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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Introducing Global Health: Practice, Policy, and Solutions is a contemporary overview of the major issues in global public health. The book explores how population health might be maximized with the right blend of health system, education, antipoverty, infectious disease, urban development, governance, and incentive-based policies. It covers topics critical for understanding the state of the world today, including wars for natural resources, the missing women phenomenon, and whether global aid really works. The book's case studies focus on developing economies, mixed economies, and new emerging superpowers. Thematic chapters are interwoven with running motifs, such as the health risks and benefits associated with different totalitarian, capitalist, and market socialist economies. Moving beyond statistics, the book represents a major innovation in the teaching of global health by presenting technical concepts including the incidence and prevalence of disease within the context of more accessible topics such as global poverty. This helps students contextualize otherwise challenging but critical concepts, such as the burden of infectious disease. By encouraging reflection, focusing on what works, and using activities and exercises, Introducing Global Health both teaches fundamentals of global public health and cultivates a policy perspective that is appealing and compelling for today's students.
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Veröffentlichungsjahr: 2013
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Table of Contents
Title page
Copyright page
Figures and Tables
Figures
Tables
The Authors
Introduction: An Overview of Global Health
Why a Public Health Perspective?
The Global Health Landscape
About the Book
Acknowledgments
Key Terms
PART ONE: The Basics of Global Health
CHAPTER 1: A Very Brief History of Global Health Policy
Health and Public Policy through the Twentieth Century
The Age of Global Health Policy
The Fall of Global Governance
The Millennium Development Goals
An Alternative History
Love and Health in Modern Times
Summary
Key Terms
Discussion Questions
CHAPTER 2: Case Studies in Development and Health
The Puzzle of “Good” Development for Health
The Next Superpowers? Taking a Closer Look at Middle-Income Countries
Growth-Mediated Models
Support-Led Models
Toward a Happy Medium?
China's Explosive Growth
Kerala's Quality of Life
Chile Aims for a Balancing Act
Summary
Key Terms
Discussion Questions
PART TWO: Global Health and the Art of Policy Making
CHAPTER 3: The Global Burden of Disease
Who Dies Where?
Counting Global Deaths (with an Eye toward Saving Lives)
Dead Children Make for Bad Statistics
The Health Effects of Evil Genies
Quantifying the Global Burden of Disease
Cost-Effectiveness Analysis
Summary
Key Terms
Discussion Questions
CHAPTER 4: Aid
Different Types of Aid
The Aid Controversy
Models of Global Aid for Public Health
Argument: Aid Is Harmful
Argument: Aid Is Poorly Managed
Argument: Aid Is Misused
Argument: “Aid” Further Consolidates Power for the Powerful
Argument: All Is Well, Just Send More
Argument: We Are Making Progress, but the Hurdles Are High
Summary
Key Terms
Discussion Questions
CHAPTER 5: Health Systems
Health Care Delivery Systems
Health Care Payments
Health Care Markets
Health Care Delivery Systems in High-Income Countries
Health Care Delivery Systems in Low- and Middle-Income Countries
Pharmaceutical Spending
What Makes Us Healthy?
Summary
Key Terms
Discussion Questions
CHAPTER 6: Social Policy and Global Health
How Policies Are Made
Political Economy and Health
Lessons for Health-Optimizing Social Policies
Summary
Key Terms
Discussion Questions
CHAPTER 7: A Closer Look at Three Political Economies: China, Kerala, and Chile
China: Sustainable State of Development?
Kerala: Experiments with Radical Decentralization
Chile: A Precarious Third Way
Summary
Discussion Questions
CHAPTER 8: Global Governance and Health
The World Health Organization
The World Trade Organization
An Evolution of Global Governance
Summary
Key Terms
Discussion Questions
PART THREE: Key Challenges in Global Health
CHAPTER 9: Poverty
Income and Health across Nations
Definitions of Poverty
Why Do We Worry about Poverty in Public Health?
