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0:01
It’s a pleasure to be with you. The title of this session is “Global Health Introduction.” There are no disclosures for this presentation. Objectives include: Discuss reasons to study global health, Review national immunization days and smallpox eradication as examples of global health best practices, Discuss progress and challenges for global health, Review the importance of addressing disparities,
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Review the concept of health linked to development, Discuss the importance of global collaboration, and Define health, public health and global health. Let’s start our session discussing the definition of global health. The United States Institute of Medicine defined global health as “health problems, issues and concerns that transcend national boundaries and may best be addressed by cooperative actions…” Why should we be concerned about the health of people in other countries?
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There are several reasons including: 1. We live in a global village where contact with cultures from around the world is one flight away. Because of our increasing connectedness and travel, the geographic boundaries that used to insulate people from diseases are now dissolved. Examples include the rapid annual worldwide spread of influenza viruses and the CoVid-19 situation that expanded from a local epidemic in Wuhan, China in November and
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December of 2019 to a World Health Organization declared pandemic in March 2020. So, the health of others around the world can and does impact us personally along with our families, communities and countries. 2. The health and wellbeing of people impacts global security and freedom. Disease outbreaks, like those previously mentioned and myriad others, have and will continue to exert a destabilizing effect on countries, communities and families around the world. 3.
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There are ethical dimensions to global health concerns. Thousands of children suffer and die from malnutrition and preventable and curable diseases daily. Adults also die each day due to a lack of medical care or medications. Children from underprivileged families who suffer malnutrition may fail to reach their full mental potential resulting in poor school performance and educational opportunities. Sick adults will not be as productive at work, impacting the economies of families and
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communities, perpetuating an endless cycle of poverty. Is it ethically appropriate for all of us as global citizens to just accept these situations, complications and deaths or do we have a responsibility as human beings to take steps to prevent them? A main reason to study global health is the same as with any other discipline: to learn lessons that will help improve the health and wellness of people not only in other countries but also people in our own countries, communities and families.
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The study of global health provides: Worldwide surveillance data and Program assessment information. Worldwide surveillance systems and data are essential for public health to anticipate and plan for disease outbreaks. A few examples include: The Ebola outbreak of 2014 to 2016 in West Africa. By January 2016, suspected and confirmed cases had totaled more than 28,600, and reported deaths numbered about 11,300, making the outbreak significantly larger than all previous Ebola outbreaks combined.
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All states developed plans to monitor and address potential cases from international travel. The 2019 Measles outbreaks in Israel, the Ukraine and the Philippines. In the United States, Washington state, Oregon and Georgia were significantly impacted by that outbreak Once again, all states developed plans to advise and monitor travelers from those countries. Other examples would include the Zika virus epidemic that started in Brazil in 2015 and CoVid-19 pandemic initiating from China in 2019.
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Global health studies also provide program assessment data, that informs best and promising practices and progress to reach health and wellness goals. Let’s discuss how program assessment impacts public health practices for a few minutes. Two examples of global promising and best public health practices would include: National immunization days and The Smallpox eradication program. Let’s consider one study of National Immunization Days
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In 1995, Bangladesh held two National Immunization Days (NIDs) as part of the country's goal to eradicate poliomyelitis. This program brought together government agencies, the media, voluntary organizations and individual volunteers in a concentrated effort to immunize as many children as possible in Bangladesh. As a result 88% of children under five years received at least one dose of oral polio vaccine (OPV). Sixty-seven percent received two doses.
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There were no significant differences between the vaccinations received by children in the slum or non-slum groups. In addition, 68% of all children were given vitamin A supplementation. This and other similar studies suggests that strategies like national immunization days can be effective to increase immunization rates. Polio was eradicated from Bangladesh in November 2006. This concept could be used in various forms to improve immunizations worldwide.
