Introduction To Global Health: DR Yoga Nathan

Introduction to Global
Health
Dr Yoga Nathan
Senior Lecturer in Public Health

GEMS UL
Learning Objective
To understand the link between water,

sanitation and health from a global
perspective.
To understand the environmental,

social, economic and political factors
playing a role in cholera.
Definition
What is global health?
Health problems, issues, and concerns

that transcend national boundaries,
which may be influenced by
circumstances or experiences in other
countries, and which are best addressed
by cooperative actions and solutions
(Institute Of Medicine, USA- 1997)
Global Health Issues
Refers to any health issue that concerns
many countries or is affected by
transnational determinants such as:
Climate change
Urbanisation
Malnutrition under or over nutrition
Or solutions such as:

Polio eradication
Containment of avian influenza
Approaches to tobacco control
Historical Development of Term
Public Health: Developed as a discipline in the mid
19th century in UK, Europe and US. Concerned more
with national issues.
Data and evidence to support action, focus on populations,
social justice and equity, emphasis on preventions vs cure.
International Health: Developed during past

decades, came to be more concerned with
the diseases (e.g. tropical diseases) and
conditions (war, natural disasters) of middle and low income
countries.
Tended to denote a one way flow of good ideas.
Global Health: More recent in its origin and

emphasises a greater scope of health problems and
solutions
that transcend national boundaries
requiring greater inter-disciplinary approach
Disciplines involved in Global
Health
Social sciences
Behavioural sciences
Law
Economics
History
Engineering
Biomedical sciences
Environmental sciences
Communicable Diseases and Risk
Factors
Infectious diseases are communicable
But..
so are elements of western lifestyles:

Dietary changes
Lack of physical activity
Reliance on automobile transport
Smoking
Stress
Urbanisation
Its the Real Thing
Key Concepts in Relation to Global
Health
1. The determinants of health
2. The measurement of health status
3. The importance of culture to health
4. The global burden of disease
5. The key risk factors for various
health problems
6. The organisation and function of
health systems
1. Determinants of Health
Genetic make up
Age
Gender
Lifestyle choices
Community influences
Income status
Geographical location
Culture
Environmental factors
Work conditions
Education
Source: Dahlgren G. and
Access to health Whitehead M. 1991
services
Determinants of Health
PLUS MORE GENERAL FACTORS
SUCH AS:
POLITICAL STABILITY
CIVIL RIGHTS
ENVIRONMENTAL DEGRADATION
POPULATION GROWTH/PRESSURE
URBANISATION
DEVELOPMENT OF COUNTRY OF
RESIDENCE
Multi-sectoral Dimension of the
Determinants of Health
Malnutrition
more susceptible to disease and less likely to
recover
Cooking with wood and coal
lung diseases
Poor sanitation
more intestinal infections
Poor life circumstances
commercial sex work and STIs, HIV/AIDS
Advertising tobacco and alcohol
addiction and related diseases
Rapid growth in vehicular traffic often with
untrained drivers on unsafe roads-
road traffic accidents
2. The Measurement of Health Status I
Cause of death
Obtained from death certification but limited
because of incomplete coverage
Life expectancy at birth
The average number of years a new-borns
baby could expect to live if current trends in
mortality were to continue for the rest of the
new-born's life
Maternal mortality rate
The number of women who die as a result of
childbirth and pregnancy related complications
per 100,000 live births in a given year
The Measurement of Health Status II
Infant mortality rate
The number of deaths in infants under 1 year
per 1,000 live births for a given year
Neonatal mortality rate

The number of deaths among infants under 28
days in a given year per 1,000 live births in
that year
Child mortality rate

The probability that a new-born will die before
reaching the age of five years, expressed as a
number per 1,000 live births
3. Culture and Health
Culture:
The predominating attitudes and behaviour
that characterise the functioning of a group or
organisation
Traditional health systems

