Global Health

LEARNING OUTCOMES

  • Apply theories of social epidemiology to an understanding of global health issues
  • Compare and contrast health conditions in high- versus low-income countries

Global Health and Epidemiology

Social epidemiology is the study of the causes and distribution of diseases. Social epidemiology can reveal how social problems are connected to the health of different populations. These epidemiological studies show that the health problems of high-income nations differ greatly from those of low-income nations. Some diseases, like cancer, are universal. But others, like obesity, heart disease, respiratory disease, and diabetes are much more common in high-income countries and are a direct result of a sedentary lifestyle combined with poor diet. High-income nations also have a higher incidence of depression (Bromet et al., 2011). In contrast, low-income nations suffer significantly more from deadly diseases such as malaria and tuberculosis, diseases that are rare in high-income contexts.

How does health differ around the world? Some economic and political theorists, most notably Immanuel Wallerstein, differentiate among three types of countries: core nations, semi-peripheral nations, and peripheral nations. Core nations are those that we think of as highly developed or industrialized, semi-peripheral nations are those that are often called developing or newly industrialized, and peripheral nations are those that are relatively underdeveloped. While the most pervasive issue in the U.S. healthcare system is affordable access to healthcare, other core countries have different issues, and semi-peripheral and peripheral nations are faced with a host of additional concerns. Reviewing the status of global health offers insight into the various ways that politics and wealth shape access to healthcare, and it shows which populations are most affected by health disparities. As we move across international contexts, it is imperative to keep in mind the influence of cultural significance on health, as it is a mechanism that plays a role in the conceptualization of health conditions, the role of healthcare and its providers, and the consequences of illnesses.

Health in High-Income Nations

Obesity, which is on the rise in high-income nations, has been linked to many diseases, including cardiovascular problems, musculoskeletal problems, diabetes, and respiratory issues. According to the Organization for Economic Cooperation and Development (2011), obesity rates are rising in all countries, with the greatest increases occurring in the highest-income countries. Among OECD countries, which represent the most economically developed nations in the world, as of 2017, half of adults were overweight or obese, as well as nearly one in six children.[1] The United States has the highest obesity rate. Wallace Huffman and his fellow researchers (2006) contend that several factors are contributing to the rise in obesity in developed countries:

  1. Improvements in technology and reduced family size have led to a reduction of work to be done in household production.
  2. Unhealthy market goods, including processed foods, sweetened drinks, and sweet and salty snacks are replacing home-produced goods.
  3. Leisure activities are growing more sedentary, for example, computer games, web surfing, and television viewing.
  4. More workers are shifting from active work (agriculture and manufacturing) to service industries.
  5. Increased access to passive transportation has led to more driving and less walking.

Obesity and weight issues have significant societal costs, including lower life expectancies and higher shared healthcare costs. While the United States fares well in terms of health outcomes, it actually has a relatively shorter life expectancy than countries similar in economic development, standards of living, and wealth,[2] which is partially due to obesity and its consequences.

High-income countries also have higher rates of depression than less affluent nations. A recent study (Bromet et al., 2011) shows that the average lifetime prevalence of major depressive episodes in the ten highest-income countries in the study was 14.6 percent, compared to 11.1 percent in the eight low- and middle-income countries. The researchers speculate that the higher rate of depression may be linked to the greater degree of income inequality that exists in the most affluent nations.

Remember from previous sections, however, how culture can shape medical conditions, the stigma attached to them, and how healthcare deals with specific conditions. It is possible that society has conceptualized conditions such as depression differently across multiple contexts. Think about it: underdeveloped nations are facing deadly and terminal epidemics that are seemingly uncontrollable, with diseases and viruses like Zika, Ebola, and HIV being at the forefront of government policy and healthcare agendas. These societies are not yet concerned with mental illnesses, despite their well-documented effects on individuals.

Watch this video for an explanation of population health and some of the key health indicators that measure health for different populations. Consider what factors contribute to health disparities among populations.

Health in Low-Income Nations

In peripheral nations with low per capita income, it is not the cost of healthcare that is the most pressing concern. Rather, low-income countries must manage such problems as infectious disease, high infant mortality rates, scarce medical personnel, and inadequate water and sewer systems. Such issues, which high-income countries rarely even think about, are central to the lives of most people in low-income nations. Due to such health concerns, low-income nations have higher rates of infant mortality and lower average life spans.

