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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
A global view of health offers a richer understanding of ways of measuring, improving and sustaining health both in individual national settings and in the context of a strongly interconnected world. This book draws on social scientific insights and explanations to examine trends in global health. Moving beyond an epidemiological analysis, the authors use a social determinants framework and life course approaches to offer a critical introduction to the study of global health.
Through individual chapters focusing on topics such as health policy, global governance, health systems and health-related protests, the authors present the scope of global health studies and introduce readers to broader ranging issues such as globalization and political forces. Key themes such as power, inequality and inequity - and their impact on health on a global scale - recur throughout the book. International examples and case studies are used to illustrate the discussion, which is further supported by opportunities for reflection and further reading.
This book will be an important resource for students studying global health and will have broad relevance to those undertaking health, health-related and allied health professional courses.
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Veröffentlichungsjahr: 2018
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Contents
Cover
Dedication
Title Page
Copyright
Abbreviations
Introduction
1 Global Patterns of Disease
Key learning outcomes
Introduction
What is global health?
Why is global health important?
Measuring global health patterns
Global health patterns and trends
Global causes of death
Global health threats
Population changes
Ageing
Safety, war and terrorism
Mental health
Poverty and inequality
Non-communicable diseases
Infectious diseases
Health and wellbeing
Summary
Suggestions for further reading
Questions for reflection
2 Global Health: An Unequal World
Key learning outcomes
Introduction
The social model of health
Socioeconomic position
Key factors
Material circumstances
Poverty
Power, human rights and ethics
Food
Summary
Suggestions for further reading
Questions for reflection
3 The Wider Determinants of Global Health
Key learning outcomes
Introduction
What is globalization?
Globalization and health
The homogenization of human experience
Transient populations
Megacities
Globalization and climate change
Globalization and social justice
Summary
Suggestions for further reading
Questions for reflection
4 Global Health Systems
Key learning outcomes
Introduction
Health care systems
Financing health care
Getting access to health care
Provision of care
Professionals working in health care systems
The global consumer of services and treatment
Contemporary challenges to health care systems
Health care system reform
Over-reliance on health care systems
Summary
Suggestions for further reading
Questions for reflection
5 Global Health Governance
Key learning outcomes
Introduction
What is global governance?
Why do we need global governance?
Climate change and global health
Global economy and health
Key global policymakers
Aid and global health
Global social policy
The relationship between global and national policy
Global social policy futures
Summary
Suggestions for further reading
Questions for reflection
6 Policies for Health
Key learning outcomes
Introduction
Millennium Development Goals
Evaluation of MDGs
Future challenges
Sustainable Development Goals
Evaluation of current policy direction
Summary
Suggestions for further reading
Questions for reflection
7 Global Health Protests
Key learning outcomes
Introduction
Global protests
Global health protests and ‘cultural and societal values’
Defining social movements
Health social movements
Health access movements
Constituency-based movements
Embodied health movements
Contemporary health social movements
Female genital mutilation
Genetically modified crops
Fracking
The impact of social movements
Now is the time?
Summary
Suggestions for further reading
Questions for reflection
8 Contemporary Challenges in Global Health
Key learning outcomes
Introduction
Achievements in global health
Contemporary challenges to global health
The importance of a social determinants paradigm
Structural determinants of health
Intermediary determinants of health
Social cohesion and social capital
A more equal future?
Summary
Suggestions for further reading
Questions for reflection
References
Index
End User License Agreement
Tables
1.1 Top twenty leading causes of death
1.2 Differences in global life expectancy, 2000–15
1.3 Cancer country profiles, 2014
1.4 Global estimates of people living with HIV in different areas, 2015
2.1 Sociological theory and health inequality
4.1 Models of health care systems
4.2 How sick are the world’s health care systems?
4.3 Disparities in global health care spending
4.4 Numbers of medical personnel in different countries
4.5 Different requirements for health care reform
5.1 overview of key global actors
6.1 The Millennium Development Goals: a summary
6.2 Successes associated with the Millennium Development Goals
6.3 overview of the Sustainable Development Goals
7.1 The lifecycle of social movements
7.2 Reasons for why ‘it’s kicking off everywhere’
Boxes
1.1 Global health challenges
1.2 Global opportunities for health
1.3 Health challenges associated with population changes
1.4 The impact of conflict on health in Iraq
1.5 An increasingly fatter and more unequal world
2.1 Ethics, inequalities and global health
2.2 Influences on access to food
2.3 Animal protein and its impact on the environment
3.1 What is globalization?
3.2 Potential solutions to climate change
3.3 What should be done to make our societies more equal?
3.4 Recommendations of the Commission on Social Determinants of Health
4.1 Factors required to evaluate true health care access
4.2 Global inequalities in the provision of care
4.3 Challenges to contemporary health care systems
5.1 Global issues requiring governance
5.2 Climate change and human health
5.3 The impact of economic downturn on mental health
5.4 Issues with the work of the WHO
5.5 The five fundamental principles of the Paris Declaration on Aid Effectiveness
5.6 The Accra Agenda for Action
6.1 Africa and the Millennium Development Goals
6.2 The example of Cambodia
7.1 Common features of social movements
7.2 Professionals and protests
7.3 NHS Five Year Forward View
7.4 Social movements in a digital age
8.1 Top ten achievements in global health, 2000–10
Learning Tasks and Case Studies
Learning task 1.1: Measuring global health
Learning task 1.2: Differences in global life expectancy
Learning task 1.3: Creating health for all
Learning task 1.4: Trends in world happiness
Case study: End of life care across the globe
Learning Task 2.1: Socioeconomic position
Learning Task 2.2: Material circumstances and health
Learning Task 2.3: Whose responsibility is health?
