Ethical and Human Rights Concerns in Global HealthChapter Fou.docx

Ethical and Human Rights Concerns in Global Health
Chapter Four
Chapter four: Ethical and human rights concerns in global
health.
As with any area of health, global health is affected by the
issues of ethics and right for sound health outcome. In this
chapter we will explore ethical and human rights concerns,
some of the central treaties and conversions related to human
rights, some historically significant cases in human subject
research and key principles for making critical decisions in
health research.
1
Failure to respect human rights is often associated with harm to
human health
Health research with human subjects puts people at risk for the
sake of other people’s health
Health investments must be made in fair ways since resources
are limited
The Importance of Ethical and Human Rights Issues in Global
Health
Access to the health care is human right and failure to respect
this right might causes harm for health. For example, the stigma
associated with HIV, TB and leprosy makes it difficult for the
patient to obtain necessary health care, it not only cause harm to

individual health but as a whole community health even. For
example, if a TB patient remains untreated by the health care
workers, then that individual could be a source of infection for
other people.
Health research with human subject in particular in low income
countries where study participants may not have other option to
obtain the medication might become a proxy of clinical trial for
other people .Lastly, fair decision in health investment is
critical because in low income countries where health resources
are scare difficult decisions need to be made depending on the
priority and severity of disease.
2
The Foundations for Health and Human Rights
Universal Declaration of Human Rights and other legally
binding multilateral treaties
Governments are obliged to respect, protect, and fulfill the
rights they state
International Bill of Human Rights is the cornerstone for human
rights. This bill include couple of documents including the
Universal declaration of human rights that was officially
declared in 1948, that place obligation on Government to
respect , protect, and fulfill the rights of the state.
3
Selected Human Rights
The Rights-Based Approach
Assess health policies, programs, and practices in terms of
impact on human rights

Analyze and address the health impacts resulting from
violations of human rights when considering ways to improve
population health
Prioritize the fulfillment of human rights
In considering human right, first we are going to examine the
issue of right based approach. Some global health advocates
argue that this approach, which thinks that fulfillment of
people’s human right is conducive to their health, should be
followed in global health. This means we need to assess health
policies, programs or practices in terms of its impact on human
right and analyze the health impacts from the perspective of
violation of human rights
4
The right based approach reminds us that promoting health is a
synergistic approach where doctors and drugs, education,
discrimination against violence, addressing the issues of
poverty and homelessness, individual empowerment and the
participation of affected people in health promotion intervention
design each plays their role effectively.
5
Limits to Human Rights
Circumstances in which someone’s rights may be temporarily
suspended
Suspension of rights should be as narrow as possible
Suspension should be carried out with due process and
monitored

As it is important to protect human right, sometimes it is also
important to limit rights to serve the bigger purpose. For
instance, in influenza epidemic government might limit people’s
right to leave their homes, go to work or travel to some other
places for limiting the spread of the disease. However, the
suspension of such right should be as narrow as possible, only
practice in case of an emergency and it should be carried out
with due process and monitoring.
6
Human Rights and HIV/AIDS
Health condition that is stigmatized and discriminated against.
Protecting the rights of people who are HIV-positive to
employment, schooling, and participation in social activities.
Ensuring access to care.
Policies regarding testing.
Protection of confidentiality.
HIV/AIDS is a health condition that is considered with stigma
and discrimination in many parts of the world. As a result the
HIV positive encounter discrimination in employment,
schooling and participation in social activities. In some parts of
the world the health care workers are poorly informed about
HIV, as a result they are afraid to provide care for the affected
people. Policies regarding HIV testing also faces questions
related to protecting people’s well-being while respecting
human rights. For many years HIV testing was voluntary and
confidential. However, concerns have been raised regarding the

voluntary option as it spreading through the people who do not
know their status and increasing the chance of infecting many
by having multiple partners.
Issues regarding the confidentiality are questionable too as by
not disclosing the information to the spouse , the healthcare
system may risk spreading of the infection to apparently healthy
partner, on the other hand if the information is shared with the
partner specially if wife is diagnosed with HIV/AIDS ,
husband/family might harm her, reject her or throw her out of
the house.
7
Research on Human Subjects
Most research studies don’t benefit the people who participate
in them
Ethical concerns about putting participants at risk for the sake
of other people’s health
Heath research generate some ethical problems. Most research
studies are not designed to benefit the participants, rather to
gather knowledge and use them in future. This jeopardize the
benefits of research.
8
Key Human Research Cases
Nazi Medical Experiments
Conducted experiments on euthanasia victims, prisoners of war,
occupants of concentration camps.
International Scientific Commission investigated and
documented abuses after war.

Questions over whether it is ethical to use data the Nazis
generated.
Josef Mengele -twin camp, Auschwitz
Experiments on POWs
Now we’ll be talking about some research studies on human
subject in medical history that raised ethical concern and
encourage developing a guideline for future research. The Nazi
Medical Experiment is the first of this kind. Hitler’s
Nazificaion not only included German society but also research
institutions, universities, and the medical profession. German
medical researchers conducted many experiments on euthanasia
victims, prisoners of war, occupants of concentration camp by
deliberately infecting prisoners with diseases like TB and
malaria. Josef Mengele, as a camp doctor, studied around 900
children and conducted operations on children without
anesthetics, killed children’s siblings and infected children with
disease agents. Following the end of 2nd world war , 23
scientist were charged with war crime and crime against
humanity of whom seven were sentenced to death and hanged.
Most of the scientist were not prosecuted and as a matter of
fact they went on with their career. The data that were gather
from Nazi research evoked some ethical concern regarding its
qualitative value and ethical use.
9
The Tuskegee Study
US Public Health Service conducted a study on the natural
history of syphilis in African American men.