Poverty in Less-Developed Nations
Poverty and Health among Wealthy Nations
The Complexities of Poverty
Summary
Key Terms
Discussion Questions
CHAPTER 10: The Physical Environment and Disease
Infectious Disease and Development
Malaria and Other Mosquito-Borne Illnesses
Air Pollution and Health
Outer-Ring Development and Health
Climate Change and Health
Summary
Key Terms
Discussion Questions
CHAPTER 11: The Social Environment and Disease
The Ultimate Trifecta: Race, Class, and Gender
The Human Immunodeficiency Virus (HIV)
Tuberculosis
Social Networks and Chronic Disease
Individual Risk Behaviors, Urban Planning, and Health
Summary
Key Terms
Discussion Questions
CHAPTER 12: Globalization, Internal Conflict, and the Resource Curse
Globalization and Health
Spillover Effects of Poor Global Governance
Civil Conflict as a Public Health Problem
Resource Curses and Civil Conflict
Natural Resources and Civil War
Summary
Key Terms
Discussion Questions
CHAPTER 13: Frontiers in Global Health
The Many Levels of Health
Tidings, Good or Bad, Come in Clusters
Working with the System
A Rise in Targeted Social Policy Interventions
Innovations in Administration and Governance
Lessons on Social Policy Interventions
Summary
Key Terms
Discussion Questions
Index
Cover design by: Michael Rutkowski
Cover images: © Kamran Khan
Copyright © 2013 by John Wiley & Sons, Inc. All rights reserved.
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Library of Congress Cataloging-in-Publication Data
Muennig, Peter, author.
Introducing global health : practice, policy, and solutions / Peter Muennig, Celina Su. –First edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-470-53328-4 (pbk.); ISBN 978-1-118-22041-2 (ebk.); ISBN 978-1-118-23399-3 (ebk.)
I. Su, Celina, author. II. Title.
[DNLM: 1. World Health. 2. Health Policy. WA 530.1]
RA418
362.1–dc23
2013012274
Figures and Tables
Figures
I.1. This river makes finding recyclables easy.
1.1. Changes in life expectancy from 1940 to 2009 in some of the nations that we discuss extensively in this book.
1.2. Residents live near a waterway containing raw sewage and trash in Chennai, India, 2013.
1.3. During the Industrial Revolution, the advent of coal and steam use as energy sources became widespread.
1.4. In 2005, a chemical plant explosion in Jilin, a province in northern China, led to a massive release of nitrobenzene into the Songhua River. The water became foamy and was too dangerous to drink. The spill at first was covered up by the Chinese government, but the truth was disclosed after large numbers of dead fish washed ashore in the large northern city of Harbin and residents began to panic.
1.5. President Reagan meeting with Prime Minister Margaret Thatcher at the Hotel Cipriani in Venice, Italy, 6/9/1987.
1.6. Population pyramids typical in various stages of development.
2.1. The Preston curve: Life expectancy versus GDP per capita.
2.2. In China, the export revolution started during the transition to a predominantly capitalist economy led to massive environmental destruction, causing broad effects on ecosystems and adversely affecting the quality of life of hundreds of millions of Chinese citizens.
2.3. A woman helps one of China’s barefoot doctors with nursing duties in Luo Quan Wan village.
2.4. Children outside a school in Kerala.
2.5. Life expectancy of women in Chile relative to Japan, the United States, New Zealand, and Norway.
3.1. Death by broad cause group.
3.2. Child mortality rates by cause and region.
3.3. A chulla, or a traditional outdoor cook stove used in India. This particular chulla is going to be lit using branches, scrap wood, dried dung cakes, and coconut shells.
3.4. A lack of access to clean water and adequate sanitation severely inhibits many countries, especially those in sub-Saharan Africa. This problem inhibits their ability to accelerate their development.
3.5. A member of a local relief committee in a village in East Africa builds a latrine. This particular village has chosen to use aid provided by the organization Oxfam to build latrines.
4.1. Many in international development make the same mistake that this food shop in Chongqing, China, makes. It is important to have a grasp of local and international knowledge before implementation (in this case, a sign suggesting that the snack shack is selling feces).
4.2. Aid is delivered to Port Au Prince, Haiti, following the magnitude 7 earthquake that hit the city in 2010.
5.1. One of the many EMRs available from commercial vendors. Nations that are now converting to EMR systems face the challenge of either navigating the many systems that were in place prior to implementing a mandate for providers to use such records or forcing providers to drop their existing systems in favor of a universal system.
5.2. The chances that a forty-five-year-old woman will survive to her sixtieth birthday (fifteen-year survival) in twelve nations in 1975 (left half) and 2005 (right half). These fifteen-year survival estimates are plotted against health expenditures (y-axis).
5.3. Trends in self-reported health status and total household income after accounting for medical expenditures (from the General Social Survey, 1972–2008, provided by the author).
