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From Wikipedia, the free encyclopedia

Global health is the health of populations in the global context;[1] it has been defined as "the area of study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide".[2] Problems that transcend national borders or have a global political and economic impact are often emphasized.[3] Thus, global health is about worldwide health improvement (including mental health), reduction of disparities, and protection against global threats that disregard national borders.[4] Global health is not to be confused with international health, which is defined as the branch of public health focusing on developing nations and foreign aid efforts by industrialized countries.[5] Global health can be measured as a function of various global diseases and their prevalence in the world and threat to decrease life in the present day.

The predominant agency associated with global health (and international health) is the World Health Organization (WHO). Other important agencies impacting global health include UNICEF and World Food Programme. The United Nations system has also played a part with cross-sectoral actions to address global health and its underlying socioeconomic determinants with the declaration of the Millennium Development Goals[6] and the more recent Sustainable Development Goals.

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  • ✪ Talks@12: Disparities & Bias in Global Health
  • ✪ The Challenges of Global Health with David Boyd
  • ✪ Who are the Players in Global Health? A Tutorial by Michele Barry
  • ✪ HIV/AIDS and Global Health at Duke University
  • ✪ Holly Tucker | Medical/Global Health Humanities: Reflections on Identity

Transcription

Good afternoon. I'm Gina Vild. I'm the associate dean and chief communications officer for Harvard Medical School. And thank you for joining us today for this very special Talk@12-- Disparities and Bias in Global Health. The Talks@12 were launched eight years ago, as a way to share the extraordinary knowledge of our faculty with others on the quad. Today we live stream this event, and all of our Talks@12. And it's not unusual for them to be viewed in 36 countries by 40,000 or 50,000 people. So I want to welcome all of you here today, and the NRB, and also those watching from around the world on live streaming. I do welcome your topics. I invite them for future Talks@12 so please send me your ideas. We are thrilled to have with us two HMS experts on health care disparities. Dr. Paul Farmer and Dr. Joan Reede. Dr. Farmer and Dr. Reede will discuss how socioeconomic disparities among the medical community may contribute to inequitable health care outcomes here in the US and around the globe. And they will share their thoughts on how health care providers can improve health access that will lead to health care justice for all. Dr. Paul Farmer needs no introduction. His work as a humanitarian is well-known in far corners of the world. A medical anthropologist and physician, he has made his life's work delivering the most seminal care to the poorest of the poor, in many different parts of the world. Beyond this, he also works tirelessly to improve human rights and the consequences of social inequity. Dr. Farmer has been a member of the Harvard Medical School faculty for more than three decades, and is currently the chair of our Global Health and Social Medicine department. He is also the co-founder of Partners in Health-- an international nonprofit organization, that directs health care services, and initiates research and advocacy on behalf of those who are ill and living in poverty. A history of this transformational work of Partners in Health, the work of Dr. Farmer, as well as Dr. Jim Kim and Ophelia Dahl, has recently been captured in an exceptional documentary called Bending the Arc. I have seen it, and highly recommend that if you have an opportunity that you try to see it as well. Our moderator this afternoon is Dr. Joan Reede. She is dean for diversity inclusion and community partnership. Dr. Reede is a professor of medicine here at Harvard Medical School. The impact of her exceptional work is reflected in the many programs she has created to benefit minority students, residents, scientists, and physicians. Her work is changing lives. She has launched more than 20 programs that address pipeline and leadership issues for minority and women who are interested in careers spanning medicine, academia, and biomedical research. She leads Dean Daley's task force in diversity and inclusion. Thank you both for leading today's discussion. It'll be a conversation. I know they'll welcome your questions at the end of their talk. And I also invite those of you who are watching from afar to please submit your questions on Twitter at hashtag @Talks@12. That's hashtag @Talks@12. So thank you for joining us, and thank you Dr. Farmer and Dr. Reede. [APPLAUSE] So Gina has done this wonderful introduction, and thank you for that introduction. But I have a slightly different view when I think about Paul Farmer. I think of him as a friend, and someone with whom I share common values about justice and equity. But also someone who believes that the impossible can be done. So I want to open this with my introduction of Paul, and he's not heard this. And I'm taking this from-- I'm scared. --taking this from Muhammad Ali, a man who stood for his principles also, and a fighter. And Ali said, "Impossible is just a big word thrown around by small men, who find it easier to live in the world they've been given, than to explore the power they have to change it. Impossible is not a fact. It's an opinion. Impossible is not a declaration. It's a dare. Impossible is potential. Impossible is temporary. Impossible is nothing." And when I think about your career, and what you have done in moving world, I think of someone who saw impossible and said, let me push this aside. And let's continue to move forward. So if you think about the topic for today around disparities, and bias, and global health, your work has been around these inequities, and justice, and injustice. How do you relate that to disparities and bias? Where's the link? First of all, that's a beautiful Ali quote. I'm often compared to him, so-- [LAUGHING] I can see why. --I'm used to that. I just assume, when I saw this invitation, that these were the same thing. Global health-- and this is just a personal-- definition the wrong word. It's more along the lines of Ali's definition of "impossible." And I'm sorry if I've told this before, but I don't think I have in here. But I went to Haiti before I came to Harvard. I applied to Harvard Medical School from there. And this was in 1983. I came here for the first time in December, 1983, for an interview. To do that trajectory, from Harvard to Haiti, in those years, or from later at the Brigham to Roxbury, let's say. Or to-- you go right down the list. We've discussed this many times before. It never occurred to me that global health could be anything but about the globe. And that Charlottesville is on the globe, and Boston is on the globe. And on and on, down the list. And then I look at some of my teachers who are in the room today, and I understand that in their view as well, they had this transnational-- whatever you want to call it. I mean, it sounds highfalutin, but this transnational political economy that has long defined our world. And so to me those were always related problems. The specifics of bias and the specifics of health disparities in, let's say, an epicenter of medical knowledge here, might not look the same as health authorities in another place in that global economy. But one, it was usually possible to find some trace. I teach this class with, again, colleagues from Harvard Medical School. We teach at Harvard College-- Arthur Kleinman, Anne Becker, Salmaan Keshavjee. And we've been teaching for a long time. And yesterday was my turn, and tomorrow is my turn. And the topic was Ebola. But I really wanted to talk about health disparities, and to have them-- these students-- again, most of them very young. It's more sophisticated than I was when I was an undergraduate. I understand that where they're going tomorrow-- where I am actually going physically tomorrow, but where they are going intellectually in tomorrow-- is through that triangle. West Africa, North America, and the Caribbean. And that's just one way to see-- one truthful way, non-fake-news way-- of seeing health disparities. And I know it's a long answer, and I'm sure you're shocked by it. I am the Muhammad Ali of length, however. It's just the erasure of history, and the desocialization of our social worlds, is part of the problem. And that's part of the problem among medical professionals. That's part of the problem among medical students, residents, faculty, all the way down the line. It's our problem. So that's about as short as I can go, but I don't see the value in doing what I often hear-- is, oh, if you think this is bad you should visit-- and that's just the common reaction, a common reaction. Disparities hurt no matter where you are. Disparities hurt, and we need to be able to identify where they hurt most, and how they hurt most. And I was reading W.E.B Du Bois yesterday-- well, I've been calling it W.E.B Dubois for about 30 years until my daughter corrected me-- on the way back from Haiti. And he was writing about the same erasure in his time between Western-- the same circle. He grew up in Western Mass, went to Fisk, because he couldn't get a scholarship because he was African-American. Then he did go to Harvard, then eventually became the first African-American to get his PhD, which was before really the creation of sociology, history, political economy. But that's the point he made again and again in the part of the book that I read on the way back here, is that the erasure of history is one of the mechanisms by which we perpetuate