1. Health as a SOCIETAL RIGHT
Stephen Bezruchka, MD, MPH
Department of Global Health & Health Services
School of Public Health
University of Washington

2. Agenda
First two sessions
– Spirit Level
– Rationing of health care
Health as a societal right?
Determinants of Health in Rich
Countries
Global Health today
A theory of Global Health

3. Agenda
First two sessions UNFAMILIAR IDEAS
– Spirit Level – Intergenerational
– Rationing of health care transmission of health
Health as a societal right? – Biology underlying
inequality
Determinants of Health in Rich
Countries
Global Health today
A theory of Global Health

4. (first paragraph)
"There is no known
biological reason wh
every population
should not be as
healthy as the best."

5. So Far…..

6. Health as a SOCIETAL RIGHT
Societal right?

9. SOCIETAL RIGHT
MEDLINE:
Religious racism
Equity, food security and health equity in the Asia
Pacific Region
Ruptures, rights and repair: the political economy
of trauma in Haiti

10. SOCIETAL RIGHT
..
Social Right
..
Human right
EARTH/GLOBAL RIGHTS
"rights are context bound"

11. GLOBAL HEALTH
Spatial-temporal spectrum of
human health around the globe
– cut across political and cultural units
– very little non-national data exist
Human health measured by mortality indicators
– IMR, life expectancy,
• healthy life expectancy, disability adjusted life expectancy
– Quality of life and well-being related to mortality
World systems analysis

12. Health Olympics 2004 UNDP HDR 2006
Japan 82.2 Denmark Palestine Thailand Tajikistan Uganda
Switzerland Cuba Colombia Peru India 63.6 Mali
Australia United States Lithuania Egypt Kazakhstan Burkina Faso
Sweden Portugal Bulgaria Nicaragua Pakistan Ethiopia
Canada Korea, Lebanon Morocco Bangladesh Kenya
Italy Czech Republic Saudi Arabia Turkey Turkmenistan South Africa
Israel Uruguay China 71.9 Belarus Nepal Tanzania
Spain Mexico Armenia Moldova, Yemen Côte d'Ivoire
Norway Croatia Jordan Honduras Myanmar Cameroon
France Panama Romania Guatemala Ghana Niger
New Zealand Argentina Algeria Dominican Republic Cambodia Rwanda
Austria Poland Paraguay Indonesia Sudan Burundi
Belgium Ecuador El Salvador Kyrgyzstan Senegal Chad
Germany Slovakia Brazil Azerbaijan PNG Congo (DR)
Singapore Bosnia Herzegovina Viet Nam Uzbekistan Madagascar Nigeria
Finland Sri Lanka Philippines Ukraine Lao Eq Guinea
Netherlands Macedonia, Iran, Russian Federation Togo Mozambique
United Kingdom Albania Georgia Bolivia 64.4 Eritrea Angola
Greece Libya Benin Sierra Leone
Costa Rica Syria Guinea Malawi
UAE Tunisia Mauritania CAR
Chile Malaysia Djibouti Zambia
Ireland Hungary Congo Zimbabwe
Venezuela 73 Haiti Swaziland 31
1629 million 2693 million 2256 million
LIFE EXPECTANCY RANGE
9.2 YEARS 8.3 YEARS 32 YEARS

13. GLOBAL
HEALTH
2007/09
Gap 40
years
1990/93
Gap 37

14. Your thoughts on
global health disparities?

16. RICH COUNTRIES

17. How healthy is the US?
Health Olympics
Number one Gold 16-20 _______
1-5 _______ 21-25 _______
6-10 _______ 26-30 _______
11-15 _______ 31+ _______

18. HEALTH OLYMPICS 2007
5
10
15
20
25
30
United Nations Human Development Report 2009

19. 35.0
34.5
Health Olympics Age 50 (2006)
34.0
33.5 5
33.0 10
32.5 15
32.0 20
31.5 25
30
31.0
30.5
30.0
years
WHO 2009