5.4. Global health expenditures, average number of doctor visits per year, and life expectancy.
5.5. An Ayurvedic medicine shop in India.
6.1. The percentage of women who feel that husbands are justified in hitting their wives under certain circumstances by selected nations. The data for each country are broken down by wealth so that we see that poorer women are more likely to favor beatings than wealthier women.
6.2. A man appears to collect fish for human consumption after extreme river pollution and high temperatures lead to large numbers of fish dying in the river in Wuhan, China.
8.1. Citizens of Mexico City wear masks to prevent the spread of influenza.
8.2. An anti-WTO protestor demonstrates in Hong Kong in 2005.
9.1. This child, like millions of others in India, suffers from extreme poverty and hunger.
9.2. A Nigerian girl suffers from kwashiorkor.
9.3. In India, a father and child suffering from marasmus.
9.4. The life cycle of the hookworm parasite.
9.5. A diagram outlining the potential connections between poverty and health. We see that inadequate resources are linked to poor education, low wages, and poor environmental conditions (boxes). However, these factors are in turn caused by a confluence of poor governance and historic circumstances (among other factors).
10.1. Hookworm is one of the most frequently encountered parasitic infections in the world.
10.2. A factory in China on the Yangtze River.
10.3. Slash-and-burn agriculture is a common form of farming in developing countries. It is also a major contributor to air pollution.
10.4. Slum upgrade in India. One approach to improving the quality of life in slums is to formally recognize them as neighborhoods within urban centers and to then install critical infrastructure, such as sewage, sidewalks, electricity, and in some cases, even improving the quality of the housing itself.
10.5. Potential land loss due to polar melting. The black outline represents the current landmass above sea level. With sufficient global warming, we can expect New York, Washington, DC, Baltimore, and Philadelphia to be under water.
11.1. From a purely economic perspective, it makes more sense to invest scarce aid dollars in women rather than men because women are more likely to comply with interventions, pass on information to their children, and are less likely to squander income on alcohol or other drugs than are men.
11.2. The missing women phenomenon. Some nations have many more boys than would be expected by natural sex ratios at birth.
11.3. A public communications campaign from the New York City Department of Health and Mental Hygiene. Top panel: An advertisement frequently seen on the subway. Bottom panel: Still from an accompanying YouTube video.
11.4. Adbusters is an organization stocked with disenfranchised advertisers that seeks in part to counter the harmful effects of consumer advertising in a process called culture jamming. This ad attempts to delink male virility and alcohol. It might be particularly effective at reducing alcohol consumption because most men know what alcohol can do when they actually do get lucky with their bar date.
11.5. A bike lane in Kunming, China. Sophisticated bike lanes are a regular feature of mainstream Chinese urban planning.
12.1. This map shows six special economic zones set up by the Chinese government in areas of Africa.
12.2. Natural resources in poorly governed nations not only encourage dangerous mining conditions, but also can lead to civil war.
13.1. How the concept of herd immunity works.
13.2. The different levels of disease causation or prevention.
13.3. The life cycle of the Onchocerca volvulus. This is a parasitic worm that is the cause of river blindness.
13.4. A Bolsa Família center in Feira de Santana, Brazil.
Tables
3.1. Counting Deaths Worldwide, by Disease
3.2. Leading Causes of Death for the World Overall and by Level of Economic Development
3.3. Counting Deaths Worldwide by Disease and the Most Relevant Policy for Addressing the Disease
3.4. Counting Deaths Worldwide by Preventive Policy Needed
3.5. Burden of Disease Worldwide in DALYs
3.6. DALYs Ranked by Country Categories
3.7. A Hypothetical Cost-Effectiveness League Table
5.1. Health Care Spending in 2009, per Person, in US Dollars
6.1. Three Forms of Social Democracy in Low- and Middle-Income Countries
6.2. Two Types of Nondemocratic Governance
6.3. Main Political Economy Types in Industrialized Countries
The Authors
Peter Muennig is an associate professor at Columbia University's Mailman School of Public Health, where he teaches global health policy, comparative health systems, and health disparities to graduate students in public health. He has consulted for numerous foreign governments and has run a nongovernmental organization, the Burmese Refugee Project (which he cofounded while still a student), for twelve years. He has published more than sixty peer-reviewed articles, two books, and many chapters and government reports. He or his work has appeared in many media outlets, including the New York Times, the Washington Post, Slate, the Wall Street Journal, NPR, and CNN.