structural violence. Or whatever you care to call it. And keep the structures in place. How as you talk about something that is truly global-- no matter where you turn, these issues of disparity, and injustice, and inequity exist. And lots of this is structural. As a health professional, as a provider, what is our role in addressing that? Or do we have a role? Well, you already know that my belief is the same as yours, that we do have a role. And I think that role is really roles. For example, if I'm doing an infectious disease console at the Brigham, and I know that structurally determined forces like gender, inequality, and racism have worked themselves into the body of a patient, that's not why the surgery team is consulting me on a patient. And to ignore that-- meaning to ignore the fact that these forces get in the bodies of patients as they do in the bodies of our colleagues and our students. To ignore that is always wrong, I think. But there is a way of-- Maybe Remember, this is a conversation. I'm not assuming that I know the answer to that question. All I can say is I struggle with it mightily. A number of our colleagues-- my colleagues from Harvard Medical School. In 1996, we wrote a book called Women, Poverty and AIDS. I know you've read it. Everybody seemed to buy it like hotcakes. And Mary Jo, [INAUDIBLE],, contributed, Jo Rhatigan, lot of people you know. Johanna Daily. And there's no question that we could at least try to trace how social inequality, social disparities, structural forces, as you said, get into-- in this case-- women's bodies. But during an infection, these consult-- that's really not what you're being consulted on. It's like, that's the wrong dose of this, you might want to try that, here's the combination of antibiotics. That's their job. The problem is that then do we back away too much from confronting structural forces that we weren't trained to take on? Actually, as an anthropologist I was trained to do it, but not as a Med student, or a resident, or a fellow. And I know the answer to that also has to be, yes, we certainly do move back too quickly. And that's one of the reasons I love being a teacher, whether here, or in Haiti, or anywhere else. So there's these structural forces, and you have to figure out-- and the Kenny Rogers-- no one to hold up, no one to fold up, no one to act. Yeah. And what's your role. But what about the forces that we bring into the world at the same time? Well, that's the thing about humans. There's no structural force that we're talking about that isn't brought into the equation by us. And that means that, I would assume, that they can be undone by us. And they also affect us in bias that we're willing to acknowledge or not. And I think the exercise of trying to sort through that, as humbling as it is, is a good one. We don't do it very well in a clinical setting, where it sometimes gets formulaic like a check list. But if you have a fellowship program, for example, that goes on over time, that's not just a formulaic response. If we have acknowledgement that we have a serious problem with all this bounty that we have, that's better than saying, ah, we're doing the best we can. Or these are forces that are determined-- the fates of either faculty, or patients, or students be patients before we can get our hands on them. So there is a piece of this, though, as you even describe-- you're this infectious disease consult. And you're sort of saying, my role in this is to say this is-- antibiotic is better than the other, or how to treat. But if you take it to that next level of who's determining what antibiotics would be available in the formulary. And so it's not just for that patient. It's how you interact with that system around that decision that may or may not make that available. So I'd look at some of the things that are going on in the world today. What's available in one place is not available in another. And as a provider, isn't there a part of it where we need to step back and say, we need to speak up about this? It's not right. It's not fair. Well, that's been the great drama of-- I say our work. I'll say my life, too, because it's true. But it's never -- the best way to be able to do nothing is to think of this is an "I" problem. But I'm looking, and again, looking around the room, some of my colleagues from Harvard and PIH, Partners in Health are here-- Lee [INAUDIBLE],, and on and on it goes. This is a great drama of the clinical work that we do. That drama is lessened whenever we have the right staff stuff, space, and systems. So the global disparities, which I knew you'd bring up and I'm relieved, because I feel like that's in my wheel house, that they're material manifestations of bias. And I don't want to go overboard on the materiality of the social, which is a title of a paper that I once gave, and I'm sure you've read it, along with my mother. All of us, yeah. All of us, yeah. Cool title, though-- Materiality of the Social. So that was the point. How do you-- in this particular case I was talking about, the distribution of HIV disease or tuberculosis in a global sense. But that's only part of the way that bias gets in. Because what about after distribution [INAUDIBLE]?? Then there's the fact that we know in a global political economy that there is some tool. And of course you're going back and forth from Harvard to Haiti, Harvard to Haiti, then you really know it-- you're reminded. But I'll just give an example because I just saw Louise come in. The only other time I've given a Talk@12-- I know you know when it was. It was my first talk after the earthquake in 2010, and it was very difficult to do, emotionally. And I was nervous about doing it. Claire Pierre came. I think Louise was probably still just working there in Haiti. And I thought, I really want to get this organized so that I don't have the difficulty expressing myself. Love that being the Muhammad Ali of global health and all. And shortly after that, one of the great complications and horrors-- not a complication of the earthquake, because this would have happened with or without the earthquake-- was the introduction of cholera. Now the introduction of cholera was, obviously, a manifestation of precisely the structural forces that you're talking about. Came from-- it happened to be Nepal. Again, if you look at the history of the great pandemics of cholera, there's always these-- they're translocal, they're transnational. And there's enormous blame and suffering-- blame and suffering, both-- that happen. And then they run right along the fault lines of social disparities. But the last time there was a big epidemic in the Americas, I happened to have been involved in that one, too. Because it went from Peru, where I just started working, all the way up Latin America, across the Caribbean, another disaster. Unknown in Haiti, as far as we can tell. But the difference between 1991 and 2010, was that there were new tools for the diagnosis and prevention of cholera. Old tools for the care of cholera, but there were some new tools, too, including an oral cholera vaccine. So that is what I mean about-- I know that it doesn't sound like a punch line but I'm just saying, therefore, in the view of those acknowledging that transnational global economy-- which should be all of us, since we're all part of it-- there were tools. And just to say, well, they're not cost-effective, available. And that's exactly what happened, even though people like Louise and her Haitian colleagues fought like hell to make sure that that didn't happen. But it did. Now who were the people we were arguing with? No more Haitians who were running away like superstitious peasants. Again, the accusations of the colonial authorities across Africa. It was our own peers, again. That is people who had trained with and like us, who looked like us, who sounded like us, regardless of what language they were speaking, by the way. To me, that's disparities, and bias in global health. So how did it get into them? How did it get into us? And it is, obviously, through our professional socialization. If it's not an 18-year-old, it's not going to give you a lecture about whether or not an oral cholera vaccine is effective, cost-effective, sustainable, or might possibly distract people from washing their hands. That's exactly the kind of discussion that we expected and heard. So that bias, and that ability to judge what people should and shouldn't have access to, or who is deserving and not deserving is another way to think about it. How do you counter that? In medical education, we train our students, be they nursing, or dental, or physicians. But how do we also counter that in the faculty that train the students? Well, I would argue-- and again, I love how this has turned into Joan revealing Paul's-- Why not? --uncertainty. But I'm not trying to sound like a guru, and you know that. And I don't know the answers to these questions. But I do not think the answer to that question can be only by understanding health disparities, and their distribution. Now an 18-year-old probably could guess what the city of Baltimore might look like in terms of health disparities. And that's an important task, to learn about the burden of disease and health disparities. But if there's a materiality of the social, then the response has to include activism, engagement, to counter the inequalities. And the history. Understanding the history. So part of this is this history in context. That can fuel us. Right. Then understanding that. But there's a part of this for me of, how do you get to this core of somebody who's trying to understand what they themselves are bringing to the table? That it's not all outside. But these biases, these stereotypes, these views, I'm carrying into my deliberations. I'm carrying, and oftentimes, making the problem worse. How do you build that capacity for self-reflection? Well, if we had been successful then we wouldn't be