Social Determinants of Low Resource Countries A Global Health knowledge resource

January 26, 2017 The State of Global Health: What are the social determinants of health?

As someone who wants to enter the field of global health, and as someone who has encountered and interacted with healthcare systems of developing nations, it is important to not just understand health as a definition. To understand the state of health globally, one must first understand the backbone of health.

Health is a 'universal right' (WHO Constitution 1948), yet there are still huge disparities in healthcare across the world. How and why is this?

At the heart of the global health debate stands two concepts: access and provision. Access is defined as the right to seek care and not be prevented from seeking care, and provision is to be provided with the highest quality of care possible situationally. It is fact that worldwide, equality in healthcare is severely lacking. Some reasons for this include Burden of Disease and 'Brain Drain,' but these are only two of many.

There are many ways that professionals are tackling the issue of access and provision of healthcare. The Sustainable Development Goals (2016-2030) are making an effort to develop 'a world we want.' The goals are global in nature, and are important because they are meant to take in national realities, development levels, and national policies and priorities. The Millennium Development Goals (UN) are a list of goals focusing on eradication of poverty, universal education, gender equality, elimination of child mortality, maternal health, HIV/AIDS, environmental care, and the development of global partnerships in health. But what are these goals actually tackling? It is impossible to reach these goals without a target in mind.

Targets of these goals are wide and long, but they are meant to fight existing and rising health threats. Present emerging health threats are infectious diseases, antibiotic resistant bacterias, unintentional injuries (i.e. car wrecks), war and violence, mental health issues, tobacco, and air pollution. Health threats such as these are not just issues of medicine; they are an issue of society.

The chart above summarizes the social determinants of health. To clarify terms, measures of population health are as follows: Life expectancy, healthy life expectancy, mortality, disability, and infant mortality. The pie chart shows the distribution affecting these measures: physical environment, health care, health behaviors, and socio-economic factors. The sum of these factors defines the health status of a population.

A video we watched (linked below) summarized the social determinants of health, listing nine things that can cover all of the areas of the above pie chart: stress, early life, social exclusion, work, employment, social support, addiction, food, and transport.

So, when looking at the global institution of health, and the current goals that are challenging professionals, the 'why' is actually more important than the 'what.' Health is the complete state of physical, mental, and social well being, not just the lack of illness or disease; But why is health the way it is? The social determinants of health are the 'why,' and when health professionals change their focus to these reasons, their knowledge of health is taken to a global level.

January 31, 2017 The State of Global Health: Measures in Practice

As Global Health students, it is important not only to learn the topics in class, but to see how they realistically manifest themselves. We looked at four regions of the world, then focused on a few countries from each region to see how population measures and health are related. Central America, Southern Africa, Southern Asia, and Southeast Asia were looked at in this example. Literacy rate, income level, and life expectancy were looked at, as well as the most prominent health conditions.

In Central America, we focused on Nicaragua, Honduras, and Guatemala.

  • Nicaragua has a literacy rate of 76.6%, an income level of $2,350, and a life expectancy of 70.1 years. The most prominent diseases are communicable diseases, cardiovascular disease, and neuro/psychological disease; most deaths by disease are due to diarrheal and respiratory infections.
  • Honduras has a literacy rate of 76.6%, an income level of $2,313, and a life expectancy of 73.5 years. The most prominent diseases are bacterial diarrhea, Hepatitis A, Typhoid Fever, Dengue Fever, Malaria and Zika.
  • Guatemala has all of the same most prominent diseases as Honduras, but their literacy rate is 75%, their income level is $3,964, and their life expectancy is 71.9 years.

The Southern Africa countries looked at were Zambia, Botswana, and Zimbabwe.