Beliefs about health
e.g. epilepsy a disorder of neuronal
depolarisation vs a form of possession/bad
omen sent by the ancestors
Psychoses ancestral problems requiring the
assistance of traditional healer/spiritualist
Influence of culture of health
Diversity, marginalisation and vulnerability due
to race, gender and ethnicity
4. The global burden of disease
Predicted changes in burden of disease
from communicable to non-communicable
between 2004 and 2030
Reductions in malaria, diarrhoeal diseases, TB
and HIV/AIDS
Increase in cardiovascular deaths, COPD, road
traffic accidents and diabetes mellitus
Ageing populations in middle and low

income countries
Socioeconomic growth with increased car
ownership
Based on a business as usual assumption
High Fertility/High Mortality
Source: US
Census Bureau,
Population Report
Declining Mortality/High Fertility
Source: US
Census Bureau,
Population Report
Reduced Fertility/Reduced Mortality
Source: US
Census Bureau,
Population Report
5. Key Risk Factors for Various
Health Conditions
Tobacco use
related to the top ten causes of mortality world
wide
Poor sanitation and access to clean water-
related to high levels of diarrhoeal/water
borne diseases
Low condom use
HIV/AIDS, sexually transmitted infections
Malnutrition
Under-nutrition (increased susceptibility to
infectious diseases) and over-nutrition
responsible for cardiovascular diseases,
cancers, obesity etc.
6. The Organisation and Function
of Health Systems
A health system
comprises all organizations, institutions and
resources devoted to producing actions
whose primary intent is to improve health
(WHO)
Most national health systems

consist:
public, private,
traditional and informal sectors:
Source: WHO statistics 2008
Source: W.H.O. Statistics

Trends in Global Deaths 2002-30
Source: World Health Statistics 2007

COMPARATIVE DATA (1)
IRELAND DEVELOPING
COUNTRIES
INFANT MORTALITY 7 100-190

RATE
UNDER 5 MORTALITY 10 175-300

RATE
MATERNAL MORTALITY 2 600-1600

RATE
LIFE EXPECTANCY F - 82 F < 50

M - 77 M < 50
but may be
= or > F
COMPARATIVE DATA (2)
IRELAND DEVELOPING
COUNTRIES
POPULATION GROWTH 0.3% 3%+

RATE
HIV +ve RATE 0.15% 15%+
AIDS CASES 20/ 400/

100,000 100,000
GNP PER CAPITA $16,000 <$200
HEALTH EXPENDITURE $1,600 $1-$2

PER CAPITA
HEALTH PATTERNS
GENETIC FACTORS
ENVIRONMENTAL FACTORS
LIFESTYLE FACTORS
COMMUNICABLE vs NON-COMMUNICABLE
DISEASES DISEASES
HEALTH PATTERNS IN
RESOURCE POOR COUNTRIES
INFECTIOUS/COMMUNICABLE DISEASES
PREVALENT:
VACCINE PREVENTABLE DISEASES, e.g. measles
ACUTE RESPIRATORY INFECTIONS (ARI)
DIARRHOEAL DISEASES (cholera)
MALARIA
TB
HEPATITIS
HIV/AIDS
Plus:
MALNUTRITION RELATED CONDITIONS:
- CALORIE DEFICIENCIES
- MICRO-NUTRIENT DEFICIENCIES
TRAUMA/ACCIDENTS
Many of these diseases are treatable

HEALTH PATTERNS IN
RESOURCE RICH COUNTRIES
NON-COMMUNICABLE DISEASES PREVALENT:
Causes of death (all ages):
40% Circulatory diseases, e.g. heart disease,
strokes, etc.
25% Cancers
16% Respiratory diseases
5% Injuries and Poisonings
0.6% Infectious diseases
Premature mortality (<65):

25% Circulatory diseases
33% Cancers
16% Injuries (RTAs/Suicides) and Poisonings
1% Infectious diseases
Many of these deaths are related to lifestyle factors

and are preventable
HEALTH PATTERNS IN RESOURCE
RICH COUNTRIES
Lifestyle factors affecting physical
and mental health:
Smoking one third of cancer deaths

related to smoking
Drinking
Healthy eating/nutrition
Physical activity
Substance abuse
Cholera 1800s
Cholera: the Disease
Entry: oral
Colonization: small
intestine
Symptoms:
nausea, diarrhea,
muscle cramps,
shock
Infants with
cholera
First Cholera Pandemic
Second Cholera Pandemic
John Snow and the Pump Handle
John Snow is credited by