Celina Su is an associate professor of political science at the City University of New York. Her research concerns civil society, political participation, and social policy, especially health and education. Her publications include Streetwise for Book Smarts: Grassroots Organizing and Education Reform in the Bronx (Cornell University Press, 2009) and Our Schools Suck: Young People Talk Back to a Segregated Nation on the Failures of Urban Education (coauthored, New York University Press, 2009). Her honors include the Berlin Prize and the Whiting Award for Excellence in Teaching. Su was cofounding executive director of the Burmese Refugee Project from 2001 to 2013. She earned her PhD from the Massachusetts Institute of Technology.
Introduction: An Overview of Global Health
Before we can begin to think about global health, we must understand how institutions work. One example of an institution is a bank. Most of us deposit our money in banks because we are confident that we can retrieve our money whenever we want—that is, that the money will still be there and accessible to us, plus interest and minus fees. Banking is an institution, just as banks themselves are institutions. One way of thinking about an institution is that it constitutes the habits, cooperation, and behavior of large numbers of people. It is something that we as humans, within a given culture, collectively believe in. It is real and trustworthy because everyone believes it to be. When customers lose confidence in an institution, it collapses. This is because institutions must exist in our minds for them to exist in the real world. Just think of all the banks that went under worldwide during the Great Depression. When the banks' ability to securely hold deposits became precarious, thousands of average citizens participated in bank runs and attempted to withdraw their funds from banks and place their cash under their mattresses instead.
This, in turn, exacerbated the banks' already fragile accounting books and reserves. Many of the banking laws the United States has today stemmed from lessons learned from institutional failures in the Great Depression. The government stepped in to reinforce our collective belief in US banks and other financial institutions, or—at a bare minimum—in the existence of the currency we deposit there. If we deposit US$10,000 and the bank goes out of business, the government promises to pay that money back to us. It will do so even though this money is held only as zeros and ones on some accounting database somewhere and not in any tangible form, such as gold or even paper currency. The trust that we have in the institution, therefore, extends to a trust that we have in our nation's government.
As long as (almost) everyone in your society has agreed that a US$1 bill is worth $1 and a $100 bill is worth $100, the money has value even though each bill is nothing more than a piece of paper and ink with an actual worth of just pennies. Under this system, you can contribute a portion of your life to performing a task in a factory or office and be confident that the money you receive in return for your labors will always buy you a known quantity of avocados.
During times of financial stress, investors go to the currency that most people believe in most firmly. This way, despite the fact of the Great Recession that began in the United States in 2007, global investors bought US dollars. This sent the value of the dollar soaring relative to that of other currencies. Investors bought dollars precisely because the US dollar is widely recognized as the most reliable of the global currencies—at the time that we went to press, at least.
Institutions vary by geographical and historical context. Slavery was an accepted social institution in ancient Greece and Egypt. It was the rare leader who thought that people should not be owned by others. Now, slave-holding is rare. (The absolute number of slaves held is larger than at any point in history, but as a proportion of all inhabitants on earth, it is quite small [Bales, 2004].) Arranged marriage is a social institution in some places but not in others. Thus, institutions can be social or cultural in nature. They do not have to be inscribed into law or have official governmental agencies or buildings representing them.
Institutions—even ones that, at first glance, have little to do with an individual's health, such as banking or marriage—are important in global health in several key ways. First, much of what shapes population health around the world lies outside of the official medical and health care systems. As one example, traffic accidents are a leading cause of death globally, and whether we obey traffic light signals or drive into oncoming traffic is determined by institutions within each country. Another example might be whether we wash our hands after using the bathroom or a surgeon washes her hands before a surgery. Second, many areas around the world currently do not have rules and regulations that explicitly promote healthy institutions (such as ensuring affordable access to safe drinking water) and prohibit unhealthy ones (such as tobacco advertisements aimed at children). This is partly because some institutions that are considered “normal” in some settings—such as access to family planning, including condoms and safe early-term abortions—are quite contentious in others. Third, even if governments attempt to develop helpful public policies and programs, they may not be successful because corruption is often endemic in governmental agencies.
This last point is important for global health. Many institutions in many low-income countries—banks, currencies, or even rules of conduct, such as everyone driving in the same direction on an agreed-on side of the road—are weak. In fact, it might be argued that such nations have a low income and low life expectancy precisely because these institutions are weak. When the trust in institutions breaks down, it becomes difficult to build social infrastructure, such as roads and schools. That is, the banks can be too weak to lend money for such projects. If the money is acquired, institutionalized corruption may make it impossible to successfully pay for such programs. At every step of development, what we believe to be acceptable behaviors matters.