21. GETTING TO RETIREMENT

22. FALLING BEHIND
Munnell 2004

23. INFANT MORTALITY

24. TEEN BIRTHS
A fifth of 20-yr old women who gave birth
in the US gave birth did so in their teens
In Phillips County,Arkansas,
the birth rate among teenage girls
in 2000 was 127 births per 1,000 w
omen aged 15 to 19
- a rate higher than in 94 developing countries.
SCF State of the World's Mothers 2004

25. Youth violence Olympics—Homicide rates among youth aged 10-29 (most
recent year available) from the World Health Organizations’ World Report on
Violence and Health, 2002*
US A
New Zealand
Korea
Canada
Poland
Australia
Netherlans
YOUTH HOMICIDE
Denmark
Italy
Hungary
Belgium
Portugal
Czech Republic
UK
Greece
S pain
Germany
France
Japan
0 2 4 6 8 10 12
*Austria, Finland, Ireland, Norway, Sweden and Switzerland had fewer than 20 deaths reported and therefore
rates were not calculated.

26. MEDICAL
STUDENTS
DON'T KNOW
POPULATION
HEALTH

27. 1st & 4th yr US medical student
knowledge of Population Health
(2002)
Question First Year Fourth Year
INCORRECT INCORRECT
US has higher life 28.3% 34.4%
expectancy than any
other nation?
US has lower infant 40.6% 30.2%
mortality than any other
nation?
Agrawal et. al. (2005)

28. Population Health Concepts
Health has been improving most of the
last century
Health improvements are not shared
equally
Poorer people have poorer health
Early life is most critical period for
health

29. Female Life Expectancy by County 1990 C. Murray, Harvard, 1998
Female Life Expectancy
70.0 to 77.1
77.1 to 78.1
78.1 to 78.6
78.6 to 79.1
79.1 to 79.6
79.6 to 80.1
80.1 to 80.8
80.8 to 90.0
Where is our health?

30. CLOSER TO HOME
Life Expectancy

31. Cascadia
2002
NW Env Wa

32. Sightline

33. Population Health Concepts
Health has been improving most of the
last century
Health improvements are not shared
equally
Poorer people have poorer health
Early life is most critical period for
health

34. Health and Social Problems are not Related to Average
Income in Rich Countries
Index of:
• Life expectancy
• Math & Literacy
• Infant mortality
• Homicides
• Imprisonment
• Teenage births
• Trust
• Obesity
• Mental illness – incl.
drug & alcohol
addiction
• Social mobility
Source: Wilkinson & Pickett, The Spirit Level (2009) www.equalitytrust.org.uk

35. Health and Social Problems are Worse in More Unequal Countries
Index of:
• Life expectancy
• Math & Literacy
• Infant mortality
• Homicides
• Imprisonment
• Teenage births
• Trust
• Obesity
• Mental illness – incl.
drug & alcohol
addiction
• Social mobility
Source: Wilkinson & Pickett, The Spirit Level (2009) www.equalitytrust.org.uk

37. Davidson's textbook of
Medicine 2006, pg 97
"Recent research suggests that
uneven distribution of wealth
is a more important
determinant of health than
the absolute level of wealth
as measured by the GDP;
Countries that have a narrower
or more even distribution of
wealth enjoy longer life
expectancies than countries
with similar or higher GDPs
but wider distributions of
wealth.
The mechanism is not
understood."

38. Population Health Concepts
Health has been improving most of the
last century
Health improvements are not shared
equally
Poorer people have poorer health
Early life is most critical period for
health

