Health as a SOCIETAL RIGHT




       Stephen Bezruchka, MD, MPH
Department of Global Health & Health Services
          S...
Agenda
First two sessions
   – Spirit Level
   – Rationing of health care
Health as a societal right?

Determinants of Hea...
Agenda
First two sessions                 UNFAMILIAR IDEAS
   – Spirit Level                    – Intergenerational
   – R...
(first paragraph)
"There is no known
biological reason wh
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, r...
SOCIETAL RIGHT
       ..
  Social Right
       ..
  Human right

 EARTH/GLOBAL RIGHTS

  "rights are context bound"
GLOBAL HEALTH
Spatial-temporal spectrum of
 human health around the globe
   – cut across political and cultural units
   ...
Health Olympics 2004 UNDP HDR 2006
Japan       82.2       Denmark                   Palestine             Thailand        ...
GLOBAL
HEALTH

2007/09
Gap 40
 years

1990/93
Gap 37
Your thoughts on
global health disparities?
RICH COUNTRIES
How healthy is the US?
      Health Olympics
Number one Gold   16-20   _______
1-5   _______     21-25   _______
6-10 ____...
HEALTH OLYMPICS 2007

                  5

                                 10


                                         ...
35.0


  34.5
         Health Olympics Age 50 (2006)
  34.0


  33.5   5

  33.0          10

  32.5                15

  ...
GETTING TO RETIREMENT
FALLING BEHIND




                 Munnell 2004
INFANT MORTALITY
TEEN BIRTHS



                                        A fifth of 20-yr old women who gave birth
                         ...
Youth violence Olympics—Homicide rates among youth aged 10-29 (most
recent year available) from the World Health Organizat...
MEDICAL
 STUDENTS
DON'T KNOW
POPULATION
  HEALTH
1st & 4th yr US medical student
   knowledge of Population Health
                (2002)
Question                     Firs...
Population Health Concepts
Health has been improving most of the
 last century
Health improvements are not shared
 equally...
Female Life Expectancy by County 1990 C. Murray, Harvard, 1998




Female Life Expectancy
70.0 to 77.1
77.1 to 78.1
78.1 t...
CLOSER TO HOME



                 Life Expectancy
Cascadia
2002
NW Env Wa
Sightline
Population Health Concepts
Health has been improving most of the
 last century
Health improvements are not shared
 equally...
Health and Social Problems are not Related to Average
                                 Income in Rich Countries



  Index...
Health and Social Problems are Worse in More Unequal Countries




  Index of:
  • Life expectancy
  • Math & Literacy
  •...
Davidson's textbook of
 Medicine 2006, pg 97
"Recent research suggests that
  uneven distribution of wealth
  is a more im...
Population Health Concepts
Health has been improving most of the
 last century
Health improvements are not shared
 equally...
womb with a view
EARLY LIFE




     Newsweek September 27, 1999
The daughter
Is the mother             Life begins at
Of the                    Conception
woman                     Ends ...
Epigenetics
Do POORER People
Have POORER PROTOPLASM?
INFLAMMATION
MESA US Cohort

                             Ranjit et. al. 2007




            <$20k

                 $20-50k

        ...
MESA US Cohort

                             Ranjit et. al. 2007




            <$20k

                 $20-50k

        ...
Hegewald et. al. 2007
Hegewald et. al. 2007
Intergenerational Stress
                                      Cytokine production in women
Prenatal psychosocial         ...
IMMUNE SYSTEM TESTING of lymphocytes:
 Production: no difference
 Activation
 in vitro phytohemaglutinin (PHA)
 induced cy...
Disease approach




                   CHRONIC
                   DISEASE RISK




Birth                    DEATH
Health Care and
Risk factor approach




                       CHRONIC
                       DISEASE RISK




Birth     ...
"As dramatic and
consequential as medical
care is for individual cas
and for specific condition
much evidence suggests
tha...
OTHER COUNTRIES
There walk the earth now both the richest peo
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 poor...
Distribution of length of life for males in Niger, Brazil and Japan in 20