In addition to these challenges, and largely because of these challenges, underdeveloped regions face epidemics of disease. As was mentioned in the introduction, several countries in Africa have dealt with the spread of Ebola in the last five years, and the Democratic Republic of the Congo is currently trying to address an Ebola epidemic. The Ebola epidemic is not the result of a single factor, but instead is the consequence of a combination of them, ranging from the lack of a cure, to Ebola being highly infectious and difficult to diagnose, to its being coupled with structural contexts of underdeveloped health systems, lack of workers, stigmatizing cultural beliefs, and migratory practices.

The Zika virus, which was first discovered in Uganda over 6 decades ago, has resulted in recent outbreaks in the Pacific Islands and Brazil and in a widespread epidemic in 2015-2016. The virus causes Zika fever, which is a mild illness with symptoms such as a fever and a rash, but as the disease became more common, evidence suggested that the virus was also connected to Guillain–Barré syndrome in adults, as well as birth defects and other neurological problems. The virus can be transmitted from an infected pregnant woman to her fetus, then can cause microcephaly (an abnormally small head) and other severe brain anomalies in the infant. The virus is spread mainly by the Aedes aegypti mosquito, which is commonly found throughout the tropical and subtropical Americas, and in parts of the southern United States. It can also be spread by the Aedes albopictus (“Asian tiger”) mosquito, which is distributed as far north as the Great Lakes region in North America. Men infected with Zika can transmit the virus to their sexual partners.

Learn about the spread of the Zika virus—and beware of massive soccer events! The Zika virus is said to have begun its recent spread after visitors flocked to Brazil for the World Cup in 2014.

One of the biggest contributors to medical challenges in low-income countries is the lack of access to clean water and basic sanitation resources. According to a 2014 UNICEF report, almost half of the developing world’s population lacks improved sanitation facilities. The World Health Organization (WHO) tracks health-related data for 194 countries. In their 2018 World Health Statistics report (supplemented by UNICEF 2018 demographic reports)[3] they document the following statistics:

  1. Globally, the rate of mortality for children under age five in 2018 was 41 per 1,000 live births. More than half of under-five deaths occurred in Sub-Saharan Africa.[4] In low-income countries, however, that rate is almost double at 74 per 1,000 live births. In high-income countries, that rate is significantly lower than seven per 1,000 live births.
  2. The most frequent causes of death for children under five were prematurity and respiratory infections, accounting for 18 an 16 percent, respectively. Diarrhea also accounts for 8 percent of deaths in children under five, and malaria in 5 precent. Many of these deaths could be easily avoided with cleaner water and more coverage of available medical care.
  3. The availability of doctors and nurses in low-income countries is less than one-tenth that of nations with a high income. In 2006, per 1,000 population, African countries had 2.3 health workforce employees, while European countries had 18.9, and countries in the Americas had nearly 25.[5] Challenges in access to medical education and access to patients exacerbate this issue for would-be medical professionals in low-income countries (World Health Organization, 2011).

THINK IT OVER

Healthcare Systems

There are broad, structural differences among the healthcare systems of different countries. In core nations, those differences might arise in the administration of healthcare, while the care itself is similar. In peripheral and semi-peripheral countries, a lack of basic healthcare administration can be the defining feature of the system. Most countries rely on some combination of modern and traditional medicine. In core countries with large investments in technology, research, and equipment, the focus is usually on modern medicine, with traditional (also called alternative or complementary) medicine playing a secondary role. In the United States, for instance, the American Medical Association (AMA) resolved to support the incorporation of complementary and alternative medicine in medical education. In developing countries, even quickly modernizing ones like China, traditional medicine (often understood as “complementary” by the western world) may still play a larger role.

Healthcare in Other Developed Areas

Clearly, healthcare in the United States has some areas for improvement. But how does it compare to healthcare in other countries? Many people in the United States are fond of saying that this country has the best healthcare in the world, and while it is true that the United States has a higher quality of care available than many peripheral or semi-peripheral nations, it is not necessarily the “best in the world.” In a report on how U.S. healthcare compares to that of other countries, researchers found that the United States does “relatively well in some areas—such as cancer care—and less well in others—such as mortality from conditions amenable to prevention and treatment” (Docteur and Berenson, 2009). A 2016 study on global healthcare ranked the United States at 29th,[15] an improvement from its ranking of 37th by The World Health Organization in 2000.[16]

One critique of the Patient Protection and Affordable Care Act is that it will create a system of socialized medicine, a term that for many people in the United States has negative connotations lingering from the Cold War era and earlier. Under a socialized medicine system, the government owns and runs the system. It employs the doctors, nurses, and other staff, and it owns and runs the hospitals (Klein, 2009). The best example of socialized medicine is in Great Britain, where the National Health System (NHS) gives free healthcare to all its residents. And despite some U.S. citizens’ knee-jerk reaction to any healthcare changes that hint of socialism, the United States has one socialized system in the form of the Veterans Health Administration.

