By Jahangir Moini , M.D., M.P.H. - PowerPoint Presentation

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ByJahangir Moini, M.D., M.P.H.andMorvarid Moini, D.M.D., M.P.H.

Chapter 9

Introduction to

global health issues

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OverviewGlobal health = international issues that may be solved by worldwide cooperationGlobal perspective about public health neededImportant concerns: Pregnancy-related deathsMalnutrition

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Concepts of global healthAntimicrobial resistanceEmergence or re-emergence of infectious diseasesHIV and AIDSMalariaTuberculosisEradication of polioIncreases in:

Cancer

Diabetes

Cardiovascular disease

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Questions on global healthWhat determines health?How is health status measured?How does disease relate to global health care?How important are cultures in relation to health care?How are health systems organized and, how do they function?

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Questions on global healthWhat transitions relate to demographics and epidemiology?What are important risk factors for various conditions?What are the links between the following?HealthDevelopmentEducation

Health care balance or equity

Poverty

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Concepts of public health and community-based carePublic health = disease prevention, preservation of life via community effortsCommunity-wide infectionsSanitary conditionsHygiene educationOrganization of earlier diagnoses and treatments

Improvement of living standards

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Concepts of public health and community-based careChildhood immunizations; prophylaxis against wormsSmoking cessationExercise programsFood for the malnourished; healthier dietsHand washingHIV/AIDS education

Screening for hypertension, diabetes, eyesight

Seat belts in cars; helmets when cycling

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Public health code of ethicsDisease preventionPatient rightsCommunity health promotionFocus on disenfranchisedEvidence-based public health Cooperation between disciplinesAppreciation of beliefs, cultures, values

Enhanced physical and social environments

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Public healthPopulations, not just individualsEthics about public serviceDisease prevention, health promotion Environment, human behaviors, lifestylesEpidemiology:

Studies patterns, causes of disease in specific populations

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Smallpox eradicationIn 1966, smallpox caused 2 million global deaths Vaccine was mass-produced, refrigerated in 1950sOriginally developed in 1798CDC, World Health Organization (WHO) help implement plan for compulsory smallpox vaccinations in 1965

By 1980, declared eradicated worldwide

Partly due to assigning one person per country to be responsible

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The effects of disease on life expectancyLife expectancies vary due to: Disease prevalence, environment conditions, other factorsHealth-adjusted life expectancy (HALE) Calculates

life expectancy

globally

Considers years of good health

The longer a person sick or disabled:

More difference between life expectancy at birth and HALE

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Life expectancy at birth and HALE for various countries

Country

Male life expectancy at birth

Male (HALE)

Female life expectancy

at birth

Female (HALE)

Australia

80

71

85

74

Brazil

72

63

79

68

Iran

72

63

76

65

Italy

80

71

85

74

Japan

80

72 (highest)

87 (highest)

78 (highest)

Russian Federation

63

55

75

66

South Africa

57 (lowest)

49 (lowest)

64

(54 lowest)

United Kingdom

79

69

83

72

USA

76

68

81

71

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The effects of disease on life expectancyDisability-adjusted life year (DALY)Total years lost by premature deathYears lived with disability

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The effects of disease on life expectancyHigh-income countries, top 3 causes of death:Ischemic heart diseaseStrokeRespiratory cancersLow- and middle-income countries: Stroke

Ischemic heart disease

Chronic obstructive pulmonary disease (COPD)

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Risk factors for disease: Low- and middle-income countriesUnsafe work conditionsHypertension, high cholesterolSmoking, air pollutionUnsafe water, poor sanitation

Poor cooking techniques; household smoke

Lack of exercise,

high body mass index (BMI)

, and fasting glucose

Poor breastfeeding practices

Wars, conflicts

Underweight

children

Iron deficiencies

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Risk factors for disease:High-income countriesSimilar factors to poorer countries, plus:Presence of lead in enviromentDrug use

More overweight or obese people and smokers

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Top 10 risk factors for death