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Let’s discuss the smallpox eradication strategy for a few minutes. The last naturally occurring case of smallpox was in Somalia in 1977. In 1978 there were laboratory related cases of smallpox at the University of Birmingham, England — 6 cases that resulted in 3 deaths. In 1980 the World Health Assembly certified the global eradication of smallpox. A major lesson learned from this situation was that the most effective method of final
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eradication was not just the implementation of a mass vaccination program, though that was important, but a ring vaccination protocol that provided a practical and effective elimination strategy. These next few slides provides some basic information about smallpox. Smallpox was caused by variola virus a member of the pox-viridae family of viruses. Smallpox was passed by human to human transmission. There was no animal or insect reservoirs or vectors for this infection.
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Transmission in most cases was due to close contact when individuals were within 6 feet of an infected person. Smallpox was transmitted primarily by respiratory droplets generated by a cough or sneeze from a person with disease. This slide summarizes smallpox disease. The incubation period, or time from exposure to disease onset, was, in most cases, 12 – 14 days. With disease onset there was generally 2-3 days of high fever, prostration, headache and backache.
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The classic smallpox rash started on days 4 or 5 of illness. The rash progressed over 4 to 14 days from raised red bumps to fluid filled vesicles or blisters, that turned into pustules and then scabs. The scabs separated from the skin at about the 21st to 28th days of the illness often leaving scars. Individuals were most infectious from 1 day before the rash onset through the first week of the rash but were still infectious until the scabs separated at about 3-4 weeks after illness onset.
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The mortality rate was approximately 30% for individuals with no history of having a smallpox vaccination. The mortality rate was less than 10% for infected individuals with a history of vaccination and thought to be due to immune system memory that helped prevented severe disease in those previously vaccinated. There was a higher mortality rate in infants and the elderly. Smallpox vaccine contained a live virus called vaccinia.
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Vaccinia was not the smallpox virus but a virus from the same pox virus family. An Immune response to vaccinia provided cross protection to smallpox. Smallpox vaccine was 95 to 99% effective in preventing illness or severe disease if given within 3-4 days of exposure. A smallpox vaccination provided immune protection from disease for at least 5-10 years though protection against severe disease may last up to 15 to 30 years after vaccination.
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Routine smallpox vaccination was discontinued in the United States in 1972. It was generally discontinued in most of the world by1982, lagging behind the World Health Organization’s declaration of eradication in 1980, due to lingering fear of its potential reappearance. The US military discontinued smallpox vaccinations in 1990. Post 9/11 there was a limited smallpox vaccination program provided to key response personnel due to the heightened fear of bioterrorism.
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As previously mentioned, the ring vaccination strategy was key to the eradication of smallpox from the world. Ring vaccination consists of 3 components. Step one was to isolate confirmed and suspected cases to prevent the exposure of additional people to the smallpox virus. The second step included the identification, vaccination, and surveillance of significant contacts of proven cases represented by the 1st or yellow ring.
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The goal of this 1st ring was to prevent further spread of the disease to contacts and, also, to identify contacts who developed disease and isolate them as a case. Since a person is infectious starting 1 day prior to rash onset, the onset of fever, which is seen 1 to 3 days prior to the rash, was chosen to identify a person with significant contact to an infected individual. The second ring, or purple ring is an additional safety net.
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This second ring is the vaccination of household contacts of contacts. Smallpox vaccinations are about 95-99% effective in preventing disease: good but not perfect. That’s why the second ring of vaccination was chosen to provide that second safety net. This ring vaccination approach led to the eradication of smallpox and informs public health strategies to eliminate other infectious diseases with similar disease attributes.
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Let’s now consider some information about global health program progress. Significant progress has been made to improve global human health over the past 50 years. Since 1950 the death rate of children under 5 years old has fallen from 148 deaths per 1000 to 60 per thousand. The average life expectancy in developing countries has increased from 40 to 65 years. As previously mentioned, smallpox has been eradicated and polio is nearing elimination.
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As of 2020, Afghanistan and Pakistan are the only countries in the world currently reporting polio disease. There has also been progress in reducing the burden of other childhood vaccine preventable diseases. For example, the CDC reports that from 2000 to 2014 the annual estimated measles deaths worldwide has declined 79%, from 546,800 to 114,900. There has been a decline of some tropical diseases like Guinea worm, also known as
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Dracunculiasis, that have seen a decrease in Africa do to clean water programs. Dracunculiasis is transmitted from contaminated water and results in worms developing in the body and surfacing as adults causing painful skin lesions as demonstrated in this picture. Even though there has been some progress toward global health goals there are still many challenges. These next few slides include a few select examples. 10,000 babies die every day before they reach 4 weeks old.