In extreme cases, when trust disappears, it becomes difficult to perform basic, everyday activities, such as buying basic goods by any means other than bartering or using some other nation's currency. At the time of this writing, the cost of a medical examination in most clinics in Zimbabwe was listed in terms of units of grain or livestock. This is because people had lost all faith in the value of their currency.
These institutions sometimes break down when individual self-interest overrides collective interest—this is sometimes known as the “tragedy of the commons.” Those who take bribes in exchange for a road project break down the notion of trust that we hold in the overall institution.
In nations with weak institutions, it becomes not only almost impossible to run government programs but also to deliver aid. Thus, the real challenge of global health is to figure out how to make institutions work to get global agencies and individual countries functioning to improve health.
This is partly challenging because the needs of one region are so very different from those of another. In some areas, the average person can expect to live only thirty to forty years because there is no clean water to drink, and the soil is contaminated with feces because there are no toilets. This, in turn, leads to high rates of mortality, especially among children, because of diarrhea. At this level of health development, small sums of money can go a long way because the leading health problems—lack of clean water and sanitation—are so basic and cheap to fix. But this is precisely also the context in which institutions are often weakest. In fact, these problems still exist precisely because it is so difficult to get anything done.
In a wealthy country such as the United States, however, problems such as poor access to medical care, reliance on the automobile for transit, poverty, and weak pollution controls form the major institutional challenges. Nations solve these problems in different ways. For instance, the United Kingdom has a centralized, socialized medical system. Switzerland, however, relies on highly regulated private health insurance to get the job done. In both cases, these nations are successful because their institutions work well—there is logic to how their systems run, in a way that seems to reflect many of their respective peoples' overall wishes and reasoning.
This textbook focuses on institutions and the policies that might help government to develop them if they do not exist and to reform them if they are not running well. It covers most of the pressing global health problems from this angle. This way, the student not only will learn about the leading health concerns but also will get a sense of some of the ways that these problems might be fixed at the international, national, and local levels. As such we emphasize policies that either shape or bypass existing institutions. At a minimum, we point out the difficulties in doing so (as in our discussion of international aid in chapter 3).
At a very local level, if we wish to build latrines in a poor village, for example, we attempt to get buy-in, that is, we attempt to get the people in the village to believe in the idea of latrines. At a global level, the challenge is to build institutions that a much wider range of people (or at least their political representatives) view as legitimate and worthy of respect. Neither the World Health Organization (WHO) nor its parent, the United Nations (UN), has always instilled a great amount of trust among those who are aware of their existence.
Building stronger institutions at the global level, though, is not a straightforward process. This is difficult when the UN has few regulatory powers to punish nation-states and agencies that flout its rules and recommendations. Then, for every recommendation that the UN or the WHO writes but is subsequently ignored, the institution becomes weaker, provoking a vicious cycle. The institutions fail because people believe they are ineffective, and people believe they are ineffective when they fail. Organizations work best when local branches are built around a central list of priorities and each arm is staffed with an outstanding manager who is accountable for his or her department's performance and who can operate with relative independence and agency.
Of course, getting everyone to collectively believe in a solution—to institutionalize a solution—is very challenging. Moreover, “solutions” can backfire. These unintended consequences of our policies frequently arise when we fail to fully consider the systems that gave rise to the problem in the first place. Our world is a world of paradoxes. Building a healthier world requires at best an understanding that these paradoxes are possible and concurrently and systematically thinking about public health at the individual, social, local, regional, national, and global levels.
Why a Public Health Perspective?
The place you live is the single most important determinant of how healthy you will be and how long you will live. Imagine that you are a fetus nestled comfortably in your mother's womb. If you are borne in rural eastern parts of the Democratic People's Republic of the Congo (DPRC), the chances of you or your mother dying during your birth or shortly thereafter can be as high as 50 percent (WHO, 2012). Bleeding, infection, or other labor complications are easily managed by a health worker with just a few months of training, but chances are that your mother was never able to get these services (Kruk, Galea, Prescott, & Freedman, 2007). If you make it out of the womb, your chances of seeing your fifth birthday are also low, with about a 20 percent chance of death in many areas (WHO, 2012). The lack of basic sanitation or clean water means that you are almost certainly likely to be exposed to bacteria and parasites that cause diarrhea and intestinal bleeding. Poor mosquito control means that you are also likely to contract malaria. You mother probably does not make much in a day, and lacking access to basics such as fertilizers and seeds, local farmers are unlikely to produce food at a cost that your mother can afford. Weak from poor nutrition, you immune system probably cannot fight off all these infectious diseases.