Participants were told they were being treated for “Bad Blood”
Study Sample: 399 with Syphilis, 201 without
Study went on for 40 years
Subjects were never given treatment
Movie made: Miss Evers’ Boys
Eventually led to regulations for human research subjects.
U.S Public Health Services began a study in collaboration with
the Tuskegee institute to justify the creation of syphilis
treatment for African American.
600 African American men with and without syphilis took part
in the study and they were told that they were being treated for
“Bad Blood” a term used to describe syphilis, anemia and
fatigue. However, they only received iron tonics to make them
think that they were being treated. The original plan of the
study was to watch the natural history of the disease for six
month-it ended up continuing for 40 years. Participants had
limited access to doctors and treatment options available, after
world war II when penicillin was widely available, the PHS
actively intervene to prevent them from getting the treatment. It
was only 1972 when an article was published in NY times about
the story of Tuskegee study, US Assistant Secretary for Health
and Scientific Affairs appointed a committee to review the
study. The study quickly brought to the end and in response to
the class-action lawsuit filed by National Association for the

Advancement of Colored People, the US government settled the
lawsuit outside of court in $9 million.
10
The “Short-Course” AZT Trials
Trials of a “short-course” AZT regimen to prevent mother-to-
child transmission of HIV
Some people thought that poor people were being exploited
since the trials were taking place in low-income countries
Studies remain controversial
After the recognition of effectiveness of antiretroviral therapy
during pregnancy, a therapy which was able reduce the mother
to child transmission by two thirds, it became the standard of
care in developed countries. However, countries where
HIV/AIDS rates are higher for them antiretroviral therapy
became too complex and too costly to administer. As 15 trials
were organized in developing countries through a meeting
arranged by WHO, a test of short course AZT (antiretroviral
drug Zidovudine) was introduced in Sub Saharan Africa.
Controversy has started since then-those who oppose the short
course regimen made a point that this would not be acceptable
in developed countries, so they accused the sponsors of the
short course AZT trials of ethical double standard. Those who
are proponents of regimen defined their situation by saying that
the regimen would not be accessible to the study participants in
any other case and the reason of having a placebo groups are to
prove the hypothesis that short course regimen is better than
nothing at all and to assess the comparativeness of HIV mother
to child transmission across different population.
11

Ethics Vs Life
Video:
http://video.pbs.org/video/1990304722
Medical Cost-Benefit Ethics
Expensive cancer-fighting drugs are sparking ethical debate
about the tremendous costs and small benefits of some new
treatments.
Watch the video to see the ethics related to a costly cancer
treatment.
12
Research Ethics Guidelines
The Nuremberg Code
First document to specify ethical principles that should guide
physicians engaged in human research
“Voluntary consent of the human subject is absolutely
essential”
Nuremberg trial lead the US judges to issue Nuremberg Code.
This was the first document that specify the ethical principles
that should guide physicians engaged in human subject

research. It made sure that voluntary consent of the human
subject is absolutely essential.
13
The Declaration of Helsinki
Developed ethical principles to guide physicians conducting
biomedical research on humans
Principles apply equally to non-physicians
In 1964, World Medical Association developed a set of
guidelines for the physician conducting biomedical research
with human subjects. This set of guidelines went through
several revisions with including the non-physician as well to
follow these guidelines.
14
The Declaration of Helsinki: Key Principles (cont.)
Discuss this slide
15
The Belmont Report
US National Commission for the Protection of Human Subjects
of Biomedical and Behavioral Research

Identified basic ethical principles
Developed guidelines for research
The Belmont report was created by U.S. National Commission
for the protection of human subjects of biomedical and
behavioral research. The commission also developed guidelines
for the researchers so that all human research would conform to
the principles identified.
16
Evaluating the Ethics of Human Subjects Research
Clinical research protocol must satisfy six conditions:
Social value
Scientific validity
Fair subject selection
Acceptable risk/benefit ratio
Informed consent
Respect for enrolled subjects
The framework for research mentioned here is developed based
on Belmont Report which should help one to systemically think
through the ethical process of research. A study should be of
social value meaning it should ask the questions that are
important and beneficial for the society. It should also have
scientific validity by ensuring proper methodology. Subject

selection should be fair with caution regarding the vulnerable
populations. The risk of participating in the study should be
thoroughly checked and should be as minimum as possible.
Voluntary informed consent is a must, participants should make
aware about all the key elements of research. Researcher must
respect the participant’s right to withdraw from the study any
time, protect their confidentiality and show respect to any other
situation as they arise.
17
Research in Low- and Middle-Income Countries
Important issues when the subjects are likely to be poor, under-
educated and without access to good care:
Standard of care
Post-trial benefits
Ancillary care
Some important issues come up as the research is done in low
and middle country setting. In cases of new drug trial where one
group of participants receive a new drug while the other group
does not, or receive the established treatment or placebo that
raises a lot of debate. In cases where patients do not receive
any care after the trial ends, and there is chance that without the
medication, the patient might deteriorate, that poses ethical
dilemma. In most of the low and middle income countries the
clinical trial may be the only source of medication for the poor.
As for ancillary care, they are not the part of the original design
of the trial however, researchers are faced with providing
ancillary care for the patients other than what disease they are
studying. This again happens in low and middle income
countries where diseases like pneumonia, diarrhea, parasitic
infections are very common.

18
Human Subjects Research Oversight Today
Ethical review by a research ethics committee(REC)
Safeguard against exploitation
Regulations vary from country to country
In majority of the countries it is a legal requirement for most
clinical research to undergo independent ethical review by a
research ethics committee. They are also named as research
ethics board, institutional review board or an independent ethics
committee. Such committees are deigned to provide safeguard
for human subjects in research. The regulations designed by the
ethics committee differ from country to country.
19
Ethical Issues in Making Investment Choices in Health
Resources will always be fewer than needed to meet everyone’s
health needs.
Government ministries have tight budgets and need to decide
how to allocate funds among options.
Better that the choices be made according to explicit, publicly
justified criteria.
Cost-effectiveness analysis.
A central issue in global health is the need to make right
choices that can enhance the health of a population. Resources
will always be fewer than needed to meet everyone’s health
needs and government ministries always have tight budgets and
need to decide how to allocate funds among options. It is better
that the investment choices, that are made in heath, be made

according to explicit, publicly justified criteria. Cost effective
analysis is an important tool for making health investments.
20
Principles for Distributing Scarce Resources
Most plausible allocation proposals is justified by at least one
of these ethical principles:
Health maximization
Equality
Priority to the worst off
Personal responsibility
When allocating resources like health, it is best if one could
follow at least one of the three principles mentioned here.
Health maximization is the way that when resources is allocated
the beneficial impact on health should be as large as possible.
Principals of equity tells us we should try to ensure that
everyone has an equal chance at receiving health care resources.
In make the equity process easier, it is advisable by some that
priority should not be given to the worst off because it makes
existing health disparity ever more serious. Lastly it is
suggested that personal responsibility should be a basis for
allocation of health resource.
21
Fair Processes
Transparency about how decisions are made.
Representation from stakeholders affected.
Appropriate use of scientific data.