having arguments with our own peers, because they're the very people you're talking about. I know some of the ways that don't work. Sarcasm, calling people out by name, which is why I was a little embarrassed when I did that on that film you saw last week. Gina probably hasn't seen it. She'd say, naughty, Paul. So you could be-- I mean, Muhammad Ali would just knock them out, right? But to be effective-- in other words, if we're just trying to win the argument, we'll win. But that's a very hollow sense of satisfaction [INAUDIBLE] of winning an argument, when you're trying to change. So you just brought up self-reflection, and awareness, and the cultivation of discernment. I've heard you do it before, and that's what you're talking about. That's got to be a big part of it. And it's hard. It's hard as-- I find it difficult. And I noticed that when we bring this up among first-year students in our social medicine class, one of the first things we hear is, oh, we already know about bias. We already know about racial disparities. I know the definition. And we would never do that. And yet, somehow we do. And so and then it's probably too cheap to say, well, structured German. There's nothing we can do about it. So I want to challenge you on one part, because you mentioned what doesn't work. But what happens when you don't name the elephant in the room? I shouldn't have said it doesn't work, because we can all find examples in which it does work. And one of the ones that has struck me most is AIDS activists, taking precisely those tactics. But they also complemented their efforts with the pragmatic solidarity of thinking about the provision of care. And again, this at a time when some people were just willing to write off the provision of care. And not just in Africa. This happened in Mississippi, Louisiana. There were state lotteries for these new medications. I could go right through the list. So it's not just about over there. So that's, to me, a very important model. And being strategic in naming it. So I think about when I turn on the television or look at my smartphone, and see the divisiveness, and the anger, and the disrespect, and the devaluing of individuals. And in that space, what happens if you don't name it? If you don't call it out. And what are the risks that are there? So I understand being sort of strategic and tactful. But are there moments when you have to just say, this is wrong, or you're wrong? Yeah. I think it probably happens on a daily basis. Now avoiding sanctimony, or smacking of it, is another challenge. But at some point after the Civil War, reconstruction fell apart. At some point after the Civil War, Jim Crow came and placed-- those Confederate statues weren't put up by grieving widows in 1866. Those were the work of legislators and white supremacists, who not only had local backing, but translocal backing. In other words, if President Grant said, no, we're not going to let this happen-- which, evidently, he did-- somebody later said, it takes a long time. And so I think naming problems-- we're talking about that one-- is an important part of this undoing. And that's a very commonplace thing to hear. Do some reconciliation in South Africa, gacaca in Rwanda. But I've seen some pretty remarkable things happen in Rwanda in a fairly short amount of time. And I guess that's why some of what I've been seeing with this divisive-- or feeling, rather-- what we've been seeing as Americans, has been, in addition to maddening, it's been saddening. It's very sad. It's very tragic. And then you realize, look, if we don't go through more personal discernment, or if the medical profession says, well, that's not really us. It's not really our job. That obviously, we're not going to move forward quickly enough. I think that, and understanding-- We'll step backwards. --a couple of things. One, the importance of coalitions. And sometimes those movements of medicine come outside of medicine. So as we look back, and you trace this sort of history of civil rights, and justice, and medicine, it wasn't medicine that integrated the hospitals. It wasn't medicine that said, we'll give blacks privileges in our hospitals. It was a legal system that came in. And so sometimes medicine, as much as we may talk about equity, and justice, and those types of things, we need pushes from outside to act. Absolutely. And if you look at the assault on affirmative action, which is an ideological and legal assault, the fact that there exists any-- Thurgood Marshall's dissenting opinion after one of those reverse discrimination judgments from the Supreme Court, was-- I'm sure all mangled up, but the basic idea was it's just bizarre to assert that there is no legal remedy needed to undo something that has been going on, which is-- he was talking about the institutional racism that's been going on for hundreds of years. And it's absurd, likewise, to assume that we don't need, as you said, broad coalitions. And to think about all the remedies at our disposal. A lot of our work has been broad coalitions that include community health workers, women's groups, peasant cooperatives, et cetera et cetera. It's also-- if we work in a prison in Rwanda-- we were talking about prison health this morning, your early engagement. There's only two ways to get into a Siberian prison. Let me put it that way. For a doctor. And I prefer only one of those two. And that involves make a coalition not just with the legal authorities, but with the Ministry of Justice. That's what they call their national legal system. And anybody who's been successful in global health-- and I've already said, I don't think we're very successful. I don't think we're very successful. But anyone who's been successful on a modest level, knows there's no other way to do it than coalitions. And coalitions are hard. And they're frustrating. They're also the only way for it, though. I can't imagine any ranking problem, even in a resource-rich city like this one-- any ranking problem in disparities and bias that isn't going to require that. And I think with that, as you talk about community work, is this understanding of you have these different methodologies, different kinds of expertise you bring to bear, but people with very different perspectives. So how does the community, how do our patients, how do they bring their understanding of the issues as we come up with our grand solutions, that may or may not be on target with what our community needs? Well, you and I, again, agree entirely on this. I wanted to just give an example that you already know about, but many will not. I just came from a meeting with Michelle Morris, faculty member at HMS, at Brigham. And she, and some others started this group called Equal Health. And it's related to a number of other endeavors in social medicine, which is obviously a term that I care about. And that my colleagues, and I hope the students here care about, because they have to take it. This is one of the few medical schools in the United States where those are required in the curriculum. Looking at health disparities and thinking through the social determinants of ill health, or good health, but also, the social determinants of distribution of access to diagnosis and care. And again, it's the fruits of basic science. And this group, Equal Health, proceeded along precisely those lines. That yeah, they were mostly physicians and medical students, but they weren't mostly from the United States. When I saw a huge gathering of this last social medicine meeting-- well, not the last one. One of the earlier ones-- there must have been 700 people there, including people I knew quite well from Rwanda, and Haiti, and all over. Mostly the United States, but all over. But that's not the diversity that you were talking about. That's not a professional diversity. Those are physicians, and physicians in training, and some other health professionals. But that required sitting and listening to people in where they live or where they work, which we often describe as "the community." Most social scientists don't say "the community" because Harvard Medical School is a community as well. Quad, for example. Anyway, it's just that that work, where you say, well, we're lucky that we get to go to medical school, or nursing school, or graduate school, whatever. And we know that we are in institutions that are reflecting these global biases, and national biases-- national being part of global-- but we're going to take active steps to counter them. There was that personal reflection that you're talking about, and often do. That collective reflection as professionals, but then also shutting up and listening to people. And that kind of reverent attention is easy to talk about in medicine, and hard to do. But that's supposed to be what we do. Same with anthropologists, right? It's either you talk about, I'm going to be quiet and-- And just listen. And just listen. But it's very important. What are the ways we can help our institutions understand the values of things we're talking about, and move them in this direction? So there's a part of this understanding this diversity, and there's all types of diversity. But often, that's not reflected in who we see within our institutions as we look at our leadership, as we look at our faculty. Our student body at Harvard Medical School is wonderfully diverse, but it's not reflected across the board. How do we move in a direction so that that diversity and that inclusion is truly valued, and we get the full benefits? Well, one thing I just want to say. I think it's only fitting for me to start answering that. I mean, you already 89% of what I'm going to say, if not 94. But for the benefit of the exercise, I always try to start by saying, Harvard Medical School has given me everything. If I had not been a scholarship student at HMS, I would certainly not have been able to do an MD-PhD here, and then go to the Brigham, and then serve right on the