An Introduction to Global Health [Paperback ed.] 1773380036, 9781773380032

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AN INTRODUCTION TO H25fl

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AN INTRODUCTION TO

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Michael Seear and Obidimma Ezezika

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An Introduction to Global Health, Ihird Edition by Michael Seear and Obidimma Ezezika First published in 2017 by Canadian Scholars 425 Adelaide Street West, Suite 200 Toronto, Ontario M5V3C1 www.canadianscholars.ca Copyright © 2007,2012,2017, Michael Seear, Obidimma Ezezika, and Canadian Scholars. All rights reserved. No part of this publication may be photocopied, reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, or otherwise, without the written permission of Canadian Scholars, except for brief passages quoted for review purposes. In the case of photocopying, a licence may be obtained from Access Copyright: 320-56 Wellesley Street West,Toronto, Ontario M5S 2S3, (416) 868-1620, fax (416) 868-1621, toll-free 1-800-8935777, www.accesscopyright.ca. Every reasonable effort has been made to identify copyright holders. Canadian Scholars would be pleased to have any errors or omissions brought to its attention.

Library and Archives Canada Cataloguing in Publication Seear, Michael, 1950[Introduction to international health] An introduction to global health / Michael Seear and Obidimma Ezezika. — Third edition. Previous editions published under title: An introduction to international health. Includes bibliographical references and index. Issued in print and electronic formats. ISBN 978-1-77338-003-2 (softcover).-ISBN 978-1-77338-004-9 (PDF).ISBN 978-1-77338-005-6 (EPUB) 1. World health—Textbooks. 2. Poverty—Developing countries— Textbooks. 3. Public health—Developing countries—Textbooks. I. Ezezika, Obidimma, author II. Title. III. Title: Introduction to international health. RA441.S43 2017

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Cover and text design by Elisabeth Springate

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TABLE OF CONTENTS Acknowledgements

Part I

What Is Global Health? 1 2

Part II

An Overview of Global Health A History of International Aid

2 27

The Basic Requirements for a Healthy Life 56 War and Civil Unrest 81 Poverty and Developing World Debt 109 Malnutrition 145 Governance and Human Rights in Developing Countries Water, Sanitation, and Infectious Diseases in Developing Countries 221

184

What Are the Types and Extent of 111 Health in Developing Countries? 259 9 10

Part IV

1

Why Are Poor Populations Less Healthy Than Rich Ones? 55 3 4 5 6 7 8

Part III

vii

How to Define and Measure Health 260 The Diseases of Adults and Children in Developing Countries 290

What Can Be Done to Help?

321

11 12

The Structure of the Foreign Aid Industry 322 Primary Health Care Strategies: The Essential Foundation 360

13 14 15

Curative Medical Care and Targeted Programs 384 Poverty Reduction. Debt Relief, and Economic Growth Building Peace. Good Governance, and Social Capital

423 462

vi Table of Contents

Part V

Part VI

Other Aspects of Global Health

493

16

Natural and Humanitarian Disasters and Displaced Populations 494

17

The Health and Rights of Indigenous Populations

530

Working Safely and Effectively in a Developing Country 561 18

Planning and Preparing for Safe and Effective Development Work 562

19

How to Manage a Sustainable Aid Partnership

CopyrightAcknowledgements Index 614

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ACKNOWLEDGEMENTS I would like to thank the following people who have provided invaluable insights and comments on various chapters of the manuscript: Mark Brender, Trillium Chang, Jacqueline Ezezika, Jessica Oh, Vanessa Reddit, and Ken Simiyu. —Obidimma Ezezika

1

CHAPTER 1 An Overview of Global Health

There are two things which I am confident I can do very well: one is an introduction to any literary work, stating what it is to contain, and how it should be executed in the most perfect manner; the other is a conclusion showing from various causes why the execution has not been equal to what the author promised to himself and to the public. —Samuel Johnson. 1775

OBJECTIVES Global health is a rapidly evolving and exciting field with many huge opportunities to make a difference in the lives of millions. This chapter provides an overview of global health and how far the field has come in the last century. •

understand the scope of the subjects covered by the term "global health'

•

understand how global health relates to the new Sustainable Development Goals (SDGs)

•

understand the design and content of this book and how to get the most out of the material

•

start to apply human faces and experiences to the broad concepts of poverty, mal­ nutrition, and injustice

Chapter 1 An Overview of Global Health 3

INTRODUCTION There is simply no good reason why in the 21st century, thousands ofwomen and children in developing countries should be dying during childbirth and the early years of life. —Hon.Aileen Carroll, Canadian Minister of International Cooperation, 2005

