Introducing Global Health

Introducing Global Health

 

 

 

Introducing Global Health

Practice, Policy, and Solutions

Peter Muennig

Celina Su

 

 

Cover design by: Michael Rutkowski Cover images: © Kamran Khan

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Library of Congress Cataloging-in-Publication Data

Muennig, Peter, author. Introducing global health : practice, policy, and solutions / Peter Muennig, Celina Su. –First edition. p. ; cm. Includes bibliographical references and index. ISBN 978-0-470-53328-4 (pbk.); ISBN 978-1-118-22041-2 (ebk.); ISBN 978-1-118-23399-3 (ebk.) I. Su, Celina, author. II. Title. [DNLM: 1. World Health. 2. Health Policy. WA 530.1] RA418 362.1–dc23 2013012274

Printed in the United States of America first edition PB Printing 10 9 8 7 6 5 4 3 2 1

 

 

Contents

Figures and Tables ………………………………………………………………………………….. ix The Authors ………………………………………………………………………………………….xiii Introduction: An Overview of Global Health ………………………………………………. xv

Part 1 The Basics of Global Health ……………………………………. 1 1 A Very Brief History of Global Health Policy …………………………….. 3

Key Ideas …………………………………………………………………………….. 3 Health and Public Policy Through the Twentieth Century ………………. 4 The Age of Global Health Policy ……………………………………………….11 The Fall of Global Governance ……………………………………………….. 16 The Millennium Development Goals ………………………………………… 19 An Alternative History ……………………………………………………………21 Love and Health in Modern Times ………………………………………….. 25 Summary ……………………………………………………………………………. 27 Key Terms ………………………………………………………………………….. 27 Discussion Questions ……………………………………………………………. 27 Further Reading …………………………………………………………………… 28 References ………………………………………………………………………….. 28

2 Case Studies in Development and Health …………………………………31 Key Ideas …………………………………………………………………………….31 The Puzzle of “Good” Development for Health ………………………….. 33 The Next Superpowers? Taking a Closer Look at Middle-Income Countries ……………………………………………………………………………. 37 Growth-Mediated Models ………………………………………………………. 40 Support-Led Models ……………………………………………………………….41 Toward a Happy Medium? ……………………………………………………… 43 China’s Explosive Growth ……………………………………………………… 45 Kerala’s Quality of Life………………………………………………………….. 49 Chile Aims for a Balancing Act ……………………………………………….. 52 Summary ……………………………………………………………………………. 56 Key Terms ………………………………………………………………………….. 56 Discussion Questions ……………………………………………………………. 56 Further Reading …………………………………………………………………… 57 References ………………………………………………………………………….. 57

Part 2 Global Health and the Art of Policy Making ……………. 61 3 The Global Burden of Disease ………………………………………………. 63

Key Ideas …………………………………………………………………………… 63 Who Dies Where? ………………………………………………………………… 64

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Counting Global Deaths (with an Eye Toward Saving Lives) …………. 69 Dead Children Make for Bad Statistics ……………………………………… 73 The Health Effects of Evil Genies ……………………………………………. 74 Quantifying the Global Burden of Disease …………………………………. 77 Cost-Effectiveness Analysis ………………………………………………………81 Summary ……………………………………………………………………………. 83 Key Terms ………………………………………………………………………….. 84 Discussion Questions ……………………………………………………………. 84 Further Reading …………………………………………………………………… 84 References ………………………………………………………………………….. 84

4 Aid …………………………………………………………………………………… 87 Key Ideas …………………………………………………………………………… 87 Different Types of Aid …………………………………………………………… 88 The Aid Controversy ………………………………………………………………91 Models of Global Aid for Public Health ……………………………………. 92 Argument: Aid Is Harmful ……………………………………………………… 95 Argument: Aid Is Poorly Managed …………………………………………… 97 Argument: Aid Is Misused ……………………………………………………… 99 Argument: “Aid” Further Consolidates Power for the Powerful …….. 101 Argument: All Is Well, Just Send More ……………………………………. 102 Argument: We Are Making Progress, But the Hurdles Are High ……. 102 Summary ……………………………………………………………………………104 Key Terms …………………………………………………………………………. 105 Discussion Questions …………………………………………………………… 105 Further Reading …………………………………………………………………..106 References ………………………………………………………………………….106

5 Health Systems …………………………………………………………………..109 Key Ideas …………………………………………………………………………..109 Health Care Delivery Systems ………………………………………………….111 Health Care Payments ………………………………………………………….. 114 Health Care Markets ……………………………………………………………. 116 Health Care Delivery Systems in High-Income Countries …………….. 117 Health Care Delivery Systems in Low- and Middle-Income Countries ……………………………………………………………………………124 Pharmaceutical Spending ………………………………………………………132 What Makes Us Healthy? ………………………………………………………134 Summary ……………………………………………………………………………138 Key Terms ………………………………………………………………………….138 Discussion Questions ……………………………………………………………139 Further Reading …………………………………………………………………..139 References ………………………………………………………………………….139

6 Social Policy and Global Health …………………………………………… 143 Key Ideas …………………………………………………………………………..143 How Policies Are Made …………………………………………………………144 Political Economy and Health ………………………………………………… 151 Lessons for Health-Optimizing Social Policies ……………………………164

 

 

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Summary ……………………………………………………………………………165 Key Terms ………………………………………………………………………….166 Discussion Questions ……………………………………………………………166 Further Reading …………………………………………………………………..166 References ………………………………………………………………………….166

7 A Closer Look at Three Political Economies: China, Kerala, and Chile …………………………………………………………………………. 169 Key Ideas …………………………………………………………………………..169 China: Sustainable State of Development? …………………………………170 Kerala: Experiments with Radical Decentralization ……………………..176 Chile: A Precarious Third Way ……………………………………………….181 Summary ……………………………………………………………………………190 Discussion Questions ……………………………………………………………190 Further Reading …………………………………………………………………..191 References ………………………………………………………………………….191

8 Global Governance and Health ……………………………………………. 193 Key Ideas …………………………………………………………………………..193 The World Health Organization ………………………………………………194 The World Trade Organization ………………………………………………..197 An Evolution of Global Governance …………………………………………200 Summary ……………………………………………………………………………208 Key Terms ………………………………………………………………………….209 Discussion Questions ……………………………………………………………209 Further Reading …………………………………………………………………..209 References …………………………………………………………………………. 210

Part 3 Key Challenges in Global Health …………………………. 213 9 Poverty ……………………………………………………………………………..215

Key Ideas ………………………………………………………………………….. 215 Income and Health Across Nations …………………………………………. 216 Definitions of Poverty ………………………………………………………….. 218 Why Do We Worry About Poverty in Public Health? …………………..222 Poverty in Less-Developed Nations ………………………………………….228 Poverty and Health Among Wealthy Nations ……………………………..232 The Complexities of Poverty …………………………………………………..240 Summary ……………………………………………………………………………240 Key Terms ………………………………………………………………………….241 Discussion Questions ……………………………………………………………241 Further Reading …………………………………………………………………..241 References ………………………………………………………………………….241

10 The Physical Environment and Disease ………………………………… 245 Key Ideas …………………………………………………………………………..245 Infectious Disease and Development ………………………………………..246 Malaria and Other Mosquito-Borne Illnesses …………………………….. 251 Air Pollution and Health ……………………………………………………….255 Outer-Ring Development and Health………………………………………..259

 

 

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Climate Change and Health ……………………………………………………262 Summary ……………………………………………………………………………267 Key Terms ………………………………………………………………………….267 Discussion Questions ……………………………………………………………267 Further Reading …………………………………………………………………..268 References ………………………………………………………………………….268

11 The Social Environment and Disease …………………………………….271 Key Ideas …………………………………………………………………………..271 The Ultimate Trifecta: Race, Class, and Gender ………………………….272 The Human Immunodeficiency Virus (HIV) ………………………………282 Tuberculosis ……………………………………………………………………….286 Social Networks and Chronic Disease ………………………………………289 Individual Risk Behaviors, Urban Planning, and Health ……………….292 Summary ……………………………………………………………………………297 Key Terms ………………………………………………………………………….297 Discussion Questions ……………………………………………………………298 Further Reading …………………………………………………………………..298 References ………………………………………………………………………….298