faculty. So that's my first thing I want to say, and I would recommend it to others. And I'm talking about others who define themselves not as some nice, little, white guy. That starting with gratitude for your own good fortune is a big part of that reflection that you always recommend to us, to your Fellows. That's the main thing, is we're already-- It's privilege. We're already these incredibly privileged people no matter what our background. And I also think that gratitude only makes it easier to be a voice within a privileged institution for change within it. But I just want to start that way. And not because we're in the Joseph Martin conference room, and Joseph Martin's here. Really. I swear. I said this before he was dean. It's just I feel like I owe everything. Now that said, there's no buts, but next. Clearly, if we can celebrate the diversity of the student body-- and it's varied kinds of diversity, as no one knows better than the dean who is tasked with thinking it through. Sometimes there is a lack of class diversity. And that's only going to be addressed by active case finding, as the School of Public Health people might say. And I know there are some of you here. It's interesting. Because even as you talk about that, many of our students are very-- they're different generation. And they feel like they are the only ones. And as we've talked about it more, there are many of us. As you talk about your journey here, and lack of privilege but privilege in being able to come here and move forward. As I think about my journey, and my family's journey. As I talk to more and more faculty, their stories aren't told, and there's this myth of who's here sometimes. And I'm wondering if there are ways for us to be more open and sharing about who we are, and how we got here. And that might help our students to be more open to exploring their own sort of journeys, and this concept of self-reflection. We try to put on a Harvard professor facade, and then behind it is who you were when you grew up, and your family, and the rest of it. And so really trying to find a space to have those kind of conversations. I think it's about time to open it up to some questions or comments from everyone. There's microphones here. While you shy people are coming forth, I think there are reasons for someone like me to also mistrust. Again, I've just been preaching-- preach, for Reverend. Listening. But you're right. Maybe it is helpful. I know that I've learned a lot from listening to medical students, from listening to people at the Brigham. I'm talking about my colleagues. Again, starting with your own privilege, if at all possible. And for us, it should be possible. Because I keep saying-- I keep thinking. I often don't say it, but I'm going to say it here. Sometimes the discussions that I've heard within universities, research universities-- not just this one-- the discussions are happening as if they're cut off from the rest of the world. And I think that's part of the pathogenic force, not part of the solution. And if you define your institution as the quad, or a hospital, the faculty of Arts and Science-- I'm not talking about this one only, but any place. I went to Duke, and I still involved Duke, again, with the same kind of gratitude. And I've just heard some of these internal discussions, and I keep thinking-- what on earth would someone living in a squatter settlement in Haiti think of this discussion? So divorced from the rest of the world. And you don't always get lot of applause when you say that in the middle of a meeting about student faculty diversity, or Med school. And again, that that could just reflect a lack of Ali-esque courage, for saying it anyway. That, and understanding that the faculty, the students, our trainees residents, are not the only ones in the institutions who could help us understand. So if we look at our staff, if we look at everyone from the custodial, to the park, and the others who help make our institutions work, and having conversations with them about their real lives. So if I think about some of our programs where individuals on our staff are able to bring their children into programs, and to see their children having the potential to be a future doctor, or a future whatever. So how do we break down some of the bridges in our own institution? You have somebody on the microphone? Thanks, Dr. Reede and Dr. Farmer. Early in the Ebola response, one of our colleagues, when asked in an interview to describe the Ebola response up until that point-- I'm talking maybe July or August of 2014-- she described it very appropriately as racist. Period. And I think caught a lot of grief from that. Certainly not from our groups, but otherwise. Can you talk about-- and I think she was saying that in a way to address this idea of disparity within global health, and Ebola specifically. Can you talk about the moment within the Ebola response that the global community started to take interest, and started to decide it was a problem worth their addressing? Thanks. Is that like a set-up, John? So I get to give a disposition? Yes, please. Because I will Happily do it. Yes, please. And my students here know. And my colleague. It's a great question and I'm going to try to be brief, but not too, too brief. Because this is the kind of complexity that we just don't have the time-- I mean, we're not given the time to address in global health, as many of you will be thinking of it. But in that particular instance of the current West African epidemic-- the 2013, 2016-- this is, to me, an overlooked point. What did we hear that summer? By the way, I only knew four Sierra Leoneans in June of 2014. One of them in Harvard Medical School. The other three, also doctors. Four doctors. By November, two were dead of Ebola. And no white American stricken with Ebola died of Ebola. And that's because they were airlifted out of that clinical desert here. But what you asked, John, is when did it start. Well, first of all, the claim that it was new to West Africa. How about you, like an HMS student who you know, Cameron [INAUDIBLE],, how about just go on to Google Scholar and find out that there are several papers showing that it was already present in Liberia and Sierra Leone? I understand why-- I'm just guessing the colleague you're referring to. Why is it permissible to not even get that part right? That it was not new, or that the retrospective stories that were held up to be the origin stories, that there really were not ever confirmed. Because there's no way of confirming things in a public health and clinical desert. So all the way through was-- or it's looking at the previous ones, the previous epidemics of Ebola-- it's a good way, again, to reflect on disparities. And they're very subtle. What you're looking for me to say, and then I will stop, is that when it becomes a threat to us that the world reacts. And the other part is how do we react? We react with a disease control paradigm. Not with the care paradigm. It's a disease of caregivers. That's why it's spread. Because people care about each other. Nursing and last rites. That's the last step of caregiving, right? Burying the dead. You don't have to be a Catholic to know that that's one of the seven corporal works of mercy. Anyway, so I personally would argue that a disease control over care response is racist. Now how do you say that effectively and not alienate the very colleagues of yours-- mine, anyway-- who are totally accustomed to doing things like that in Africa, and have been since the end of the 19th century? That wouldn't fly here. You'd say Tuskegee. It did fly here. That's a control over care example. When I say, it wouldn't fly, it flies, but then you get busted. Hopefully. Hopefully. And I'm not even sure that we got busted yet, as far as West Africa and Ebola go. Not that I feel strongly on it. It's interesting that racism is such a charged word and we're so afraid to say it, or to acknowledge its existence. And so we push it aside, which gives it even more power because it's still present, but we're not doing anything about it or acknowledging it. We were talking before, and we were talking about this concept of something that's sort of caged, being better than something that's let loose. And when I thought about that was the problem-- when you think something is caged, and you think it's solved, and then you it's put away, is that you can start to forget that it's dangerous and it hurts. And so when I think about some of the issues of racism and these other issues, particularly in the United States, and what we're seeing today, where there's this surprise that it's there. It was always there, and it's let loose. But that allows us to be able to name it and to do something about it. Maybe we need more spaces where we can talk about racism, and not feel the sense that we're being-- somebody is talking about us, rather than about something that just exists. Hi. Thank you for allowing us all to witness this conversation. I feel very privileged to be in this space right now. I just have a question maybe going back to the idea of just global health at its core. Because when I hear global health outreach, American global health outreach, I think US imperialism. You think what? US imperialism. So I guess my question is, if we're thinking about things in a framework of community organizing, and this idea of working with, and not on behalf of communities, how do you ensure that you, as a white man, you as someone working from an American organization, are working with, and not on behalf of? And how do you navigate that in a space that isn't actually your own? Yup. Well, I'm going to take that as a-- I know that is a sincere question, and so I don't want to sound overly technical, especially after Joan's soul-ripping suggestion just now, which I hope you all heard. That is the beast wasn't caged, it never was. And maybe it'd be better if we just didn't fool ourselves. The