Global health is, very broadly, the study of the health of populations in a global context. Although poor levels of health are common in many developing countries, it is important not to concentrate solely on diseases and to remember that they are just the most visible result of underlying social disruption. The need to study both the diseases and their causes means that global health covers a very wide range of subjects. These vary from tropical medicine and primary health care at one end of the spectrum to epidemiology and economics at the other end, with a great many stops in between. The solutions to these problems are, of course, no less complex than their underlying causes. Despite widespread improvements in health and prosperity over the last few decades, malnutrition, poverty, and all the ills that stem from them are still very common around the world. In fact, to the newcomer, the statistics can be quite overwhelming. During a period when citizens of industrialized countries are healthier than at any time in history, hundreds of millions of people in the least developed countries still live lives of terrible deprivation. There is, of course, a nat­ ural human desire to assist people living under those conditions. Since the end of World War II, a complex mix of private, governmental, and international organi­ zations has developed with the overall aim of improving the health of populations in developing countries. While the developing aid industry has had successes, it has also had its share of trials and considerable errors. Fortunately, the new millennium seems to have brought a renaissance in aid. Current developments—such as the Debt Relief Initiative, the Millennium Development Goals (MDGs, which have now been replaced with the SDGs), several successful disease eradication efforts, and serious attempts to improve the quantity and effectiveness of foreign aid—have all combined to bring a sense of great optimism to the field of aid. Another development has been the growing popular interest in global health issues. When the world’s seven richest countries first decided to hold annual meet­ ings, about 30 years ago, it is unlikely that the average person paid much attention. This is in marked contrast to the period leading up to the 2005 Group of Eight (G8) Conference at Gleneagles, when it seemed as if the whole world was waiting for the latest word on debt relief. The health of developing populations (particularly the developing world debt) became a bandwagon that staggered under the weight of politicians, pop stars, and various other celebrities as they clambered aboard.

4 PARTI WHAT IS GLOBAL HEALTH?

When Tony Blair announced general agreement on the Multilateral Debt Relief Initiative, there was a real sense of worldwide excitement. While the agreement may not quite have lived up to its billing, it cannot be denied that there is now widespread interest in the broad topic of global health. This increased awareness of global health issues has probably been fashioned by events that were large enough to reach news reports. A lot has happened over the last 20 or 30 years—some of the international issues that caught public attention included a steady increase in political freedom (South Africa, eastern Europe), several widely reported famines (Ethiopia, Sudan), destructive civil wars (Rwanda, Bosnia), and natural disasters (Asian tsunami, Haitian earthquake). Tie current level of interest was exemplified by the spontaneous public response to the Asian tsunami. So much money was given by private citizens that the Red Cross actually asked people to stop sending any more, since it had enough! Strangely enough, despite the increased demand for courses, books, and general information on the subject of global health, there is no clearly defined preparato­ ry educational path for entry into the field. Degree and post-graduate courses in global health can be found in large centres, but there is still a surprisingly limited amount of educational material considering the level of interest. This book is de­ signed to meet at least some of that demand by providing a broad overview of global health that nevertheless includes as much detail as possible on key topics, and by

Box 1.1 History Notes

Amartya Sen (1933-) Amartya Sen is an Indian economist whose work has had a profound effect on the broad sub­ ject of global health. His early work on the origins of famine highlighted what everyone knew but few had articulated. Superficially 'simple' population health problems such as famine are far more complex than they initially seem. He showed that starvation is not due just to lack of food any more than poverty is due only to lack of money. At the root of most complex problems lies inequity. His later work. Development as Freedom, is also widely quoted. Based on a wide range of his early research, he further develops his arguments in favour of political and economic freedom. He outlines five specific types of freedoms: political freedoms, eco­ nomic facilities, social opportunities, transparency guarantees, and protective security, which are usually viewed as only the ends of development. However, he argues that such freedoms should be both the ends and the means of development. Sen was born on a university campus established by the Indian philosopher and previous Nobel Prize winner, Rabindranath Tagore. He studied economics in India and England. After

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serving as master of Trinity College, Cambridge, he recently moved to Harvard University. He was awarded the Nobel Prize for Economics in 1998. Please follow the reference for more details: Nobelprize.org (2011).

Chapter 1 An Overview of Global Health 5

considering other aspects of global health that are rarely given attention, such as poverty, wars, humanitarian disasters, and governance. Although the subject of global health is unavoidably medical in nature, this is not a medical textbook and is intended for readers with a wide range of interests. Whether you are a pure researcher tied to a laboratory bench, a nursing student planning a career in de­ velopment work, or a fieldworker in a large aid agency, this book aims to provide a detailed introduction to global health and its inevitable companion, the modern aid industry. We would like to wish a warm welcome to anyone opening this book for the first time, and hope that it will help you find your way through the complex but fascinating subject of global health.