High-income countries

Low- and middle-income countries

1. Dietary risks

1. Dietary risks

2. Hypertension

2. Hypertension

3. Smoking

3. Smoking

4. High body mass index

4. Household air pollution

5. Physical inactivity

5. Ambient particulate matter pollution

6. High-fasting plasma glucose

6. High-fasting plasma glucose

7. High total cholesterol

7. Physical inactivity

8. Ambient particulate matter pollution

8. High body mass index

9. Alcohol use

9. Alcohol use

10. Lead

10. High total cholesterol

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Population growth and agingCurrent worldwide populationJust under 7.3 billion, and growingHuge growth in low- and middle-income countriesMore sanitation and water supply improvements neededPossibly causing harm to health and education

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Population growth and agingWorldwide population is also agingElderly support ratioImbalance between those aged 65+ and those aged 15-64Longer lives = more morbidities, disabilitiesHealth care costs are risingHigh-income countries: 26.2% over age 65

Low- and middle-income countries: 14.6% over 65

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Poverty and the economyHealth costs very important to poverty-level peopleMental health conditions, chronic diseases:Long-term disabilitiesHealth care costs over time can be significant

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Health and educationEducation of families leads to long-term changes in behaviorsRelated to good healthBetter education = fighting illness successfullyResults in children receiving all immunizationsDiscourages unhealthy behaviors and lifestyles

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Ethical and human rights concernsAccess to health services, information:Generally, considered basic human rightsOther issues:Severe Acute Respiratory Syndrome (SARS) Ebola

Research on human subjects

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Limits to human rightsIn infection epidemics:Travel suspensions affect work and freedomSports events, gatherings postponedGoal: Minimize likelihood of a larger outbreakFollow due process of law

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Universal health coverageEveryone should receive services that are:PromotivePreventiveCurativeRehabilitative

Palliative

Appropriate services should be affordable

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Universal health coverageOffers integrated basic services for:Maternal and child healthNon-communicable diseasesControl of communicable diseases:HIVTuberculosisMalaria

Neglected tropical diseases (NTDs)

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Culture and healthCulture: Societal group with Accepted knowledgeBeliefsMoralsCustoms

Laws

Also, a group with shared behaviors and beliefs

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Culture and healthThere may be cultures within:Families Social groupsEconomic groups The artsReligion Languages

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Culture and healthCulture helps determine perceptions of “good health” and “illness”SubculturesSmaller groups with more specified differencesU.S. has many large foreign subculturesSociety

Groups within a locality sharing cultural traditions

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Culture and healthHealthier cultures believe in: Safer sexBetter dietsRegular exercise Cultural relativism: Every unique culture is evaluated only by its own values and standards

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Health beliefs and practicesDiffer by culture South Africa considers malaria to be normalEgypt considers schistosomiasis normalDiseases:

Biological,

psychophysiologic

malfunctions,

maladaptations

AIDS, pneumonia, polio

Illnesses

:

Reactions to disease

May be personal, interpersonal, or cultural

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Western medical paradigmUsed in USA to explain causes of disease:Type 2 diabetesObesityGeneticsColds and influenzaViruses

Heart disease

High cholesterol

Obesity

Smoking

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Biomedical modelUsed in low- and middle-income countries to explain illnessIf body is out of balance – too hot or cold – illness occursLinked to: Unhealthy behaviors or diets

Supernatural or natural causes

Need to re-evaluate life

Enemies

Ancestors or hereditary causes

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Conditions and treatments based on theories of “hot” and “cold”

“Hot” conditions

“Cold” medical

remedies

“Cold” food remedies

Constipation, fever, infections,

sore throat, ulcers

Bicarbonate of soda, milk of magnesia, orange flower water, sage

Chicken, dairy products, honey, lima beans, milk, raisins, vegetables

“Cold conditions”

“Hot” medical

remedies

“Hot” food remedies

Cancer, colds, headache, pneumonia, tuberculosis

Aspirin, cinnamon, cod liver oil, garlic, penicillin

Beef, cereals, eggs, oils, spicy

foods, wine

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Other beliefsExtreme emotional stress causes illnessOthers link illness to sex practicesFolk illnessesBelieved due non-physiologic factors Poor diet or eating habitsOften treated by natural “healers”

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Other beliefsSome cultures believe that bad or evil spirits cause disease, must be removed by:Traditional potionsJewelryTechniques such as scarification

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Examples of health care providers in various culturesWestern biomedical health service providersPhysicians, nurses, pharmacists, dentistsEastern medical providersAcupuncturists, chemists, herbalists