Fairness is expected everywhere, in politics, in justice, in
health. A fair process will involve transparency about how
decisions are made and representation from stakeholders
affected.
22
Future Challenges
Students of global health get insufficient exposure in their
training to ethical issues.
No mechanisms of enforcement of humans rights.
Shortage of trained personnel for reviewing research.
Lack of reviews of how investments are made.
Unsolved ethical problems.
To incorporate ethics and right into global health workforce
there remain a number of challenge. First, students of global
health get insufficient exposure in their training to ethical
issues. They do not understand the concept of research and how
an institutional review board works. Second, there is no
established measurement guideline to assess the extent of
compliance to human right in biomedical research. There is
shortage of trained personnel for reviewing research-research
committee are often underfunded, understaffed and
underdeveloped. The final challenge global health workers face
is unsolved ethical problem. There is no clear definition
regarding the human rights in global research in particular in
low and middle income countries.
23
Health, Education, Poverty,
and the Economy
Chapter Three

Chapter three: Health, Education, Poverty and the Economy
1
To understand the two way relationship between health and
development.
To examine the connection between health and education.
To review the link between health and poverty and health and
equity.
To explore the link between health and income and health and
expenditure at the individual and national level.
Learning Objectives
Learning Objectives
To understand the two way relationship between health and
development
To examine the connection between health and education
To review the link between health and poverty and health and
equity
To explore the link between health and income and health and
expenditure at the individual and national level.
2
Health and education of parents affects health and education of
children.

Malnutrition and disease affect cognitive development.
Education contributes to disease prevention.
Health and Education
Health, Education, Productivity, and Poverty
The AIDS epidemic has shown us the impact of parents’ health
on children’s health. When mothers die of HIV/AIDS or get
diagnosed with the disease, the children are more likely to be
malnourished, less likely to attend the school, and more likely
to drop out from school. When children are malnourished it
affects the their ability to perform in the school by interacting
with their cognitive development. Education is such a strong
determinants of health that mothers education influence child
health to a greater extent. Numerous studies have shown that
better educated mothers are more likely to keep their children
healthy, more likely to play a role in child’s survival. It was
shown that higher educational attainment of mother is positively
associated with reduced infant, neonatal and under five child
mortality rate.
3
Health Productivity and Earnings
Good health increases longevity, lifetime earnings.
Healthy workers are more productive than unhealthy workers.

Health is wealth. A person’s productivity depends on his or her
health. A study done in Indonesia on rubber worker, it was
shown that workers’ productivity was increased by 20% after
they were treated for anemia that was caused by hookworm
infection. As it could be imagined that as good health increases
the productivity, lacking good health cost high to the
individual, family, and in the long run on the health care
system.
4
Costs of health care are high.
Illness often leads to a decrease in earnings.
Health, the Costs of Illness, and Poverty
When people become sick in poor countries, they lose their
earnings and need to pay for the direct and indirect cost of
healthcare which could be a very substantial amount. On one
hand they do not have earnings as they miss work, on another
hand their spending after health increase. It puts them further in
poverty which could be devastating. A study done in
Bangladesh showed that a Bangladeshi lost the equivalent of
four month income from getting TB . As it can be seen from the
graph above, the perception of poor or fair health status depends
on household income. Only 4% of people who live in a
household income of 50K think they have poor or fair health in
contrast to 21% of people who live in household of less than

15K.
5
From: The Economic Burden of Illness for Households in
Developing Countries: A Review of Studies Focusing on
Malaria, Tuberculosis, and Human Immunodeficiency
Virus/Acquired Immunodeficiency Syndrome
Health, the Costs of Illness, and Poverty E.g.
This table is taken from a study that assessed the economic
burden of illness in developing countries where they showed in
low income countries like Bangladesh and India spent a
significant amount of their annual household income on direct
and indirect cost of illness, in this case TB.
6
Health equity is achieved when every person has the
opportunity to “attain his or her full health potential” and no
one is “disadvantaged from achieving this potential because of
social position or other socially determined circumstances.”
(CDC)
Health equity is multidimensional. ( Amartya Sen)
Differences in health that are not only unnecessary and
avoidable, but also unfair and unjust. ( Margaret Whitehead)
Equity

Equity is an important issue in public health and so many
opinions exist in regarding definition of Equity. For example,
economist Amarty sen thinks equity is multidimensional and
social justice, social arrangements, and countries resource
allocation should act as a background for assessing equity.
British Public health scholar Margaret Whitehead considered
equity as a must for health and according to her differences in
health unnecessary, avoidable, unjust and unfair. Next we will
be examining equity in the context of health.
7
Equity Across Countries
Enormous variance in basic indicators of health across
countries.
Largely, but not completely varies by income.
Health and Equity
Data source: World Bank
There is significance variance on basic health indicators across
countries. High income countries have higher life expectancy
and lower infant, child, and maternal mortality whereas low
income countries are low on life expectancy and high on
mortality (child, infant, maternal). The difference largely
reflects the status of economic variance. Though weak
economic development attributes to the health , it is not the
only reason for such inequity. There are other factors play role
in health inequity.
8