Now imagine that you were born in Malmo, Sweden. Your mother not only has free access to high-quality medical care at birth, but she also started receiving care as soon as she discovered that she was pregnant, including free essential vitamins, such as folate. After a carefully monitored birth in a cutting-edge hospital, you are discharged into a comfortable home. Even if your mother is single and unemployed, the government ensures that she has access to high-quality housing, health care, and nutrition. There are no infectious agents in the water, no mosquitoes infected with malaria, and no West Nile virus. Your chances of making it to your seventieth birthday are greater than your chances of making it to age five in the DPRC (CIA, 2012; Oeppen & Vaupel, 2002; WHO, 2012).
You might see this Congo-born you as having low chances of survival because there is lousy medical care and bad economic circumstances. That is true. But where do the bad economy and lousy health system come from? Health systems cannot be repaired unless political institutions are repaired as well.
The Global Health Landscape
Water, water, everywhere,
Nor any drop to drink.
—Samuel Taylor Coleridge, “The Rime of the Ancient Mariner”
With global climate change and the human destruction of natural protective barriers, such as mangrove forests, many of the world's coastal regions are now exposed to cyclical flooding. This, in turn, leads to destruction of homes and livelihoods. Many of these areas will one day be permanently under water because global warming exacerbates the destruction already done by human habitation (Bush et al., 2011).
The Polynesian island nation of Tuvalu, for example, is only 4.5 meters above sea level, and it will be uninhabitable by 2050 (Connell, 2003). It is one of twenty-two Pacific island nations. Together, these nations contain seven million inhabitants that, altogether, contribute 0.06 percent of global greenhouse gas emissions. But these nations will suffer a disproportionate blow from the climate changes caused by their wealthy, industrialized neighbors, particularly China and the United States. On Tuvalu, the government is arranging to move the remaining ten thousand residents off the island. The residents will try to establish themselves and earn their living in countries such as New Zealand and Australia. They will disperse, and linguists expect the Tuvalu language to disappear within two or three generations (Farbotko, 2005; Hammond, 2009).
Even without forced migration and displacement, flooding greatly increases human exposure to infectious agents. Sanitation systems become useless as sewer water mixes with rising ocean waters. On a planet with an expanding population, there is too much water.
Perhaps an even bigger problem arises from the damming of rivers and water pollution from industry and human settlement, choking off vital international waterways. With irrigation and damming, many major rivers fail to reach the sea at all. Those that do are often contaminated with salt, lead, mercury, pesticides, trash, and sometimes with thick black toxic sludge that no one dares to test. Some inland seas and lakes, such as the Aral Sea, have become either too dry or too polluted to sustain life, let alone use as a source of drinking water (figure I.1.). This water shortage problem is only getting worse with climate change. There is too little water to sustain the rising human population.
Figure I.1. This river makes finding recyclables easy.Source: Copyright © Jurnasyanto Sukarno/epa/Corbis.
Thus, the global water supply presents major public health challenges not only because there is massive flooding resulting from human activities, but also drought resulting from human activities. There is simultaneously too much water in some places and too little water in others.
Low-income nations are growing at a blinding pace, even as they are having trouble supporting the people that are already there with their already weak institutions. Rising populations lead to poverty, pollution, human waste, and overcrowded schools. Sub-Saharan Africa and India are growing at such a rapid pace that it seems that many regions cannot overcome the poverty trap. A poverty trap occurs when the conditions underlying poverty prevent poor people (or their children) from escaping poverty. In this case, they cannot eat, and without adequate nutrition they cannot fight off infectious diseases or learn in school. This combination of disease and undereducation makes it almost impossible for future generations of children to escape poverty, thus perpetuating the trap from one generation to the next. There are too many people.
At the same time, rich nations are in stark population decline. Japan's birthrate is so low that, by 2050, the country is projected to be half the size it was in 2004 and its social services will be straining under the load of one million people over the age of one hundred. If trends continue, most European nations, along with Chile, Singapore, South Korea, and China, will soon follow in Japan's footsteps. There are too few people.