12 Globalization, Internal Conflict, and the Resource Curse ………… 303 Key Ideas …………………………………………………………………………..303 Globalization and Health ……………………………………………………….303 Spillover Effects of Poor Global Governance ………………………………307 Civil Conflict as a Public Health Problem …………………………………308 Resource Curses and Civil Conflict …………………………………………. 310 Natural Resources and Civil War ……………………………………………. 316 Summary …………………………………………………………………………… 319 Key Terms ………………………………………………………………………….320 Discussion Questions ……………………………………………………………320 Further Reading ………………………………………………………………….. 321 References …………………………………………………………………………. 321

13 Frontiers in Global Health ………………………………………………….. 325 Key Ideas …………………………………………………………………………..325 The Many Levels of Health ……………………………………………………328 Tidings, Good or Bad, Come in Clusters ………………………………….. 331 Working with the System ………………………………………………………333 A Rise in Targeted Social Policy Interventions ……………………………338 Innovations in Administration and Governance ………………………….347 Lessons on Social Policy Interventions ……………………………………..349 Summary ……………………………………………………………………………349 Key Terms ………………………………………………………………………….350 Discussion Questions ……………………………………………………………350 Further Reading …………………………………………………………………..350 References …………………………………………………………………………. 351

Index ………………………………………………………………………………………………….. 357

 

 

Figures and Tables

FIGURES

I.1. This river makes finding recyclables easy. xx 1.1. Changes in life expectancy from 1940 to 2009 in some of the nations

that we discuss extensively in this book. 4 1.2. Residents live near a waterway containing raw sewage and trash in

Chennai, India, 2013. 7 1.3. During the Industrial Revolution, the advent of coal and steam use as

energy sources became widespread. 8 1.4. In 2005, a chemical plant explosion in Jilin, a province in northern

China, led to a massive release of nitrobenzene into the Songhua River. The water became foamy and was too dangerous to drink. The spill at first was covered up by the Chinese government, but the truth was disclosed after large numbers of dead fish washed ashore in the large northern city of Harbin and residents began to panic. 10

1.5. President Reagan meeting with Prime Minister Margaret Thatcher at the Hotel Cipriani in Venice, Italy, 6/9/1987. 17

1.6. Population pyramids typical in various stages of development. 26 2.1. The Preston curve: Life expectancy versus GDP per capita. 34 2.2. In China, the export revolution started during the transition to a

predominantly capitalist economy led to massive environmental destruction, causing broad effects on ecosystems and adversely affecting the quality of life of hundreds of millions of Chinese citizens. 44

2.3. A woman helps one of China’s barefoot doctors with nursing duties in Luo Quan Wan village. 46

2.4. Children outside a school in Kerala. 51 2.5. Life expectancy of women in Chile relative to Japan, the United States,

New Zealand, and Norway. 52 3.1. Death by broad cause group. 65 3.2. Child mortality rates by cause and region. 68 3.3. A chulla, or a traditional outdoor cook stove used in India. This

particular chulla is going to be lit using branches, scrap wood, dried dung cakes, and coconut shells. 70

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3.4. A lack of access to clean water and adequate sanitation severely inhibits many countries, especially those in sub-Saharan Africa. This problem inhibits their ability to accelerate their development. 78

3.5. A member of a local relief committee in a village in East Africa builds a latrine. This particular village has chosen to use aid provided by the organization Oxfam to build latrines. 79

4.1. Many in international development make the same mistake that this food shop in Chongqing, China, makes. It is important to have a grasp of local and international knowledge before implementation (in this case, a sign suggesting that the snack shack is selling feces). 88

4.2. Aid is delivered to Port Au Prince, Haiti, following the magnitude 7 earthquake that hit the city in 2010. 90

5.1. One of the many EMRs available from commercial vendors. Nations that are now converting to EMR systems face the challenge of either navigating the many systems that were in place prior to implementing a mandate for providers to use such records or forcing providers to drop their existing systems in favor of a universal system. 114

5.2. The chances that a forty-five-year-old woman will survive to her sixtieth birthday (fifteen-year survival) in twelve nations in 1975 (left half) and 2005 (right half). These fifteen-year survival estimates are plotted against health expenditures (y-axis). 119

5.3. Trends in self-reported health status and total household income after accounting for medical expenditures (from the General Social Survey, 1972–2008, provided by the author). 119

5.4. Global health expenditures, average number of doctor visits per year, and life expectancy. 128

5.5. An Ayurvedic medicine shop in India. 130 6.1. The percentage of women who feel that husbands are justified in

hitting their wives under certain circumstances by selected nations. The data for each country are broken down by wealth so that we see that poorer women are more likely to favor beatings than wealthier women. 147

6.2. A man appears to collect fish for human consumption after extreme river pollution and high temperatures lead to large numbers of fish dying in the river in Wuhan, China. 160

8.1. Citizens of Mexico City wear masks to prevent the spread of influenza. 197

8.2. An anti-WTO protestor demonstrates in Hong Kong in 2005. 198 9.1. This child, like millions of others in India, suffers from extreme

poverty and hunger. 221 9.2. A Nigerian girl suffers from kwashiorkor. 224 9.3. In India, a father and child suffering from marasmus. 225 9.4. The life cycle of the hookworm parasite. 226

 

 

F I G U R E S A N D T A B L E S xi

9.5. A diagram outlining the potential connections between poverty and health. We see that inadequate resources are linked to poor education, low wages, and poor environmental conditions (boxes). However, these factors are in turn caused by a confluence of poor governance and historic circumstances (among other factors). 229

10.1. Hookworm is one of the most frequently encountered parasitic infections in the world. 250

10.2. A factory in China on the Yangtze River. 257 10.3. Slash-and-burn agriculture is a common form of farming in developing

countries. It is also a major contributor to air pollution. 258 10.4. Slum upgrade in India. One approach to improving the quality of life

in slums is to formally recognize them as neighborhoods within urban centers and to then install critical infrastructure, such as sewage, sidewalks, electricity, and in some cases, even improving the quality of the housing itself. 261

10.5. Potential land loss due to polar melting. The black outline represents the current landmass above sea level. With sufficient global warming, we can expect New York, Washington, DC, Baltimore, and Philadelphia to be under water. 263

11.1. From a purely economic perspective, it makes more sense to invest scarce aid dollars in women rather than men because women are more likely to comply with interventions, pass on information to their children, and are less likely to squander income on alcohol or other drugs than are men. 278

11.2. The missing women phenomenon. Some nations have many more boys than would be expected by natural sex ratios at birth. 280

11.3. A public communications campaign from the New York City Department of Health and Mental Hygiene. Top panel: An advertisement frequently seen on the subway. Bottom panel: Still from an accompanying YouTube video. 291

11.4. Adbusters is an organization stocked with disenfranchised advertisers that seeks in part to counter the harmful effects of consumer advertising in a process called culture jamming. This ad attempts to delink male virility and alcohol. It might be particularly effective at reducing alcohol consumption because most men know what alcohol can do when they actually do get lucky with their bar date. 292

11.5. A bike lane in Kunming, China. Sophisticated bike lanes are a regular feature of mainstream Chinese urban planning. 294

12.1. This map shows six special economic zones set up by the Chinese government in areas of Africa. 312

12.2. Natural resources in poorly governed nations not only encourage dangerous mining conditions, but also can lead to civil war. 318

13.1. How the concept of herd immunity works. 329

 

 

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13.2. The different levels of disease causation or prevention. 330 13.3. The life cycle of the Onchocerca volvulus. This is a parasitic worm that

is the cause of river blindness. 334 13.4. A Bolsa Família center in Feira de Santana, Brazil. 343

TABLES

3.1. Counting Deaths Worldwide, by Disease 64 3.2. Leading Causes of Death for the World Overall and by Level of

Economic Development 67 3.3. Counting Deaths Worldwide by Disease and the Most Relevant Policy

for Addressing the Disease 69 3.4. Counting Deaths Worldwide by Preventive Policy Needed 72 3.5. Burden of Disease Worldwide in DALYs 77 3.6. DALYs Ranked by Country Categories 79 3.7. A Hypothetical Cost-Effectiveness League Table 82 5.1. Health Care Spending in 2009, per Person, in US Dollars 127 6.1. Three Forms of Social Democracy in Low- and Middle-Income

Countries 158 6.2. Two Types of Nondemocratic Governance 161 6.3. Main Political Economy Types in Industrialized Countries 164

 

 

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The Authors

Peter Muennig is an associate professor at Columbia University’s Mailman School of Public Health, where he teaches global health policy, comparative health systems, and health disparities to graduate students in public health. He has consulted for numerous foreign governments and has run a nongov- ernmental organization, the Burmese Refugee Project (which he cofounded while still a student), for twelve years. He has published more than sixty peer- reviewed articles, two books, and many chapters and government reports. He or his work has appeared in many media outlets, including the New York Times, the Washington Post, Slate, the Wall Street Journal, NPR, and CNN.