Maternal mortality by various factors by region
“Achieving the SDG target of a global MMR below 70 will
require reducing global MMR by an average of 7.5% each year
between 2016 and 2030. This will require more than three times
the 2.3% annual rate of reduction observed globally between
1990 and 2015. Accurate measurement of maternal mortality
levels remains an immense challenge, but the overall message is
clear: hundreds of thousands of women are still dying due to
complications of pregnancy and/or childbirth each year. Many
of these deaths go uncounted. Working towards SDG 3.1 and
ultimately towards ending preventable maternal mortality
requires amplifying the efforts and progress catalysed by
MDG 5. Among countries where maternal deaths remain high,
efforts to save lives must be accelerated and must also be paired
with country-driven efforts to accurately register births and
deaths, including cause of death certification. Strengthening
civil registration and vital statistics will support measurement
efforts and help track progress towards reaching SDG 3.1.
Among those countries with low overall maternal mortality, the
next challenge is measuring and amending inequities among
subpopulations. The new Global Strategy for Women’s,
Children’s and Adolescents’ Health will spearhead an enhanced
global collaborative response aimed at ending all preventable
maternal deaths.” from the Trends in Maternal Mortality 1990 to
2015 Estimates by WHO, UNICEF, UNFPA, World Bank Group
and the United Nations Population Division.
9
Some countries have substantial variation in health indicators
across population groups.
Tend to be low- and middle-income countries or high-income

countries with significant ethnic minorities.
Equity Within Countries
Under-5 Child Mortality Rates, for Selected States, India, 2005-
2006.
Equity also exist within countries. The graph here shows under
five mortality rates among five states of India. According to
2005-2006 data , Uttarpradesh had almost five times more child
mortality than Kerala. What do you think are the reasons for
such variance within countries?
10
Sources
Measure of America calculations using mortality counts from
the Centers for Disease Control and Prevention, National Center
for Health Statistics. Mortality – All County Micro-Data File, as
compiled from data provided by the 57 vital statistics
jurisdictions through the Vital Statistics Cooperative Program.
Population counts are from the CDC WONDER Database.
Equity Within Countries
This table shows data for life expectancy for different
ethnicities in United States. This data is an example for you to
see the inequity in health within a country.

11
Urban dwellers tend to enjoy better health status, coverage, and
access to services than rural dwellers.
Rural people tend to have lower incomes, less education, less
access to services, and weaker political voice.
Health and Equity-Equity and Location
We expect to see the variance in health by location. Urban
dwellers enjoy better health as they have more access to health
care, whereas rural dwellers are deprived of such care just
because of the location. In Sub-Saharan Africa, the rural
children are 33 times more likely to be stunted than urban
children.
12
Large gap in access, coverage, fairness, and benefits between
less well off and better off.
Equity and Income

Percentage of Births Attended by Skilled Personnel, by Income
Quintile, Latest Data 2003-2009, for selected Regions
Health equity and income relationship has been examined in so
many literature. The difference in variance in different health
indictors according to income quintiles showed well off
population enjoy the blessing of good health much more than
poor population. For Example, In South Asia richest 20% of the
population are almost 8 times more likely to have a birth
attendant than poorest 20%. Similarly very few children of the
richest 20% are underweight.
13
Equity and Gender
“Being born female is dangerous to your health”
Women face health concerns related to their diminished place in
many societies.
Examples: female infanticide, less food for female children,
lower enrollment in school, violence against women.
Think equal for Women and Girls (1:20)
http://www.youtube.com/watch?feature=player_embedded&v=U
aCwOdNeA7k
Equity and Ethnicity
Strong association between ethnicity and health status, access,
and coverage.
Linked to strong association between ethnicity and power,
education, and income.
Health and Equity

In many parts of the world just being born as female poses
health risk. The discrimination starts from shorter duration of
breastfeeding, less food for girl, less attention for healthcare
needs for girls. Adult women also suffer from lack of health
care, less power, lack of education and less voice in the society.
Ethnicity and health status correlation is a strong one and very
evident in the form of access to health care and coverage. In the
United States there is large gap between White people and
Black people in health care services. Similar differences can
also be seen in different health indicators between indigenous
people and non-indigenous people, between majority and
minority.
14
Substantial out-of-pocket costs for poor in low-income
countries
Benefit of public subsidies often received by better off people
Get Well, Maya: Universal Health Coverage Ensures Healthy
Futures (2:12)
http://www.youtube.com/watch?v=6prBrGHI2Ws
Equity and Financial Fairness
In high income countries and some of the middle income

countries have some type of mandatory and universal health
insurance system that ensure access to health for all. However,
for poor countries this is not the case at all. Other than the free
or low cost provision from public sector or from NGOs whose
services are questionable, most of the poor need to pay out of
pocket for health service. Poor countries fail to protect their
own population from health related catastrophic event.
15
Most high-income countries spend 9-12% of GDP and have
higher life expectancies.
Most low-income countries spend 3-6% of GDP and have lower
life expectancies.
Important outliers like Sri Lanka and Cuba spend relatively
little, but achieve higher life expectancies.
Health Expenditure and Health Outcomes
The more you spend on health the more likely you expect to
have better outcome. Most high income countries spend 9-12%
of GDP and have higher life expectancy. Most low income
countries spend 3-6% of their GDP and expect lower life
expectancy. However, countries like Sri Lanka and Cuba spend
less of their GDP and still have achieved life expectancies.
16
Source:
http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS/countries
?display=map
GDP and Health

National Income and Health Expenditure, Selected Countries,
2003/2004
Expenditure on Health as a Share of GDP, Compared to Life
Expectancy, Selected Countries, 2003/2004
GDP and Health Example
As it can be seen from this figures, most high income countries
cluster around 9-12 % of their national income on health and
have a higher life expectancy for example Germany and Iceland.
Most low income countries cluster around 3-6% of their GDP
and have a lower life expectancy as in the case of Mali, Kenya,
and Nigeria. There are some outliers in these figures like
Cambodia and Cuba who spent less of their GDP after health
and still have higher life expectancy.
18
Public and Private Expenditure on Health
Private Expenditure: expenditure by sources other than the
government such as a non-governmental organization
Out-of-Pocket Expenditure: expenditure by individuals that is
not covered or reimbursed by an insurance program
Public Expenditure: expenditure by any level of government or
government agency