                                           S...
BIG PICTURE
  DETERMINANTS OF HEALTH
 communities, SOCIETIES, global

BASIC NEEDS (food, water, shelter)

Nature of caring...
Population Health Concepts

Health declined with development
of agriculture
Health Declined with agriculture
“Agriculture has long been regarded as an
  improvement in the human condition: Once
  Ho...
80    Japan
                     Life Expectancy Trends: Paleolithic On
 70    USA

 60
                Russia
  50


  40...
Hassan 1981
Countries ranking in health
              WHY?
     Theory of Global Health
1. Where they ranked when the race
   started
...
GLOBAL HEALTH
    HISTORY
  World health
by colonial troop
    mortality
Curtin 1968
Curtin 1968




   Curtin 1998
World health before health started improving?




                                       Curtin 1989
                     ...
HEALTH HISTORY TRANSITIONS



                                     End of    Global
     Euro-         End of Euro-       ...
When did health start improving?




                           Easterlin 1999
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 bac...
Leigh & Jencks 2007
Factors influencing health
         improvements
Colonizing country or not
Type of colonialism experienced
Societal and po...
Global Health Determinants
Where countries were in the health olympics
  starting blocks
Colonial history 3 groups:
1 few ...
Global Health Determinants
  Where countries were in the health olympics starting blocks
Colonial history:
2 Europeans set...
Global Health Determinants
  Where countries were in the health olympics starting blocks
Colonial history:
3 Europeans set...
Wilkinson & Pickett 2009 Spirit Level
Health Outcomes Map 2000
                                   (Hegyvary, Berry, & Murua, Journal of Public Health Policy, 20...
PRECOLONIAL INSTITUTIONS
affect
Colonial
Postcolonial AFRICAN GOVERNMENTS
PRECOLONIAL:
 – Centralized (politically not fragmented) ethnic
   groups where chiefs accountable to traditional
   autho...
PRECOLONIAL CENTRALIZATION:
 – In modern era, benefits public goods provision in
   stratified more than in egalitarian go...
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 nations
Where countries were in the health olympics starting blocks
History of poor health affects ...
GLOBAL HEALTH
Spatial-temporal spectrum of
 human health around the globe
   – cut across political and cultural units
   ...
BIG PICTURE
   DETERMINANTS OF HEALTH
    communities, nations, global

BASIC NEEDS

Nature of caring and sharing
 relatio...
Life course approach   CHRONIC
                              DISEASE RISK


Timely
intervention




          Life course
...
PRIMORDIAL PREVENTION
 HEALTH approach
                     CHRONIC
                     DISEASE RISK


Timely
interventio...
Factors influencing health
         improvements
Colonizing country or not
Type of colonialism experienced
Societal and po...
Health Determinants of nations
   Where countries were in the health olympics starting blocks
Provided basic needs (food) ...
(Advertisement)
(first paragraph)
                                 "There is no known
                                 biological reason w...
Health Societal Right100122 Web
Health Societal Right100122 Web
Health Societal Right100122 Web
Health Societal Right100122 Web
Health Societal Right100122 Web
Health Societal Right100122 Web
Health Societal Right100122 Web
Health Societal Right100122 Web
Health Societal Right100122 Web
Health Societal Right100122 Web
Health Societal Right100122 Web
Health Societal Right100122 Web
Health Societal Right100122 Web
Health Societal Right100122 Web
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  • Entringer et. al. 2008
  • RGW Figure 1.1 2009
  • Health Societal Right100122 Web