  • Zambia has a huge gender gap in literacy rate, where men are 70.3% literate, and women are 58.5% literate. Fifty-four percent of the population lives below the poverty line, and the life expectancy is 60.05. The most prominent diseases are Hepatitis A, Hepatitis E, Typhoid Fever, and vector-borne illness such as Malaria and Zika.
  • Botswana has a literacy rate of 78.9%, the highest per capita income in south Africa at $7,740, but their life expectancy is 36.5 years. The most prominent diseases are HIV/AIDS and cardiovascular disease.
  • Zimbabwe has the highest literacy rate of Africa at 90%, an income of $2,180, and a life expectancy of 57.5 years. The most common diseases in Zimbabwe are HIV/AIDS, bacterial and protozoal diarrhea, hepatitis A, typhoid fever, malaria, dengue fever, and schistosomiasis, which is a disease caused by parasitic worms in fresh water.

In Southern Asia, we looked at Afghanistan, Sri Lanka, and Pakistan.

  • Afghanistan has a 36% literacy rate, an income of $2,000 and a life expectancy of 60.37 years. The highest rated cause of deaths are typically undiagnosed communicable diseases, such as infection and diarrhea, and also cardiovascular disease.
  • Sri Lanka has a high 92% literacy rate, an income of $585.03, and have a life expectancy of 78.6 years. The popular disease list is an extensive list: These diseases include cholera, malaria, Escherichia coli diarrhea, hepatitis A, typhoid fever, insect and parasitic diseases, dengue fever, filariasis, leishmaniosis, Japanese encephalitis, onchocerciasis, plague, toxoplasmosis, HIV/AIDS, hepatitis B, and chikungunya.
  • Pakistan has a literacy rate of 57.9%, an income of $1,256, and a life expectancy of 66.18 years. The most popular diseases are bacterial diarrhea, hepatitis A and E, typhoid fever, dengue fever, and malaria.

Cambodia, Thailand, and Vietnam are Southeast Asian countries that were compared.

  • Cambodia has a literacy rate of 73.6%, average income at $1,970, and a life expectancy of 54.6 years. A combination of HIV/AIDS, Tuberculosis, and diarrheal diseases account for a quarter of all deaths, with respiratory infections ranked at the top.
  • Thailand has a literacy rate of 92.6%, an average income of $6,890, and it has a life expectancy of 69.3 years. The diseases at the highest rates are HIV/AIDS and Tuberculosis.
  • Vietnam has a literacy rate of 90.3%, an average income of $2,310, and a life expectancy of 69.6. The most prominent diseases are cardiovascular disease, communicable disease, and respiratory infections.

To compare, the United States has a literacy rate of 97%, an average income of $50,000, and a life expectancy of 78.9.

The only population measures we looked at here were literacy rate and income, but it is obvious the relationship here. The lower the literacy rate means the less emphasis on education, and the less emphasis on education there is, the more likely that disease will be spread. When somebody doesn't know or understand how disease works and how they spread, they do not have the necessary means to stop it or to prevent it. Income is a factor because of access; the more money there is, the more money is put into the health system, the more money that people have to spend on health services.

These examples are prime proof that health is not just biological. Health is defined by social constructs, which all fit together like a puzzle, whether all of the pieces are there or not.

It is our job as global health professionals to examine this puzzle, find the missing pieces, and put them in their place. It is only then that the health of the world will no longer contain extreme disparities.

February 7, 2017 Health Disparities in Developed Countries

Health disparities by definition refers to population-specific differences in the presence of disease, health outcomes, quality of health care and access to health care services that exist across racial and ethnic groups.

Health disparities are not just for the developing; there is a significant amount of health disparity within our own American borders. It is surprising to hear the statistics that define the healthcare of the United States, especially when it is often thought that America has the highest rated healthcare system in the world (MYTH.)

FACTS

  • The US has a population of 320.5 million, which is the third largest population in the world.
  • The US has the largest and most technologically powerful economy in the world with a GDP of $16.8 trillion USD.
  • Life expectancy is 78 for men and 81 for women, and infant mortality is 6.4 deaths per 1,000 live births.

BUT HERES THE CATCH....

  • The most common causes of death in the states today are obesity, which affects more than 1/3 of US adults (34.9%).
  • 42.1 million people smoke cigarettes, and 480,000 deaths per year are due to smoking.
  • 85,000 people a year die in the United States from alcohol-related causes.