THE SCOPE AND DEFINITION OF GLOBAL HEALTH There can be no real growth without healthy populations. No sustainable development without tackling disease and malnutrition. No international security without assisting crisis-ridden countries. And no hope for the spread of freedom, democracy, and human dignity unless we treat health as a basic human right. —Gro Brundtland, Director General ofthe World Health Organization, 2003

Providing a concise, inclusive definition for a subject as varied as global health is a challenge. This is reflected in the common questions that newcomers ask: What is global health? How does it differ from international health? Where do tropical medicine, epidemiology, and public health fit in? An all-inclusive definition of glob­ al health would be similar to the description of an elephant by the blind philoso­ phers—there are lots of parts, but no coherent whole. It is perhaps more useful to define the subject using its broad basic aims. Taking that approach, global health can be defined as a subject that tries to find practical answers to the following questions: • • •

Why is population health so poor in many developing countries? What is the extent of the problem? What can be done about it?

Those questions have dictated the general layout of this book and their answers will cover varied and interesting topics. Global health has been defined as “collaborative trans-national research and action for promoting health for all” (Beaglehole 6c Bonita, 2010). Global health has “health equity among nations and for all people” as its major objective (Koplan et al., 2009). Before World War II, global health was largely the preserve of doctors and missionaries. As the industry has grown, ever-increasing numbers of new special­ ists have been added to the list. Investigating the causes and extent of ill health

I 6

PARTI WHAT IS GLOBAL HEALTH?

requires researchers, biostatisticians, and epidemiologists. Addressing the last question—-What can be done about it?—requires a small army. Health initiatives may include economic interventions (economists, business specialists, agrono­ mists, small-scale bankers, etc.), medical initiatives (doctors, nurses, pharmacists, nutritionists, etc.), and human rights initiatives (politicians, rights activists, and constitutional lawyers). Increasingly, standards of project management are im­ proving, which requires accountants, project managers, and the full range of support staff associated with any large company. Finally, a large part of many aid projects consists of trying to get people to change their behaviour, so projects now also include psychologists, anthropologists, popular public figures, and even directors of soap operas. While a successful project certainly requires money and well-trained staff, it must always be remembered that the most important people in the whole process are the target population. No initiative stands a chance unless local people are included (and listened to) at every stage of planning and implementation.

FROM MILLENNIUM DEVELOPMENT GOALS TO SUSTAINABLE DEVELOPMENT GOALS Learn from the past, set vivid, detailed goals for the future, and live in the only moment of time over which you have any control: now. —Denis Waitley

Established following the Millennium Summit of the United Nations in 2000, the Millennium Development Goals (MDGs) helped guide the global health devel­ opment community for 15 years. Hie eight MDGs were: 1. 2. 3. 4. 5. 6. 7. 8.

To eradicate extreme poverty and hunger To achieve universal primary education To promote gender equality To reduce child mortality To improve maternal health To combat HIV/AIDS, malaria, and other diseases To ensure environmental sustainability To develop a global partnership for development

Important strides have been taken at the global level toward achieving many of the health-related MDGs. For example, the targets for both malaria and tuberculosis

Chapter 1 An Overview of Global Health 7

were met. In addition, substantial progress was made in reducing child undernutrition, child mortality, and maternal mortality. There was also recorded progress in increasing access to improved sanitation (WHO, 2015). While the MDGs have promoted increased health and well-being in many countries, progress toward reaching these goals has been uneven across countries. Studies have pointed out that the MDGs were prepared by only a few stakeholders without adequate involvement by developing countries and overlooked develop­ ment objectives previously agreed upon and not appropriately adapted to national needs (Fehling et al., 2013). Overall, the outcome of the MDGs has been incredible, particularly in the areas of poverty reduction, increased access to safe drinking water and education. For example, extreme poverty has declined significantly over the last two decades. In 1990, nearly half of the population in the developing world lived on less than US$1.25 a day; that proportion dropped to 14 percent in 2015. There has also been advancement on the three health goals and targets. For example, between 1990 and 2015, the global under-five mortality rate has declined by more than half, dropping from 90 to 43 deaths per 1,000 live births, and HIV, tuberculosis, and malaria epidemics were staved. The transition from the MDGs to the Sustainable Development Goals (SDGs) is premised on building a sustainable world where environmental sus­ tainability, social inclusion, and economic development are equally valued. There were a number of shortcomings or challenges in the MDGs that left out issues such as disasters, conflict situations, the epidemic of non-communicable diseases, I NO I POVERTY

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Photo 1.1: The Sustainable Development Goals Source: Image courtesy of the Global Goals for Sustainable Development, www.globalgoals.org.