It is important to distinguish between socialized medicine, in which the government owns the healthcare system, and universal healthcare, which is simply a system that guarantees healthcare coverage for everyone. Germany, Singapore, and Canada all have universal healthcare. People often look to Canada’s universal healthcare system, Medicare, as a model for the system. In Canada, healthcare is publicly funded and is administered by the separate provincial and territorial governments. However, the care itself comes from private providers as opposed to government providers, and is therefore not a socialized medicine system. This is the main difference between universal healthcare and socialized medicine. The Canada Health Act of 1970 required that all health insurance plans must be “available to all eligible Canadian residents, comprehensive in coverage, accessible, portable among provinces, and publicly administered” (International Health Systems Canada, 2010).

Underdeveloped and Undeveloped Regions

Heated discussions about socialization of medicine and managed-care options seem frivolous when compared with the issues of healthcare systems in developing or underdeveloped countries. In many countries, per capita income is so low, and governments are so fractured, that healthcare as we know it is virtually non-existent. Care that people in developed countries take for granted—like hospitals, healthcare workers, immunizations, antibiotics and other medications, and even sanitary water for drinking and washing—are unavailable to much of the population. Organizations like Doctors Without Borders, UNICEF, and the World Health Organization have played an important role in helping these countries get their most basic health needs met.

A map highlighting countries where malaria is known to occur is shown. Those at risk of malaria include Mexico, countries in northern South America, most of Africa, and the lower half of Asia.

Figure 11. This map shows the countries where malaria is known to occur. In low-income countries, malaria is still a common cause of death. (Photo courtesy of the CDC/Wikimedia Commons)

WHO, which is the health arm of the United Nations, set eight Millennium Development Goals (MDGs) in 2000 with the aim of reaching these goals by 2015. Some of the goals dealt more broadly with the socioeconomic factors that influence health, but MDGs 4, 5, and 6 all related specifically to large-scale health concerns, the likes of which most people in the United States will never contemplate. MDG 4 was to reduce child mortality, MDG 5 aimed to improve maternal health, and MDG 6 strived to combat HIV/AIDS, malaria, and other diseases. The goals may not seem particularly dramatic, but the numbers behind them show how serious they are. In 2015, these goals were revised and were turned into the UN’s Sustainable Development Goals—one of which is focused specifically on Good Health and Well-Being, another which is focused on Clean Water and Sanitation, and a myriad of other goals that would support the implementation and improvement of healthcare systems. These goals seek to show tangible results by 2030.

The fact that these goals, some of which are closely related to healthcare, remain at the forefront of the United Nations’ agenda suggests that preventable deaths and medical conditions continue to be an international issue. Maternal mortality has fallen by 37 percent since 2000, yet the maternal mortality ratio in developing countries is 14 times higher in developing regions relative to mothers in developed regions. Thirty-seven million people globally were living with HIV in 2017, with tuberculosis being the leading cause of death among people living with HIV, accounting for roughly one third of deaths. Malaria incidence rates have dropped, as have mortality rates, but millions are still affected.[17] Access to healthcare would lower these numbers and improve the lives of individuals around the world.

An important component of disease prevention and control is epidemiology, or the study of the incidence, distribution, and possible control of diseases. Fear of Ebola contamination, primarily in Western Africa but also to a smaller degree in the United States, became national news in the summer and fall of 2014 and again in 2018, and Zika virus outbreaks in the Pacific Islands as well as in South America, now spreading to Central and North America, have been alarming. Countries might have their own healthcare systems, but we live in an increasingly globalized and interconnected world, and the consequences of one system of healthcare do not stop at the country’s borders.

Watch this video to learn more about a pilot program for universal healthcare in a county in Kenya launched by the World Health Organization in 2018:

FURTHER RESEARCH

Project Mosquito Net says that mosquito nets sprayed with insecticide can reduce childhood malaria deaths by half.