Health Societal Right100122 Web
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  • Entringer et. al. 2008
  • RGW Figure 1.1 2009

Transcript

  • 1. Health as a SOCIETAL RIGHT Stephen Bezruchka, MD, MPH Department of Global Health & Health Services School of Public Health University of Washington
  • 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. 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. (first paragraph) "There is no known biological reason wh every population should not be as healthy as the best."
  • 5. So Far…..
  • 6. Health as a SOCIETAL RIGHT Societal right?
  • 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. SOCIETAL RIGHT .. Social Right .. Human right EARTH/GLOBAL RIGHTS "rights are context bound"
  • 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. 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. GLOBAL HEALTH 2007/09 Gap 40 years 1990/93 Gap 37
  • 12. Your thoughts on global health disparities?
  • 13. RICH COUNTRIES
  • 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. HEALTH OLYMPICS 2007 5 10 15 20 25 30 United Nations Human Development Report 2009
  • 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. GETTING TO RETIREMENT
  • 18. FALLING BEHIND Munnell 2004
  • 19. INFANT MORTALITY
  • 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. 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. MEDICAL STUDENTS DON'T KNOW POPULATION HEALTH
  • 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. 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. 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. CLOSER TO HOME Life Expectancy
  • 27. Cascadia 2002 NW Env Wa
  • 28. Sightline
  • 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. 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. 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. 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. 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. womb with a view
  • 35. EARLY LIFE Newsweek September 27, 1999
  • 36. The daughter Is the mother Life begins at Of the Conception woman Ends at Birth pathway cumulative latent CONCEPTION
  • 37. Epigenetics
  • 38. Do POORER People Have POORER PROTOPLASM?
  • 39. INFLAMMATION
  • 40. MESA US Cohort Ranjit et. al. 2007 <$20k $20-50k $≥50k
  • 41. MESA US Cohort Ranjit et. al. 2007 <$20k $20-50k $≥50k
  • 42. Hegewald et. al. 2007
  • 43. Hegewald et. al. 2007
  • 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. 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. Disease approach CHRONIC DISEASE RISK Birth DEATH
  • 47. Health Care and Risk factor approach CHRONIC DISEASE RISK Birth DEATH
  • 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. OTHER COUNTRIES
  • 50. There walk the earth now both the richest peo who ever lived and the poorest. Clark 2007
  • 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. Distribution of length of life for males in Niger, Brazil and Japan in 20 Smits & Monden 2009
  • 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. Population Health Concepts Health declined with development of agriculture
  • 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. 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. Hassan 1981
  • 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. GLOBAL HEALTH HISTORY World health by colonial troop mortality
  • 60. Curtin 1968
  • 61. Curtin 1968 Curtin 1998
  • 62. World health before health started improving? Curtin 1989 Curtin 1998
  • 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. When did health start improving? Easterlin 1999
  • 65. Hundreds of years ago: Life Expectancy increased after childhood
  • 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. Leigh & Jencks 2007
  • 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. 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. 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. 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. Wilkinson & Pickett 2009 Spirit Level
  • 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. PRECOLONIAL INSTITUTIONS affect Colonial Postcolonial AFRICAN GOVERNMENTS
  • 75. PRECOLONIAL: – Centralized (politically not fragmented) ethnic groups where chiefs accountable to traditional authority • Can modernize better • Less tyranny, disorder halting modernization
  • 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. Precolonial African Centralization and IMR decline Gennaioli et al. 2007
  • 78. Precolonial African Centralization and paved roads Gennaioli et al. 2007
  • 79. Precolonial African Centralization and adult literacy Gennaioli et al. 2007
  • 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. 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. BIG PICTURE DETERMINANTS OF HEALTH communities, nations, global BASIC NEEDS Nature of caring and sharing relationships or quality of social relationships health care
  • 83. Life course approach CHRONIC DISEASE RISK Timely intervention Life course CONCEPTION DEATH
  • 84. PRIMORDIAL PREVENTION HEALTH approach CHRONIC DISEASE RISK Timely intervention Trans-generational Conception DEATH EARLY LIFE LASTS MANY LIFETIMES
  • 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. 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. (Advertisement)
  • 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."