Learning Task 2.4: Structural barriers
Case Study: Women in prison
Learning Task 3.1: Globalization and health
Learning Task 3.2: McDonaldization
Learning Task 3.3: Megacities and health
Learning Task 3.4: Solutions to climate change
Case Study: The impact of globalization on the Canadian Inuit
Learning Task 4.1: Defining primary health care
Learning Task 4.2: Suicide tourism
Learning Task 4.3: Rationing as a form of budget control
Learning Task 4.4: Revisiting the determinants of health
Case Study: The Cuban health care system
Learning Task 5.1: Global health and climate change
Learning Task 5.2: Reflecting upon global priority making
Learning Task 5.3: Nongovernmental organizations and governance
Learning Task 5.4: Global futures
Case Study: Childhood immunization
Learning Task 6.1: Exploring the Millennium Development Goals
Learning Task 6.2: Global debt relief
Learning Task 6.3: Exploring the Sustainable Development Goals
Learning Task 6.4: What is sustainable development?
Case Study: Evidence-based public health
Learning Task 7.1: Exploring the impact of global protests
Learning Task 7.2: Health social movements
Learning Task 7.3: Social movements in health in the global north and south
Learning Task 7.4: For and against abortion
Case Study: Occupy
Learning Task 8.1: Achievements in global health
Learning Task 8.2: Contemporary challenges to global health
Learning Task 8.3: A social science perspective
Learning Task 8.4: What might a more equal and ethical future in global health look like?
Case study: Microfinance and women’s empowerment
Guide
Cover
Table of Contents
Begin Reading
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Dedicated to my fourth child and only son, Race – a lost boy amongst the girls!
Dedicated to my parents Gail and Clifford Dunn – I am so proud of you both.Love always.
Global Health Studies
A Social Determinants Perspective
Louise Warwick-Booth & Ruth Cross
polity
Copyright © Louise Warwick-Booth & Ruth Cross 2018
The right of Louise Warwick-Booth & Ruth Cross to be identified as Authors of this Work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
First published in 2018 by Polity Press
Polity Press65 Bridge StreetCambridge CB2 1UR, UK
Polity Press101 Station LandingSuite 300Medford, MA 02155, USA
All rights reserved. Except for the quotation of short passages for the purpose of criticism and review, no part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher.
ISBN-13: 978-1-5095-0420-6
A catalogue record for this book is available from the British Library.
Library of Congress Cataloging-in-Publication Data
Names: Warwick-Booth, Louise, author. | Cross, Ruth, author.Title: Global health studies : a social determinants perspective / Louise Warwick-Booth, Ruth Cross.Description: Cambridge, UK ; Medford, MA : Polity, 2018. | Includes bibliographical references and index.Identifiers: LCCN 2017031925 (print) | LCCN 2017033840 (ebook) | ISBN 9781509504206 (Epub) | ISBN 9781509504169 (hardback) | ISBN 9781509504176 (pbk.)Subjects: | MESH: Global Health | Social Determinants of HealthClassification: LCC RA441 (ebook) | LCC RA441 (print) | NLM WA 530.1 | DDC 362.1--dc23LC record available at https://lccn.loc.gov/2017031925
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Abbreviations
AAA
Accra Agenda for Action
ANH
Alliance for Natural Health
CAAA
Community Action Against Asthma
CFCs
chlorofluorocarbons
CSDH
Commission on Social Determinants of Health
DALYs
disability adjusted life years
DFID
Department for International Development
EU
European Union
FAO
Food and Agricultural Organization
FGM
female genital mutilation
GAVI
Global Alliance for Vaccines and Immunization
GBD
Global Burden of Disease
GDP
Gross Domestic Product
GHG
greenhouse gases
GHO
Global Health Observatory
GMCs
genetically modified crops
HIPC
heavily indebted poor countries
HIPC
Enhanced Heavily Indebted Poor Countries
IMF
International Monetary Fund
MDGs
Millennium Development Goals
NCD
non-communicable disease
NHS
National Health Service
NIEHS
National Institute for Environmental Health Services
NTDs
neglected tropical diseases
OECD
Organisation for Economic Co-operation and Development
OHCHR
Office for the High Commissioner of Human Rights
PD
Paris Declaration
PHM
People’s Health Movement
PPP
public–private partnership
QALYs
quality-adjusted life years
SAPs
structural adjustment programmes
SARS
Sudden Acute Respiratory Syndrome
SDGs
Sustainable Development Goals
SDH
social determinants of health
SES
socioeconomic status
TB
tuberculosis
TNCs
transnational corporations
TRIPS
Trade Related Intellectual Property Rights
UN
United Nations
UNDP
United Nations Development Programme
UNESCO
United Nations Educational, Scientific and Cultural Organization
UNFCCC
United Nations Framework Convention on Climate Change
WHO
World Health Organization
WTO
World Trade Organization
Introduction
In Global Health Studies: A Social Determinants Perspective we have adopted a specific approach to exploring the health issues that affect us all living in our world today. Rather than taking an epidemiological or pathological approach, as other books in this area often do (and do well), we use a social scientific lens to critically consider global health. This enables us to forefront the importance of the social determinants of health (SDH). That is not to say that the physical and biological aspects of global health are not important; in fact, we do make mention of these at times. However, like many others, we believe that a social scientific perspective brings a new, valuable dimension and that it offers alternative understandings and potential solutions to current global health issues. We believe that our approach is unique within the global health literature and that this offers a new way of examining contemporary global health issues.