Factors needed to consider in public expenditure
The investment should benefit society
Promote equity
Financial protection to the poor
Discuss this slide
19
The Cost Effectiveness of Health Interventions : Cost-
effectiveness analysis
Amount of health is measured by life years saved/DALYs
Alternative approach
A specific goal
Cost and gain of different interventions
Investment choices
An important tool for setting priorities for public expenditure
on health is cost effective analysis. This is a method that
compares couple of things like it compares cost of an
intervention with the amount of health that can be purchased

with that investment and the amount of health is measured by
life years saved/DALYs. It also compares alternative
approaches to achieving a specific goal/intervention, such as TB
drug therapy.
Finally, it compares different interventions to assist investment
choices. Cost effective analysis can help to set priorities among
different ways of achieving a health goal
20
Incidence & prevalence of the health condition considered for
intervention
Cost of the intervention
Expected reduction in morbidity , mortality and disability
Effectiveness of intervention implementation
Factors influence cost effective analysis
The amount of health that can purchased with an investment
depends on couple of factors like incidence & prevalence of the
intervention in consideration, cost of the intervention, expected
outcomes and the effectiveness of intervention implementation.
21
Good health promotes economic development.
For Example: A high prevalence of malaria is associated with a
reduction of economic growth of 1%/year or more (Commission
on Macroeconomics and Health. Macroeconomics and Health:
Investing in Health for Economic Development. Geneva: World
Health Organization,2001).

Higher levels of economic development also promote better
health, but not quickly enough.
Therefore, low- and middle-income countries must adopt
policies that speed achievement of health goals, even with
constrained incomes.
Health and Development
Discuss this slide
22
Health Determinants, Measurements, and Trends
Chapter 2
Chapter 2: Health determinants, measurements, and trends
1
Key Concepts in Relation to Global Health
The determinants of health
Key health indicators
Measuring the burden of disease
The global burden of disease
The key risk factors for various health problems
The demographic and epidemiological transitions

In this chapter we are going to discuss what the issues that
influence global health are, how health status is measured, what
are the global burden and what are some key risk factors for
global health problems. Many factors act in combination that
affect the health of individuals, communities, and in the bigger
picture global health.
2
The factors that influence health status most
The indicators used to measure health status
The key trends that have occurred historically
The Importance of Measuring Health Status
As we try to define health, we also try to quantify the amount of
health an individual or a community possesses. Two basic
things are taken in consideration –what are the indicators taken
into account to measure the health status and what are the
factors that influence health status. Finally, the key trends in
health status that have been going on historically gives us clear
idea about the health in a certain country.
3
Figure 2.1: Key Determinants of Health
Data from: The Public Health Agency of Canada. What
Determines Health. Available at: http://www.phac-
aspc.gc.ca/ph-sp/determinants/index-eng.php#determinants.
Accessed November 19, 2010.

Source: Dahlgren G. and Whitehead M. 1991
The notion of good health became synonymous with access to
health care while health depends on number of factors. As we
will move with this course, we will see that there are
interconnected factors that determine an individual’s health
status. Determinants include personal features, like genetic
makeup, sex and age; have significant contribution on what
diseases we get and how healthy we live. For instance, if one
inherits genetic component for breast cancer then to have the
disease, it is also important to have appropriate exposures
which might actually cause the disease in that person. Social
status and culture very intricately relate with disease
occurrence. Higher social status paired with higher income
often leads to higher education and better health. Environment,
both indoor and outdoor, plays a role in determining health.
Safe and pollution free outdoor environment could enhance
health while indoor air pollution and poor ventilation could lead
to respiratory diseases and asthma. Education is another strong
determinant of health. Education has shown to have extremely
strong and positive correlation between level of education and
all key health indicators. Recent attention has been given to
individual health practices and behaviors in relation to being
healthy. One’s health depends on personal behaviors like eating,
drinking, driving or smoking. Recent research has brought our
attention to physical activity and its link to a number of
diseases for example obesity, and breast cancer. Access to
health care does have its role in good health as even after being
born healthy, practicing healthy behavior, one might get sick.

The more quickly one has access to quality health care , the
more likely he/she is to stay healthy. Finally, government policy
and intervention also fit in the puzzle of the status of health as
countries where government promote and ensure higher
education, safe water, or universal health insurance are more
likely to have healthy nations.
4
Determinants of Health
Determinants of Health : A Framework for Reaching Healthy
People 2020 Goals.
http://www.youtube.com/watch?v=5Lul6KNIw_8
This video demonstrates determinants of health with examples
for further clarification on the topic.
5
Evidence and data are vital to address key global health issues.
Health data like infant mortality concern the health status of
people and communities. Such data are useful for finding which
diseases people suffer from, determining the extent to which the
disease causes death or disability, and practicing disease
surveillance. To perform these functions, it is important to use a
consistent set of indicators so that comparisons could be made
across people in the same country or across different countries.
The table here listed some commonly used health indicators

which are more elaborately discussed in your textbook.
6
Life Expectancy at Birth, by World Bank Region, 2008
Data from the World Bank. World Development Indicators, Data
Query. Available at: http://databank.worldbank.org. Accessed
Jan. 1, 2016.
As you can see from this slide, the life expectancy for high
income countries that belong to the organization for economic
cooperation and development is around 80 years, to be more
precise, high income country like in the United States the life
expectancy is about 77 years. However, in Sub-Saharan Africa
the life expectancy is pretty low around 52 years.
7
Infant Mortality Rate, by World Bank Region, 2008
Data from The World Bank. World Development Indicators,
Data Query. Available at: http://databank.worldbank.org.
Accessed Jan 11, 2016
In high life expectancy countries infant mortality is low. We see
very low infant mortality rates for high income countries
whereas countries from Sub-Saharan Africa experience high
infant mortality rates. Sub-Saharan African countries have as
high as 100 infant deaths for every 1000 live birth. Which

region is next to Sub-Saharan Africa for high infant mortality
rate? Can you think of some reasons for such high infant
mortality rates for these regions?
8
Neonatal Mortality Rate
Data from
http://www.who.int/gho/child_health/mortality/neonatal/en/Acc
essed Jan 11, 2016.
The health status indicator neonatal mortality rate reflects how
many infants die younger than 28 days of age in a given year for
1000 live births. From this chart we can see that poor countries
in Sun-Saharan region or in South Asian region experience high
neonatal mortality rates.
9
What are neonates dying of?
Preterm births
Severe infection
Asphyxia
Congenital anomalies
Tetanus

Let’s quickly take a view what are the reasons for neonatal
death. We’ll be discussing in detail all of these reasons when
we talk about child’s health.
10
Under-5 Child Mortality Rate
Data from
http://www.who.int/gho/child_health/mortality/neonatal/en/Acc
essed Jan 11, 2016.
The probability that a newborn will die before reaching age
five, expressed as a number per 1000 live births. The graph here
shows similar to infant mortality the under-five mortality is also
higher in Sub-Saharan Africa and South East Asia.
11
Worldwide, under- five mortality rate has gone down and it has
gone down significantly for high income countries. For
countries like Sub-Saharan Africa and South East Asia –the rate
has dropped since 1980 to 2010, however around 1990-1995 Sub
– Saharan Africa experienced high rates of under-five mortality
which started to show downward trend after 2000.