EXAMPLES OF US HEALTH DISPARITIES

  1. INFANT MORTALITY rates for African American babies remain 2.5 times higher than for white babies.
  2. LIFE EXPECTANCY for black men and women are 10 years lower than whites.
  3. DEATH RATES ATTRIBUTABLE TO HEART DISEASE, STROKE, PROSTATE AND BREAST CANCER are higher for African Americans than for whites.
  4. DIABETES is 30% more likely in Native Americans and Hispanics than in whites.

Why do these disparities and these health issues exist in a developed country? In the United States, it is an issue of many things. One cause is unequal and inadequate access to insurance coverage, which has become so expensive that lower class people cannot even afford to try to buy it. Other causes include scarcity of healthcare professionals in inner cities, language barriers, and lack of diversity in healthcare providers. Unfortunately, it is also an issue of the incomes, social class, and occupation/education level of the populations involved.

It is appalling to me that out of four developed countries analyzed (Japan, Sweden, United Kingdom, and United States), the United States has the highest infant mortality rate at a 6.06 (compared to 2.78, 2.74, and 2.62 respectively). The biggest difference between us and them is that they all three provide universal coverage free of charge.

It is understandable from a citizen perspective how healthcare is expensive in the states, but it is an issue that because people cannot afford healthcare, they are dying of preventable diseases. They are dying from lack of education on behaviors, and they are dying because they do not have access to a physician because they do not have enough money in their pocket to purchase insurance. All people deserve the right to health, and this issue is not just abroad, it is in our own backyard. All of the facts on disparities display that clearly; populations of minority are not receiving the health services that they have the right to as humans, and this is a sad truth for the home built on the idea of all people as equals.

February 8, 2017 Health Pandemics: Human Trafficking

Definition: (via the Palermo Protocol, UN Protocol 2000) "the recruitment, transportation, transfer, harboring, or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation."

Types of Human Trafficking:

  • Forced Labor: Any industry can use forced labor, for example domestic workers, fishers, housekeepers, migrant workers, etc. Often this form of slavery comes about when a person needs money and receives an offer, but it becomes an issue of debt bondage when they are taken into the business and forced to 'work themselves free.'
  • Sex Trafficking: The victims here are not prostitutes, for they do not control where they go and how they are to please their masters. Often children or young adults will enter the business to get money for their family, and fall victim to the fraud of the person offering them money.
  • Organ Trafficking: The selling of body parts for the black market actually has a long wait list, but often leads to transplants that end in infection and death. In vulnerable populations, children may be kidnapped for the removal and selling of organs.
  • Baby Trafficking: Black market adoptions and selling for infants for organs are two types of baby trafficking. They are often used as leverage against mothers to force cooperation.
  • Child Brides: Child brides enter into involuntary marriage through cultural traditions but are often treated as slaves in the household and are not given the opportunity to be educated or grow up.
  • Child Soldiers: Like child brides, involuntary 'drafting' into guerilla armies by being kidnapped is common in war raging countries.

Health issues that human trafficking survivors are victim too are extensive, for they are deprived of food, sleep, proper care, and are beaten and forced to do things of unhealthy nature. Sexually transmitted diseases, drug abuse, mental illnesses, and injury from discipline are common in these situations.

Often, victims of human trafficking do not approach medical officials unless they happen to have a serious medical issue, such as the need for care from an abortion or a beating to near death. This is a hard barrier to break, but there are ways to tell that a person is in need of liberation. There are signs listed in The Polaris Project's website that gives red flags on how to spot a victim of human trafficking.

Human trafficking is not just an issue in far away countries. There are victims of human trafficking found every day in the United States, even in your own town or on your own college campus. That is what hurts the most about human trafficking existing: it can happen to people you love, by people you love, in the place you call home. It is not a far away issue. Strip clubs and strip bars are common gathering places for human traffickers, and victims often do not realize what the perpetrator is trying to do until it is too late. Construction sites and labor-heavy workplaces also 'recruit' workers that become a victim to what is 'modern day slavery.'