Traditional approaches to global health tend to draw on biomedical and epidemiological understandings and explanations, whereas we focus our attention on a range of issues and problems that are explored through a social scientific lens. This necessitates looking first at the historical context underpinning today’s global health approaches. Global health today is seen in a very different light from how it was understood in the past: previous events, such as technological medical developments, advances in drug treatments as well as less positive influences, for example colonialism, all serve to shape the contemporary landscape. European colonization had an impact on the health of many indigenous populations with the spread of diseases such as smallpox, destructive environmental impacts and widespread oppression. Concerns remain today in relation to the dominance of the global north, the advantaging of the agendas of more powerful countries and the many remaining challenges associated with the health of the most vulnerable. Many remain critical of the reach both of global health policy and of interventions, particularly when asking why the poorest and most vulnerable still have the worst health. So, despite progress in many areas, including the eradication of smallpox, much work remains to be done. We argue throughout this book that contemporary global issues and health challenges are related to power, policies and the social context underpinning them. Social determinants are part of the causal pathway of many global health challenges, and remain linked to communicable and non-communicable disease patterns.
While health has improved in many global contexts, numerous challenges remain. The world has experienced an epidemiological transition in which populations grew as a result of medical advances and improved standards of living, but this has not resolved all health problems. Many of the world’s inhabitants are still exposed to vulnerabilities associated with poverty and inequality and infectious diseases are therefore still an issue in many contexts. Furthermore, the increasing rate of NCDs can be linked to rapid urbanization that runs alongside contemporary lifestyle patterns. Inequalities remain prevalent and are increasing in several places; we pay attention to them in this book using a social scientific lens.
A social scientific lens necessitates a social determinants approach. The importance of social determinants in shaping health and health experience has been highlighted by the work led by Sir Michael Marmot and his team in the Commission on Social Determinants of Health (CSDH). This work emphasizes the ‘causes of the causes’: namely, how the conditions in which we live our lives directly and indirectly affect our health. Closer examination of these conditions tends to show that those who live in relative disadvantage suffer more than those who are better off (whether financially or socially). This leads to inequality and inequity and, ultimately, comes down to issues of social justice. As will be seen, equity, equality and issues of power are key themes within this book.
A social determinants perspective differs considerably from biomedical or epidemiological perspectives. It is concerned with identifying and addressing avoidable differences in health at a global level – that is, differences that exist because of social factors rather than biological ones, for example socioeconomic status, education and housing. Using a social determinants perspective means examining such factors and the impact that they have on health outcomes and health experience. Throughout this book, we draw on a range of different issues to illustrate how global health can be viewed using a social determinants lens. The World Health Organization (WHO, 2017) defines the social determinants of health as ‘the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of everyday life’. Further, the WHO purports that this ‘includes economic policies and systems, development agendas, social norms, social policies and political systems’.
Central to a social determinants perspective are issues of equity and equality and, as such, these recur as key themes within this book. As you will appreciate when you engage with this text (or as you may already know), health inequalities and health inequities persist on a global scale within and between countries and regions. By health inequities and health inequalities, we are referring to the systematic, avoidable, unfair and unjust differences in health that exist across the globe and which are influenced by social circumstances (Satcher, 2010). Differences may be due to several factors, including social, cultural and geographical. These result in some groups of people experiencing poorer health outcomes than others. In this book, we outline what we see as some of the key issues and, with the reader, explore several potential responses to these.
Alongside issues of inequity and inequality, we also consider power as a key theme. You will note that we refer to issues of power in relation to many different things. We present a critical take on power, looking at who has power and who does not, and at how this impacts on health outcomes and health experience. Power is inextricably linked to social determinants. Generally, the wealthier someone is, the more power they have to affect change in their own lives and to influence others. Power also exists at a state or governmental level and is therefore tied up with political agendas and governance. Throughout the text, we come back again and again to such debates, illustrating how important power is to a social scientific examination of global health.
In addition to power and health inequalities, there are two other key themes within this book that we believe are of paramount importance in discussions of global health from a social science perspective. The first is a critique of neoliberalism and the second is ethics. For the purposes of our discussion, we conceive of neoliberalism as an ideology that privileges the power of the individual and assumes that individuals are in control of their lives, free to do as they wish. As a result, the role of the state in people’s lives is minimized. Responsibility for health therefore becomes private rather than public. Individualist explanations for health and health inequalities are tied up with neoliberal ideology. Individualist perspectives promote individual responsibility for health and a belief that health is located and created at an individual level. Efforts to promote health therefore centre on getting people to change their behaviour. In contrast, materialist or structuralist approaches to health and health inequalities purport that government and state have a responsibility for people’s health through providing structures that support good health – such as a quality education and access to health care services. In keeping with a social determinants perspective, we view materialist/structuralist explanations as more important for understanding global health experiences. Ethics is another important theme within the book, and we discuss this in more detail in various places in relation to different issues.