    1. 1. Health as a SOCIETAL RIGHT Stephen Bezruchka, MD, MPH Department of Global Health & Health Services School of Public Health University of Washington
    2. 2. Agenda First 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
    3. 3. Agenda First two sessions UNFAMILIAR IDEAS – Spirit Level – Intergenerational – Rationing of health care transmission of health Health as a societal right? – Biology underlying inequality Determinants of Health in Rich Countries Global Health today A theory of Global Health
    4. 4. (first paragraph) "There is no known biological reason wh every population should not be as healthy as the best."
    5. 5. So Far…..
    6. 6. Health as a SOCIETAL RIGHT Societal right?
    7. 7. 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
    8. 8. SOCIETAL RIGHT .. Social Right .. Human right EARTH/GLOBAL RIGHTS "rights are context bound"
    9. 9. 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
    10. 10. Health Olympics 2004 UNDP HDR 2006 Japan 82.2 Denmark Palestine Thailand Tajikistan Uganda Switzerland Cuba Colombia Peru India 63.6 Mali Australia United States Lithuania Egypt Kazakhstan Burkina Faso Sweden Portugal Bulgaria Nicaragua Pakistan Ethiopia Canada Korea, Lebanon Morocco Bangladesh Kenya Italy Czech Republic Saudi Arabia Turkey Turkmenistan South Africa Israel Uruguay China 71.9 Belarus Nepal Tanzania Spain Mexico Armenia Moldova, Yemen Côte d'Ivoire Norway Croatia Jordan Honduras Myanmar Cameroon France Panama Romania Guatemala Ghana Niger New Zealand Argentina Algeria Dominican Republic Cambodia Rwanda Austria Poland Paraguay Indonesia Sudan Burundi Belgium Ecuador El Salvador Kyrgyzstan Senegal Chad Germany Slovakia Brazil Azerbaijan PNG Congo (DR) Singapore Bosnia Herzegovina Viet Nam Uzbekistan Madagascar Nigeria Finland Sri Lanka Philippines Ukraine Lao Eq Guinea Netherlands Macedonia, Iran, Russian Federation Togo Mozambique United Kingdom Albania Georgia Bolivia 64.4 Eritrea Angola Greece Libya Benin Sierra Leone Costa Rica Syria Guinea Malawi UAE Tunisia Mauritania CAR Chile Malaysia Djibouti Zambia Ireland Hungary Congo Zimbabwe Venezuela 73 Haiti Swaziland 31 1629 million 2693 million 2256 million LIFE EXPECTANCY RANGE 9.2 YEARS 8.3 YEARS 32 YEARS
    11. 11. GLOBAL HEALTH 2007/09 Gap 40 years 1990/93 Gap 37
    12. 12. Your thoughts on global health disparities?
    13. 13. RICH COUNTRIES
    14. 14. How healthy is the US? Health Olympics Number one Gold 16-20 _______ 1-5 _______ 21-25 _______ 6-10 _______ 26-30 _______ 11-15 _______ 31+ _______
    15. 15. HEALTH OLYMPICS 2007 5 10 15 20 25 30 United Nations Human Development Report 2009
    16. 16. 35.0 34.5 Health Olympics Age 50 (2006) 34.0 33.5 5 33.0 10 32.5 15 32.0 20 31.5 25 30 31.0 30.5 30.0 years WHO 2009
    17. 17. GETTING TO RETIREMENT
    18. 18. FALLING BEHIND Munnell 2004
    19. 19. INFANT MORTALITY
    20. 20. TEEN BIRTHS A fifth of 20-yr old women who gave birth in the US gave birth did so in their teens In Phillips County,Arkansas, the birth rate among teenage girls in 2000 was 127 births per 1,000 w omen aged 15 to 19 - a rate higher than in 94 developing countries. SCF State of the World's Mothers 2004
    21. 21. 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* US A New Zealand Korea Canada Poland Australia Netherlans YOUTH HOMICIDE Denmark Italy Hungary Belgium Portugal Czech Republic UK Greece S pain Germany France Japan 0 2 4 6 8 10 12 *Austria, Finland, Ireland, Norway, Sweden and Switzerland had fewer than 20 deaths reported and therefore rates were not calculated.
    22. 22. MEDICAL STUDENTS DON'T KNOW POPULATION HEALTH
    23. 23. 1st & 4th yr US medical student knowledge of Population Health (2002) Question First Year Fourth Year INCORRECT INCORRECT US has higher life 28.3% 34.4% expectancy than any other nation? US has lower infant 40.6% 30.2% mortality than any other nation? Agrawal et. al. (2005)