12
What are Under –Fives dying of? (excluding neonatal causes of
death)
Pneumonia
Diarrhoea
Malaria
Measles
HIV/AIDS
}
~ 50%
Malnutrition contributes to more than half of all under-five
deaths
50% of death among under-five in developing countries
occurred because of pneumonia, diarrhea, malaria, measles and
HIV/AIDS.
13
Maternal Mortality Rate
Data from Trends in Maternal Mortality 1990 to 2015.
http://apps.who.int/iris/bitstream/10665/193994/1/WHO_RHR_1
5.23_eng.pdf?ua=1 Accessed Jan 11, 2016.

Maternal mortality indicator shows the number of deaths among
pregnant women per 100,000 live births due to child birth
related complications. Can you find out why Sub-Saharan
Africa region has highest number of maternal mortality rates
than any other region? How do you think maternal mortality
rates, infant mortality rates, neonatal rates and under five child
mortality rates are connected?
14
Concepts and Definition
Terms
Morbidity- sickness or any departure, subjective or objective,
from a psychological or physiological state of well-being
Mortality- death
Disability- temporary or long-term reduction in a person’s
capacity to function
Prevalence- number of people suffering from a certain health
condition over a specified time period
Incidence- the rate at which new cases of a disease occur in a
population
These are some key concepts and definitions we need to know
to study the health status of a country.
15
Incidence or Prevalence?
Source: Interactive Textbook on Clinical Symptom Research.
Available at
http://painconsortium.nih.gov/symptomresearch/chapter_19/sec4
/cihs4pg1.htm

(no audio)
16
Communicable disease- illnesses caused by a particular
infectious agent that spread directly or indirectly from people to
people, animals to people, or people to animals
Non-communicable disease- illnesses not spread by an
infectious agent
Injury- include road traffic injuries, falls, self-inflicted injuries,
and violence, among other things
(no audio)
17
Measuring the Burden of Disease
Life expectancy minus the period of less than a full healthy life
Highest HALE is Canada 70.1 years for male and 74.0 for
female

“Health gap measure,” indicating losses due to illness,
disability and premature death in a population
Better estimation of the health of a population than death rate
Accounts for health conditions like mental illness that rarely
cause death
Health Adjusted Life Expectancy (HALE)
Disability Adjusted Life Year (DALY)
Two indicators used to compare how far countries are from a
state of good health are as follows Health-Adjusted Life
Expectancy (HALE)- summarizes expected number of years to
be lived in what might be termed the equivalent of good health
and Disability-Adjusted Life Year (DALY)- a unit for
measuring the amount of health lost because of a particular
disease or injury
18
The Global Burden of Disease
Causes of Death by Region
Causes of Death by Age
Causes of Death by gender
To understand global burden of disease, it is important to
understand the leading causes of illness, disability, and death in
the world and their variations by region, age and gender. It is
also essential to understand the changes that occur over time.
19

The 10 Leading Causes of Death, 2001
Source: Adapted with permission from Lopez AD, Mathers CD,
Murray CJL. The burden of disease and mortality by condition:
data, methods, and results for 2001. In: Lopez AD, Mathers CD,
Ezzati M, Jamison DT, Murray CJL, eds. Global Burden of
Disease and Risk Factors. Washington, DC and New York: The
World Bank and Oxford University Press; 2006.
As the table illustrate, major share of the leading causes of
death belongs to non-communicable diseases and this is true for
low and middle income countries and high income countries.
The rest goes to communicable diseases for low and middle
income countries, but for high income countries only a very
minimum percentage of death attributed to communicable
diseases.
20
The 10 Leading Causes of DALYs, 2001
Low and middle income countries
High –income countries
When we look at DALYs for low and middle income countries,
we see that communicable diseases and injuries are little more
important than non-communicable diseases. Unipolar depressive

disorders which were not among the ten leading causes of death
are in the ten leading causes of DALYs.
21
Leading cause of death by income
The global burden of disease hasn’t changed much since 2001,
but this chart is interesting because it displays the differences in
income group. What do you think the primary reasons are that
the differences occur (e.g. why lower respiratory infections are
number one in low income countries?)
22
Causes of Death by Region
Diseases vary by region as one might expect. In general, the
higher the income status of one region, the more likely it is that
the leading causes of death will be non-communicable diseases.
23
Causes of Death by Age

Children in low-and middle-income countries often die of
communicable diseases that are no longer problems in the more
developed countries. In high income countries more than 2/3 of
all people live beyond the age of 70 and die of chronic disease
otherwise known as non-communicable disease. In middle
income countries almost 50% of all people live to the age of 70
and die of chronic diseases however, conditions like TB, HIV
and road traffic accidents are also leading causes of death. In
low income countries only 20% of all people reach to the age of
70 and more than 1/3 of all deaths occur among children under
15. People predominantly die of infectious diseases like
diarrheal disease, complication of pregnancy, and TB.
24
Causes of Death by Gender
In low and middle income countries the causes of death are
alike for men and women. However, men tend to die more from
road traffic accidents and women from diabetes. Some social
and environmental factors play critical role in women mortality
and morbidity. 99% of maternal mortality occurs in the
developing countries. On the other hand, men are more
diagnosed with TB and die from it than women. So is true for
cardiovascular disease.
25