As part of the continuing work of the CSDH, a specific conceptual framework, developed by Solar and Irwin (2010) for the WHO, has been created to further an understanding of SDH. In brief, the framework aims to make sense of the hugely complex factors that impact on and determine health. ‘A key aim of the framework is to highlight the difference between levels of causation, distinguishing between the mechanisms by which social hierarchies are created, and the conditions of daily life which then result’ (Solar & Irwin, 2010).
The diagram of Solar and Irwin’s framework (see Figure i.1) brings together several theoretical concepts, including psychosocial, political, ecological and economic factors. Importantly, the framework distinguishes between structural determinants (social position/stratification and proxy indicators of this such as income, education, occupation, social class, gender, race/ethnicity) and intermediary determinants of health (material circumstances, psychosocial circumstances, behavioural/biological factors and, importantly, the health system). The socioeconomic and political context is incorporated, including issues of governance through macroeconomic, social and public policies. Culture and societal values also feature, as do social cohesion and social capital. In short, this results in a comprehensive framework, which lends itself well to considering global health from a social scientific perspective. For this reason, we have used it to underpin our discussion and we draw on the concepts within the framework to explicate our social determinants approach to understanding global health.
Figure i.1 The Commission on Social Determinants of Health conceptual framework
Source: Solar and Irwin, 2010
Each chapter discusses different aspects of Solar and Irwin’s framework in detail, with specific reference to certain issues in global health. Chapter 1 discusses the global distribution of health and wellbeing regarding global patterns of disease. Chapter 2 explores inequalities in global health specifically in relation to social position and material circumstances. Chapter 3 considers the wider determinants of health, specifically focusing on globalization and the uneven impact that this has on the distribution of health and wellbeing across the world. Chapter 4 focuses on global health systems and discusses the importance of health care systems in relation to global health. Chapter 5 centres on governance and policy exploring global health governance in detail. Chapter 6 takes the discussion about governance and policy further, looking at policies for health in a global context. Chapter 7 explores cultural and societal norms and values through mechanisms of global health protests. Lastly, Chapter 8 brings all the aspects of Solar and Irwin’s framework together in consideration of contemporary challenges for global health.
This book has several pedagogical features to enable the reader to explore issues in more depth and to critically reflect on the implications of some of the social scientific debates within it. Each chapter begins with a ‘key learning outcomes’ section to enable the reader to understand the purpose of it. Key points are summarized at the end of each chapter, in addition to ‘questions for reflection’, which will facilitate deeper appreciation. Four learning tasks are presented in each chapter that give the reader an opportunity to engage more actively with the content. Finally, each chapter ends with a detailed global case study that aims to bring the chapter content to life. Throughout the book, different international examples are drawn upon to illustrate the discussion. While we have not taken a topic-based approach to presenting material, as other books on global health do, we have drawn on a wide range of diverse issues to illustrate key points – these vary enormously, from climate change to reproductive health. Where topics are discussed, they are used to illustrate key points or ideas. For further depth on individual topics, readers are encouraged to look elsewhere.
In summary, we hope you enjoy reading this book as much as we have enjoyed writing it. We have both learned a great deal in doing so. We would like to acknowledge those who have supported us in the process: our families, friends and colleagues. In addition, we recognize the important role that our editor has played and the valuable input of those who have reviewed some of the content. Most importantly, we recognize the significant contribution that the students we work with from around the world have made to the development of our ideas and the motivation that they give us to write.
1Global Patterns of Disease
Key learning outcomes
By the end of this chapter, you should be able to:
define global health and understand why it is so important;
demonstrate awareness of the measurement issues associated with recording patterns and trends in global health;
identify the main public health issues, threats and trends in global contemporary society
Introduction
This chapter begins by defining global health and outlining why it is important. It then moves on to look at how global health is measured and why this is not a simple task. The chapter discusses health in a changing world, providing detail in relation to the changing patterns of disease burdens across the globe by drawing on the latest research evidence and statistical projections into the future. With discussion located within the distribution of health and wellbeing (Solar and Irwin, 2010), the key global killers are outlined in relation to the challenge of communicable and non-communicable diseases to illustrate how patterns and trends are changing. The burden of diseases, disability and death across the world varies hugely both between and within countries. This chapter illustrates how disease burdens are spread unequally. It focuses on the key risk factors for those in lower-income countries using a SDH approach to explore this area, and it outlines the complexities associated with the measurement of global health in relation to measuring death rates, disease spread and inequalities in life expectancy, as well as violence (wars, conflicts), natural disasters and mental health. The chapter provides a broad introduction to global inequalities in health as well as current global health priorities, setting the scene for later chapters, which examine global policy approaches and responses. Finally, it sets the scene for the quantification of contemporary health problems that affect the world’s population.
What is global health?