Now, this is an issue that can be fought and won, and there are organizations everywhere that are fighting this social epidemic. Although it doesn't seem like an explicit issue of health, how can we, as healthcare professionals, allow human beings to be forced into slavery of sex, of work, of organ thievery? These ARE issues of health, and issues of human welfare that every health professional should be aware of and fighting against.

February 10, 2017 Health Pandemics: New War

In the past, war was one side fighting against another in 'clear cut' battles on a front line with a clear victor. Presently, what is considered 'war' is much different.

War now has a different sort of combatant, often terrorist groups or extremists fighting for political or economic goals.

The most devastating thing is that war now uses civilian casualties and destruction of innocents to prove their point further. For example, in the 20th century, 191 million people died of conflicts. ONE HALF of these people were civilians, or indirect casualties that aren't necessarily dying on the front line. In fact, by the 1990's the civilian death rate was 80% of all conflict casualties, whether due to malnutrition, removal from homes, removal of medical resources, etc. It is also found that typically, higher rates of these civilian casualties due to conflict are women, children, and elderly. I am still appalled that women and children have a higher death rate than soldiers.

It is a morbid thing to want to watch the rate of the innocents that die rise, but it is an extremely useful fact when considering how humanitarian efforts should be focused, where healthcare should be brought, and actually can help lessen the health effects of a conflict.

Humanitarian Agencies

Humanitarian agencies are now taking on the caretaker role over the civilians in conflict areas, which are very successful in decreasing the number of indirect death. For example, the Sphere Project following the 1994 Rwandan Genocide conflict was built of humanitarian agencies that went in during an outbreak of Cholera. It created standards to be used in the event of conflict, such as nutrient intake for civilians, tent size, standard of access to water. A code of conduct was also included because not every agency works at the same level of conduct, so this provided a sort of accountability to the NGO's. BUT adhering to strict guideline can actually make matters worse. It is so important that you remember to focus on the needs of each country, because what works for one country may not work for another country.

To win the war on 'terror,' there are many blurry lines concerning what agencies can do, what they will do, and how they will do it. There are military agencies and humanitarian agencies that work with armed conflict, but unfortunately this had led to BOTH groups of agencies being targeted by terrorists. There are 'perceived links' that must be considered before entering a foreign area to provide aid. Military aid also brings up an issue of neutrality when giving care, which must also be considered.

It is difficult for agencies to remain neutral in conflict situations, and it is also difficult to decide whether the actions of the NGO are helping continue or helping end the war. To help this issue, an agency MUST be clear in who they are trying to help and how these people will be benefitting, so that they are not prolonging the war by unintentionally helping the wrong side of the conflict.

This does not seem like a direct health issue, but during and after conflict, health is an important factor. Health is often the cause of many preventable civilian deaths, such as in malnutrition, access to clean water, access to household or necessary sanitation. It is also an important factor in rebuilding. The health of the remaining will determine the health of the future population, especially concerning life expectancies, mortality rates, etc. It is also important to know the strengths and weaknesses of a country's health following conflict, so that it can be known where the issues will arise in the future, and where the healthcare system that was previously there failed. Healthcare does not protect completely; systems can fail especially in the face of conflict, and if this becomes the case there can be a significant growth of indirect, preventable civilian deaths.

As a student whose future goal is to establish an NGO that assists in developing countries, the idea of how to work in armed conflict is very important. In fact, whether armed or without arms, every place has conflict, and it is important to know how to approach this idea when entering a foreign place. When establishing, objectives must be strict and clear, and must be clearly understood by all involved. It must truly benefit the correct people, and must not add to the conflict nor create a sense of reliance. It is incredible to think about how much external and internal thought must go into creating an NGO for a developing country, especially to remain culturally relative and allowing the country's needs to be the focus of the organization. In all global health situations, you have to consider the unique needs of each country, because one size does NOT fit all.

February 14, 2017 Infectious Diseases of Poverty

FAST FACT: Only 10% of research that is conducted focuses on 90% of the diseases that occur worldwide.