The Global Burden of Disease
The Burden of Deaths and Disease Within Countries
In most low- and middle-income countries:
Rural people will be less healthy.
Disadvantaged ethnic minorities will be less healthy.
Women will suffer from their weak social positions.
Poor people will be less healthy.
Uneducated people will be less healthy.
In addition to consider the influence of region, gender, and sex,
it is vital to examine the mortality rates and DALYs within
countries by same factors. As it can be imagined in low and
middle income countries, rural people are less likely to be
healthy because of lack of access to care and/or malnutrition.
Disadvantaged, poor, and uneducated people are less likely to
be healthy and women are more likely to suffer from morbidity
because of their weak social positions.
26
Risk Factors
Probability of an adverse outcome, or a factor that raises the
probability
Risk is defined as “a probability of an adverse outcome, or a

factor that raises this probability.” when we answer a questions
in health history, we are helping the provider to find out the
risk factors that we face ourselves.
27
Risk Factors by countries
Lack of safe drinking water
Lack of proper sanitation
Indoor cooking with coal and wood
Malnutrition
War and injury
Smoking
Overweight and obesity
High blood pressure
High cholesterol
Smoking
Unsafe sex
Low-and Middle Income Countries
High-Income countries
Risk factors vary by geographical variation, educational status,
socioeconomic status, genetic and so on. Risk factors for low
and Middle income countries and high income countries vary
significantly. Some of the questions we consider to assess the
risk for low and middle income countries are as follows
Does the family have safe water to drink?
Do their house and community have appropriate sanitation?
Does the family cook indoors in a way that makes the house
smoky?
Do the mother and father work in places that are safe

environmentally?
Think of some questions that are applicable for high income
countries to assess risk.
28
Demography and Health
Population growth
Population again
Urbanization
The “Demographic divide”
The demographic transition
Population dynamics like growth rates, aging, urbanization, the
trends of disease all influence health. In the next couple of
slides we’ll discussing each of the five factors in more elaborate
fashion.
29
Population Growth
http://www.youtube.com/watch?v=sc4HxPxNrZ0
After growing very slowly, the world’s population more than
doubled in the last half century to reach 6.9 billion. The

overwhelming majority of population growth in future is
projected to happen in low and middle income countries which
reflect the fact that fertility is falling slowly in countries where
there is high fertility rates. Lower mortality rates, longer life
expectancy and large youth population have contributed to the
high rise of human population.
30
Population Aging
Population of the world is aging. While it can be seen as
success story for public health policies, it is also an implication
for burden of disease because people will be living longer with
morbidities and disabilities. Healthcare financing will be
affected by change in ratio of working people to those over 65
years which will result in raising the healthcare cost.
31
Aging population percentage
Data from the World Bank. World Development Indicators, Data
Query. Available at: http://databank.worldbank.org. Accessed
Jan. 1, 2016.

Population ages 65 and above as a percentage of the total
population. Population is based on the de facto definition of
population, which counts all residents regardless of legal status
or citizenship--except for refugees not permanently settled in
the country of asylum, who are generally considered part of the
population of the country of origin.
32
Urbanization
The world is becoming increasing urbanized.
Tremendous change has happened in developing countries.
Emerging health problems
Environment- water, sanitation, air pollution
Housing – crowding, respiratory disease, infectious disease
Social – lack of education, health service, crime, violence, drug
use
Lifestyle- physical inactivity, smoking, alcohol, stress
The majority of world’s population live in urban areas than ever
before. Between 1990 and 2025 the urban population worldwide
is expected to double with 22% increase happened in developing
countries. This phenomenon has emerged health problems in
several areas. For example, water and sanitation systems are
under increased pressure, unclean water supply can cause the
transmission of infectious diseases, physical and mental
condition gets affected by unhealthy housing, overcrowding can
leads to the transmission of respiratory and infectious diseases,
the social infrastructure systems gets overloaded .As a result
there will be lack of education, health services, and increased
crime, violence and drug use. The lifestyle factors like stress,
physical inactivity, smoking and alcohol consumption

ultimately leads to increase in chronic diseases.
33
The Demographic DivideHigh- Income CountriesMiddle-and
Low –Income countriesLow fertility Higher fertility Declining
populationsGrowing populationsAging populationsLess aging
populationsHigher life expectancyLower life expectancy
The demographic indicators in low and middle income countries
and in high income countries vary tremendously. High income
countries are facing the issues of having aging population, very
low fertility and declining population. In contrast low and
middle income countries have higher fertility, growing
populations and less aging populations.
34
Demographic Transition
What is demographic transition?
The shift from a pattern of high fertility and high mortality to
low fertility and low mortality, with population growth
occurring in between.
The first population pyramid reflects a country with high
mortality and high fertility. The second pyramid reflects a
country in which mortality has begun to decline but fertility
remains high. The third pyramid which looks like a cylinder
than pyramid , reflects a country in which fertility has been

reduced and share a greater number of aged population.
35
Epidemiologic Transition
A transition from infectious/communicable disease to
chronic/non-communicable disease
Closely related to demographic transition
High income countries went through the transition
Low income countries are in ongoing transition, thus share the
burden of both communicable and non-communicable diseases.
Source: http://www.pitt.edu/~super1/lecture/lec33241/005.htm
Discuss this slide.
36
The Burden of Disease: Looking Forward
Economic development
Scientific and technical change
Climate change
Political stability
Emerging and re-emerging infectious diseases.
Economic development of a country is critically linked with the

health of all people of that country. As low income countries
continue to grow economically and have more equitable access
to such growth across all strata of population, the chance to
invest in health will raise more. Scientific and technical
changes are also imperative for improved health status. For
example, development of new diagnostic for TB or vaccine for
HIV will have enormous impact on the global health. The direct
effect of climate change on health is not simple to understand.
A direct effect of climate change is extreme weather conditions
such as droughts, storms or flood that in turn harm people’s
health It could also lead to favorable condition for some disease
vectors which allow a disease to reemerge. In low income
countries political stability appears to be necessary for good
health. Countries like Liberia, Afghanistan , Sierra Leone,
Democratic republic of Congo are lacking well-structured health
system for many years. The conflicts in these countries lead to
disability, illness, death.
37
The Development Challenge of Improving Health
Health usually increases as national income increases.
Some countries have achieved higher life expectancies than
their incomes would predict.
This is possible with investments in nutrition, education, good
hygiene, and low-cost services that have a high impact such as
vaccination programs.
Health care cost remains the challenge for low and middle
income countries. As low income countries moves through the
demographic and epidemiological transitions, it becomes much
more challenging to face such transition in lowest possible cost.