technical response-- first of all, this is a question that I hear very often, almost always in an American University. It's not something I bump into in Haiti or Sierra Leone. That doesn't mean it isn't being said, although I would be shocked to believe that the people I've lived with for that long in Haiti, who are unable to hold their tongues on many other subjects, would. But I don't know about Rwanda, even though I lived there for 10 years. So it is also interesting to me given Joan's comment just now about why we don't talk about this more openly here, that that question about identity politics, I routinely hear in American universities. And pretty much only. And I'm not just saying that as as my reporting, where I hear certain questions and where I don't. Is that fair enough? But what you said about it's an American organization is actually not the case. Partners in Health was set up as a-- if you go back and look at-- and I assume you're talking about Partners in Health and not the other organizations I belong to, like Harvard Medical School, the Brigham Women's hospital. They're actually set up as sister organizations, not as daughter organizations. When we were starting this organization, the Haitians we work with had already started it. And the Haitian sister organization is called [NON-ENGLISH],, which means "partners in health" in Haitian Creole. And in Rwanda it's [NON-ENGLISH],, which means "partners in health" in Rwanda, which I'm sure you all speak fluently. So my point is that is baked in, at least an an idea. Now how do you do that without erasing history and political economy? That's my ponderous and clumsy way of putting it. But to talk about community, organizing communities already stripped of resources is erasing history. If you talk to Alabama sharecroppers who were involved in a non-treatment experiment-- neuros syphilis or complications of syphilis, and saying, all right, we need to organize within our communities. But their community includes the medical institutions that designed this program, and would continue to do so until the Atlantic Constitution exposed it, I think, Alan Branislav in 1972. So the word "community," as I said, is a tricky word. But shutting up and listening is not that tricky. I'm not saying I'm good at it, as you can guess by my long-winded answers, but there's two different things. So a social justice approach to global health, as opposed to an empire-focused approach. You just said US imperialism. And I just described what I-- disease control over care, control over care paradigms was born in the late 19th century. Born how? Out of colonialism. I'm not denying that that's the roots of many health interventions. I just don't think that's where global health equity comes from. I think that's a rupture with those paradigms. And again, I would credit activism, and particularly AIDS activists, with helping to break that. If I may, when I came here, again, feeling like the luckiest person in the world, which I was, I made a really adventurous trip. Not from Harvard to Haiti or back, but all the way across the courtyard to the Harvard School of Public Health for a class, which actually, most medical students didn't do. I took a class there, thinking well, this is where you're going to learn about what was then called International Health. We actually had clubs called the International Health club. It's not a very critical way to think about it. What nation? What empire? Where's the role of equity? Organizing? Activism? These are some of the things you're asking. And that was where I learned, at least for me personally, about the peril of erasing history in political economy. Because the recommendations that something wasn't cost-effective, sustainable, or you could even do this community interviews, and surveys. You could listen to what people said, and then ignore it as policy. That was very much the case in the 80s. So for me, global health is global health equity. Not global international health as constituted in the area of structural adjustment et cetera. I don't want to sound like a windbag. I am, but I don't want to sound like one. This is the rupture fighting back with redistribution of resources, acknowledgment of historical past, acknowledgement of historical injustices, acknowledgement of things like institutionalized racism. That's what global health should be about. And that's why I think we should just call it global health equity, and not global health. Love, Paul. I have a Twitter question. Twitter question. And it says, how do we allocate efforts to the quote, "right people," places, et cetera, and control for systemic biases? Well, I'm focusing today on our own systemic biases. So I've just described again, and again, these fatal errors are not made by poor people facing huge burdens of disease. I'm looking at it wherever Twitter is. I haven't quite figured that out, although we have rude and regular reminders these days. Since I've already said-- I'm talking about us, right? This is about as often and openly as I can. I think that, again, there are sort of quasi technical answers to that. And one of them is to understand the burden of disease. Like where does this burden of disease sit most heavily? 19th century social medicine folks figured that out. Berkow, et cetera. And the second, though, is in this era of real possibility, given that now, thanks to actually biomedical research-- basic science research-- if you think of these three-- I'm looking at you. This is what you've been fighting for your whole life. Not to say we don't care about basic science research, but to say, we want it to be justly distributed. We want our people, however-- not however we mean our people. We want our people, really, to participate in the production of scientific knowledge and care. By the way, that's another big part of it, to your question. One of the other ways to do that, is actually to listen to people that say, hey, I want to be a doctor, or a nurse, or a researcher. That happens every day in the places we work in Africa, just like it does here. But to get back to this formulaic response, and then I'll hush up again, understanding the burden of disease is not enough. Understanding to understand disparities and bias, you have to look at gaps. And you have to go look for them. Because you could say, well-- and again, this is right here in Harvard. Just look at the historical record to say that the three leading infectious killers of young adults in the world in the year 2000, they were HIV, TB, and malaria. That's not the burden of disease in Boston anymore, or in the Mississippi Valley. It is on that continent, and in particular parts of it. So there you got number one, two, and three. For none of them is there a effective vaccine? Where is that going to come from? Basic science research. For none of them was there readily-available rapid diagnostics that would require more? They exist. The platforms exist, but this distribution is critical. And then third, we had our peers saying, it's not cost effective, not sustainable, not realistic, not-- again, I never heard anyone in Africa who had HIV disease, AIDS say that. But it was coming from us. So again, just like where you haven't yet been busted on Ebola-- back to John's question-- I think we should reckon with that it can only be-- if you just say "racist" at the end of the conversation, it's the beginning of the conversation. It does reflect, and must reflect in the global political economy the belief that some people's lives are worth less than others. What else could it be? Of course, then you get told, lectured, well, no it's just that we're living in a world of limited resources. But they're more limited for some people, and unlimited for other. It's the same world. And some of what might impact that is having some of those individuals represented in the discussions, and the decision-making, and the allocation of those resources. And that's exactly what AIDS activists helped us to recognize. Survivorship, whether you're talking about breast cancer, or-- we have to embrace that openly. And then you look at survivorship in cancer, for example, and you see there's again, a preponderance of these same social disparities among survivors for various reasons. But also among those who are engaged in survivorship. It's not like there's any way of getting away from that basic "the beast was never caged" question. You were waiting longer. Thank you so much. Thank you for this great conversation. I was really excited when I saw the title of this talk, because having lived in Rwanda, providing care there with HRH, I felt like every week we had a new kind of organization coming in providing aid in one way or another, visiting. And there's so much kind of racism embedded in the way they come in and help, in a very different model than PIH is providing. My question is around-- global health has become so popular now in medicine. I think largely as a result of your advocacy, and leadership on the subject. And we have all of these trainees, students, residents, Fellows, wanting to go abroad and do global health rotations. How do we make sure that the rotations that we're sending them abroad for are done in a way that's really sensitive to that bias and racism that's present in a lot of that global health work that's happening? We're sending them out there not necessarily with US faculty to observe. Not even necessarily with trusted local faculty to observe. And they're often going in kind of-- and they're excited because they get to see new diseases, and try procedures they would never get to try at home. I feel really strongly while I was abroad never to do anything outside of my scope of practice. I felt like, ethically, I wasn't there to kind of try new sexy things. But I've talked to leaders in global health even here in Boston, who are very senior, saying, I opened the book and the child had no better option, and so I did the