REALITY: The 90% of diseases that occur worldwide are found in poverty stricken places. What does this mean for medicine? Unfortunately, doctors and researchers do not want to put the money where the money won't be made. If they know that the people won't be able to afford the medicine, the effort to provide it is diminished.

Low resource countries with the following qualities.....

  • Unsafe drinking water
  • improper disposal of human waste
  • crowded living conditions
  • lack of medical care
  • insect vectors and animal vectors
  • lack of vaccinations

Has led to.....

  • E. Coli, Typhoid, Cholera, Hepatitis
  • Helminthic Disease (parasites)
  • Influenza and Tuberculosis
  • Malaria, Zika, and Dengue Fever

The biggest preventative methods are vaccination and education. Training parents to recognize early signs of things such as pneumonia and influenza is one way to prevent deaths and allow for treatment of the disease. In fact, pneumonia is the leading cause of death for children up to age 5; a large portion of which could be prevented by education of signs and symptoms. The second leading cause of death of children under five is diarrheal diseases.

Often, living conditions limit the ability to fix the rates of these diseases without education. For example, E. Coli, one of the leading strains of bacteria that causes diarrhea, is spread because of lack of resources and education concerning food safety, sanitation, defecation, hand washing, proper disposal of waste, etc. These are all things that could be fixed with the proper knowledge, but instead it is causing millions of deaths that could be prevented.

Another common disease is HIV and AIDS. This disease, with its prevalence, affects mostly ages 20-49. Because of this, it creates a critical issue for families. It is also spread through genes, therefore it is difficult to make the decision to reproduce if you are an HIV positive mother. HIV positive mothers have a 25% chance of passing HIV to their infant in pregnancy, and this jumps to 4% if she breast feeds. This is spread through sexual activities and through non-sterile drug injection, both of which are huge issues of education.

It is incredible that so many people are still incredibly affected by infectious diseases, especially those with names that are considered rare in the United States. It is unheard of to see most of these diseases in epidemic form in this day and age, but when looking at developing countries, they are still often leading causes of death. But the worst part? They are preventable. Through sanitation, vaccination and education, infectious diseases are so easily preventable. The efforts being taken now are making significant differences in infectious disease epidemics worldwide, but there are still deaths of children, brothers, sisters, mothers, and fathers that can be prevented by relatively simple measures.

There are issues with stigma with many infectious diseases, such as with HIV and AIDS, so it is so significantly important to not only look at the disease itself, but also look at the cultural perspective of the disease. To be fully effective in treating patients in another culture, it is important to consider the opinions and beliefs of the people that you are working with. Without this culturally relative approach, potential causes and solutions to the infectious disease are overlooked, possibly creating an issue larger than the disease itself. I have said it before, and I will say it again, the person you are treating is a human being before a patient, and they deserve to be treated with utmost respect and honor through acknowledgement of their concerns and values.

March 14, 2017 Violence

Violence: intentional behavior with a goal to hurt, damage, or kill.

Violence includes many types.....

  • Child abuse and neglect by caregivers
  • Violence by youth
  • Intimate partner violence
  • Sexual violence
  • Elder abuse
  • Self-Inflicted abuse
  • Collective violence

The worst thing is that most places do not have true knowledge of their rates of types of violence, nor do they have true measures. There is a lack of research on prevention, on violent behaviors themselves, or on causes of violent behavior. Because of this, there is a lack of response towards victims of violence, which leads to a significantly more dangerous problem.

Hospital visits related to violence include alcohol consumption, death by suicide, death by firearms, children who have been beaten by their parents; all things that break my heart to think about. In fact, intentional violence is the leading cause of death with most victims living in poverty and young males.

Out of all of the diseases, natural disasters, cases of lack of necessary resources, and the leading cause of death of young males that live in poverty is intentional violence. THIS IS MIND-BLOWING. How, as human beings, have we let this become the leading cause of death of young boys in poverty? This is a fact that, as an older sister, I cannot fathom.

