693 million 2256 million
2007/09Gap 40years
1990/93Gap 37
GLOBALHEALTH
Your thoughts on global health disparities?
RICH COUNTRIES
How healthy is the US?Health Olympics
Number one Gold 1-5 _______6-10 _______11-15 _______
16-20 _______21-25 _______26-30 _______31+ _______
United Nations Human Development Report 2009
HEALTH OLYMPICS 2007
5
15
10
2520
30
WHO 2009
Health Olympics Age 50 (2006)
Japan
Austra
lia
Switzer
land
Andorra
France
Italy
Icel
and
Spain
Canad
a
New Z
eala
ndIs
rael
Sweden
Norway
Austria
Cypru
s
Greec
e
Germ
any
Nether
lands
Belgiu
m
Finla
nd
Irela
nd
Portugal
Costa
Rica
United K
ingdom
Mal
ta
United S
tate
s
Korea,
Rep
.
Chile
Panam
a
Cuba
Denm
ark
30.0
30.5
31.0
31.5
32.0
32.5
33.0
33.5
34.0
34.5
35.0
10
20
5
15
25
30
year
s
GETTING TO RETIREMENT
Mu
nn
ell 2
004
FALLING BEHIND
INFANT MORTALITY
SCF State of the World's Mothers 2004
In Phillips County,Arkansas, the birth rate among teenage girls in 2000 was 127 births per 1,000 women aged 15 to 19 - a rate higher than in 94 developing countries.
A fifth of 20-yr old women who gave birthin the US gave birth did so in their teens
TEEN BIRTHS
0 2 4 6 8 10 12
Japan
France
Germany
Spain
Greece
UK
Czech Republic
Portugal
Belgium
Hungary
Italy
Denmark
Netherlans
Australia
Poland
Canada
Korea
New Zealand
USA
*Austria, Finland, Ireland, Norway, Sweden and Switzerland had fewer than 20 deaths reported and therefore rates were not calculated.
Youth violence Olympics—Homicide rates among youth aged 10-29 (most recent year available) from the World Health Organizations’ World Report on Violence and Health, 2002*
YOUTH HOMICIDE
MEDICAL STUDENTS
DON'T KNOW POPULATION
HEALTH
1st & 4th yr US medical student knowledge of Population Health
(2002)Question First Year
INCORRECTFourth Year
INCORRECT
US has higher life expectancy than any other nation?
28.3% 34.4%
US has lower infant mortality than any other nation?
40.6% 30.2%
Agrawal et. al. (2005)
Population Health Concepts
Health has been improving most of the last century
Health improvements are not shared equally
Poorer people have poorer healthEarly life is most critical period for
health
Where is our health?
Female Life Expectancy by County 1990 C. Murray, Harvard, 1998
Female Life Expectancy70.0 to 77.1
77.1 to 78.1
78.1 to 78.6
78.6 to 79.1
79.1 to 79.6
79.6 to 80.1
80.1 to 80.8
80.8 to 90.0
Life Expectancy
CLOSER TO HOME
Cascadia2002NW Env Wa
Sightline
Population Health Concepts
Health has been improving most of the last century
Health improvements are not shared equally
Poorer people have poorer healthEarly life is most critical period for
health
Health and Social Problems are not Related to Average Income in Rich Countries
Index of: • Life expectancy• Math & Literacy • Infant mortality• Homicides• Imprisonment• Teenage births • Trust• Obesity• Mental illness – incl.
drug & alcohol addiction
• Social mobility
Source: Wilkinson & Pickett, The Spirit Level (2009) www.equalitytrust.org.uk
Index of: • Life expectancy• Math & Literacy • Infant mortality• Homicides• Imprisonment• Teenage births • Trust• Obesity• Mental illness – incl.
drug & alcohol addiction
• Social mobility
Health and Social Problems are Worse in More Unequal Countries
Source: Wilkinson & Pickett, The Spirit Level (2009) www.equalitytrust.org.uk
Davidson's textbook of Medicine 2006, pg 97
"Recent research suggests that uneven distribution of wealth is a more important determinant of health than the absolute level of wealth as measured by the GDP;
Countries that have a narrower or more even distribution of wealth enjoy longer life expectancies than countries with similar or higher GDPs but wider distributions of wealth.
The mechanism is not understood."