The phrase ‘global health’ is a much-discussed term, but what exactly does it mean? Which health problems, issues or diseases come to mind when you think of the term global health? Academics and policymakers discuss global health and associated action in this area, but there is no clearly agreed definition in the literature. Kickbusch (2006) defines it as relating to the health issues transcending national boundaries and governments and as calling for action on the global forces that determine the health of people. However, this definition has received criticism because it uses geographical boundaries to understand global health problems. Koplan et al. (2009: 1995) offer a broader definition, saying that global health is ‘an area for study, research and practice that places a priority on improving health and achieving equity for all people worldwide’. Beaglehole and Bonita (2010) use a more succinct definition: ‘collaborative international research and action for promoting health for all’. Koplan et al. (2009) argue that global health has three elements:
It is a notion (referring to the state of global health).
It is a goal (an objective based upon improving global health across the world).
It is a mixture of research, practice and scholarship (with issues that are multidisciplinary in nature, as well as teams from a range of disciplines questioning and participating).
Debates are ongoing about the extent to which global health as a discipline is separate from fields such as international health and public health (Koplan et al., 2009). This lack of consensus is important because it results in debate about the aims of global health and the benchmarks that should be used to measure progress. Macfarlane et al. (2008) argue that high-income countries define global health through their own perspective, with most literature produced by authors located in the global north (Beaglehole & Bonita, 2010). Koplan et al. (2009) call for a universal definition, and debates continue in terms of values underpinning the field. Battams and Matlin (2013) suggest that, despite the definitional debate found within the literature, the reduction of health inequities is now recognized as a primary goal of global health. This is ideological in its basis because improving health entails addressing the social and economic inequalities that underpin and cause poorer health. Bozorgmehr (2010) argues that many definitions lack specificity about what they mean when using the term ‘global’ and he therefore asks for attention to be paid to the notion of supraterritoriality, in which the SDH are understood to be connected anywhere. This is the definition that we take forward throughout the later chapters of the book, given our focus on the importance of social determinants.
Why is global health important?
Put simply, our health is bound together in a range of global relationships, and the global context in which we are located influences our health (Bambra, 2016). Globalization has led to the interconnection of health trends (see Chapter 3) and it has therefore been argued that our individual health is increasingly conditioned and determined by both global processes and relationships (Yuill et al., 2010). The interconnectedness of the world affects our health in a variety of ways, via the spread of diseases (both communicable and non-communicable) and the availability of health care staff and health system capacity and funding (see Chapter 4). Furthermore, numerous health problems, risks and issues require action and resolution on a global scale, hence the need for global solutions (see Chapter 5 for further discussion of global governance). Davies (2010) and Bambra et al. (2005) argue that health is a political issue and that the global political environment determines health and wellbeing outcomes in national contexts (see Chapter 6 for analysis of the current global policy environment). In addition, there are environmental considerations that need attention at the global level as our changing environment is likely to lead to additional health considerations, as outlined throughout later chapters. Much evidence exists in relation to global SDH, illustrating that a disproportionate disease burden is experienced by lower-income countries and that this is a significant threat to both global wealth and security (Brundtland, 2003). Furthermore, millions of poor people die from preventable and treatable conditions simply because of their societal position, as discussed in Chapter 2. Using a social determinants framework allows us to make note of many health-related impacts and outcomes resulting from inequality and injustice. While we present evidence of unequal disease patterns and differential life expectancies, it is important to understand that these occur within a social context and are therefore socially determined. Solar and Irwin (2010) present a framework outlining the many SDH that we use throughout this and later chapters to illustrate that social hierarchies are detrimental to health. Numerous health challenges exist on a global level, as outlined in Box 1.1, and these are likely to have more impact on people in poorer societal positions – hence the need to continue to pay attention to social determinants.
The list of global health challenges given in Box 1.1 is by no means exhaustive, and commentators do not always agree on the importance of each challenge, so debates are ongoing about the priorities. There have also been lists of ‘grand challenges’, which include HIV/AIDS, malnutrition and lack of resources (Grand Challenges in Global Health, 2012). In such lists, we see that ‘so many of the challenges we face now have a global impact, requiring global solutions and a global response’ (Brundtland, 2003: 8). Global health security is important for politicians and for the economy. While there are many challenges remaining, there has been notable progress in several areas, and global opportunities for health remain open. Box 1.2 illustrates some of these.
Box 1.1 Global health challenges
Epstein and Ferber (2016) argue that climate change is the biggest threat to human wellbeing because it is likely to affect health in numerous ways, with rising temperatures facilitating increases in disease-spreading mosquitoes, more heatwaves that kill people and the development of further extreme weather threatening health through floods and fires.
Jonas (2014) argues that pandemics are a significant global threat, with the global community continuing to face threats from infectious diseases.
Parry (2014) suggests that environmental hazards, particularly pollution, are a significant health threat.
Chisholm and Banatvala (2014) argue that mental health disorders and NCDs are causing massive ill-health and compromise both human and economic development.
Laxminarayan (2014) argues that antibiotic resistance remains an issue particularly in high-income countries because of their high usage rates.
Nathe (2016) lists ten global health issues that she sees as requiring attention, with her list ranked in order of importance:
Refugees – increasing numbers have implications for health and health care systems.
Wealth gap – inequalities in wealth are growing which means more health disparities.