39. womb with a view

40. EARLY LIFE
Newsweek September 27, 1999

41. The daughter
Is the mother Life begins at
Of the Conception
woman Ends at
Birth
pathway
cumulative
latent
CONCEPTION

42. Epigenetics

43. Do POORER People
Have POORER PROTOPLASM?

45. INFLAMMATION

46. MESA US Cohort
Ranjit et. al. 2007
<$20k
$20-50k
$≥50k

47. MESA US Cohort
Ranjit et. al. 2007
<$20k
$20-50k
$≥50k

49. Hegewald et. al. 2007

50. Hegewald et. al. 2007

51. Intergenerational Stress
Cytokine production in women
Prenatal psychosocial offspring (34 subjects and 28
stress comparison) mean age 24, healthy
Pregnancy stress:
divorce, breakup, paternity
denial, marital
infidelity, death of
partner, parent, child, illnes
s in other
(cancer, MI, stroke), financi
al problems (loss of house
by flooding, husband
unemployed, foreclosure, M
VA, unmarried (father not
accepted by
family), political refugee
(Entringer et.al. 2008)

52. IMMUNE SYSTEM TESTING of lymphocytes:
Production: no difference
Activation
in vitro phytohemaglutinin (PHA)
induced cytokine production
Efficacy not tested
PS = Prenatal Stress
PS
CG
Entringer et. al. 2008
IFN interferon

53. Disease approach
CHRONIC
DISEASE RISK
Birth DEATH

54. Health Care and
Risk factor approach
CHRONIC
DISEASE RISK
Birth DEATH

55. "As dramatic and
consequential as medical
care is for individual cas
and for specific condition
much evidence suggests
that such care is not and
probably never has been
the major determinant of
levels or changes in
population health." Pg 4.

56. OTHER COUNTRIES

57. There walk the earth now both the richest peo
who ever lived and the poorest. Clark 2007

58. WORLD INCOME TRENDS LAST 3000 YEARS
There walk the earth now both the richest people
who ever lived and the poorest. Clark 2007

59. Distribution of length of life for males in Niger, Brazil and Japan in 20
Smits & Monden 2009

60. BIG PICTURE
DETERMINANTS OF HEALTH
communities, SOCIETIES, global
BASIC NEEDS (food, water, shelter)
Nature of caring and sharing
relationships or
quality of SOCIETAL relationships
health care

61. Population Health Concepts
Health declined with development
of agriculture

62. Health Declined with agriculture
“Agriculture has long been regarded as an
improvement in the human condition: Once
Homo sapiens made the transition from
foraging to farming in the Neolithic, health and
nutrition improved, longevity increased, and
work load declined. Recent study of
archaeological human remains worldwide by
biological anthropologists has shown this
characterization of the shift from hunting and
gathering to agriculture to be incorrect.
Contrary to earlier models, the adoption of
agriculture involved an overall decline in
oral and general health.” (Larsen, C. S. (1995). "Biological
changes in human populations with agriculture." Annual Review of Anthropology)

64. 80 Japan
Life Expectancy Trends: Paleolithic On
70 USA
60
Russia
50
40 Paleolithic
Sub-Saharan
30 Afr ica
Rome
20
Present (1990) (1900) 1000 10000 100,000
Y e a r s b e f o r e p r e s e n t ( l o g sc a l e )

65. Hassan 1981

67. Countries ranking in health
WHY?
Theory of Global Health
1. Where they ranked when the race
started
2. When did health begin to improve
3. Mix of factors influencing health
improvements

68. GLOBAL HEALTH
HISTORY
World health
by colonial troop
mortality

69. Curtin 1968

70. Curtin 1968
Curtin 1998

71. World health before health started improving?
Curtin 1989
Curtin 1998

72. HEALTH HISTORY TRANSITIONS
End of Global
Euro- End of Euro- Cold Economic
Colonialism Colonialism War Collapse
Military Tropical International GLOBAL ?Population
Medicine Medicine health HEALTH health
1500s 1960s 1990s 2010s

73. When did health start improving?
Easterlin 1999

74. Hundreds of years ago:
Life Expectancy increased
after childhood

75. CHILDHOOD
"The history of childhood is a
nightmare from which we
have only recently begun to
awaken. The further back
in history one goes the
lower the level of child
care, and the more likely
children are to be
killed, abandoned, beaten, t
errorized and sexually
abused."
DeMause The History of
Childhood 1974