Population Health Concepts
Health has been improving most of the last century
Health improvements are not shared equally
Poorer people have poorer healthEarly life is most critical period for
health
womb with a view
Newsweek September 27, 1999
EARLY LIFE
pathway
latent
cumulative
Life begins atConception Ends at Birth
The daughterIs the motherOf the woman
CONCEPTION
Epigenetics
Do POORER PeopleHave POORER PROTOPLASM?
INFLAMMATION
Ranjit et. al. 2007
MESA US Cohort
<$20k
$20-50k
$≥50k
Ranjit et. al. 2007
MESA US Cohort
<$20k
$20-50k
$≥50k
Hegewald et. al. 2007
Hegewald et. al. 2007
Intergenerational Stress Prenatal psychosocial
stress Pregnancy stress:
divorce, breakup, paternity denial, marital infidelity, death of partner, parent, child, illness in other (cancer, MI, stroke), financial problems (loss of house by flooding, husband unemployed, foreclosure, MVA, unmarried (father not accepted by family), political refugee
Cytokine production in women offspring (34 subjects and 28 comparison) mean age 24, healthy
(Entringer et.al. 2008)
Activationin vitro phytohemaglutinin (PHA) induced cytokine production
Efficacy not tested
Production: no difference
Entringer et. al. 2008IFN interferon
PSCG
IMMUNE SYSTEM TESTING of lymphocytes:
PS = Prenatal Stress
CHRONICDISEASE RISK
Disease approach
Birth DEATH
CHRONICDISEASE RISK
Health Care and Risk factor approach
Birth DEATH
"As dramatic and consequential as medical care is for individual cases and for specific conditions, much evidence suggests that such care is not and probably never has beenthe major determinant of levels or changes in population health." Pg 4.
OTHER COUNTRIES
There walk the earth now both the richest people who ever lived and the poorest. Clark 2007
WORLD INCOME TRENDS LAST 3000 YEARS
There walk the earth now both the richest people who ever lived and the poorest. Clark 2007
Smits & Monden 2009
Distribution of length of life for males in Niger, Brazil and Japan in 2000
BIG PICTUREDETERMINANTS OF HEALTH
communities, SOCIETIES, global
BASIC NEEDS (food, water, shelter)
Nature of caring and sharing relationships or
quality of SOCIETAL relationships
health care
Population Health Concepts
Health declined with development of agriculture
“Agriculture has long been regarded as an improvement in the human condition: Once Homo sapiens made the transition from foraging to farming in the Neolithic, health and nutrition improved, longevity increased, and work load declined. Recent study of archaeological human remains worldwide by biological anthropologists has shown this characterization of the shift from hunting and gathering to agriculture to be incorrect. Contrary to earlier models, the adoption of agriculture involved an overall decline in oral and general health.” (Larsen, C. S. (1995). "Biological changes in human populations with agriculture." Annual Review of Anthropology)
Health Declined with agriculture
Sub-SaharanAfrica
Russia
Present (1990) (1900) 1000 10000 100,000
Y e a r s b e f o r e p r e s e n t ( l o g s c a l e )
Japan
USA
Rome
Paleolithic
20
30
50
60
70
80
40
Life Expectancy Trends: Paleolithic On
Hassan 1981
Countries ranking in healthWHY?
Theory of Global Health1. Where they ranked when the race
started
2. When did health begin to improve
3. Mix of factors influencing health improvements
GLOBAL HEALTHHISTORY
World health by colonial troop
mortality
Curtin 1968
Curtin 1968
Curtin 1998
Curtin 1998
Curtin 1989
World health before health started improving?
End of Euro-Colonialism
End of Cold War
Global Economic Collapse
1960s 1990s 2010s
HEALTH HISTORY TRANSITIONS
Euro-Colonialism
TropicalMedicine
Internationalhealth
GLOBALHEALTH
?Populationhealth
MilitaryMedicine
1500s
Easterlin 1999
When did health start improving?
Hundreds of years ago:Life Expectancy increased
after childhood
CHILDHOOD"The history of childhood is a
nightmare from which we have only recently begun to awaken. The further back in history one goes the lower the level of child care, and the more likely children are to be killed, abandoned, beaten, terrorized and sexually abused."