Thus, there are no simple trends in public health. We do not simply have too much water or too little, too many people or too few. The fundamental questions in public health are complex and sometimes paradoxical. Most common health problems are local. Nevertheless, there is emphasis on the global, the buzzword of the early twenty-first century. This suggests that our policies are best directed transnationally.
Economic and public health projects fail time and again because global institutions tend to take one policy and apply it to all localities as one giant bandage. Many of the misadventures of global health agencies can be attributed to thinking globally rather than locally. For instance, the International Monetary Fund (IMF) and World Bank got together in the 1980s and contributed to the “Washington Consensus,” or the idea that rising debt in low-income countries can be addressed only by tough love. (This is a simplification of a very complicated and controversial topic. We will keep it at this simple level for now and expand later.) The Washington Consensus probably worked in some places, but in others it probably set the development agenda back a few decades.
The structural adjustment programs recommended by the IMF and World Bank (described in more detail in chapter 1) essentially led to the wholesale destruction of the middle class in sub-Saharan Africa. These “programs” required cuts to nations' social programs, such as health, education, and transportation, along with other economic changes. As a result, sub-Saharan Africa has never really recovered. The WHO's recommended tuberculosis treatment program did not take into account local patterns of drug resistance (Khan, Muennig, Behta, & Zivin, 2002). People living in areas where the drugs simply did not work were treated so many times they sometimes died from the treatment rather than the disease (Farmer, 2004).
Although there is no such thing as a one-size-fits-all solution to economic, health, or education policies, global public health does exist. Pollution, infectious disease, people, and products all cross borders. These problems exist because countries with weak pollution controls and cheap labor tend to be more attractive for business investors. Global environmental regulations would go a long way toward solving problems like these.
A more nuanced vision of health is needed to solve “global” problems. Poverty might be viewed as a global phenomenon, but if so, it is certainly very different in Germany than it is in Sierra Leone. Despite a proliferation of doctors, journalists, and even clowns “without borders,” borders most definitely exist, with very real consequences to the lives of those who live within them. Habits, laws, social networks, means of grievance, economic stability, and stratification and mobility by class, race, space, caste, and language—institutions—vary profoundly from one place to the next. So, why would a one-sized formula for development or public health fit all?
If global is such a misused word, why is it in the title of this book? Ultimately, policy responses to most local public health problems are shaped by and require global governance. And this brings us to the focus of this book. We ask, “How can we better understand global health problems and strengthen the institutions that fix these problems?” We do our best to teach students the status quo and then try to tear it apart. We ask whether the current set of buzzwords and policies are really going to address the problems that they set out to fix. By dissecting these problems as critically as possible, we hope that the student can come to a better understanding of the issues altering the world's health and well-being.
About the Book
The remainder of the book is organized as follows. Part 1, which consists of chapters 1 and 2, focuses on the foundational basics of global health. In chapter 1, we give a brief history of major historical forces, such as industrialization and urbanization, that helped to shape the major epidemiologic trends and public health challenges we face today. Because population health outcomes are integrally tied to economic and human development overall, and because they increasingly cross national borders, we emphasize the ways in which intergovernmental institutions and international actors have struggled to implement policies that are coordinated and appropriately contextualized.
In chapter 2, we introduce China, Chile, and a state in India called Kerala as case studies. We use these case studies to explore how different types or sets of social and economic investments influence health and why. We chose these case studies because they represent different types of governance (democratic and nondemocratic) and different types of social investments (social investments versus free market). Kerala has generally been democratic in governance but has elected communists to power for long stints punctuated by more market-leaning officials. Chile has experienced periods of heavy social investment and periods of heavy social divestment. We revisit these three political economies again in chapter 7.
For instance, some nations that make effective investments in basic education might gain more in longevity than nations that invest in universal medical care. Although medical care treats disease after it has already struck, basic education provides a survival toolkit. In Darwinian terms, education can be used to optimize one's environmental niche for survival over the course of an entire life. This way, in some cases, education can prevent disease before it has a chance to strike.
Part 2, “Global Health and the Art of Policy Making,” will help students to identify the major policies shaping global health and will critically investigate how these policies might be improved or better implemented. Chapter 3 presents the predominating diseases in different development contexts. Chapter 4 looks at the aid that is delivered to address this burden of disease. Chapter 5 explores health delivery systems that are charged with using this aid to reduce the burden of disease, and chapters 6 and 8 investigate how effective global governance is at helping low-income nations stem disease and to prevent it from spreading between nations (first examining social policies and then the global governance institutions that implement these policies).