The issue of self-inflicted knowledge often leads to suicide. 75% of suicides occur among people from poor or middle-income countries; the countries with the highest rates are Guyana, North Korea, and South Korea. In fact, it is found to be the 2nd leading cause of death in 15-29 year olds. The most common forms are pesticide poisonings, hanging, and the use of firearms.

Sexual violence is often found in lower-income countries. Women are often held against their will and 'pimped out' to help their owner get money, and it happens to children and men as well. In this case, people are property, rented-out to multiple people a day to satisfy their sexual needs. Influence of sexual violence on health:

  • Depression
  • Unwanted pregnancy
  • Sexually Transmitted Diseases
  • HIV/AIDS
  • Risk of development of high-risk sexual behaviors through sexual promiscuity
  • Post-traumatic stress disorders
  • Suicide

The reason that this is one of the most difficult facets of healthcare is that these are diseases that cannot be 'treated' with medicines or 'fixed' with access to clean water. How are we supposed to approach these issues as global health professionals?

I believe that as someone passionate about people around the world, it is important that we change these rates. People should not be inflicting violence on themselves or on another to the point of death, nor should there be a lack of initiative to stop them. Violence should not be a problem of lack of research or a problem of lack of resource. There should be help available for each and every person who is a victim of violence; it hurts my heart to know that there are people hurting because they are a victim of abuse, but have no one to talk to. There are people like this that are more willing to inflict this same violence on themselves so that they can escape the pain in the only way they think possible. This is not acceptable.

April 4, 2017 Children's Part in Global Health
FACT: 21,000 CHILDREN EACH DAY DIE. 15 DIE EVERY MINUTE.

In 2010, there were 57 deaths per 1000 children younger than the age of 5. (WHO, 2011)

What do they most often die from? Preventable diseases and incidents including:

  • Pneumonia
  • Diarrheal Disease
  • Malaria and Measles
  • HIV/AIDS
  • Injuries

To restate, 21,000 children die each minute from preventable causes... how does this happen?

Many social determinants affect the children mortality rate. Lower socioeconomic status leads to less use of delivery care, exposure to poor sanitation and undernutrition, and less preventative health and use of treatment. The issue of gender is big on the status of women; low status for women leads to greater exposure to health risks such as gender based violence, and often preference for the birth of sons leads to the neglect of female children in areas of the world. Education is important because educated women are less likely to die and have improved domestic health care and hygiene, and they are more likely to use health services.

Many children die just because they do not have access to basic means of living such as nutrient-rich food, clean water, and sanitary conditions.

But certain barriers significantly limit how these social determinants of children health can be altered.

The highest rates of child mortality exist in the poorest countries, and many of these countries are or have been involved in war or civil conflict. The government of many of these countries are unwilling or unable to provide effective health services, and the poorest are the most difficult to reach. Influences of politics, economics, and culture also create barriers to decreasing child mortality.

If children are not focused on, a downward spiral begins; if children are getting sick because of lack of access to nutrients, there is a cycle of impaired learning, development of disabilities, mental health decreases, and marginalized groups as malnutrition becomes fatal. Living in areas of low well-being does not just affect the immediate health of children; this inability to obtain necessary nutrients leads to chronic malnutrition in children, which leads to much more significant health problems that affect the population group by hurting the growing generation of future leaders.

It is so important to do all in our power to bring health to all of the people of the world, especially the health of our growing children. The survival of each and every population group depends on the health of the children, and the health of the children is reliant on those supporting them. The children are the future, and if they aren't invested in now, how will they ever grow to be the next changers and leaders? These preventative causes of death must be eliminated in order to eliminate the now epidemic of resource-based child mortality.

Credits:

Created with images by stokpic - "hands world map" • Tama66 - "globe world earth" • Tama66 - "globe earth world" • Calsidyrose - "Compass Study" • Cali4beach - "Linked" • moonhouse - "IMG_7450" • byJoeLodge - "33/365 Atlas" • fdecomite - "travel" • DVIDSHUB - "ANCOP: the new face of security to Kandahar Province's Zhari District [Image 16 of 28]"

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