DeMause The History of Childhood 1974
Leigh & Jencks 2007
Factors influencing health improvements
Colonizing country or not
Type of colonialism experienced
Societal and political policies
Economic issues: rapid growth or not
Cultural factors
Global Health Determinants
Where countries were in the health olympics starting blocks
Colonial history 3 groups:
1 few Europeans settled (PEASANT COLONIES) – societies were peasant colonies with Europeans as
administrators or tax collectors or exploiters• plantations dominated economy in some places
– Europeans didn't stay in power after independence– Outcomes depended on how much Europeans
helped local elites to plunder– India, Nigeria, Sri Lanka
Global Health DeterminantsWhere countries were in the health olympics starting blocks
Colonial history:
2 Europeans settled as a minority (SETTLER COLONIES) – Tended to expropriate land and resources– Used indigenous peoples labor, imported slaves
• Plantations, mining in Americas• Locals often not allowed to own land
– After independence Europeans remained in power• Colonial system prevailed with elite exploitation
– South Africa, Zimbabwe, Latin America
Global Health DeterminantsWhere countries were in the health olympics starting blocks
Colonial history:
3 Europeans settled as a majority (NEW EUROPE COLONIES) – Wiped out local peoples– Adopted systems similar to homeland Europe– Where there was more slavery, there was a greater
hierarchy and worse health outcomes
Wilkinson & Pickett 2009 Spirit Level
Health Outcomes Map 2000 (Hegyvary, Berry, & Murua, Journal of Public Health Policy, 2008)
Life Expectancy
Ch
ild M
ort
alit
y (
log
sc
ale
)
How do child mortality and life expectancy vary throughout the world?
1
2
3
PRECOLONIAL INSTITUTIONS
affect
Colonial
Postcolonial AFRICAN GOVERNMENTS
PRECOLONIAL: – Centralized (politically not fragmented) ethnic
groups where chiefs accountable to traditional authority • Can modernize better• Less tyranny, disorder halting modernization
PRECOLONIAL CENTRALIZATION: – In modern era, benefits public goods provision in
stratified more than in egalitarian gorups– High Geographic Spillover: roads, immunization
benefits both stratified & egalalitarian groups– Education, IMR benefits stratified but not egalitarian
(where already have less local tyranny)
Precolonial African Centralization and IMR decline
Gennaioli et al. 2007
Precolonial African Centralization and paved roads
Gennaioli et al. 2007
Precolonial African Centralization and adult literacy
Gennaioli et al. 2007
Health Determinants of nationsWhere countries were in the health olympics starting blocks History of poor health affects cohort & subsequent
generationsHow well they provided basic needs (food)How much they support early lifeHow much they support ALL (social welfare systems)Sense of community, social capitalCulture, values, ethos Political systems: especially redistributive policies
– "educated, capable, and demanding public" (Caldwell 1986)
Economic growth (up to ~1850 ↑living standards), then whether rapid & shared or not, if not shared, can worsen health
Hierarchy details: economic, social Access to health carePublic health programs
GLOBAL HEALTH
Spatial-temporal spectrum of human health around the globe– cut across political and cultural units– very little non-national data exist
Human health measured by mortality indicators– IMR, life expectancy,
• healthy life expectancy, disability adjusted life expectancy– Quality of life and well-being related to mortality
World systems analysis
BIG PICTUREDETERMINANTS OF HEALTHcommunities, nations, global
BASIC NEEDS
Nature of caring and sharing relationships or
quality of social relationships
health care
Life course
Life course approach
Timely intervention
CHRONICDISEASE RISK
CONCEPTION DEATH
Trans-generational
PRIMORDIAL PREVENTIONHEALTH approach
Timely intervention
CHRONICDISEASE RISK
Conception DEATH
EARLY LIFE LASTS MANY LIFETIMES
Factors influencing health improvements
Colonizing country or not
Type of colonialism experienced
Societal and political policies
Economic issues: rapid growth or not
Cultural factors
Health Determinants of nationsWhere countries were in the health olympics starting blocks
Provided basic needs (food) Forager-Hunters, UK (WWII)How much they support early life SWEDENHow much they support ALL (societal welfare systems)
CUBASense of community, social capital OKINAWACulture, values, ethos JAPANPolitical systems: especially redistributive policies NORDIC,
KERALA, USA
– "educated, capable, and demanding public"
Economic growth (up to ~1850 ↑living standards), then whether rapid & shared or not, if not shared, can worsen health
Hierarchy details: economic, societal Access to health care, Public health programs
(Advertisement)
(last paragraph) "The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social. Medicine and politicscannot and should not be kept apart."
(first paragraph) "There is no known biological reason why every population should not be as healthy as the best."