Politics – at the time of writing, US elections and a new president have implications for aid, development policy and funding.
Health systems – understanding these as a whole rather than seeing them as disease specific services is essential.
Climate change – progress is needed in reducing carbon emissions and supporting the most vulnerable people and populations.
Emerging and waning health threats – old diseases such as polio are declining; however, new diseases such as Zika and Ebola pose challenges to global health security.
Air pollution – this is increasing in some parts of the world, resulting in more respiratory infections and deaths.
Health workers – more health workers are required to address the Sustainable Development Goals (SDGs).
Mental health support – increasing numbers of people are experiencing trauma because of war, natural disasters and gender-based violence, yet there is a lack of support available and an inadequate global workforce.
Pandemic survivors (e.g., Zika, Ebola) – there are increasing numbers of survivors who require ongoing support for their health needs, which present health care challenges.
To understand the scale of global health challenges and to measure positive progress towards specific goals (see Chapter 8 for fuller discussion of such progress), data is a fundamental requirement; hence, much work focuses on measuring global health patterns.
Box 1.2 Global opportunities for health
the Millennium Development Goals (MDGs) and the SDGs that followed, focusing on gender, education, the environment and many other priority areas;
the increased focus on primary health care that was first discussed at Alma Ata in 1978, and then again in the 2008 World Health Report;
aid to lower-income countries in the form of development assistance has increased in recent years.
Source: Adapted from Laaser and Epstein, 2010
Measuring global health patterns
The dominant contemporary discourse underpinning the measurement of health is one related to threats and disease in which biomedical concerns are also linked to worries about security. The need to contain the spread of contemporary infectious diseases is much discussed in western media outlets, for example in relation to the Ebola outbreak in 2014 and the Zika outbreak in 2016. Thus, global health measurement focuses on threats as a mechanism to try to prevent and reduce mortality and morbidity, and also on the achievement of ‘health’ targets to reducing illness – for example, reductions in HIV prevalence. More recent measures have been expanded and contain integrative frameworks of action which consider the wider determinants of health such as those noted in the SDGs (see Chapter 6). However, the measurement of global health patterns remains challenging for several reasons. To explore some of these issues in more depth, complete learning task 1.1.
Learning task 1.1 Measuring global health
You have been successful in securing an interview for a research assistant post in a department specializing in global health. In preparation for your interview you have been asked to:
Use the internet as well as other academic sources, and explore how global health has been measured, as well as the meaning of words and indicators such as mortality and morbidity rates.
Select two important global health indicators.
Think about how data for your indicators might be obtained.
List any challenges that you might anticipate in using your indicators to measure global health patterns
Make notes in each of the listed areas.
In doing this activity did you consider how your measures could be used to compare one country to another and if they could illustrate which country had better health? Would your data have revealed any issues of inequality?
When completing the learning task, did you consider measuring the number of global deaths? One of the main ways in which global health patterns are currently measured is in terms of the numbers of people who die each year, as well as the reasons for their death. Examination of these cause of death statistics can help policymakers to determine causes of actions (WHO 2016k). For example, if figures show that high numbers of children are dying from malaria, then action is needed to specifically target this problem. However, one complication of using data such as this is that, while high-income countries have systems in place to document causes of death in their populations, many lower-income countries do not have full or accurate data sets. The WHO (2016d) reported the latest data on the health-related targets being used to measure the SDGs; however, data was only available for four indicators for fewer than 40 per cent of countries. Where countries are not able to provide data, or have data that is lower than the required standards in terms of quality, the WHO uses statistical models to calculate estimates, but questions remain about whether this approach is fit for purpose (Stevens et al., 2016), with many disagreements being evident in this area.
Another approach that you might have considered could have been a comparison of life expectancy between countries. Life expectancy at birth is used to record the overall mortality level of a population across all age groups in each year (WHO, 2016b), and is used later in this chapter to provide a comparative benchmark across different countries.
The Global Burden of Disease (GBD) study uses disability adjusted life years (DALYs) as a mechanism to quantify the burden of disease from a range of health conditions across the globe, which follows on from other measures such as childhood mortality rates and the Human Development Index to try to offer a fairer measurement system (Voight, 2012). DALYs quantify an individual’s loss of health resulting from a specific disease and injury and has been used to assess and prioritize different global diseases. It is easier to understand the DALY mechanism as a calculation of the gap between current health status and a person’s ideal health based upon notions of the communities living to old age without any illnesses or disabilities. It can be argued that the DALY measure has been a helpful tool in relation to the development of global policy, in ensuring that decisions are more evidence-based and directing attention at neglected diseases.
However, questions remain about this measure (and many others) – for example, can suffering be measured? Suffering related to ill-health is very difficult to quantify and there are, arguably, western values embedded within the metrics (Becker et al., 2013) given that so many people expect to live much longer than previous generations, without any health complications. Indeed, as Becker et al. note, important dimensions of the illness experience, such as distress, demoralization and stigma, are currently not measured by DALYs. However, despite the limitations associated with current measures of global health, this remains an important activity to monitor and deal with the global burden of disease.