Celina Su is an associate professor of political science at the City University of New York. Her research concerns civil society, political participation, and social policy, especially health and education. Her publications include Street- wise for Book Smarts: Grassroots Organizing and Education Reform in the Bronx (Cornell University Press, 2009) and Our Schools Suck: Young People Talk Back to a Segregated Nation on the Failures of Urban Education (coauthored, New York University Press, 2009). Her honors include the Berlin Prize and the Whiting Award for Excellence in Teaching. Su was cofounding executive direc- tor of the Burmese Refugee Project from 2001 to 2013. She earned her PhD from the Massachusetts Institute of Technology.

 

 

 

Introduction: An Overview of Global Health

Before we can begin to think about global health, we must understand how institutions work. One example of an institution is a bank. Most of us deposit our money in banks because we are confident that we can retrieve our money whenever we want—that is, that the money will still be there and accessible to us, plus interest and minus fees. Banking is an institution, just as banks themselves are institutions. One way of thinking about an institution is that it constitutes the habits, cooperation, and behavior of large numbers of people. It is something that we as humans, within a given culture, collectively believe in. It is real and trustworthy because everyone believes it to be. When customers lose confidence in an institution, it collapses. This is because institutions must exist in our minds for them to exist in the real world. Just think of all the banks that went under worldwide during the Great Depres- sion. When the banks’ ability to securely hold deposits became precarious, thousands of average citizens participated in bank runs and attempted to withdraw their funds from banks and place their cash under their mattresses instead.

This, in turn, exacerbated the banks’ already fragile accounting books and reserves. Many of the banking laws the United States has today stemmed from lessons learned from institutional failures in the Great Depression. The government stepped in to reinforce our collective belief in US banks and other financial institutions, or—at a bare minimum—in the existence of the currency we deposit there. If we deposit US$10,000 and the bank goes out of business, the government promises to pay that money back to us. It will do so even though this money is held only as zeros and ones on some accounting database somewhere and not in any tangible form, such as gold or even paper currency. The trust that we have in the institution, therefore, extends to a trust that we have in our nation’s government.

As long as (almost) everyone in your society has agreed that a US$1 bill is worth $1 and a $100 bill is worth $100, the money has value even though each bill is nothing more than a piece of paper and ink with an actual worth of just pennies. Under this system, you can contribute a portion of your life to performing a task in a factory or office and be confident that the money

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you receive in return for your labors will always buy you a known quantity of avocados.

During times of financial stress, investors go to the currency that most people believe in most firmly. This way, despite the fact of the Great Recession that began in the United States in 2007, global investors bought US dollars. This sent the value of the dollar soaring relative to that of other currencies. Investors bought dollars precisely because the US dollar is widely recognized as the most reliable of the global currencies—at the time that we went to press, at least.

Institutions vary by geographical and historical context. Slavery was an accepted social institution in ancient Greece and Egypt. It was the rare leader who thought that people should not be owned by others. Now, slave-holding is rare. (The absolute number of slaves held is larger than at any point in history, but as a proportion of all inhabitants on earth, it is quite small [Bales, 2004].) Arranged marriage is a social institution in some places but not in others. Thus, institutions can be social or cultural in nature. They do not have to be inscribed into law or have official governmental agencies or buildings representing them.

Institutions—even ones that, at first glance, have little to do with an indi- vidual’s health, such as banking or marriage—are important in global health in several key ways. First, much of what shapes population health around the world lies outside of the official medical and health care systems. As one example, traffic accidents are a leading cause of death globally, and whether we obey traffic light signals or drive into oncoming traffic is determined by institutions within each country. Another example might be whether we wash our hands after using the bathroom or a surgeon washes her hands before a surgery. Second, many areas around the world currently do not have rules and regulations that explicitly promote healthy institutions (such as ensuring affordable access to safe drinking water) and prohibit unhealthy ones (such as tobacco advertisements aimed at children). This is partly because some institutions that are considered “normal” in some settings—such as access to family planning, including condoms and safe early-term abortions—are quite contentious in others. Third, even if governments attempt to develop helpful public policies and programs, they may not be successful because corruption is often endemic in governmental agencies.

This last point is important for global health. Many institutions in many low-income countries—banks, currencies, or even rules of conduct, such as everyone driving in the same direction on an agreed-on side of the road—are weak. In fact, it might be argued that such nations have a low income and low life expectancy precisely because these institutions are weak. When the trust in institutions breaks down, it becomes difficult to build social infrastruc- ture, such as roads and schools. That is, the banks can be too weak to lend

 

 

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money for such projects. If the money is acquired, institutionalized corruption may make it impossible to successfully pay for such programs. At every step of development, what we believe to be acceptable behaviors matters.

In extreme cases, when trust disappears, it becomes difficult to perform basic, everyday activities, such as buying basic goods by any means other than bartering or using some other nation’s currency. At the time of this writing, the cost of a medical examination in most clinics in Zimbabwe was listed in terms of units of grain or livestock. This is because people had lost all faith in the value of their currency.

These institutions sometimes break down when individual self-interest overrides collective interest—this is sometimes known as the “tragedy of the commons.” Those who take bribes in exchange for a road project break down the notion of trust that we hold in the overall institution.

In nations with weak institutions, it becomes not only almost impossible to run government programs but also to deliver aid. Thus, the real challenge of global health is to figure out how to make institutions work to get global agencies and individual countries functioning to improve health.

This is partly challenging because the needs of one region are so very different from those of another. In some areas, the average person can expect to live only thirty to forty years because there is no clean water to drink, and the soil is contaminated with feces because there are no toilets. This, in turn, leads to high rates of mortality, especially among children, because of diarrhea. At this level of health development, small sums of money can go a long way because the leading health problems—lack of clean water and sanitation—are so basic and cheap to fix. But this is precisely also the context in which insti- tutions are often weakest. In fact, these problems still exist precisely because it is so difficult to get anything done.

In a wealthy country such as the United States, however, problems such as poor access to medical care, reliance on the automobile for transit, poverty, and weak pollution controls form the major institutional challenges. Nations solve these problems in different ways. For instance, the United Kingdom has a centralized, socialized medical system. Switzerland, however, relies on highly regulated private health insurance to get the job done. In both cases, these nations are successful because their institutions work well—there is logic to how their systems run, in a way that seems to reflect many of their respective peoples’ overall wishes and reasoning.

This textbook focuses on institutions and the policies that might help government to develop them if they do not exist and to reform them if they are not running well. It covers most of the pressing global health problems from this angle. This way, the student not only will learn about the leading health concerns but also will get a sense of some of the ways that these prob- lems might be fixed at the international, national, and local levels. As such

 

 

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we emphasize policies that either shape or bypass existing institutions. At a minimum, we point out the difficulties in doing so (as in our discussion of international aid in chapter 3).

At a very local level, if we wish to build latrines in a poor village, for example, we attempt to get buy-in, that is, we attempt to get the people in the village to believe in the idea of latrines. At a global level, the challenge is to build institutions that a much wider range of people (or at least their political representatives) view as legitimate and worthy of respect. Neither the World Health Organization (WHO) nor its parent, the United Nations (UN), has always instilled a great amount of trust among those who are aware of their existence.

