what is global health? dr slim slama, geneva university hospitals

What is global health and

how can it be applied ?

Division of international and humanitarian medicine –

Department of community medicine, primary care & emergency

how can it be applied ?

Dr Slim Slama, MD, MPHDivision of International & Humanitarian Medicine

Geneva University Hospitals

September 11, 2013

[email protected]

Outline

• Let’s first have your insights – group work

• Global health: a new paradigm or just a

fashion ?fashion ?

• From «international» to «global»

• Health in a context of global changes

• Global Health in practice

Group work

• 10 minutes

• One rapporteur

Questions:Questions:

1. What does the term «global health» evoke to

you ?

Where do we start?

“Health is a state of complete

physical, mental, and socialphysical, mental, and social

well-being and not merely the

absence of disease or infirmity.”

World Health Organization

Public Health

"the science and art of preventing disease,

prolonging life and promoting health through

the organized efforts and informed choices of the organized efforts and informed choices of

society, organizations, public and private,

communities and individuals."

C.E.A. Winslow, 1920

Global health: a new paradigm or just

a fashion ?

• Recent change in terminology : from«international» to «global health»

A field growing in popularity and visibility • A field growing in popularity and visibility over the past several years

• Is this shift in terminology trendy, trivial, or trenchant?

Global health: a new paradigm or just

a fashion ?

• Bunyavanitch and Walkupinterview with 29 international health leaders in 1999: 50% thought the in 1999: 50% thought the new vocabulary was meaningless jargon; 50% thought a major shift was underway but seemed unable to clearly articulate what it was

Bunyavanich, S. and R. B. Walkup (2001). "US public health leaders shift toward a new paradigm of global health."

American journal of public health 91(10): 1556.

From international health

to global health

A long history…

� The Roots of International Health: Colonialism and Tropical Medicine

� The Interwar period and the Origins of International � The Interwar period and the Origins of International Health Institutions

� The Postwar Period and the era of Decolonization: from Disease Eradication to Primary Health Care

� Health Care in the 1980s and 1990s: From Primary Health Care to Disease Eradication

� The Global Health Era

Any changes or old wines

of international health in

the new bottles of neo-

liberal discourses ?

Some common trends

1. Health strategies tend to be developed outside of countries where health problems exist.

2. Approaches to health tend to be selective rather 2. Approaches to health tend to be selective rather than comprehensive.

3. Health programs are linked to economic development but serving ideological/political purposes

4. Neglect of underlying determinants of health


to global health

“ the term ‘global health’

emerged as part of larger

political and historical

processes, in which WHO found

Brown, T. M., M. Cueto, et al. (2006). "The World Health Organization

and the transition from “international” to “global” public health."

Journal Information 96(1). http://1.usa.gov/SoodPs

processes, in which WHO found

its dominant role challenged

and began to reposition

itself within a shifting set of

power

alliances.

International health

• Focuses on health issues in other countries in

comparison with our own, stressing

differences rather than the commonalities

between nationsbetween nations

• Historically linked to missionary work and

disease control in low-income countries

• Involved the efforts from wealthier northern

countries to improve the health of peoples

living in poorer southern areas of the globe

Characteristics that makes global

health ”global”

• Central concern with the interconnectedness among populations

• The consequences of globalization on evolving patterns of health, disease, and social determinants

• The consequences of globalization on evolving patterns of health, disease, and social determinants

• The transfer of health risks across national borders

(Harvard Global Health Institute 2012)


to global health

“The shift from international to global

health can be said to be occurring where the

determinants of health or health outcomes

circumvent, undermine or are oblivious to thecircumvent, undermine or are oblivious to the

territorial boundaries of states and, thus,

beyond the capacity of individual countries

alone to address through domestic institutions.”

Lee and Collin (2005)

Global health

3 main features

1. Trans-national: health issues and determinantsthat transcend national boundaries

2. Health equity for all with a focus on the global 2. Health equity for all with a focus on the global socioeconomic, environmental and cultural factors that determine health

3. Collaborative (or collective) action: criticalimportance of collaboration across countries, sectors and disciplines

Global health:

Towards a common 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 emphasises transnational health issues, Global health emphasises transnational health issues,

determinants, and solutions; 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.”

Source: Koplan, J.P., T.C. Bond, and M.H. Merson et al. (2009). “Towards a common definition of global health”. The Lancet, Volume

373, Issue 9679, 6 June 2009-12 June 2009, Pages 1993-1995

Differences between Global, International, and

Public Health

Source: Koplan, J.P., T.C. Bond, and M.H. Merson et al. (2009). “Towards a common definition of global health”. The Lancet, Volume

373, Issue 9679, 6 June 2009-12 June 2009, Pages 1993-1995

Globalization

“A set of processes intensifying human

interaction across economic, political,

sociocultural, environmental and sociocultural, environmental and

technological realms. These changes are

evident across spatial, temporal and

cognitive boundaries.”