Finally, part 3 takes a look at some of the issues and cutting-edge solutions in global health today. Chapter 9 discusses poverty as the central node in a complex web of public health challenges, the ways in which poverty manifests differently in low- versus high-income countries, and what antipoverty programs should look like. Chapter 10 reviews some of the ways in which poor physical environments—especially lack of sanitation, air pollution, and outer-ring development and urbanization—lead to poor population health. Chapter 11 takes a look at how our social environments, especially social forces such as race and gender, shape patterns in health outcomes. Chapter 12 examines challenges in trade liberalization, especially nations' attempts to avoid the so-called resource curse, whereby countries with great natural resources surprisingly do worse in terms of economic, social, and human development. Chapter 13 focuses on cutting-edge solutions to addressing these problems. These include changes in how we think about the cities we live in, innovative ways of incentivizing people to be healthier, and radical reshaping of our drug and immigration policies. As these chapters suggest, students studying global health need to analyze problems and potential solutions on many levels—individual, local, national, and international—at once. Chapter 13, our conclusion, attempts to articulate emerging trends and next steps in global health by presenting several prominent case studies of social policy interventions.
As a final word, we should note that instead of listing key concepts in sequential order, we try to revisit and discuss certain complex themes throughout the book. So, for example, we do not have a chapter on epidemiology (the study of health problems in populations). Such a chapter would be full of information on how to calculate disease rates and how to conduct public health studies. Instead, we mention the major bits of epidemiology that you will need to understand how to study global health as they arise in real-life situations or in the news. For example, when we discuss the politics of making policies, we talk about how to understand how policies are tested and improved. It is here that the relevant concept in epidemiology is briefly discussed, and always within the context of a real-world example. In social environments and health in chapter 13, for instance, we discuss how, from the standpoint of maximizing health, girls tend to benefit more from education than boys. This is because girls respond to education by having fewer children when they become women (partly because it may allow them to make better-informed decisions and to participate in the workforce). Many researchers believe that educated women also tend to pass their knowledge on to their children and thereby help increase their children's survival to a much greater extent than educated men. But in some nations, such as India, boys tend to be favored over girls. This is true not only when it comes to deciding which children go to school but also which children get fed when food is scarce. Because food is needed for education, girls lose out twice over. In fact, in India, China, and parts of the Middle East, there are many fewer girls than boys because some families abort female fetuses and some starve or otherwise neglect female children in order to better provide for males. This has led to massive gender imbalances, a phenomenon known as missing women. Although this has been a long-standing problem, it may have been made worse by the advent of low-cost ultrasound machines that allow for the quick determination of fetal sex and sex-selective abortions. This section builds on discussions on the root causes of health, governance structures, and disparities in outcomes from previous chapters.
Because of the pedagogical approach we use, readers who read this book front to back will benefit most. It also helps to read it completely through because, after introducing a concept, we try to revisit it, building on it in a fresh way. This allows the mind to naturally learn and absorb the material without the need for notes. Although readers who skip around may occasionally encounter unfamiliar concepts, the good thing about our approach is that we redefine and reintroduce more-complex ideas as they arise and let less-complex ideas relax comfortably where they first appear.
One consideration that readers should keep in mind is that all works in the social sciences—be they works of journalism or academic articles—are influenced by the opinions of their authors. Researchers tend to focus on topics and concerns that they believe in or feel emotionally compelled by and—often unwittingly—interject their beliefs in a search for truth in numbers. Negative findings often go unpublished in the academic literature because editors do not see them as likely to promote their journals. Few fields are as rife for editorials presented as fact than global health. Authors of textbooks are no different. We attempt to bring you informed opinion that covers multiple sides of the issues we present.
Acknowledgments
Elly Schofield, who worked hard to smooth and unify the text, and Jana Smith, who wrote most of the class exercises, were graduate students at Columbia University at the time of writing. Muhiuddin Haider, Marilyn Massey-Stokes, and Joyce Pulcini provided thoughtful and constructive comments on the complete draft manuscript. Javeria Hashmi and Amira Ahmed, then students at Brooklyn College, provided invaluable research assistance.
Key Terms
References
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PART ONE
The Basics of Global Health
CHAPTER 1
A Very Brief History of Global Health Policy
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Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