Building stronger institutions at the global level, though, is not a straight- forward process. This is difficult when the UN has few regulatory powers to punish nation-states and agencies that flout its rules and recommendations. Then, for every recommendation that the UN or the WHO writes but is sub- sequently ignored, the institution becomes weaker, provoking a vicious cycle. The institutions fail because people believe they are ineffective, and people believe they are ineffective when they fail. Organizations work best when local branches are built around a central list of priorities and each arm is staffed with an outstanding manager who is accountable for his or her department’s performance and who can operate with relative independence and agency.

Of course, getting everyone to collectively believe in a solution—to insti- tutionalize a solution—is very challenging. Moreover, “solutions” can backfire. These unintended consequences of our policies frequently arise when we fail to fully consider the systems that gave rise to the problem in the first place. Our world is a world of paradoxes. Building a healthier world requires at best an understanding that these paradoxes are possible and concurrently and sys- tematically thinking about public health at the individual, social, local, regional, national, and global levels.

WHY A PUBLIC HEALTH PERSPECTIVE?

The place you live is the single most important determinant of how healthy you will be and how long you will live. Imagine that you are a fetus nestled comfortably in your mother’s womb. If you are borne in rural eastern parts of the Democratic People’s Republic of the Congo (DPRC), the chances of you or your mother dying during your birth or shortly thereafter can be as high as 50 percent (WHO, 2012). Bleeding, infection, or other labor complications are easily managed by a health worker with just a few months of training, but chances are that your mother was never able to get these services (Kruk, Galea, Prescott, & Freedman, 2007). If you make it out of the womb, your chances of seeing your fifth birthday are also low, with about a 20 percent chance of

 

 

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death in many areas (WHO, 2012). The lack of basic sanitation or clean water means that you are almost certainly likely to be exposed to bacteria and para- sites that cause diarrhea and intestinal bleeding. Poor mosquito control means that you are also likely to contract malaria. You mother probably does not make much in a day, and lacking access to basics such as fertilizers and seeds, local farmers are unlikely to produce food at a cost that your mother can afford. Weak from poor nutrition, you immune system probably cannot fight off all these infectious diseases.

Now imagine that you were born in Malmo, Sweden. Your mother not only has free access to high-quality medical care at birth, but she also started receiv- ing care as soon as she discovered that she was pregnant, including free essential vitamins, such as folate. After a carefully monitored birth in a cutting- edge hospital, you are discharged into a comfortable home. Even if your mother is single and unemployed, the government ensures that she has access to high- quality housing, health care, and nutrition. There are no infectious agents in the water, no mosquitoes infected with malaria, and no West Nile virus. Your chances of making it to your seventieth birthday are greater than your chances of making it to age five in the DPRC (CIA, 2012; Oeppen & Vaupel, 2002; WHO, 2012).

You might see this Congo-born you as having low chances of survival because there is lousy medical care and bad economic circumstances. That is true. But where do the bad economy and lousy health system come from? Health systems cannot be repaired unless political institutions are repaired as well.

THE GLOBAL HEALTH LANDSCAPE

Water, water, everywhere, Nor any drop to drink.

—Samuel Taylor Coleridge, “The Rime of the Ancient Mariner”

With global climate change and the human destruction of natural protective barriers, such as mangrove forests, many of the world’s coastal regions are now exposed to cyclical flooding. This, in turn, leads to destruction of homes and livelihoods. Many of these areas will one day be permanently under water because global warming exacerbates the destruction already done by human habitation (Bush et al., 2011).

The Polynesian island nation of Tuvalu, for example, is only 4.5 meters above sea level, and it will be uninhabitable by 2050 (Connell, 2003). It is one of twenty-two Pacific island nations. Together, these nations contain seven million inhabitants that, altogether, contribute 0.06 percent of global green- house gas emissions. But these nations will suffer a disproportionate blow

 

 

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from the climate changes caused by their wealthy, industrialized neighbors, particularly China and the United States. On Tuvalu, the government is arrang- ing to move the remaining ten thousand residents off the island. The residents will try to establish themselves and earn their living in countries such as New Zealand and Australia. They will disperse, and linguists expect the Tuvalu language to disappear within two or three generations (Farbotko, 2005; Hammond, 2009).

Even without forced migration and displacement, flooding greatly increases human exposure to infectious agents. Sanitation systems become useless as sewer water mixes with rising ocean waters. On a planet with an expanding population, there is too much water.

Perhaps an even bigger problem arises from the damming of rivers and water pollution from industry and human settlement, choking off vital inter- national waterways. With irrigation and damming, many major rivers fail to reach the sea at all. Those that do are often contaminated with salt, lead, mercury, pesticides, trash, and sometimes with thick black toxic sludge that no one dares to test. Some inland seas and lakes, such as the Aral Sea, have become either too dry or too polluted to sustain life, let alone use as a source of drinking water (figure I.1.). This water shortage problem is only getting worse with climate change. There is too little water to sustain the rising human population.

Figure I.1. This river makes finding recyclables easy.

Source: Copyright © Jurnasyanto Sukarno/epa/Corbis.

 

 

I N T R O D U C T I O N xxi

Thus, the global water supply presents major public health challenges not only because there is massive flooding resulting from human activities, but also drought resulting from human activities. There is simultaneously too much water in some places and too little water in others.

Low-income nations are growing at a blinding pace, even as they are having trouble supporting the people that are already there with their already weak institutions. Rising populations lead to poverty, pollution, human waste, and overcrowded schools. Sub-Saharan Africa and India are growing at such a rapid pace that it seems that many regions cannot overcome the poverty trap. A poverty trap occurs when the conditions underlying poverty prevent poor people (or their children) from escaping poverty. In this case, they cannot eat, and without adequate nutrition they cannot fight off infectious diseases or learn in school. This combination of disease and undereducation makes it almost impossible for future generations of children to escape poverty, thus perpetuating the trap from one generation to the next. There are too many people.

At the same time, rich nations are in stark population decline. Japan’s birthrate is so low that, by 2050, the country is projected to be half the size it was in 2004 and its social services will be straining under the load of one million people over the age of one hundred. If trends continue, most European nations, along with Chile, Singapore, South Korea, and China, will soon follow in Japan’s footsteps. There are too few people.

Thus, there are no simple trends in public health. We do not simply have too much water or too little, too many people or too few. The fundamental questions in public health are complex and sometimes paradoxical. Most common health problems are local. Nevertheless, there is emphasis on the global, the buzzword of the early twenty-first century. This suggests that our policies are best directed transnationally.

Economic and public health projects fail time and again because global institutions tend to take one policy and apply it to all localities as one giant bandage. Many of the misadventures of global health agencies can be attrib- uted to thinking globally rather than locally. For instance, the International Monetary Fund (IMF) and World Bank got together in the 1980s and contrib- uted to the “Washington Consensus,” or the idea that rising debt in low- income countries can be addressed only by tough love. (This is a simplification of a very complicated and controversial topic. We will keep it at this simple level for now and expand later.) The Washington Consensus probably worked in some places, but in others it probably set the development agenda back a few decades.

The structural adjustment programs recommended by the IMF and World Bank (described in more detail in chapter 1) essentially led to the wholesale destruction of the middle class in sub-Saharan Africa. These “programs” required cuts to nations’ social programs, such as health, education, and

 

 

xxii I N T R O D U C T I O N

transportation, along with other economic changes. As a result, sub-Saharan Africa has never really recovered. The WHO’s recommended tuberculosis treat- ment program did not take into account local patterns of drug resistance (Khan, Muennig, Behta, & Zivin, 2002). People living in areas where the drugs simply did not work were treated so many times they sometimes died from the treat- ment rather than the disease (Farmer, 2004).

Although there is no such thing as a one-size-fits-all solution to economic, health, or education policies, global public health does exist. Pollution, infec- tious disease, people, and products all cross borders. These problems exist because countries with weak pollution controls and cheap labor tend to be more attractive for business investors. Global environmental regulations would go a long way toward solving problems like these.