    24. 24. Population Health Concepts Health has been improving most of the last century Health improvements are not shared equally Poorer people have poorer health Early life is most critical period for health
    25. 25. Female Life Expectancy by County 1990 C. Murray, Harvard, 1998 Female Life Expectancy 70.0 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 Where is our health?
    26. 26. CLOSER TO HOME Life Expectancy
    27. 27. Cascadia 2002 NW Env Wa
    28. 28. Sightline
    29. 29. Population Health Concepts Health has been improving most of the last century Health improvements are not shared equally Poorer people have poorer health Early life is most critical period for health
    30. 30. 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
    31. 31. Health and Social Problems are Worse in More Unequal 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
    32. 32. 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."
    33. 33. Population Health Concepts Health has been improving most of the last century Health improvements are not shared equally Poorer people have poorer health Early life is most critical period for health
    34. 34. womb with a view
    35. 35. EARLY LIFE Newsweek September 27, 1999
    36. 36. The daughter Is the mother Life begins at Of the Conception woman Ends at Birth pathway cumulative latent CONCEPTION
    37. 37. Epigenetics
    38. 38. Do POORER People Have POORER PROTOPLASM?
    39. 39. INFLAMMATION
    40. 40. MESA US Cohort Ranjit et. al. 2007 <$20k $20-50k $≥50k
    41. 41. MESA US Cohort Ranjit et. al. 2007 <$20k $20-50k $≥50k
    42. 42. Hegewald et. al. 2007
    43. 43. Hegewald et. al. 2007
    44. 44. Intergenerational Stress Cytokine production in women Prenatal psychosocial offspring (34 subjects and 28 stress comparison) mean age 24, healthy Pregnancy stress: divorce, breakup, paternity denial, marital infidelity, death of partner, parent, child, illnes s in other (cancer, MI, stroke), financi al problems (loss of house by flooding, husband unemployed, foreclosure, M VA, unmarried (father not accepted by family), political refugee (Entringer et.al. 2008)
    45. 45. IMMUNE SYSTEM TESTING of lymphocytes: Production: no difference Activation in vitro phytohemaglutinin (PHA) induced cytokine production Efficacy not tested PS = Prenatal Stress PS CG Entringer et. al. 2008 IFN interferon
    46. 46. Disease approach CHRONIC DISEASE RISK Birth DEATH
    47. 47. Health Care and Risk factor approach CHRONIC DISEASE RISK Birth DEATH
    48. 48. "As dramatic and consequential as medical care is for individual cas and for specific condition much evidence suggests that such care is not and probably never has been the major determinant of levels or changes in population health." Pg 4.
    49. 49. OTHER COUNTRIES
    50. 50. There walk the earth now both the richest peo who ever lived and the poorest. Clark 2007
    51. 51. WORLD INCOME TRENDS LAST 3000 YEARS There walk the earth now both the richest people who ever lived and the poorest. Clark 2007
    52. 52. Distribution of length of life for males in Niger, Brazil and Japan in 20 Smits & Monden 2009
    53. 53. BIG PICTURE DETERMINANTS OF HEALTH communities, SOCIETIES, global BASIC NEEDS (food, water, shelter) Nature of caring and sharing relationships or quality of SOCIETAL relationships health care
    54. 54. Population Health Concepts Health declined with development of agriculture
    55. 55. Health Declined with 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)
    56. 56. 80 Japan Life Expectancy Trends: Paleolithic On 70 USA 60 Russia 50 40 Paleolithic Sub-Saharan 30 Afr ica Rome 20 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 sc a l e )
    57. 57. Hassan 1981
    58. 58. Countries ranking in health WHY? Theory of Global Health 1. Where they ranked when the race started 2. When did health begin to improve 3. Mix of factors influencing health improvements
    59. 59. GLOBAL HEALTH HISTORY World health by colonial troop mortality