Kelley Lee, LSHTM

Global connectivity

Global Connectivity

mobile phone subscriptions (billions)

In 2013, there are almost as many

mobile-cellular subscriptions (6.8

Source: ITU World Telecommunication/ICT 2013 Facts and Figures. Available at: http://bit.ly/1aA8eqB

mobile-cellular subscriptions (6.8

billion) as people in the world, with

more than half in the Asia-Pacific

region

Global ConnectivityInternet users by development level, 2003-2013


Global Connectivity

In 2013, over 2.7 billion people are using the

Internet, which corresponds to 39% of the

world’s population.


world’s population.

In the developing world, 31% of the population

is online, compared with 77% in the developed

world.

Malaria supply chain data

collection using mobile

phone

and an open source cloud-

based mobile data

collection platform collection platform

(Magpi) in Zambia

Globalization and mass media

until 1980s media systems

(print and broadcast) national

in scope

• trade in books, films, music,television for

decades, but broadcasting and publishingdecades, but broadcasting and publishing

industries largely domestically

owned and regulated

• deregulation and privatisation

of media and communication

systems since 1980s

• advent of new satellite and

digital technologies

Global Mobility

World Air Transport in 2012

and World Passenger Traffic Forecastsk

ilo

me

tre

s p

erf

orm

ed

pa

sse

nge

r-k

ilo

me

tre

s p

erf

orm

ed

World Air Transport in 2012

and World Passenger Traffic Forecasts

World Passenger Traffic increased by 4.5% in

2012, corresponding to 3 billion passengers and 2012, corresponding to 3 billion passengers and

43.5 million aircraft departures

Source: International Civil Aviation Organization (ICAO)

http://bit.ly/1aAaYV9

Cognitive dimension of global change

• Changes to how we think about ourselves and the world around us

• Mass media culture

• Culture

• Wants/needsculture

• Advertising firms

• Consultancy firms

• Research institutions

• religious groups political parties

Wants/needs

• Aspirations

• Knowledge

• Values

• Ideologies

Health in the context of globalization

“the world is rapidly being

moulded into a shared social space by

economic and technological forces and that

developments in one region of the world candevelopments in one region of the world can

have profound consequences for the life

changes of individuals and communities on

the other side of the globe”

Held et al. (1999)


• World become single entity

• Increased movements of information, services

and people

• Across borders of countries• Across borders of countries

• Facilitated by

– IT : improved communication

– Policies on various sectors

Globalization and Economy

From economic perspective, globalisation is

characterised by:

• Increase in international trade

• Foreign Direct Investment• Foreign Direct Investment

• Capital Market Flows

• “Openness”of individual countries economy to

the rest of the world

Globalization:

Opportunities or threat to health?

“All the indications are that the current forms

of globalisation are making the world a safe place

for unfettered market liberalism and the consequent

growth of inequities. This economic globalisationisgrowth of inequities. This economic globalisationis

posing severe threats to both people’s health and

the health of the planet.”

Professor Fran Baum

Flinders University, Australia (2001)

Impacts of globalization on health

• Spread of Communicable Diseases and Non Communicable Diseases

SARS Outbreak, Avian Influenza (H5N1)

Obesity, DM and increase in lifestyle related NCDs

Global Trade including liberalisation in health services• Global Trade including liberalisation in health services

Brain drain, medical tourism, telemedicine

Access to Medicine and Drugs (IPs)

Tobacco trade

• “Forced adoption” of adverse health policies

Privatisation

User fees

Private Health Insurance

Global health threats: Bioterrorism

Between November 2002 and July 2003,

an outbreak of SARS spread from Hong

Kong to infect individuals in 37 countries

becaming a pandemic, with 8,422 cases

and 916 deaths worldwide

Global health threats- Emerging

infectious diseases

An example of

health risk at the

human-animal-

ecosystem

interface

H5N1 viruses are thought

to be circulating

endemically in poultry in

China, Egypt, Indonesia,

Viet Nam, Bangladesh

and India

Cumulative number of confirmed human cases for

avian influenza A(H5N1) reported to WHO, 2003-2012

(as August 2012)

608 cases, 359 deaths, 15 countries

Global Trade of Harmful Products

Global Trade of Harmful Products

In 2011, tobacco use killed almost 6 million

people, with nearly 80% of these deaths

occurring in low- and middle-income

countries. countries.