Indigenous providers

Healers, midwives, priests, shamans, spiritualists, witches

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Health behaviorsMay contribute to risks for illness, premature deathIn low- and middle-income countries, underweight infants more likely to die: May be linked to food taboos for pregnant womenPeople may be unaware of:

Standard hand washing

Safe water use

Disposal of human waste

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The ecological perspectiveTries to explain behaviors concerning healthBased on areas including: Individual CommunityInterpersonal Public policy

Institutional

Influenced by:

Attitudes

Beliefs

Knowledge

Personality

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Nutrition and global healthWomen and children in poorer countries are undernourishedUnderweight children below age 5 have high death risksInfants may die due to inadequate breastfeeding

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Nutrition and global healthMillennium Development GoalsCreated to: Eradicate poverty and hunger Reduce child mortalityUniversal education about nutrition Improve maternal health

Promote gender equality

Battle diseases

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UndernutritionCaused by inadequate food supply, or inability to use nutrientsIn children, based on:Height-for-ageWeight-for-ageWeight-for-height

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UndernutritionMore than 3 million child deaths every yearThis is more than 8,000 deaths dailyFor adults, it is measured by a body mass index (BMI) less than 18.5Though decreasing, undernutrition leads to:Weakening

Illness and infection

Development of chronic conditions

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UndernutritionGlobal statistics:165 million children have growth stunting100 million children are underweight50 million children are wastedMicronutrients in diet are often lacking

Vitamin and mineral deficiencies:

Vitamin A

Iodine

Zinc

Iron

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ObesityAbnormal increase in fat cells, mainly in viscera and subcutaneous tissuesExcess body weight in comparison to heightCalculated by: Dividing weight (in kilograms) by the square of the person’s height (in meters)

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BMI calculationsUnderweight = less than 18.5Normal weight = 18.5 to 24.9Overweight = 25 to 29.9Obese = greater than 30To estimate body fat, a caliper measures thickness of a fold of skin

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Statistics37% of the world overweight or obeseUp 28% since 1980, and increasing7% of children under age 5 are overweightLinked to: Hypertension Gallbladder disease

Hyperlipidemia

Osteoarthritis

Coronary artery disease

Sleep apnea

Heart attack

Breast/colon cancer

Diabetes

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Figure 9-1: Using a caliper to measure BMI in an obese patient

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CausesIncreased total energy intakeDecreased total energy expenditureThe condition is usually due to chosen lifestyleGlobal increases based on: Increased wealthSocioeconomic status

Urbanization

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Obesity factorsDrinks with more sugarHighly processed, less nutritional foodsMore popular due to convenienceReduced exercise Less obesity in countries using traditional food culturesResisting modernization of available foods

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Dangerous changesIntake of red and processed meat: Weight gain Type 2 diabetesHeart disease CancerPoor consumption of fruits, vegetables, whole grains

Jobs with less activity

Television and video games

Availability of motor vehicles for travel

Lack of exercise + processed, sugary foods = obesity

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Exercise30+ minutes of moderate physical activity for most days of each weekOften avoided due to limited exercise areas, fear of crimeLess high energy expenditure jobs exist – less walkingOther factors: Decreased sleepIncreased stress

Increased indoor forms of entertainment

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Rates of U.S. obesity in individual populationsBlacks = 47.8%Hispanics = 42.5%Whites = 32.6%Asians = 10.8%

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Global obesityChildhood obesity often continues into adulthoodGlobal percentage has increased over 47% since 1980 (much faster in children)Largest increases in low- to middle-income countries2.8 million adult deaths annually

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Nutrition and pregnancyImportant nutrients for pregnant women:Folic acidDeficiency linked to neural tube defects (spina bifida)IronCalcium

Pregnant women should eat 300 calories per day more than usual

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Nutritional needs during infancy and childhoodYoung children need adequate: Protein Vitamins and mineralsCarbohydrates

Fats

For infants’ health:

Breastfeed for first 6 months without supplementation

After breastfeeding finishes, replacement nutrition helps avoid:

Infections and illness

Being

stunted

in development

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Nutritional needs during adulthood and old ageDiets must be managed closely to avoid harmNo excessive cholesterol, fat, salt, and sugarMany elderly have poor diets

Due to financial situations or lack of support

Diet must supply correct protein, energy, and iron

Calcium,

vitamin D

Crucial to reduce risks of

osteoporosis