Global health patterns and trends
Historical analysis demonstrates that the types of diseases that affect populations change as countries develop, which results in different health issues and disease patterns. Therefore, identifying current health challenges ultimately depends upon the context in which the population is based. Epidemiological transitions (Wainwright, 2009) have taken place in many contexts globally, with the traditional diseases of poverty (for example, infectious diseases and malnutrition) being replaced by diseases of affluence (for example, cancers and heart disease). This has been called the ‘risk transition’ (WHO, 2009), resulting from improvements in medical care, the ageing of the population and successful public health interventions such as vaccinations and sanitation. Indeed, countries show different trends in relation to changing life expectancy because of the interrelationship of these different threats to health and other social determinants. Despite differences (illustrated in the next section of this chapter), an overall general trend shows that contemporary health challenges are influenced by human behaviour, played out in the high rates of chronic diseases. In addition, while an epidemiological transition has occurred, global health and illness patterns have changed in ways that were not expected – for example, new infectious diseases (Zika) as well as older illnesses (TB) remain as threats. Health patterns and associated health threats are open to constant change.
Global causes of death
The ten leading causes of death in the world between 2000 and 2012 broadly remained the same, with ischaemic heart disease, stroke, lower respiratory infections and chronic obstructive lung disease remaining the top major killers (WHO, 2014b). Predictions for the future, developed using 2011 global health estimates of causes of death, reflect similar trends. Table 1.1 illustrates WHO predictions in relation to the leading causes of death between 2015 and 2030.
More detailed analysis of global causes of death data (WHO, 2016k) illustrates the following patterns:
High-income countries have the highest proportion of deaths caused by NCDs (87 per cent of all deaths were caused by NCDs in 2012). The four main NCDs are cardiovascular diseases, cancers, diabetes and chronic lung diseases.
Smoking is a hidden cause of death but underpins many of the top killers, such as cardiovascular disease, chronic obstructive lung disease and lung cancer; it is estimated to be responsible for the death of about one in ten adults worldwide.
There are differences in the causes of death between high- and low-income countries:
In high-income countries, most people (70 per cent) die over the age of 70, with chronic diseases being responsible for most deaths, such as cardiovascular diseases, cancers, dementia, chronic obstructive lung disease or diabetes.
In lower-income countries, almost 40 per cent of deaths are in children aged under 15 years, and only 20 per cent of those who die are aged over 70. Furthermore, many more people die from infectious diseases, such as lower respiratory infections, HIV/AIDS, diarrhoeal diseases, malaria and tuberculosis.
Table 1.1 Top twenty leading causes of death
Source: Adapted from WHO, 2013b
Rank
2015
2030
1
Ischaemic heart disease
Ischaemic heart disease
2
Stroke
Stroke
3
Lower respiratory infections
Chronic obstructive pulmonary disease
4
Chronic obstructive pulmonary disease
Lower respiratory infections
5
Diarrhoeal diseases
Diabetes mellitus
6
HIV/AIDS
Trachea, bronchus, lung cancers
7
Trachea, bronchus, lung cancers
Road injury
8
Diabetes mellitus
HIV/AIDS
9
Road injury
Diarrhoeal diseases
10
Hypertensive heart disease
Hypertensive heart disease
11
Preterm birth complications
Cirrhosis of the liver
12
Cirrhosis of the liver
Liver cancer
13
Tuberculosis
Kidney diseases
14
Kidney diseases
Stomach cancer
15
Self-harm
Colon and rectum cancers
16
Liver cancer
Self-harm
17
Stomach cancer
Falls
18
Birth asphyxia and birth trauma
Alzheimer’s disease and other dementias
19
Colon and rectum cancers
Preterm birth complications
20
Falls
Breast cancer
These figures show clear global health disparities. There are many ways in which health disparities can be measured, for example via burden of diseases studies and disability status. Another way is to examine life expectancy, which is a term used to describe the average age that someone reaches before death. Complete learning task 1.2 to explore current patterns and trends in global life expectancy.
Learning task 1.2 Differences in global life expectancy
Using the internet, go to the WHO website, specifically finding the Global Health Observatory (GHO) data pages. Explore the pages to find life expectancy data, then compare at least three countries (hint: select one high-income country, one middle-income country and one low-income country).
1 Using your selected countries, describe the different trends in terms of life expectancy.
Think about what might influence these trends and list possible factors.
In completing the learning task, you will have seen that there are significant differences between life expectancy globally. In 2015, the average life expectancy at birth of the global population was 71.4 years (WHO, 2016g); however, this figure masks large differences, as illustrated in Table 1.2. In addition, many commentators refer to the concept of healthy life expectancy, which is the number of years that an individual can be expected to live in a healthy state. Globally, the average healthy life expectancy in 2015 was estimated as 63.1 years (WHO, 2016g), so although people are living longer in many places, this does not necessarily equate to a healthy older age, as Table 1.2 further illustrates. Marmot (2015) argues that, despite the improvements in life expectancy globally, the use of average figures masks the ongoing existence of inequality in length of life. For example, in Scotland (UK) there was a twenty-eight-year gap in life expectancy within the same city, Glasgow, between the years 1998 and 2002. Thus, Marmot (2015: 28) argues that attention also needs to be paid to the gradient of life expectancy, because it is not about ‘them’ (the poor) and ‘us’ (the non-poor); it is about all of us below the very top whose health is worse than it could be. Using a gradient to examine life expectancy demonstrates that health inequalities affect the entire population: the rich, the poor and those in-between. When examining the gradient of life expectancy that can be seen in many places, we see that relative inequality as well as poverty has an impact on life expectancy. The large-scale differences that are evident in global life expectancy (see Table 1.2) illustrate the need for improvement.