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529,000 women die each year in childbirth. A previously mentioned, 114,000 children die every year of measles. 1.6 million people die annually of tuberculosis. Local diseases like West Nile virus, endemic to Egypt, spread to the Middle East, Africa, Asia and by 1999 reached the United States. Dengue fever, endemic in Southeast Asia, is now spreading around the world, in tropical and subtropical areas where the Aedes mosquito vectors live.
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Before we go on, for a more detailed example, let’s consider Dengue fever disease and a new vaccine developed to help control that viral infection. Dengue is a viral disease passed primarily by the female Aedes aegypti, but also Aedes Asian tiger and albopictus mosquitoes. The Incubation period for the disease is 4-13 days. There are 5 distinct viral serotypes with the 5th identified in 2013. Recovery from one strain provides life-long immunity for that strain
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Infection with a different strain after recovery from a previous infection can result in dengue hemorrhagic fever through a suspected mechanism called antibody enhancement. Dengue hemorrhagic fever occurs more commonly if someone has recovered from infection with type 1 and gets re-infected with type 2 or 3 or if initially infected with type 3 and then re-infected later with type 2. The mortality rate from dengue hemorrhagic fever is 2.5 %.
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This slide lists common symptoms and signs of dengue fever including: Flu like symptoms of headache and fever lasting 2 to 7 days, eye pain, myalgia, joint pain, lethargy, a macular-papular skin rash, and gastrointestinal symptoms of diarrhea, nausea and vomiting. Dengue hemorrhagic fever occurs during a second infect from a different dengue serotype. The main symptoms and signs of this serious infection include hemorrhage, hypotension, shock, neurologic symptoms and cognitive impairment.
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As previously mentioned, dengue hemorrhagic fever is associated with a 2.5% mortality rate. This is a picture of a child demonstrating hemorrhage associated with dengue hemorrhagic fever. DenVaxia, a dengue tetravalent vaccine developed by Sanofi Pasteur, was approved by the FDA in May, 2019. DenVaxia is given in a three-dose series at 0, 6 months, and 12 months. It is indicated for the prevention of dengue disease caused by dengue virus serotypes 1,
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2, 3 and 4 and was approved for use in individuals 9 through 16 years of age with laboratoryconfirmed previous dengue infection and living in endemic areas. This may protect those individuals from dengue hemorrhagic fever. Endemic US dengue areas include the Caribbean islands of Puerto Rico and the Virgin Islands along with Pacific Islands that are under US jurisdiction. Outbreaks in Hawaii have occurred since 2001 and are associated primarily with the Aedes Albopictus vector.
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There have been small outbreaks of dengue in the continental United States, including Texas since 1980 and south Florida since 2009. Other states with dengue vectors include Georgia, Alabama, Louisiana, South Carolina, North Carolina, Arizona and California. The CDC Advisory Committee on Immunization Practices (ACIP) is considering whether a 3- dose series should be routinely administered to persons 9-16 years old who have laboratory evidence of previous dengue infection
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and who are living in dengue-endemic areas within the US territories, Hawaii and outbreak areas in the continental US. Additional challenges in global health include: Health disparities, Links between health and development, and Engaging collaborators Let’s consider health disparities for a few minutes. There are many global health disparities including: Life expectancy, Healthcare access, and Health outcomes including: Child mortality, Food security, and Maternal health.
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For an example of disparities in life expectancy, a child born in Malawi can expect to live for only 47 years while a child born in Japan could live for as long as 83 years. There is no biological or genetic reason for these alarming differences in health and life opportunity. Two major factors that drive health disparities associated with life expectancy are the availability and functionality of public health programs and the availability of medical
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technology in the form of equipment, medications, trained personnel and their distribution. Even though both factors are important, the availability of functional public health programs is an extremely important factor. For example, the CDC demonstrated that the life span of Americans increased by approximately 30 years from 1900 to 1999. Twenty-five of those years were due to public health interventions.