surgery on the child. I think that that wouldn't happen if that child was white. I think that we're kind of experimenting on black and brown kids. And how do we address that racism, as we're sending more and more people out to these global health opportunities, and training them for a career in global health? Thanks. Well, let me make three points. Don't worry. First of all, again, we're saying that-- I believe we're both saying that we don't think of global health as something over there. So that needs-- again, one of the minor problems of international health as constituted in the 70s and 80s. In other words, there are lots of major problems. But we don't even share, yet, an analysis of what global health means. Which is why we ought to keep thinking of it as global, and adding the "E" word, equity, every time. Because then we'll be making it clear-- back to the wonderful question that was asked about how do you do this to avoid it. Getting back to [INAUDIBLE],, I would say that it is really a good exercise for us to recognize those same sins in ourselves. I certainly know the unseemly excitement of seeing something new, the unseemly desire to do something that I wouldn't-- where I get to feel like I did something heroic. So that's an important part of the process if I'm reading you right. Is that the self-reflection, we'll see that in ourselves. At least I see it in myself. And I'm ashamed of it, but I'm very familiar with it. The third part is, again, you can't do what you're calling us to do without acknowledging that history has already happened. History which is what-- we're living in the aftermath. Whether you have Charlottesville, or the Human Resource for Health project in Rwanda. And again, what would be good, and I try to do it in my limited interaction with-- too limited interaction with faculty, said, this is going to happen, and on their first beginning, as part of their orientation. I said, this is going to happen and it's not going to be good. But one of the things about listening, is in addition to listening to people afflicted by poverty and disease, the so-called community, which again-- we're part of the medical community and our colleagues, various colleagues, had a lot to say about this, our colleagues in [INAUDIBLE].. I think listening to them is good, and it's not like they're speaking with one voice. But those are three things that I would add-- is global health is global. I recognize anything that you could say, no matter how bad. I'll recognize it in myself as an exercise because it's an important one. And third, health disparities are already profound. So a child with a acute abdomen, having one of us-- not you. But one of us said, well, I would never do this in that part of the political economy, but I'm doing it here. We should acknowledge, then, that there will be a very good chance that we get to feel good about something that's still going to result in a death. And that's a very hard process, especially when you're trying to bridge-- this is a Harvard Medical School backed program, that I think has bridged the most stunning divide, much more than Harvard in Haiti, actually. And that was Harvard Rwanda in recent years. Now that divide has been lessened by people like you going to serve there. And the right way to do it, in my view, is not as like me, a 23-year-old in-between college and medical school, but faculty as well. The people who are experienced, and at the height of their powers clinically, working collegially with Rwandan professionals. And raising the Rwandan, and increasing the capacity for Rwandan professionals to act on their own behalf. Exactly. And be a part of it In a way, I'm just saying I think you're choosing one of the least racist global health programs. [INAUDIBLE] No, I know. I know you weren't. I'm just saying that is something Harvard Medical should be proud of. I just was saying to one of Gina Vild's colleagues that this is like the dean's report ought to have a whole-- it's an amazing kind of engagement. I have gotten the wrap-up. But wait, I'm just getting started. I came all the way-- And I know you're just getting started. But I have also gotten the wrap-up. And want to-- Hey, you're a dean, too. You can just fight right back. I'm a dean and an African-American woman. Now I've been told I can take orders from all different places. This side of the room I'm wrapping up, and this side of the room I can take one more question. So one more question. OK. Thank you. Thank you. So to that point is a question about kind of channeling power for good. Common scenario. A person of means, a celebrity, shines a light on a global issue, and the funds come in, and the resources go at it. Can you speak to how to channel that power while being mindful of bias? And I guess there's a danger in sort of following the celebrity to the cause. How can we spread that mindfulness out and be more equitable about it? Spread the mindfulness out. God, You guys are tough. Meaning, I don't know. I wish I did. I'm doing my best up here, OK. I get uncomfortable with that. So it's kind of-- to the question about HRH, human resources for help, that was a great question that she just asked. I'm talking to you over there. Where did you go? Sam? I'm saying I'm praising you. This discomfort that I may feel when there's a celebrity-directed Angelie-style approach to something-- it's really not about me. It's really not about us. I do still feel uncomfortable, just like I feel uncomfortable about the unseemly enthusiasm that I saw in myself, and see in my American colleagues when they suddenly show up in the clinical desert like, where'd you been, surgeon? But I'm glad they're there. And I'm glad we're there. And I'm glad that there is someone there. Now the next question is, OK. This makes me uncomfortable, makes you uncomfortable, makes you uncomfortable. Why? And again, that's restoring history to understand that. I don't understand celebrity culture. Even though I tried for many years to read the Journal of Popular Studies-- people-- I don't understand how that works. There are sociologists, anthropologists, and psychologists who do study that. But I am very reluctant to be entirely dismissive, and sanctimonious, and to above that, and I don't want to be close to it. But it's not about how I feel. Because it's about a materiality of the social. Again, it's about a fact of disparity. So if a celebrity fights to ban landmines, or to eradicate polio, or to take on breast cancer in Uganda, I would be very, very careful to understand that I don't have breast cancer in Rwanda, and I don't have polio, and I do have clean water. Thank you, Matt Damon. You know what I'm saying? I worry about, again, our university-based ethics, that kind of race history and-- not yours, but I'm saying it is something I've seen a lot in privileged institutions. Let's go to the corporate world. To have a workshop on diversity, of course they all have-- they can all afford those kind of workshops ad nauseam, if that's not mean to say. But that doesn't mean that a corporation is actually-- it may have a diversity inside. And which they don't, by the way. But it doesn't mean that changing the makeup of, let's say, the board of directors, is going to alter a fundamentally extracted process. And I think that requires hard-nosed analysis. And I would try and do it, or be part of a team that does it, or fields questions from people who might be affected. And so that's why I would, again, try to shut up and hold my tongue, and sort through something that involves celebrity-based addressing of our attention deficit disorder. So social suffering, and poverty, and structural violence. And again, I know that's not a short answer, but I'm just explaining my own caution. When you say, well, the beast has never been in the cage and we all need to address it, another way of saying it is-- and President Obama said this at the end of his service-- is that we really need to be happy warriors. Like we're fighting for social justice, our own grumpiness is not really the point. He didn't say all that, but that's how I would interpret it. And I would say the same about celebrity-based ADD treatment. It doesn't last long, but sometimes you get a chance to pull a lever where people-- I'm more comfortable working with activists, who are going to be at this for years. Thank you. So no more questions. I thank you for your-- I'll stay around, though. For those of you standing, I'll stay around. I didn't mean to interrupt you. Thank you for your attention. I think-- [APPLAUSE] Part of what I would say is that all of us have a role to play. And sometimes before critiquing other people's roles, we need to step back and look at our own. And you don't always know another person's heart, or mind, or intent. And it's actually together, that we're able to accomplish. There's a saying I got from my mother. That "I" is like the "I" in the word "individual." And "we"-- W-E-- is like the "we" in power. And it's when the "we" come together that you can actually have the power to create change. And so it's how do we work together to create the change. And so I want to thank Paul. I want to thank my friend for this. I want to thank Harvard and Talks@12 for this opportunity for us to have this dialogue. And I'm going to end with a quote from somebody that, in no way, makes me think of disparities, bias, or social justice. But they said something that I think makes sense. And I'm going to quote Henry Ford. Doesn't come to mind in this space. And Henry Ford said, "Whether you think you can, or you think you can't, you're right." And we've talked about these, what can seem daunting problems and daunting issues. And part of this is your frame of mind. Part of this is being a happy warrior. Part of this is being willing to take on the problems and issues, and create the change that's needed. And that's what we all need to be about. Thank you, Paul. [APPLAUSE] You're welcome.