A more nuanced vision of health is needed to solve “global” problems. Poverty might be viewed as a global phenomenon, but if so, it is certainly very different in Germany than it is in Sierra Leone. Despite a proliferation of doctors, journalists, and even clowns “without borders,” borders most defi- nitely exist, with very real consequences to the lives of those who live within them. Habits, laws, social networks, means of grievance, economic stability, and stratification and mobility by class, race, space, caste, and language— institutions—vary profoundly from one place to the next. So, why would a one-sized formula for development or public health fit all?

If global is such a misused word, why is it in the title of this book? Ulti- mately, policy responses to most local public health problems are shaped by and require global governance. And this brings us to the focus of this book. We ask, “How can we better understand global health problems and strengthen the institutions that fix these problems?” We do our best to teach students the status quo and then try to tear it apart. We ask whether the current set of buzzwords and policies are really going to address the problems that they set out to fix. By dissecting these problems as critically as possible, we hope that the student can come to a better understanding of the issues altering the world’s health and well-being.

ABOUT THE BOOK

The remainder of the book is organized as follows. Part 1, which consists of chapters 1 and 2, focuses on the foundational basics of global health. In chapter 1, we give a brief history of major historical forces, such as industri- alization and urbanization, that helped to shape the major epidemiologic trends and public health challenges we face today. Because population health outcomes are integrally tied to economic and human development overall, and because they increasingly cross national borders, we emphasize the ways in

 

 

I N T R O D U C T I O N xxiii

which intergovernmental institutions and international actors have struggled to implement policies that are coordinated and appropriately contextualized.

In chapter 2, we introduce China, Chile, and a state in India called Kerala as case studies. We use these case studies to explore how different types or sets of social and economic investments influence health and why. We chose these case studies because they represent different types of governance (demo- cratic and nondemocratic) and different types of social investments (social investments versus free market). Kerala has generally been democratic in gov- ernance but has elected communists to power for long stints punctuated by more market-leaning officials. Chile has experienced periods of heavy social investment and periods of heavy social divestment. We revisit these three political economies again in chapter 7.

For instance, some nations that make effective investments in basic educa- tion might gain more in longevity than nations that invest in universal medical care. Although medical care treats disease after it has already struck, basic education provides a survival toolkit. In Darwinian terms, education can be used to optimize one’s environmental niche for survival over the course of an entire life. This way, in some cases, education can prevent disease before it has a chance to strike.

Part 2, “Global Health and the Art of Policy Making,” will help students to identify the major policies shaping global health and will critically investi- gate how these policies might be improved or better implemented. Chapter 3 presents the predominating diseases in different development contexts. Chap- ter 4 looks at the aid that is delivered to address this burden of disease. Chapter 5 explores health delivery systems that are charged with using this aid to reduce the burden of disease, and chapters 6 and 8 investigate how effective global governance is at helping low-income nations stem disease and to pre- vent it from spreading between nations (first examining social policies and then the global governance institutions that implement these policies).

Finally, part 3 takes a look at some of the issues and cutting-edge solutions in global health today. Chapter 9 discusses poverty as the central node in a complex web of public health challenges, the ways in which poverty manifests differently in low- versus high-income countries, and what antipoverty pro- grams should look like. Chapter 10 reviews some of the ways in which poor physical environments—especially lack of sanitation, air pollution, and outer- ring development and urbanization—lead to poor population health. Chapter 11 takes a look at how our social environments, especially social forces such as race and gender, shape patterns in health outcomes. Chapter 12 examines challenges in trade liberalization, especially nations’ attempts to avoid the so-called resource curse, whereby countries with great natural resources sur- prisingly do worse in terms of economic, social, and human development. Chapter 13 focuses on cutting-edge solutions to addressing these problems.

 

 

xxiv I N T R O D U C T I O N

These include changes in how we think about the cities we live in, innovative ways of incentivizing people to be healthier, and radical reshaping of our drug and immigration policies. As these chapters suggest, students studying global health need to analyze problems and potential solutions on many levels— individual, local, national, and international—at once. Chapter 13, our conclu- sion, attempts to articulate emerging trends and next steps in global health by presenting several prominent case studies of social policy interventions.

As a final word, we should note that instead of listing key concepts in sequential order, we try to revisit and discuss certain complex themes through- out the book. So, for example, we do not have a chapter on epidemiology (the study of health problems in populations). Such a chapter would be full of information on how to calculate disease rates and how to conduct public health studies. Instead, we mention the major bits of epidemiology that you will need to understand how to study global health as they arise in real-life situations or in the news. For example, when we discuss the politics of making policies, we talk about how to understand how policies are tested and improved. It is here that the relevant concept in epidemiology is briefly discussed, and always within the context of a real-world example. In social environments and health in chapter 13, for instance, we discuss how, from the standpoint of maximizing health, girls tend to benefit more from education than boys. This is because girls respond to education by having fewer children when they become women (partly because it may allow them to make better-informed decisions and to participate in the workforce). Many researchers believe that educated women also tend to pass their knowledge on to their children and thereby help increase their children’s survival to a much greater extent than educated men. But in some nations, such as India, boys tend to be favored over girls. This is true not only when it comes to deciding which children go to school but also which children get fed when food is scarce. Because food is needed for education, girls lose out twice over. In fact, in India, China, and parts of the Middle East, there are many fewer girls than boys because some families abort female fetuses and some starve or otherwise neglect female children in order to better provide for males. This has led to massive gender imbalances, a phenomenon known as missing women. Although this has been a long-standing problem, it may have been made worse by the advent of low- cost ultrasound machines that allow for the quick determination of fetal sex and sex-selective abortions. This section builds on discussions on the root causes of health, governance structures, and disparities in outcomes from previous chapters.

Because of the pedagogical approach we use, readers who read this book front to back will benefit most. It also helps to read it completely through because, after introducing a concept, we try to revisit it, building on it in a fresh way. This allows the mind to naturally learn and absorb the material

 

 

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without the need for notes. Although readers who skip around may occasion- ally encounter unfamiliar concepts, the good thing about our approach is that we redefine and reintroduce more-complex ideas as they arise and let less- complex ideas relax comfortably where they first appear.

One consideration that readers should keep in mind is that all works in the social sciences—be they works of journalism or academic articles—are influenced by the opinions of their authors. Researchers tend to focus on topics and concerns that they believe in or feel emotionally compelled by and—often unwittingly—interject their beliefs in a search for truth in numbers. Negative findings often go unpublished in the academic literature because editors do not see them as likely to promote their journals. Few fields are as rife for editorials presented as fact than global health. Authors of textbooks are no different. We attempt to bring you informed opinion that covers multiple sides of the issues we present.

ACKNOWLEDGMENTS

Elly Schofield, who worked hard to smooth and unify the text, and Jana Smith, who wrote most of the class exercises, were graduate students at Columbia University at the time of writing. Muhiuddin Haider, Marilyn Massey-Stokes, and Joyce Pulcini provided thoughtful and constructive comments on the complete draft manuscript. Javeria Hashmi and Amira Ahmed, then students at Brooklyn College, provided invaluable research assistance.

KEY TERMS epidemiology poverty trap

structural adjustment programs

Washington Consensus

REFERENCES

Bales, K. (2004). Disposable people: New slavery in the global economy. Berkeley: University of California Press.

Bush, K. F., Luber, G., Kotha, S. R., Dhaliwal, R. S., Kapil, V., Pascual, M., et al. (2011). Impacts of climate change on public health in India: Future research directions. Environmental Health Perspective, 119(6), 765–770. doi: 10.1289/ ehp.1003000.

CIA. (2009). Life expectancy at birth. Available online at www.cia.gov/library/ publications/the-world-factbook/rankorder/2102rank.html

Connell, J. (2003). Losing ground? Tuvalu, the greenhouse effect and the garbage can. Asia Pacific Viewpoint, 44(2), 89–107.