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Five years could be attributed to healthcare advances including medications like antibiotics, surgical technology, or life support. The ten health achievements that significantly impacted life span in the 20th century included: Vaccinations, the most effective public health tool in history, Motor vehicle safety, Safer work-places, Control of infectious diseases including water protection, sanitation, etc., Declines in cardiovascular heart disease and stroke deaths, Safer and healthier foods,
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Healthier mothers and babies, Family planning, Fluoridation of water, and Recognizing tobacco as a health hazard. Many of these achievements were accomplished through public health professionals working in collaboration with other stakeholders including healthcare colleagues. The availability of functional public health programs and medical technology requires the investment of adequate resources to develop and sustain them.
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Its not surprising that these factors are most commonly found in higher income countries. Low-income countries have ten times fewer physicians than high-income countries. Nigeria and Myanmar have about 4 physicians per 10,000 population, while Norway and Switzerland have 40 per 10 000. There are significant gaps in health outcomes between and within countries, rooted in differences in social status, income, ethnicity, gender, disability or sexual orientation.
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For example in the United States, infants born to African-American women are 1.5 to 3 times more likely to die than infants born to women of other races or ethnicities. American men of all ages and race or ethnicities are approximately four times more likely to die by suicide than females. African-American men in the US are the most likely, among all ethnic groups in the US, to develop cancer. Every single day, 21,000 children die before their fifth birthday of pneumonia, malaria,
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diarrhea and other diseases. Despite substantial progress in reducing under-five mortality around the world, children from the poorest 20 percent of households are nearly twice as likely to die before their fifth birthday as children in the richest 20 percent. In Chad, every fifth child, or 200 out of a 1000, dies before they reach the age of 5, while in the World Health Organization (WHO) European Region, the under-five mortality rate is 13 per 1000.
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According to the latest estimates, the number of people living in hunger in the world is over a billion or 13 percent of the world’s population, the highest on record. In developing countries, 17% of children or 100 million children are malnourished. In Sub-Saharan Africa 22% of children suffer from food insecurity followed by 17.7% in the Caribbean, 14.4% in Southern Asia, 11.5% in Southeastern Asia and 10.6% in Western Asia.
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Twenty-six countries, the ones on the map in orange or red, have alarming or extreme alarming levels of hunger. In Afghanistan, Somalia and Chad, the maternal mortality ratio is over 1000 out of 100,000 live births versus 21 / 100,000 in the WHO European Region. Developing countries account for 99% of annual maternal deaths in the world. The vast majority of adolescents’ births occur in developing countries. Roughly 11% of all births worldwide occur in teenage girls, age 15-18 years old.
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Women in the richest 20% of the global population are up to 20 times more likely to have a birth attended by a skilled health worker than a poor woman. Closing this coverage gap between rich and poor in 49 low-income countries could save the lives of more than 700,000 women. There a significant economic impact of health disparities as indicated by this quote. “The European Parliament has estimated that losses linked to health inequalities cost
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around 1.4% of Gross Domestic Product (GDP) within the European Union, a figure almost as high as the European Union’s defense spending of 1.6% of GDP.” Disparities “raise important ethical and humanitarian questions about the extent to which people everywhere should be concerned about disparities in access to health services and in health status.” Let’s now consider the concept of health linked to development. “The effects of health on development are clear.”
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Countries with poor health conditions struggle to sustain economic growth. “Indeed, economic evidence confirms that a 10% improvement in life expectancy at birth, (one useful measure of a country’s overall health), is associated with a rise in economic growth of some 0.3-0.4 percentage points a year.” Disease, poor health, and lower life expectancy hinders institutional performance and undermines productivity.
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Countries with poor health issues, like high prevalence rates of HIV or malaria, are less attractive for global business investments. Poor health can result in destabilization and security risks for communities and countries. Poor health works its way through the fabric of society destroying opportunities for generations. Poor health is a relentless parasite on countries and presents as an all too familiar and predictable cascade of effects.