Have you reflected on the influences on the figures shown in Table 1.2? What reasons did you consider as important in relation to differential life expectancy? While poverty and inequality are critical influences in relation to global health outcomes, there are many other global health issues discussed within the literature, and it is to these that we now turn.
Table 1.2 Differences in global life expectancy, 2000–15
Source: Adapted from WHO, 2016b
Country
Life expectancy (years)
Healthy life expectancy (years)
Angola
52.4
45.9
Cambodia
68.7
58.1
Iceland
82.7
72.7
Global health threats
There are many global health issues and threats, some of which are linked into the broader determinants of health, while others are more clearly directly related to health, as illustrated above in Box 1.1. We now turn our attention to discussing some of these key areas in further detail. These selected issues are not exhaustive, and further coverage of other global health challenges are discussed in later chapters.
Population changes
The world population is increasing, and much of this growth is occurring in lower-income countries, which has been seen as a threat by those in the global north in relation to perceived competition for resources. It is predicted that every continent will see an increase in their population over the course of the twentyfirst century, but it is in poorer countries where the disproportionate burden of disease is experienced (Laaser & Epstein, 2010). Increasing population numbers have long been debated within the literature, with reported concerns related to growing demands for scarce resources such as food, accommodation and water, and services such as health care and education provision. Indeed, concerns have also been linked to overcrowding and mental health issues (Warwick-Booth et al., 2012). As populations grow and divisions between richer and poorer countries also expand, the world is currently experiencing mass migration within and between countries. This has been made worse by violent conflicts in many regions, such as Syria. Movements of people from rural to urban areas in search of better and more affluent lives have long taken place. Recent migration patterns are, however, reflective of broader structural issues affecting the health and wellbeing of many populations, as illustrated in Box 1.3.
Ageing
Like changes in population movements and numbers, ageing is also an important demographic transition, with implications for health; as the world population ages, there is likely to be an increase in morbidity and mortality in all types of chronic and degenerative diseases (Laaser & Epstein, 2010). The WHO (2007) predicted that the world’s elderly population (that is, people aged 60 years and over) will reach 2 billion by 2050. Healthy older age is a global challenge that will need addressing because there will be more old people (aged 65 and above) in the world than there are children for the first time in recorded history (WHO 2011b). For many, this has raised concerns with regard to increasing costs in terms of health and social care, especially if older people are living for longer but in poorer health. The WHO (2011b) raises the following concerns with regard to the ageing population:
the rising numbers of older people living with degenerative illnesses requiring costly care such as dementia, including Alzheimer’s;
changing patterns of living which mean that fewer old people aged 65 and above have family members able to act as local carers to support them;
increasing numbers of older people living with chronic degenerative conditions such as cancers, type 2 diabetes and heart disease following the epidemiological transition described earlier in this chapter;
the quality of life that people have when living for longer – there is much debate about whether individuals live in good health as they age;
the productivity of older workforces – as workers retire at a later point, there are many employment issues that need consideration, such as training needs, appropriate roles and health at work;
finally, the need for longer-term care and the costs that accompany this.
Box 1.3 Health challenges associated with population changes
The UNFPA (2016) makes several points about the issues that are associated with the world’s population, including:
More than a billion people in the world today are affected by crisis in a variety of forms including war, instability, disasters and epidemics. Women and girls bear a disproportionate burden of this.
Natural disasters, particularly floods and storms, are occurring twice as often as they did a quarter of a century ago. National conflicts are resulting in millions of people being driven from their homes.
Any form of crisis serves to heighten women’s and girls’ risks and vulnerabilities in many ways, for example via increased risk in relation to HIV infection, more likelihood of unintended and unwanted pregnancy, maternal death, gender-based violence, child marriage as well as rape and trafficking.
Many locations in the world are faced with a lack of resources (institutionally and in terms of infrastructure), which affects their coping capacity when faced with hazardous events and crises. This in turn has a detrimental impact on population health.
The number of people in need of humanitarian assistance is increasing and, despite increased funding from a range of sources, there are some funding gaps; questions therefore remain about the financial sustainability of current global funding arrangements.
The dominant myth is that development aid is contributing to the problem of overpopulation and therefore population movement. However, development aid in the form of educational programmes, improved nutrition and the provision of reproductive health care tends to be associated with declining fertility rates.
Furthermore, there is an increasing focus on social isolation amongst older people in countries such as the UK, with researchers and policymakers arguing that this has significant health and social care risks and therefore costs attached to it.
Safety, war and terrorism
In recent years, there has been increased attention paid to terrorism, security and fear on a global scale. Much media attention focuses on these issues, which clearly impact on health in many ways. Some of the health challenges associated with population movements because of crises have already been noted in Box 1.3, but it is worth repeating that war and conflict are major threats to health in a plethora of ways. The WHO (2003) analysis of the impact on health of conflict in Iraq is an illustration of the widespread nature of the challenges, as Box 1.4 illustrates.