 

 

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Farbotko, C. (2005). Tuvalu and climate change: Constructions of environmental displacement in the Sydney Morning Herald. Geografiska Annaler: Series B, Human Geography, 87(4), 279–293.

Farmer, P. (2004). Pathologies of power: Health, human rights, and the new war on the poor. Berkeley: University of California Press.

Hammond, R. (2009). Tuvalu: Islands on the frontline of climate change. London: Panos Pictures.

Khan, K., Muennig, P., Behta, M., & Zivin, J. G. (2002). Global drug-resistance patterns and the management of latent tuberculosis infection in immigrants to the United States. New England Journal of Medicine, 347(23), 1850–1859.

Kruk, M. E., Galea, S., Prescott, M., & Freedman, L. P. (2007). Health care financing and utilization of maternal health services in developing countries. Health Policy Plan, 22(5), 303–310. doi: 10.1093/heapol/czm027.

Oeppen, J., & Vaupel, J. W. (2002). Broken limits to life expectancy. Science, 296(5570), 1029.

WHO. (2012). World Health Organization health statistics: Mortality. Available online at www.who.int/healthinfo/statistics/mortality/en/index.html

 

 

Introducing Global Health

 

 

 

PART ONE

The Basics of Global Health

 

 

 

CHAPTER 1

A Very Brief History of Global Health Policy

3

KEY IDEAS

• Although people often think of health as a question of genetics and biology, the field of global health is now largely focused on how policies and social environments affect mortality and morbidity.

• The past century, marked by the second Industrial Revolution and economic development around the world, has brought improvements in standards of living. But industrialization in low-income countries poses new threats to human health, primarily through environmental degradation and occupational hazards.

• Better nutrition and basic infrastructure such as sanitation systems have helped many societies to experience an epidemiologic transition, when infectious diseases drops and life expectancy greatly increases.

• Global health policies are now partly shaped by intergovernmental institutions, such as the United Nations (UN), formed after World War II. These institutions are chiefly concerned with economic develop- ment, human development, and preventing war.

• Although fiscal austerity, trade liberalization, and the so-called Washington Consensus dominated many intergovernmental policies in the 1980s and 1990s, more recent policies have begun to acknowledge that multiple models for development are needed.

 

 

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HEALTH AND PUBLIC POLICY THROUGH THE TWENTIETH CENTURY

People tend to think of health as a question of genetics and biology but our environment, more than our genetic code, probably explains why our feet would pop out of the bottom of the Renaissance-era beds you see in current museums. Over time, the environments around us have tended to improve our health prospects. New medical technologies, access to better nutrition, and fewer life-threatening hazards in our everyday work lives have helped increase global life expectancy. In the healthiest nations, life expectancy has increased from fifty years in 1900 to sixty-five years in 1950 to eighty years in 2000. In a much more extreme trajectory, Cuba’s life expectancy moved from nineteen in 1900 to fifty-seven in 1950 to seventy-seven in 2000 (figure 1.1).

Figure 1.1. Changes in life expectancy from 1940 to 2009 in some of the nations that we discuss extensively in this book.

Source: World Health Organization. Rendered by Gapminder.org.

0

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Chile

China

Cuba

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Sweden

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H E A l T H A n d P u B l i C P o l i C y T H R o u G H T H E T w E n T i E T H C E n T u R y 5

In this chapter, we give a very brief history of some of the key trends that have shaped population health worldwide in the past few hundred years. Along the way, we will introduce some of the key public health issues that we will dive into more deeply later in the book.

Communities and Health

In the days when humans lived as hunters and gatherers, the best hunters and the best gatherers were almost certainly more likely to get the hottest partner around. But for most people, eating and being eaten were probably bigger concerns than one’s position in the social pecking order (Diamond, 1998). These two problems—finding food and fending off attacks—were greatly miti- gated by agrarian lifestyles, introduced around ten to twelve thousand years ago (Denham et al., 2003). By keeping livestock, farming, and gathering in communities large enough to scare off predators, humans greatly increased their chances of survival.

When food could be had with less physically demanding work, a sedentary lifestyle and more rapid population growth occurred. But the agrarian life also introduced new problems. For one, there was a need for division of labor and governance. Thus, formal social hierarchies were introduced. Those at the top were more or less ensured access to food, a mate, and superior protection from threats than those at the bottom.

Europe and Asia had some native plants and animals that really benefited the people there, including barley, two types of nutritious wheat, and easily domesticated goats and sheep for wool, leather, and meat. The grains could be stored for a long time without getting spoiled, unlike fruits and vegetables. European and Asian people were also lucky because their lands were contigu- ous on an east-west axis so they could reach one another and trade products by land. Donkeys and horses from the Middle East also helped these people trade and flourish. With luck, work, and trade, the people of Europe, the Middle East, and Asia cultivated a wide range of nutritious crops and domes- ticated animals. Folks in Africa, however, mostly dealt with untamable animals, such as lions and leopards; they continued to hunt and gather (Diamond, 1998).

Of course, up until relatively recently in human history, few people died of diabetes and hypertension. It is true that the automobile, television, and high-caloric food all play big roles in the predominance of heart disease as a major cause of death (Lowry, Wechsler, Galuska, Fulton, & Kann, 2002). But few people died of these conditions mostly because more often people died of infectious disease before they had a chance to get their first heart attack. Over time, the people outside of the Americas developed immunity to common pathogens. There is even evidence that they evolved by natural selection to

 

 

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become resistant to some diseases, such as the plague (Galvani & Slatkin, 2003). When Europeans encountered Native Americans during the colonial period, they brought diseases, such as smallpox, that cut down half or more of some tribal populations. Likewise, endemic malaria in Africa and yellow fever in parts of Asia killed many Europeans during the colonial era (Diamond, 1998).

Thus, by transitioning from hunter and gatherer lifestyles to an agrarian and feudal life, old threats to survival were conquered but new ones were introduced. These newer problems tended to require higher-scale cooperation and collective problem solving so that health policies began to evolve not just in small villages or clans but also in nation-states and civilizations.

These problems included, among many others, the need to dispose of all the feces produced by large collections of people living together and to ensure clean water to drink. Some human civilizations were able to tackle these problems quite early on. Many ancient civilizations show evidence of complex water delivery and basic sewage disposal systems. Other nations to this day cannot effectively provide these basic provisions, even though it has never been cheaper or easier to provide them. Thus, we see that a given community or nation can unambiguously benefit from new ideas and technologies only if it can govern well enough to counteract the unintended consequences of col- lective living and make full use of technology so that it does more benefit than harm. (See figure 1.2.)

National Policies and Health

In the late 1700s and 1800s, manufacturing technologies and processes gave rise to the first Industrial Revolution. This opened the door to the develop- ment of new medicines and life-saving goods. In the first Industrial Revolution, the development of refined coal and the steam engine helped create a new manufacturing sector, one in which machines helped with agriculture and transport. New tools and machine parts were also made. This, in turn, led to new machines that greatly facilitated the production of textiles (with cotton spinning machines), paper, and glass. Water was easier to pump out of mines. The advent of the coal-powered steam engine transformed trade and migration along new rail routes, and the rediscovery of concrete (which had been lost for thirteen hundred years) reinvigorated building construction techniques.

The second half of the nineteenth century brought the second Industrial Revolution, with assembly-line production of goods, the internal combustion engine, and electricity power generation. This era is renowned for the develop- ment of steel, chemical industries, petroleum refinement, the car industry, and hydroelectric power.

 

 

H E A l T H A n d P u B l i C P o l i C y T H R o u G H T H E T w E n T i E T H C E n T u R y 7

But just as agrarian living created some problems and solved others, industry posed new health threats. In England, for example, the population had remained steady at six million from 1700 to 1740. After the first Industrial Revolution, the population increased from eight million in 1800 to seventeen million in 1850 and then to almost thirty-one million in 1900 (Ashton, 1997). Yet, despite this population increase, childhood survival rates remained abys- mally low. Children were not afforded the chance to receive an education, and they were expected to work. The Industrial Revolution made the hazardous conditions of child labor a lot more visible than they were before and was documented by writers such as Charles Dickens. Children died in explosions in mines; they were burned and blinded making glass. “Matchstick girls” developed phossy jaw, or phosphorous necrosis of the jaw, and then organ failure while making matches (Myers & McGlothlin, 1996). The new, dense

Figure 1.2. Residents live near a waterway containing raw sewage and trash in Chennai, India, 2013.