many with developing
the modern field of
epidemiology
John Snow and cholera in

1854 London
http://www.ph.ucla.edu
/epi/snow.html
London in the 1850s
Germ theory of disease
not widely accepted
People lived in very
crowded conditions
with water and privies
in yard (NY 1864: 900
people in 2 buildings
180 deep x 5 stories
1 pump a block
away, privy in yard)
John Snows Observations
People with cholera developed
immediate digestive problems: cramps,
vomiting, diarrhea
Face, feet, hands shriveled and turned
blue; died in less than a day
Probably spread by vomiting and
diarrhea
Comparison of pump location with
cholera deaths, first 3 days of epidemic
in 1854
Water Supply London 1850s
Cholera Epidemiology
Of 83 people, only 10 lived
closer to a different pump
than Broad Street
Of these 10, 5 preferred taste
of Broad Street water and 3
were children who went to
nearby school
Snow Index Case
Index case is first person to
become ill
40 Broad Street husband and
infant child became ill
Wife soaked diapers in pail and
emptied pail into cistern next to
pump
The Great Experiment
Two water companies supplied
central London
Lambeth Company: water
intake upstream of London
sewage outfall into Thames
Southwark & Vauxhall
Company: water intake

downstream of sewage outfall
Customers mixed in same
neighborhood
Snow went door to door
asking which water
company served home
and compared locations
with cholera data
Deaths/
# Houses # Deaths
100,000
S and V 40,046 1263 315
Lambeth 26,107 98 37
Cholera Epidemiology
Snow convinced
neighborhood council to let
him remove handle from
water pump on Broad Street
The new cases declined
dramatically
Many on council not
convinced by his evidence
Cholera in the 1990s
Epidemic in Peru beginning
1991
From 1991-1994
Cases 1,041,422
Deaths 9,642 (0.9%)
Originated at coast, spread
inland
World Cholera 2000-01
Why Has Cholera Re-emerged?
Deteriorating sanitary facilities
as larger population moves into
shanty towns
Trujullo, Peru fear of cancer
from chlorination so water
untreated
Use of wastewater on crops
Africa civil wars and drought

caused migrations into camps
How Has Cholera Re-emerged?
Simultaneous appearance
along whole coast of Peru
Traveled in ship ballast?
Traveled in plankton from

Asia?
Always present in local
zooplankton (copepods) but
dormant until triggered by ???
Copepod Carrying Vibrio
cholerae
Global Health References
Skolnik R. Essentials of Global Health. Jones
& Bartlett Publishers, Sudbury MA 2008. Chapter
1
Ed. Robert Beaglehole, 2003. Global Public
Health: A new era. Chapter 1
Megan Landon. 2006. Environment, Health
and Sustainable Development
Bonder, B. Martin L. Miracle A. Culture in
Clinical Care
Koplan J et al, 2009. Towards a common
definition of global health The Lancet, Volume
373, Issue 9679, Pages 1993-1995

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Introduction to Global

Senior Lecturer in Public Health

To understand the link between water,

To understand the environmental,

Health problems, issues, and concerns

Or solutions such as:

International Health: Developed during past

Global Health: More recent in its origin and

so are elements of western lifestyles:

Neonatal mortality rate

Child mortality rate

Traditional health systems

Ageing populations in middle and low

Most national health systems

Source: W.H.O. Statistics

Source: World Health Statistics 2007

INFANT MORTALITY 7 100-190

UNDER 5 MORTALITY 10 175-300

MATERNAL MORTALITY 2 600-1600

LIFE EXPECTANCY F - 82 F < 50

POPULATION GROWTH 0.3% 3%+

HIV +ve RATE 0.15% 15%+

AIDS CASES 20/ 400/

GNP PER CAPITA $16,000 <$200

HEALTH EXPENDITURE $1,600 $1-$2

Many of these diseases are treatable

Premature mortality (<65):

Many of these deaths are related to lifestyle factors

Smoking one third of cancer deaths

John Snow is credited by

John Snow and cholera in

Company: water intake

S and V 40,046 1263 315

Africa civil wars and drought

Traveled in plankton from

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