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8 PARTI

WHAT IS GLOBAL HEALTH?

Table 1.1: Sustainable Development Goals

I

Goall

End poverty in all its forms everywhere

Goal 2

End hunger, achieve food security and improved nutrition and promote sustainable agriculture

Goal 3

Ensure healthy lives and promote well-being for all at all ages

Goal 4

Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all

Goal 5

Achieve gender equality and empower all women and girls

Goal 6

Ensure availability and sustainable management of water and sanitation for all

Goal 7

Ensure access to affordable, reliable, sustainable, and modern energy for all

Goal 8

Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all

Goal 9

Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation

Goal 10

Reduce inequality within and among countries

Goal 11

Make cities and human settlements inclusive, safe, resilient, and sustainable

Goal 12

Ensure sustainable consumption and production patterns

Goal 13

Take urgent action to combat climate change and its impacts

Goal 14

Conserve and sustainably use the oceans, seas and marine resources for sustainable development

Goal 15

Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss

Goal 16

Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels

Goal 17

Strengthen the means of implementation and revitalize the Global Partnership for Sustainable Development

mental health disorders, and large inequalities in all parts of the world. The SDGs (Table 1.1) address many of these shortcomings and posit a new all-inclu­ sive health goal (“Ensure healthy lives and promote well-being for all at all ages”) with a broad set of targets (Table 1.2). This book makes references to these SDGs (Photo 1.1), which are officially known as Transforming Our World: The 2030Agendafor Sustainable Development. The SDGs are considered a successor to the MDGs. There are 17 SDGs and 169 core targets that relate to them. The goals are contained in paragraph 55 United Nations Resolution A/RES/70/1 of25 September 2015 (UN, 2015c). The SDGs are far reaching and applicable to all countries. They also include a broad range of socio-economic environmental and equity objectives, and offer the prospect of more peaceful and inclusive societies. Issues like poverty erad­ ication, health, education, and food security and nutrition remain priorities in

the SDGs.

Chapter 1 An Overview of Global Health 9

Table 1.2: Targets for Goal 3: Ensure healthy lives and promote well-being for all at all ages 3.1

By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births

3.2

By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births

3.3

By 2030, end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases

3.4

By 2030, reduce by one third premature mortality from noncommunicable diseases through prevention and treatment and promote mental health and well-being

3.5

Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol

3.6

By 2020, halve the number of global deaths and injuries from road traffic accidents

3.7

By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes

3.8

Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality, and affordable essential medicines and vaccines for all

3.9

By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination

3.a

Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate

3.b

Support the research and development of vaccines and medicines for the communicable and noncommunicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and. in particular, provide access to medicines for all

3.c

Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States

3.d

Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks

SDGS AND HEALTH The 13 targets of the SDG goal on health are shown in Table 1.2. You will notice that some of the MDGs have been reflected in the SDG framework, such as mater­ nal mortality (target 3.1), child mortality (target 3.2) and infectious diseases (target

! : 10 PARTI WHAT IS GLOBAL HEALTH?

Table 1.3: SDG targets related to health 1.3

Implement nationally appropriate social protection systems and measures for all. including floors, and by 2030 achieve substantial coverage of the poor and the vulnerable

2.2

By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under five years of age. and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons

4.2

By 2030, ensure that all girls and boys have access to quality early childhood development, care and pre-primary education so that they are ready for primary education

4.a

Build and upgrade education facilities that are child, disability and gender sensitive and provide safe, non-violent, inclusive, and effective learning environments for all

5.2

Eliminate all forms of violence against all women and girls in the public and private spheres, including trafficking and sexual and other types of exploitation

5.3

Eliminate all harmful practices, such as child, early and forced marriage and female genital mutilation

5.6

Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences

6.1

By 2030, achieve universal and equitable access to safe and affordable drinkingwater for all

6.2

By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations

6.3

By 2030, improve water quality by reducing pollution, eliminating dumping and minimizing release of hazardous chemicals and materials, halving the proportion of untreated wastewater and substantially increasing recycling and safe reuse globally

10.4

Adopt policies, especially fiscal, wage and social protection policies, and progressively achieve greater equality