Source: Flickr/McKaySavage.

 

 

8 C H A P T E R 1 : A V E R y B R i E f H i s T o R y o f G l o B A l H E A l T H P o l i C y

slums brought open sewers, polluted water and air, and persistent dampness, leading to widespread cholera, tuberculosis, lung diseases, and typhoid (Ashton, 1997). (See figure 1.3.)

Technological advances such as steel provided bold new opportunities to bring consumer goods to market that have greatly improved our quality of life, but they came at an enormous cost in terms of pollution, depreciation, and global climate change. Cancers, heart disease, neurological diseases, kidney disease, and liver disease slowly began to take center stage as infectious dis- eases were conquered and lifelong exposure to toxic hazards increased in industrializing nations (Parkin, Bray, Ferlay, & Pisani, 2005; Trichopoulos, Li, & Hunter, 1996). Mass cultivation of food products allowed society to feed its rapidly growing population, but it also allowed the tobacco industry to greatly expand production and market its product to a broader portion of the population.

In the United States, environmental degradation culminated in a number of river fires that took large crews of firefighters to extinguish. Factories along the Cuyahoga River in northeastern Ohio had been dumping flammable sol- vents into the water, which were probably ignited by a passing train. When this river caught fire in 1969, the last of many fires, it called national attention to waterway pollution in the United States.

Figure 1.3. During the Industrial Revolution, the advent of coal and steam use as energy sources became widespread.

 

 

H E A l T H A n d P u B l i C P o l i C y T H R o u G H T H E T w E n T i E T H C E n T u R y 9

Recently, many more severe incidents of waterway pollution in China have received notice. One factory spill effectively killed all life in the river that sup- plied water to Harbin, one of China’s largest and most important cities. This benzene spill turned the river into a giant foamy, frothy mess. Chinese officials told citizens that they were shutting the city’s water off for “routine mainte- nance” until the spill passed, but the water was probably still unsafe for some time (and by many accounts still is because so many pollutants were there to begin with) (see figure 1.4).

These examples highlight how industries bringing in economic growth and improvements in our standard of living also bring about new threats to human health through environmental degradation and occupational hazards. Cer- tainly, even today, and even in wealthy countries, environmental problems cause concerns. But in wealthy countries, these problems have been mitigated with national regulatory policies that allow their citizens to enjoy the benefits of these technologies while reducing their harms (Schmidheiny, 1992). For example, cleaner, more efficient forms of power generation have meant that even coal-fired power plants produce significantly less harmful pollutants today than they did just a few decades ago. China is trying to move toward more sustainable development, too, as it becomes a wealthy country, but the potential scope of the environmental destruction in a country with 1.4 billion people adds a good deal of concern. There is hope, however, because indus- trialization in the modern era of green technology also offers the opportunity to leapfrog right over the problems of the industrial revolution if China is willing to make the investments (Schmidheiny, 1992).

The Industrial Revolution is widely seen as a public health disaster by academics. It brought overpopulation, overcrowding, and pollution on a wide scale. How could it be anything else? We have to keep in mind, though, that the Industrial Revolution was the forerunner of modern industrial society. Today, its pollution continues to contribute to despecia- tion (the loss of animal and plant species), global warming, and cancer (among many other diseases) but it has also led the way for modern industrial civilization replete with its diverse food supply, nice homes, trains, hospitals, and, yes, consumer products that improve our quality and length of life. The question is not so much whether modern industrial civilization is good or bad, but rather how we reduce the harms that it produces while maximizing the benefits.

WAS THE INDUSTRIAL REVOLUTION A PUBLIC HEALTH DISASTER OR BOON?

 

 

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Indeed, there is a global push to use technology to solve the very prob- lems that technology creates. With advanced water and sanitation systems, it became possible to dispose of sewage and deliver clean water even in dense urban environments. These advances helped all but rid nations of diarrhea, greatly reducing the mortality of children under five (Gulland, 2012; Mayor, 2012). Greater nutrition also helped us stave off infectious disease, and mos- quito control reduced malaria and other illnesses. These advances led to what is referred to as an epidemiologic transition. This occurs when infectious disease drops to the point that death among a nation’s youth becomes a rare event and life expectancy greatly increases (Omran, 1971). This way, we see that the progress of human civilization has, in some ways and in some places, enabled the benefits of collective living—a reliable food source and protection from predators—without many of the downsides. Thanks to the epidemiologic transition, some nations enjoy average life expectancies that

Figure 1.4. In 2005, a chemical plant explosion in Jilin, a province in northern China, led to a massive release of nitrobenzene into the Songhua River. The water became foamy and was too dangerous to drink. The spill at first was covered up by the Chinese government, but the truth was disclosed after large numbers of dead fish washed ashore in the large northern city of Harbin and residents began to panic.

Source: www.greendiary.com/polluted-water-may-affect-four-million-people-in-china .html.

 

 

T H E A G E o f G l o B A l H E A l T H P o l i C y 11

are approaching eighty-five years. This would have been unthinkable not too many decades ago.

Public health is built on a discipline called epidemiology, which we men- tioned in the introduction to this textbook. Epi means on top of and demos means people. Thus, epidemiology could be the study of things that sit on top of people but that would be silly. In fact, it is the study of disease in populations. This disease can have roots in infectious agents, genes, the social environment, or some combination of these factors. As a result, epidemiology, and public health more generally, tends to be a science that combines genetics, biology, medicine, sociology, economics, political science, and urban studies, just to name a few disciplines.

EPIDEMIOLOGY IN PUBLIC HEALTH

THE AGE OF GLOBAL HEALTH POLICY

The epidemiologic transition also leads to large increases in the number of people alive on earth, posing yet another challenge. Previously we mentioned that collective living brought people together into villages and then cities and nations, opening the possibility of war.

It also brings new, improved ways of killing people. In the beginning of the twentieth century, technologies enabled us to bomb people from the air, killing dozens of people at a time from a single biplane. By the end of the twentieth century, we could do this from space (in the form of an interconti- nental ballistic missile), with the potential to kill everyone on the planet. (On the bright side, there is a global treaty that keeps us from storing the weapons in space. In the event of nuclear war, this should prolong the survival of human civilization by up to six minutes.)

More people and better killing technologies, such as missiles, mean larger- scale and more violent conflicts. With dense collections of people, alliances between civilizations with similar goals were formed. This meant that wars could become quite large and devastating in scale, as evidenced by the World War I. In that conflict, new technologies such as airplanes and toxic chemicals were used as weapons with effects that were so devastating that international agreements were drafted to ban their use during warfare. These agreements gave rise to the notion of “civilized warfare,” or wars in which attempts have since been made to limit the scale of human suffering brought about by new technologies, such as germs and chemicals.

 

 

12 C H A P T E R 1 : A V E R y B R i E f H i s T o R y o f G l o B A l H E A l T H P o l i C y

Indeed, after World War I, it became apparent that global governance— the effective formation and application of policies across nations—would be needed to prevent a recurrence of the large-scale loss of life that came as a result. Still, efforts at improving governance did not go so well. The League of Nations, formed to unify the nations of the world, did not treat nations equally. Those that lost out opted out in anger. This opened the door to yet another worldwide conflict.

Well over sixty million people lost their lives during World War II, and countless others lost their homes and livelihoods as entire cities were leveled. Moreover, when atomic bombs were dropped on two cities in Japan, it became painfully clear that new technologies would outstrip our ability to regulate their use in conflict.

World War II created strong incentives for new institutions aimed at peacekeeping and financial cooperation. The leading economic powers formed new intergovernmental institutions such as the UN, which was primarily charged with creating dialogue between nations in order to stem wars. They also formed the International Bank for Reconstruction and Development, now commonly known as the World Bank, which was charged primarily with rebuilding Europe. Finally, the IMF was formed to reduce the chance of another global recession, one of the many major factors thought to precipitate the war.