When considering 2010 deaths with tobacco

industry revenue, the tobacco industry

realizes almost $6,000 in profit for each

death caused by tobacco

Global health threats- Lifestyles

related health challenges

Trade in health services & health

workers’ brain drain

Doctors from abroad in numbers

and percentage

Adapted from the WHO 2006 World Health Report, Chap 5, p.98, Table 5.1

Climate changes and health threats

United States Areas Vulnerable to Dengue

Fever

Source: Natural Resources Defense Council: http://www.nrdc.org/health/climate/

Health and its determinants

• Determinants of health are the direct or

indirect causes of a disease

• either direct (proximal) or indirect (distal)

• The health effects of distal determinants are • The health effects of distal determinants are

often mediated through proximal and

intermediary determinants

• Distal determinants cannot be acted upon

through direct health sector interventions

Lerer LB et al. Health for All: vision to strategy – the role of health status

and determinants. World Health Statistics Quarterly, 1998, 51: 7–20.


Example:

• Smoking is a proximal determinant of health

status, while the economic, demographic and status, while the economic, demographic and

social factors that promote tobacco use are

distal determinants.


Conceptual framework for globalisation and population health.

Huynen et al. Globalization and Health 2005 1:14 doi:10.1186/1744-8603-1-14

Obesity: Web of causation

How does all this link to this course?

• Human & eco-systems health are linked

• Both are shaped by material, biological, social

and cultural circumstances

Human & eco-systems health

Courtesy: G.Rayner & T. Lang

An interesting podcast

on the concept of

ecological public health

from the British Medical

Journal:

http://bit.ly/1hBo3v2

What are these conceptual models

trying to do?

• Address complexity

• Capture dynamics and interactions

• See health as shaped by different levels, dimensions or determinantsdimensions or determinants

• Identify key transitions shaping human health

• Spot key actors and institutions both making and

breaking health

• Place human health within biological, material, social and psychological processes

Applying a systemic approach to

global health challenges

• Newly Emerging and Re-emerging Diseases of Public Health Importance

SARS, Avian Influenza, HIV/AIDS, Tuberculosis, Malaria

• Increase Global Burden of Non-Communicable Disease • Increase Global Burden of Non-Communicable Disease and Unhealthy Lifestyle

Diabetes Mellitus, Hypertension, Stroke, Obesity, Smoking

• Health Care Delivery System

Health Financing Issues, Efficiency, Equity, Access, Quality of Care

The International

Council for Science

(ICSU) Programme

on Health and

Wellbeing in the Wellbeing in the

Changing Urban

Environment

http://bit.ly/13IvRrU

http://bit.ly/13IxC8t

http://bit.ly/1hBpaec

Capacity of slum dwellers/informal settlements

to improve total health and wellbeing

Global Health as “Unifying Paradigm”

• Acknowledge complexity and adopt a

systemic approach

• Enable the integration of public health,

medecine and disciplines beyond health

sciences

Global Health Education

• Call for reforms

• From evidence based � problem based

learning � system thinking,

• Build competencies and skills to adapt to a • Build competencies and skills to adapt to a

multicultural world

• Interdisciplinarity

Global Health Research

Examples:

• Impact of globalization on health and

intersectoral policies

• Healthcare delivery in resource limited• Healthcare delivery in resource limited

settings

• Global health governance and diplomacy

Global Health advocacy

• Adopting a Human-Rights approach and taking a position in favour of equity and social justice at local and international level.

• Raising public awareness about global healthdisparities and ways to reduce themdisparities and ways to reduce them

• Keeping a critical eye on policies and activitiesthat influence health and health determinants

• Understanding who are the key actors and how do they frame/influence global health issues

• Giving a voice and listening to frontliners

Global health not just an academic

field

“Global Health is not merely academic: in fact,

promoting an ethic of social responsibility both for the

institutions and professionals involved, it embraces the institutions and professionals involved, it embraces the

fields of research, education and practice, and aims to

generate real changes in both the communities across

society, bridging the gap between scientific evidence

and operational decisions.”

Chiara Bodini, CSI, Bologna, Italy

“Education either functions as an instrument which is

used to facilitate integration of the younger generation

into the logic of the present system and bring about

conformity or it becomes the practice of freedom, the

means by which men and women deal critically and means by which men and women deal critically and

creatively with reality and discover how to participate in

the transformation of their world.”

Paulo Freire, Pedagogy of the Oppressed

The University of

Geneva undertook in

2012 an all faculties

mapping exercice

assessing the

University’s expertise University’s expertise

in the field of global

health. More than 400

people accross the

University are involved

in global health related

activities.

www.genevahealthforum.org

Thank you for your attention

Questions? Questions?

what is global health? dr slim slama, geneva university hospitals

Health & Medicine