11.5

By 2030, significantly reduce the number of deaths and the number of people affected and substantially decrease the direct economic losses relative to global gross domestic product caused by disasters, including water-related disasters, with a focus on protecting the poor and people in vulnerable situations

16.1

Significantly reduce all forms of violence and related death rates everywhere

16.2

End abuse, exploitation, trafficking, and all forms of violence against and torture of children

16.6

Develop effective, accountable and transparent institutions at all levels

16.9

By 2030, provide legal identity for all, including birth registration

17.18

By 2020, enhance capacity-building support to developing countries, including for least-developed countries and small island developing States, to increase significantly the availability of high-quality, timely and reliable data disaggregated by income, gender, age, race, ethnicity, migratory status, disability, geographic location, and other characteristics relevant in national contexts

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Chapter 1 An Overview of Global Health 11

3.3). However, the SDG framework is expanded to include neonatal mortality and other infectious diseases beyond HIV/AIDS, such as hepatitis. Due to increasing recognition of the burden of disease arising from non-com­ municable diseases, injuries, and other burdens beyond HIV/AIDS, malaria, and tuberculosis, the SDGs now include new targets on non-communicable diseases, mental health (target 3.4), substance abuse (target 3.5), injuries (target 3.6), and health impact from environmental pollution (target 3.9). Although only Goal 3 directly concerns health, all other 16 SDGs are indirect­ ly related to health. For instance, poverty and hunger as referred to in Goals 1 and 2, respectively, relate to health both as a cause of ill health and as a consequence of ill health. The goal of inclusive and equitable quality education and lifelong learning opportunities for all can only be possible if populations are well enough to enrol in classes, attend school, and have the capacity to learn. The aim of achieving gender equalities in Goal 5 is important to health issues that affect women globally and related to empowerment. Goal 6 on clean water and sanitation is an import­ ant element and cause of ill health and the spread of many infectious diseases. Employment, referred to in Goal 8, is an important social determinant of health

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Figure 3.6: Three age-standardized childhood mortality rates plotted by social class: occupational class 1 (professional) to occupational class 5 (labourer) Source: Black Report: Inequalities in Health. 1982.

70 PART II

WHY ARE POOR POPULATIONS LESS HEALTHY THAN RICH ONES?

it was argued that medical treatment would play an increasingly important part in the health of modern societies. Deaths from cancer, atherosclerosis, and other diseases of an aging population might not be governed by the same variables as infectious diseases, so all that money might finally be making a measurable change in modern life expectancy. However, subsequent studies showed this to be incor­ rect. It turns out that it does not matter what is wrong with you, whether you have cancer or measles; case fatality remains strongly affected by social class. The first large-scale report to study the question of medical care and population health was commissioned by the British government in 1980. It was led by Sir Douglas Black and is commonly called the Black Report. It represented a revolution in thought concerning the place of health care, but was very unpopular with the prevailing government attitudes of the day. Despite limited publicity, its conclusions were very influential. Its findings were repeatedly confirmed by subsequent government reports on the same subject—the Whitehead Report in 1987, the Acheson Report in 1998, and the most recent in 2010, led by Sir Michael Marmot (Marmot, 2010). Black’s committee studied mortality rates in five defined socio-economic class­ es among the British population; complete data stretched back to 1911. Predictably, the data showed clear mortality differences between the social classes. His data on child mortality (Figure 3.6) was essentially no different than Chadwick’s find­ ings from over a century earlier (Figure 3.1): mortality rates were roughly twice as high in social class 5 compared to social class 1. The most shocking result was that this relationship had not changed over time. In particular, Black showed that there had been no narrowing of the class mortality gap following the introduction of free health care for all classes with the introduction of the National Health Service (NHS). In fact, gradients had worsened slightly (Figure 3.7). The report concluded that class-related differences in mortality had little to do with failings of the NHS but were likely the result of social inequities in education, housing, diet, work conditions, and income. The need for social programs to combat these problems, rather than simply giving more money to the NHS, is a valuable lesson for those planning population health initiatives. It also failed to make the report popular with the Thatcher government of the day. Mackenbach et al. (1990) looked at studies of disease outcome in medical con­ ditions that should have been completely treatable with modern health care (such as acute appendicitis). Even when medical care ought to have had the dominant effect, these studies showed that outcomes were still more heavily influenced by so­ cio-economic factors than by medical treatment. A review article that depended on well-informed estimates rather than measurements (Bunker et al., 1994) concluded that modern medicine (including screening tests, medical treatment, and immuni­ zation) explained only about 20 percent ofthe observed improvement in American

Chapter 3 The Basic Requirements for a Healthy Life 71 150

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