The reconstruction of Europe was efficient and effective. Entire cities were rebuilt in just a few short years. To many, it seemed as if a new dawn of global governance had arrived. Once Europe was more or less completed, attention focused on poorer nations in Asia and Africa.

The thought was that global governance would be one of the final solu- tions to humankind’s perpetual public health problems. With an effective global government, poor nations could be helped to develop, war could be ended with global police actions, and global institutions would thrive in a highly regulated environment. Of course, sadly, this is one innovation in the history of humankind that did not come to pass.

Still, they gave it a good shot. Following World War II, colonial powers began a slow process of decolonization. Poor nations were given autonomy and aid but were left with little by way of social institutions. As mentioned in the introduction to this book, institutions include banks, governmental agen- cies, and enforceable laws. Without these institutions, the nations were unable to absorb development aid. That is, there was nowhere to put the money and there were no agencies to give it to. The ability of a nation to effectively use aid is referred to as absorptive capacity.

If a country receives ten million dollars but has no banks to safely put the money in, the money cannot be stored. If there is no ministry of education to build local schools, the money cannot be spent. In sum, without adequate

 

 

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economic, social, or political structures in place to absorb and distribute the money, development will happen slowly if at all.

Let’s take a look at one more example to drive the point home. To build a school, a region requires a department of education that is capable of man- aging construction, hiring teachers, and managing the schools. Efforts would be coordinated with other agencies, such as those of transportation, budgeting, and social work. For instance, the department of transportation would help ensure that there is a road to get to the school. These complex coordination efforts require top-down management. The president has to select ministers who are good managers. These ministers, in turn, have to select good manag- ers in a complex array of departments below them. And these departments must all coordinate their efforts with one another.

Of course, the alternative is to conduct all of the development from the outside, bypassing local banks and ministry offices, but that means that these social institutions never get built so that the programs must be administered by whoever is giving the money. That is a pretty suboptimal situation when the management is coming from a very different cultural framework with very little local knowledge.

Further, the effectiveness of aid programs was compromised by political concerns. In the post–World War II era, the United States was by far the world’s largest aid donor. But in that country, aid was framed in terms of national security. That is, it was mostly delivered as a counterbalance to the Union of Soviet Socialist Republics (USSR). By the 1950s, the Cold War was well under way. The United States and the USSR began to see some governments of poor nations run by sympathetic dictators as preferable to potentially unsympathetic democracies. Dictators were much easier to control and entice than democratic governments, after all. And neither the United States nor the USSR felt it could afford to lose any territory in the global struggle that pitted one political economy against the other. As one of many examples, in 1954, the United States overthrew a Jeffersonian-based democratic government in Guatemala in part because the government was left leaning (Schlesinger & Kinzer, 1982).

In 1944, Guatemala became one of the few countries in the world with a democracy styled after the United States (Schlesinger & Kinzer, 1982). This should have heralded the beginnings of a period of peace and eco- nomic prosperity that had the potential to spread to neighboring nations. In fact, despite the expected bumps along the way, Guatemala was doing

THE 1954 GUATEMALAN COUP D’ÉTAT

 

 

14 C H A P T E R 1 : A V E R y B R i E f H i s T o R y o f G l o B A l H E A l T H P o l i C y

At the start of the 1960s, the Kennedy administration in the United States set out to win the hearts and minds of people in poor nations (democratic or otherwise) with a good deal of development aid. If the problem with develop- ment was too little aid, the 1960s should have solved that problem. Wealthy nations and the citizens of wealthy nations contributed to this agenda, leading to a decade of unprecedented giving.

However, by the end of the decade, only modest economic or human development had actually taken place. It had become increasingly evident that it is difficult to impossible to speed poor nations through the cycle of develop- ment in the same way that Europe was redeveloped after World War II.

quite well as an exemplar for what can be achieved when dictators are replaced with a representative government. When he was elected in 1954, President Jacobo Árbenz Guzmán responded to the demands of his still quite poor electorate with a series of programs designed to alleviate poverty. Among these was a proposal for land reform—a policy that some communist nations have employed. Although land reform takes many different shapes, it is at its essence a program that purchases or expropri- ates land from private or government entities and then gives the land to poor people to farm. In theory, this provides low-income families with autonomy, a means to feed themselves, and a strong economic asset that can be passed down from one generation to the next. Such an asset can also be used as collateral for loans to improve farming operations, to build a house, or to start another business. With a little prodding by a major corporation that held most of the land that was to be expropriated (at its declared tax value), the US government saw this as a push for communism in its backyard. The Central Intelligence Agency therefore began a successful campaign to depose President Árbenz, installing the ironically named Colonel Carlos Castillo Armas (armas being the Spanish word for weapons). This act ultimately led to a thirty-six-year civil war that ended the lives of perhaps hundreds of thousands of Guatemalans (Gleijeses, 1992). In addition to the direct bloodshed, it greatly limited Guatemala’s ability to build a public health infrastructure or to otherwise develop economically. To this day, Guatemala is one of the poorest nations in the Americas, and its life expectancy of seventy-two years ranks it in the bottom third of all nations worldwide.

 

 

T H E A G E o f G l o B A l H E A l T H P o l i C y 15

Economic development—the growth of national economies—was slow in the 1960s. This is in part because, even after decades of development work, poor nations still had weak institutions. Thus, without the presence of good banks, even in the absence of thieving dictators, the money could not be easily spent. Another interrelated problem was that the Cold War continued on at full steam so the United States and the Soviet Union maintained strong interests in maintaining puppet governments around the world, virtually all with poor management skills.

A final possible problem, one that was only somewhat recognized at the time (and is still contentious), is that aid may itself pose challenges to devel- opment. This can occur because providing a reliable source of funding incen- tivizes corrupt people to go into government (so that they can steal it). Some also argue that aid creates dependence on outside help. This way, there is little incentive to build the complementary institutions required to ultimately form a mature and stable functioning government (e.g., a system of taxation). We will cover this hypothesis in more detail in chapter 3.

Human development was slow in part because almost none of the money given away was actually going to alleviate poverty. Human development, as measured by the UN Human Development Index (HDI), focuses on the growth in life expectancy, literacy, and standard of living (purchasing power) in a nation. (At the time of press, there were efforts to expand this measure beyond just these three measures.) Rather than focusing on schools or other institutions that directly benefited the poor, aid was mostly going to large infrastructure projects, such as dams, that were intended to help these countries move along economically. There is logic to this. Dams can provide needed electrical power for job-creating factories. But human development requires more than electric- ity. Without investing in schools, it becomes impossible to provide the educa- tion needed to ultimately transition an economy into one with skilled jobs that offers a living wage. Thus, the world of the poor entered the 1970s with only modest improvements in literacy, life expectancy, and economic growth.

The good news is that some nations, especially in Asia, did plant the seeds for future growth, investing in schools and agriculture in the post–World War II period. (Yes, a good education can be accomplished without electricity from dams.) The agricultural efforts were more or less led by a man named Norman Borlaug who helped usher in the green revolution (Evenson & Gollin, 2003). The green revolution involves investments in hearty grains and the use of cutting-edge crop technologies, particularly for poor nations. These benefits were slow to come, and, sadly, although these efforts were slowly building through the start of the 1970s, the world saw another governance setback that helped derail some of the progress in education and agriculture that had been realized up until then.

 

 

16 C H A P T E R 1 : A V E R y B R i E f H i s T o R y o f G l o B A l H E A l T H P o l i C y

THE FALL OF GLOBAL GOVERNANCE

The 1970s saw the formation of the Organization of the Petroleum Exporting Countries (OPEC) (Barsky & Kilian, 2002). These were generally poor Middle Eastern countries. However, they were able to coordinate spikes in oil prices worldwide (primarily with the intent of punishing the United States for assist- ing Israel). The plan worked, but it also hurt low-income nations that could not afford the high oil prices. Moreover, the OPEC countries did not have mature economic institutions, such as banks, and their governments had to deposit their newfound riches in the banks of the Western countries they meant to punish.

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