Contents

Definition

Global health employs several perspectives that focus on the determinants and distribution of health in international contexts:

Both individuals and organizations working in the domain of global health often face many questions regarding ethical and human rights. Critical examination of the various causes and justifications of health inequities is necessary for the success of proposed solutions. Such issues are discussed at the bi-annual Global Summits of National Ethics/Bioethics Councils, next in March 2016 in Berlin, with experts from WHO and UNESCO, by invitation of the German Ethics Council.

History

The 19th century held major discoveries in medicine and public health.[12] The Broad Street cholera outbreak of 1854 was central to the development of modern epidemiology. The microorganisms responsible for malaria and tuberculosis were identified in 1880 and 1882, respectively. The 20th century saw the development of preventive and curative treatments for many diseases, including the BCG vaccine (for tuberculosis) and penicillin in the 1920s. The eradication of smallpox, with the last naturally occurring case recorded in 1977, raised hope that other diseases could be eradicated as well.

Important steps were taken towards global cooperation in health with the formation of the United Nations (UN) and the World Bank Group in 1945, after World War II. In 1948, the member states of the newly formed United Nations gathered to create the World Health Organization. A cholera epidemic that took 20,000 lives in Egypt in 1947 and 1948 helped spur the international community to action.[13] The WHO published its Model List of Essential Medicines, and the 1978 Alma Ata declaration underlined the importance of primary health care.[14]

At a United Nations Summit in 2000, member nations declared eight Millennium Development Goals (MDGs), which reflected the major challenges facing human development globally, to be achieved by 2015.[15] The declaration was matched by unprecedented global investment by donor and recipient countries. According to the UN, these MDGs provided an important framework for development and significant progress has been made in a number of areas.[16][17] However, progress has been uneven and some of the MDGs were not fully realized including maternal, newborn and child health and reproductive health.[16] Building on the MDGs, a new Sustainable Development Agenda with 17 Sustainable Development Goals (SDGs) has been established for the years 2016-2030.[16] The first goal being an ambitious and historic pledge to end poverty.[18] On 25 September 2015, the 193 countries of the UN General Assembly adopted the 2030 Development Agenda titled Transforming our world: the 2030 Agenda for Sustainable Development.[18]

In 2015 a book titled "To Save Humanity" was published, with nearly 100 essays regarding today's most pressing global health issues.[19] The essays were authored by global figures in politics, science, and advocacy ranging from Bill Clinton to Peter Piot, and addressed a wide range of issues including vaccinations, antimicrobial resistance, health coverage, tobacco use, research methodology, climate change, equity, access to medicine, and media coverage of health research.

Measures

Measures of global health include disability-adjusted life year (DALY), quality-adjusted life years (QALYs), and mortality rate.[20]

Disability-adjusted life years

Disability-adjusted life years per 100,000 people in 2004.   No data   Less than 9,250   9,250–16,000   16,000–22,750   22,750–29,500   29,500–36,250   36,250–43,000   43,000–49,750   49,750–56,500   56,500–63,250   63,250–70,000   70,000–80,000   Over 80000
Disability-adjusted life years per 100,000 people in 2004.
  No data
  Less than 9,250
  9,250–16,000
  16,000–22,750
  22,750–29,500
  29,500–36,250
  36,250–43,000
  43,000–49,750
  49,750–56,500
  56,500–63,250
  63,250–70,000
  70,000–80,000
  Over 80000

The DALY is a summary measure that combines the impact of illness, disability, and mortality by measuring the time lived with disability and the time lost due to premature mortality. One DALY can be thought of as one lost year of "healthy" life. The DALY for a disease is the sum of the years of life lost due to premature mortality and the years lost due to disability for incident cases of the health condition.

Quality-adjusted life years

QALYs combine expected survival with expected quality of life into a single number: if an additional year of healthy life is worth a value of one (year), then a year of less healthy life is worth less than one (year). QALY calculations are based on measurements of the value that individuals place on expected years of survival. Measurements can be made in several ways: by techniques that simulate gambles about preferences for alternative states of health, with surveys or analyses that infer willingness to pay for alternative states of health, or through instruments that are based on trading off some or all likely survival time that a medical intervention might provide in order to gain less survival time of higher quality.[20]

Infant and child mortality

Infant mortality and child mortality for children under age 5 are more specific than DALYs or QALYs in representing the health in the poorest sections of a population, and are thus especially useful when focusing on health equity.[21]

Morbidity

Morbidity measures include incidence rate, prevalence, and cumulative incidence, with incidence rate referring to the risk of developing a new health condition within a specified period of time. Although sometimes loosely expressed simply as the number of new cases during a time period, morbidity is better expressed as a proportion or a rate.

Health conditions

The diseases and health conditions targeted by global health initiatives are sometimes grouped under "diseases of poverty" versus "diseases of affluence", although the impact of globalization is increasingly blurring the lines between the two.

Respiratory infections

Infections of the respiratory tract and middle ear are major causes of morbidity and mortality worldwide.[22] Some respiratory infections of global significance include tuberculosis, measles, influenza, and pneumonias caused by pneumococci and Haemophilus influenzae. The spread of respiratory infections is exacerbated by crowded conditions, and poverty is associated with more than a 20-fold increase in the relative burden of lung infections.[23]

Diarrheal diseases

Diarrhea is the second most common cause of child mortality worldwide, responsible for 17% of deaths of children under age 5.[24] Poor sanitation can increase transmission of bacteria and viruses through water, food, utensils, hands, and flies. Dehydration due to diarrhea can be effectively treated through oral rehydration therapy with dramatic reductions in mortality.[25][26] Important nutritional measures include the promotion of breastfeeding and zinc supplementation. While hygienic measures alone may be insufficient for the prevention of rotavirus diarrhea,[27] it can be prevented by a safe and potentially cost-effective vaccine.[28]

Maternal health

Maternal health clinic in Afghanistan (source: Merlin)
Maternal health clinic in Afghanistan (source: Merlin)

Complications of pregnancy and childbirth are the leading causes of death among women of reproductive age in many developing countries: a woman dies from complications from childbirth approximately every minute.[29] According to the World Health Organization's 2005 World Health Report, poor maternal conditions are the fourth leading cause of death for women worldwide, after HIV/AIDS, malaria, and tuberculosis.[30] Most maternal deaths and injuries can be prevented, and such deaths have been largely eradicated in the developed world.[31] Targets for improving maternal health include increasing the number of deliveries accompanied by skilled birth attendants.[32]

68 low-income countries tracked by the WHO- and UNICEF-led collaboration Countdown to 2015 are estimated to hold for 97% of worldwide maternal and child deaths.[33]

HIV/AIDS

The HIV/AIDS epidemic has highlighted the global nature of human health and welfare and globalisation has given rise to a trend toward finding common solutions to global health challenges. Numerous international funds have been set up in recent times to address global health challenges such as HIV. [34]Since the beginning of the epidemic, more than 70 million people have been infected with the HIV virus and about 35 million people have died of HIV. Globally, 36.9 million [31.1–43.9 million] people were living with HIV at the end of 2017. An estimated 0.8% [0.6-0.9%] of adults aged 15–49 years worldwide are living with HIV, although the burden of the epidemic continues to vary considerably between countries and regions. The WHO African region remains most severely affected, with nearly 1 in every 25 adults (4.1%) living with HIV and accounting for nearly two-thirds of the people living with HIV worldwide.[35] Human immunodeficiency virus (HIV) is transmitted through unprotected sex, unclean needles, blood transfusions, and from mother to child during birth or lactation. Globally, HIV is primarily spread through sexual intercourse. The risk-per-exposure with vaginal sex in low-income countries from female to male is 0.38% and male to female is 0.3%.[36]The infection damages the immune system, leading to acquired immunodeficiency syndrome (AIDS) and eventually, death. Antiretroviral drugs prolong life and delay the onset of AIDS by minimizing the amount of HIV in the body.