Despite the economic burden, low income countries should
concentrate on achieving higher life expectancy by following
the example of countries like Sri Lanka, Cuba and Costa Rica.
Selecting the segment of the health service that would yield
higher impact on health status at low cost should get the
priority such as TB control or vaccination program.
38
Global Health
Week One : Chapter one
Chapter one - Global Health. In this chapter we are going to
learn about three distinct concepts which are health, public
health, and global health. We will be learning about Millennium
Development Goals and their relation with global health. The
world continues to shrink at a very rapid pace. For health,
security, and humanitarian reasons, each of us should be
concerned about the health of everyone else.
1
Video : NU library films on Demand , Delivering the Goods
segment 1. Paradox of Global Health (02:03)
http://digital.films.com/PortalPlaylists.aspx?aid=655&xtid=443
51&loid=116469
Global Health
In this short video, we will get a glimpse of global health.
2
Understand the progress that has already been made.
Understand the challenges that still remain.

Diseases are not limited by national boundaries.
Significant health disparities among groups.
Link between health and development.
Why Study Global Health?
There has been significant success in human health in the last
50 years. This is reflected in the substantial progress in health,
for example, in life expectancy. However, there are also
significant health disparities as we compare health of one group
or one country to other. Hundreds of millions of people,
especially poorer people in low- and middle-income countries,
continue to get sick, be disabled by, or die from preventable
causes of diseases. Many people, especially poor people in
South Asia and sub-Saharan Africa, have been left behind.
Diseases are not limited by national boundaries – cases of HIV
could very well affect the population of other countries. There
are strong links between health, human development, labor
productivity, and economic development all of which contribute
to global health and development.
3
Health
“Health is a state of complete physical, mental, and social well-
being and not merely the absence of disease or infirmity.”
Public Health
“…the science and art of preventing disease, prolonging life,
and promoting physical health and mental health and efficiency
through organized community efforts toward a sanitary
environment; the control of community infections; the education
of the individual in principles of personal hygiene; the
organization of medical and nursing service for the early

diagnosis and treatment of disease; and the development of the
social machinery to ensure to every individual in the community
a standard of living adequate for the maintenance of health.”
Global Health
“…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 emphasizes 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.”
Public health
Global Health
Health, Public Health, and Global Health
It is necessary that we have a clear idea about health, public
health, and global health and the relationship among them. The
textbook we are following for this course, is using the WHO
definition for health which concentrate on physical, mental and
social well-being in addition to the absence of disease. While
health focuses on individual, public health focuses on
population based interventions and policies as well as
individual approaches. Public health also pays particular
attention towards vulnerable population and a basic commitment
to health as a human right. Global health implies a global
perspective on public health problems. It deals with the issues
that people face in common irrespective of geographical
boundaries. For some authorities in public health, they do not
want to distinguish between public health and global health.
According to this panel, global health is public health and
public health is global health for the public good. In this course
we will focus on global health as a part of public health and

will not worry by the structured definition of global health.
4
Selected Examples of Public Health Activities
Selected Examples of Global Health Issues
This slide talks about some examples of Public health and
Global Health activities.
5
Approaches of Public Health and Medicine
Modified from Harvard School of Public Health. About HSPH:
Distinctions Between Public Health and Medicine. Available at:
www.hsph.harvard.edu/about.html#publichealth . Accessed May
27, 2006.
It is very common to confuse between public health and
medicine. The biggest difference between the medical and
public health approach is that the later focuses on population
whereas the former focuses on the health of the individual.
6
Determinants of health
Measurement of health status
Importance of culture to health
Global burden of disease
Key risk factors
Demographic and epidemiologic transitions
Organization and function of health systems
Links among health, education, poverty and equity

Critical Global Health Concepts
In order to understand global health issues, we need to
familiarize ourselves with some vocabulary and concepts. These
concepts will be much clearer as we move forward.
7
Low-income : $995 or less
Lower middle-income : $996 to $3,945
Upper middle-income : $3,946 to $12,195
High-income : $12,196 or above
Based on gross national income per person
Key Terms
In global health we will be mentioning low income, middle
income and high income countries. The classification given here
is used by World Bank, which divide countries in four income
groups based on their gross national income per person.
8
Millennium Development Goals and their Related Targets
Source: Data from Millennium Project: Goals, Targets, and
Indicators. Available at
http://www.unmillenniumproject.org/goals/gti.htm. Accessed
April 9, 2011.
The Millennium development goals (MDGs) were formulated in
2000 at the United Nations Millennium Summit. There are 8

MDGs and 15 core targets that relates to them.
9
Millennium Development Goals and their Related Targets
(cont’d)
Source: Data from Millennium Project: Goals, Targets, and
Indicators. Available at
http://www.unmillenniumproject.org/goals/gti.htm. Accessed
April 9, 2011.
The countries that signed the declaration pledged to meet the
MDGs by 2015. All the 8 goals are relate to health
10
Current goals: Sustainable Development Goals (SDGs) 2016
Source:
http://www.un.org/sustainabledevelopment/blog/2015/12/sustain
able-development-goals-kick-off-with-start-of-new-
year/#prettyPhoto
As 2015 comes to an end, and with it the 15-year cycle of the
anti-poverty Millennium Development Goals, the United
Nations officially will usher in – on 1 January 2016 – an even
more ambitious set of goals to banish a whole host of social ills
by 2030.
“They are a to-do list for people and planet, and a blueprint for
success,” UN Secretary General added of the 17 goals and 169
targets to wipe out poverty, fight inequality and tackle climate
change over the next 15 years.
11

Video from NU library: Films on Demand
Disease warriors :
Smallpox Eradication Campaign (1:57) -
49&loid=122720
Victory over Smallpox (2:42) -
49&loid=122723
Small Pox eradication
Small pox eradication is the famous success story of public
health. This triumph of public health is well known to anyone
who works in public health. In this video we will see the
eradication campaign and the last case of small pox in the
world.
12

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