    60. 60. Curtin 1968
    61. 61. Curtin 1968 Curtin 1998
    62. 62. World health before health started improving? Curtin 1989 Curtin 1998
    63. 63. HEALTH HISTORY TRANSITIONS End of Global Euro- End of Euro- Cold Economic Colonialism Colonialism War Collapse Military Tropical International GLOBAL ?Population Medicine Medicine health HEALTH health 1500s 1960s 1990s 2010s
    64. 64. When did health start improving? Easterlin 1999
    65. 65. Hundreds of years ago: Life Expectancy increased after childhood
    66. 66. 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, t errorized and sexually abused." DeMause The History of Childhood 1974
    67. 67. Leigh & Jencks 2007
    68. 68. Factors influencing health improvements Colonizing country or not Type of colonialism experienced Societal and political policies Economic issues: rapid growth or not Cultural factors
    69. 69. 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
    70. 70. Global Health Determinants Where 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
    71. 71. Global Health Determinants Where 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
    72. 72. Wilkinson & Pickett 2009 Spirit Level
    73. 73. Health Outcomes Map 2000 (Hegyvary, Berry, & Murua, Journal of Public Health Policy, 2008) 1 Child Mortality (log scale) 2 How do child mortality and life expectancy 3 vary throughout the world? Life Expectancy
    74. 74. PRECOLONIAL INSTITUTIONS affect Colonial Postcolonial AFRICAN GOVERNMENTS
    75. 75. PRECOLONIAL: – Centralized (politically not fragmented) ethnic groups where chiefs accountable to traditional authority • Can modernize better • Less tyranny, disorder halting modernization
    76. 76. 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)
    77. 77. Precolonial African Centralization and IMR decline Gennaioli et al. 2007
    78. 78. Precolonial African Centralization and paved roads Gennaioli et al. 2007
    79. 79. Precolonial African Centralization and adult literacy Gennaioli et al. 2007
    80. 80. Health Determinants of nations Where countries were in the health olympics starting blocks History of poor health affects cohort & subsequent generations How well they provided basic needs (food) How much they support early life How much they support ALL (social welfare systems) Sense of community, social capital Culture, 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 care Public health programs
    81. 81. 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
    82. 82. BIG PICTURE DETERMINANTS OF HEALTH communities, nations, global BASIC NEEDS Nature of caring and sharing relationships or quality of social relationships health care
    83. 83. Life course approach CHRONIC DISEASE RISK Timely intervention Life course CONCEPTION DEATH
    84. 84. PRIMORDIAL PREVENTION HEALTH approach CHRONIC DISEASE RISK Timely intervention Trans-generational Conception DEATH EARLY LIFE LASTS MANY LIFETIMES
    85. 85. Factors influencing health improvements Colonizing country or not Type of colonialism experienced Societal and political policies Economic issues: rapid growth or not Cultural factors
    86. 86. Health Determinants of nations Where countries were in the health olympics starting blocks Provided basic needs (food) Forager-Hunters, UK (WWII) How much they support early life SWEDEN How much they support ALL (societal welfare systems) CUBA Sense of community, social capital OKINAWA Culture, values, ethos JAPAN Political 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
    87. 87. (Advertisement)
    88. 88. (first paragraph) "There is no known biological reason wh every population should not be as healthy as the best." (last paragraph) "The primary determinants of disease mainly economic and social, and therefore its remedi must also be economic and social. Medicine and poli cannot and should not be kept apart."
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