Malaria

Malaria is a mosquito-borne infectious disease caused by the parasites of the genus Plasmodium. Symptoms may include fever, headaches, chills, and nausea. Each year, there are approximately 500 million cases of malaria worldwide, most commonly among children and pregnant women in developing countries.[37] The WHO African Region carries a disproportionately high share of the global malaria burden. In 2016, the region was home to 90% of malaria cases and 91% of malaria deaths. [38]The use of insecticide-treated bednets is a cost-effective way to reduce deaths from malaria, as is prompt artemisinin-based combination therapy, supported by intermittent preventive therapy in pregnancy. International travellers to endemic zones are advised chemoprophylaxis with antimalarial drugs like Atovaquone-proguanil, doxycycline, or mefloquine[39]

Nutrition

In 2010, about 104 million children were underweight, and undernutrition contributes to about one third of child deaths around the world.[40] (Undernutrition is not to be confused with malnutrition, which refers to poor proportion of food intake and can thus refer to obesity.)[41] Undernutrition impairs the immune system, increasing the frequency, severity, and duration of infections (including measles, pneumonia, and diarrhea). Infection can further contribute to malnutrition.[42] Deficiencies of micronutrient, such as vitamin A, iron, iodine, and zinc, are common worldwide and can compromise intellectual potential, growth, development, and adult productivity.[43][44][45][46][47][48] Interventions to prevent malnutrition include micronutrient supplementation, fortification of basic grocery foods, dietary diversification, hygienic measures to reduce spread of infections, and the promotion of breastfeeding.

Violence against women

Violence against women has been defined as: "physical, sexual and psychological violence occurring in the family and in the general community, including battering, sexual abuse of children, dowry-related violence, rape, female genital mutilation and other traditional practices harmful to women, non-spousal violence and violence related to exploitation, sexual harassment and intimidation at work, in educational institutions and elsewhere, trafficking in women, forced prostitution and violence perpetrated or condoned by the state."[49] In addition to causing injury, violence may increase "women’s long-term risk of a number of other health problems, including chronic pain, physical disability, drug and alcohol abuse, and depression".[50]

Although statistics can be difficult to obtain as many cases go unreported, it is estimated that one in every five women faces some form of violence during her lifetime, in some cases leading to serious injury or even death.[51] Risk factors for being a perpetrator include low education, past exposure to child maltreatment or witnessing violence between parents, harmful use of alcohol, attitudes accepting of violence and gender inequality.[52] Equality of women has been addressed in the Millennium development goals.

Chronic disease

Approximately 80% of deaths linked to non-communicable diseases occur in developing countries.[53]For instance, urbanization and aging have led to increasing poor health conditions related to non-communicable diseases in India. The fastest-growing causes of disease burden over the last 26 years were diabetes (rate increased by 80%) and ischemic heart disease (up 34%). More than 60% of deaths, about 6.1 million, in 2016 were due to NCDs, up from about 38% in 1990.[54] Increases in refugee urbanization, has led to a growing number of people diagnosed with chronic noncommunicable diseases.[55]

In September 2011, the United Nations is hosting its first General Assembly Special Summit on the issue of non-communicable diseases.[56] Noting that non-communicable diseases are the cause of some 35 million deaths each year, the international community is being increasingly called to take measures for the prevention and control of chronic diseases and mitigate their impacts on the world population, especially on women, who are usually the primary caregivers.

For example, the rate of type 2 diabetes, associated with obesity, has been on the rise in countries previously plagued by hunger. In low-income countries, the number of individuals with diabetes is expected to increase from 84 million to 228 million by 2030.[57] Obesity, a preventable condition, is associated with numerous chronic diseases, including cardiovascular conditions, stroke, certain cancers, and respiratory disease. About 16% of the global burden of disease, measured as DALYs, has been accounted for by obesity.[57]

Neglected tropical diseases

More than one billion people were treated for at least one neglected tropical disease in 2015.[58] Neglected tropical diseases are a diverse group of infectious diseases that are endemic in tropical and subtropical regions of 149 countries, primarily effecting low and middle income populations in Africa, Asia, and Latin America. They are variously caused by bacteria (Trachoma, Leprosy), viruses (Dengue,[59] Rabies), protozoa (Human African trypanosomiasis, Chagas), and helminths (Schistosomiasis, Onchocerciasis, Soil transmitted helminths).[60] The Global Burden of Disease Study concluded that neglected tropical diseases comprehensively contributed to approximately 26.06 million disability-adjusted life years in 2010, as well as significant deleterious economic effects.[61] In 2011, the World Health Organization launched a 2020 Roadmap for neglected tropical diseases, aiming for the control or elimination of 10 common diseases.[62] The 2012 London Declaration builds on this initiative, and called on endemic countries and the international community to improve access to clean water and basic sanitation, improved living conditions, vector control, and health education, to reach the 2020 goals.[63] In 2017, a WHO report cited 'unprecedented progress' against neglected tropical diseases since 2007, especially due to mass drug administration of drugs donated by pharmaceutical companies.[64]

Health interventions

Global interventions for improved child health and survival include the promotion of breastfeeding, zinc supplementation, vitamin A fortification, salt iodization, hygiene interventions such as hand-washing, vaccinations, and treatments of severe acute malnutrition.[32][65][66] The Global Health Council suggests a list of 32 treatments and health interventions that could potentially save several million lives each year.[67]

Many populations face an "outcome gap", which refers to the gap between members of a population who have access to medical treatment versus those who do not. Countries facing outcome gaps lack sustainable infrastructure.[68] In Guatemala, a subset of the public sector, the Programa de Accessibilidad a los Medicamentos ("Program for Access to Medicines"), had the lowest average availability (25%) compared to the private sector (35%). In the private sector, highest- and lowest-priced medicines were 22.7 and 10.7 times more expensive than international reference prices respectively. Treatments were generally unaffordable, costing as much as 15 days wages for a course of the antibiotic ceftriaxone.[69] The public sector in Pakistan, while having access to medicines at a lower price than international reference prices, has a chronic shortage of and lack of access to basic medicines.[70]

Journalist Laurie Garrett argues that the field of global health is not plagued by a lack of funds, but that more funds do not always translate into positive outcomes. The problem lies in the way these funds are allocated, as they are often disproportionately allocated to alleviating a single disease.[71]

In its 2006 World Health Report, the WHO estimated a shortage of almost 4.3 million doctors, midwives, nurses, and support workers worldwide, especially in sub-Saharan Africa.[72]

Global Health Security Agenda

The Global Health Security Agenda (GHSA) is "a multilateral, multi-sector effort that includes 60 participating countries and numerous private and public international organizations focused on building up worldwide health security capabilities toward meeting such threats" as the spread of infectious disease. On March 26-28, 2018, the GHSA held its last high-level meeting which was located in Tbilisi, Georgia on biosurveillance of infectious disease threats, "which include such modern-day examples as HIV/AIDS, severe acute respiratory syndrome (SARS), H1N1 influenza, multi-drug resistant tuberculosis — any emerging or reemerging disease that threatens human health and global economic stability."[73] This event brought together GHSA partner countries, contributing countries of Real-Time Surveillance Action Package, and international partner organizations supporting the strengthening of capacities to detect infectious disease threats within the Real-Time Surveillance Action Package and other cross-cutting packages. Georgia is the lead country for the Real-Time Surveillance Action Package.[74]

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Further reading

External links

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