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For example, the poor health of mothers leads to the poor health of their babies. The poor health of children prevents them from reaching their full mental and physical potential. This then results in poor school performance and attendance and all of this ultimately negatively impacts them and their family’s economic potential. This is a diagram of Abraham Maslow’s Hierarchy of Needs. Let’s discuss how these concepts relate to country development and engagement.
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The lower four levels are described as deficiency needs where the top level is termed growth needs or “being” needs. While deficiency needs must be met, being needs are continually shaping institutions or the ways a country or society operates. The basic concept is that the higher needs only come into focus once all the needs that are lower are mainly or entirely satisfied. Physiological needs include such things as food, water, air, shelter, bodily comfort, and exercise etc.
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The next level is Safety and Security. This is followed by the need for Love and Belonging and includes the social aspects of relationships, friendship, sexual relationships, acceptance, belonging, and feeling needed. The 4th level is that of Esteem or the need for respect including self-respect and recognition by others. Major deficiency needs in a country or society must be significantly satisfied before growth, self-actualization or self transcendence can be successfully pursued.
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This top of the pyramid is the area where effective development and engagement occurs. The main point is that any development plan needs to assess and address major deficiency needs of a country or society to adequately move toward sustained development. Let’s now consider the importance of engaging collaborators in the struggle to improve global health. Addressing global health problems will require more innovative ideas and resources than any one human, organization or country can provide.
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We live in a global village. Although many health issues can be addressed locally, many others can only be addressed using global collaborative approaches, coordinating financial resources, technologies, protocols etc.. Enhanced collaboration is needed between non-profit organizations, faith-based groups, businesses, governments, educational systems, healthcare organizations, rural and urban ethnic, cultural and community groups etc. to improve the health of all world citizens.
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Public Health is well positioned to facilitate collaborations to address these issues at the state, local and international level. Let’s close this session with two additional definitions: health and public health and how they relate to global health. The World Health Organization defines health as “A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” In 1923, public health was defined by C.E.A Winslow, considered the founder of public
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health in the United States, as “The science and art of preventing disease, prolonging life, and promoting physical health…mental health and efficiency through organized community efforts toward a sanitary environment; the control of community infections; the education of the individual in principles of personal hygiene; the organization of medical and nursing service for the early diagnosis and treatment of disease; and the development of the social machinery to ensure to every individual in
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the community a standard of living adequate for the maintenance of health.” This definition uses phrases like “organized community efforts,” “control of community infections,” “development of the social machinery,” and “every individual in a community.” This emphasis clarifies the difference between the mission of public health and clinical medicine. Public health’s primary mission focuses on population interventions where clinical medicine’s primary mission focuses on individuals.
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There is obvious and necessary overlap of these missions underlining the importance of the integration, collaboration and partnership between clinical medicine and public health to improve the health and wellness of the public. Let’s consider another definition of global health that demonstrates the linkage with public health. Merson et al, defined global health as “the application of the principles of public health (or population health) to health problems and
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challenges that transcend national boundaries and to the complex array of global and local forces that affect them.” The study of global health considers health issues from a broad world-wide perspective versus a narrower local or individual country view-point. To practically accomplish global health goals, countries will need to collaborate and partner to not only understand health issues but also solve them. This slide lists key global health concepts including:
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The determinants of health, The measurement of health status, The importance of culture to health, The global burden of disease, Risk factors for health conditions, Demographic and epidemiologic transitions, and The organization and function of health systems. These concepts will be covered in the Global Health Module and other sessions of the North Dakota Public Health Training Network. In summary: We live in a global village where health concerns from around the world affect all of us.
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Global program assessments inform worldwide public health best practices. Major challenges for global health include health disparities, health linked to development, and engaging collaborators. There are ethical issues to consider in global health. Deficiency needs must be assessed and significantly addressed to move effectively toward development. Public Health is well positioned to facilitate collaborations to address these issues at the state, local and international level.
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Take your public health practice skills to the next level! Our specialized certificate courses give you an opportunity to work systematically through a public health topic and demonstrate your understanding of that material in a capstone project. Learn more and sign up at ndphtn.com/certificates
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