76. Leigh & Jencks 2007

77. Factors influencing health
improvements
Colonizing country or not
Type of colonialism experienced
Societal and political policies
Economic issues: rapid growth or not
Cultural factors

78. Global Health Determinants
Where countries were in the health olympics
starting blocks
Colonial history 3 groups:
1 few Europeans settled (PEASANT COLONIES)
– societies were peasant colonies with Europeans as
administrators or tax collectors or exploiters
• plantations dominated economy in some places
– Europeans didn't stay in power after independence
– Outcomes depended on how much Europeans
helped local elites to plunder
– India, Nigeria, Sri Lanka

79. Global Health Determinants
Where countries were in the health olympics starting blocks
Colonial history:
2 Europeans settled as a minority (SETTLER
COLONIES)
– Tended to expropriate land and resources
– Used indigenous peoples labor, imported slaves
• Plantations, mining in Americas
• Locals often not allowed to own land
– After independence Europeans remained in power
• Colonial system prevailed with elite exploitation
– South Africa, Zimbabwe, Latin America

80. Global Health Determinants
Where countries were in the health olympics starting blocks
Colonial history:
3 Europeans settled as a majority (NEW
EUROPE COLONIES)
– Wiped out local peoples
– Adopted systems similar to homeland Europe
– Where there was more slavery, there was a greater
hierarchy and worse health outcomes

81. Wilkinson & Pickett 2009 Spirit Level

82. Health Outcomes Map 2000
(Hegyvary, Berry, & Murua, Journal of Public Health Policy, 2008)
1
Child Mortality (log scale)
2
How do child mortality
and life expectancy 3
vary throughout the
world?
Life Expectancy

84. PRECOLONIAL INSTITUTIONS
affect
Colonial
Postcolonial AFRICAN GOVERNMENTS

85. PRECOLONIAL:
– Centralized (politically not fragmented) ethnic
groups where chiefs accountable to traditional
authority
• Can modernize better
• Less tyranny, disorder halting modernization

86. PRECOLONIAL CENTRALIZATION:
– In modern era, benefits public goods provision in
stratified more than in egalitarian gorups
– High Geographic Spillover: roads, immunization
benefits both stratified & egalalitarian groups
– Education, IMR benefits stratified but not egalitarian
(where already have less local tyranny)

87. Precolonial African Centralization and IMR decline
Gennaioli et al. 2007

88. Precolonial African Centralization and paved roads
Gennaioli et al. 2007

89. Precolonial African Centralization and adult literacy
Gennaioli et al. 2007

90. Health Determinants of nations
Where countries were in the health olympics starting blocks
History of poor health affects cohort & subsequent
generations
How well they provided basic needs (food)
How much they support early life
How much they support ALL (social welfare systems)
Sense of community, social capital
Culture, values, ethos
Political systems: especially redistributive policies
– "educated, capable, and demanding public" (Caldwell 1986)
Economic growth (up to ~1850 ↑living standards), then whether
rapid & shared or not, if not shared, can worsen health
Hierarchy details: economic, social
Access to health care
Public health programs

91. GLOBAL HEALTH
Spatial-temporal spectrum of
human health around the globe
– cut across political and cultural units
– very little non-national data exist
Human health measured by mortality indicators
– IMR, life expectancy,
• healthy life expectancy, disability adjusted life expectancy
– Quality of life and well-being related to mortality
World systems analysis

92. BIG PICTURE
DETERMINANTS OF HEALTH
communities, nations, global
BASIC NEEDS
Nature of caring and sharing
relationships or
quality of social relationships
health care

93. Life course approach CHRONIC
DISEASE RISK
Timely
intervention
Life course
CONCEPTION DEATH

94. PRIMORDIAL PREVENTION
HEALTH approach
CHRONIC
DISEASE RISK
Timely
intervention
Trans-generational
Conception DEATH
EARLY LIFE LASTS MANY LIFETIMES

95. Factors influencing health
improvements
Colonizing country or not
Type of colonialism experienced
Societal and political policies
Economic issues: rapid growth or not
Cultural factors

96. Health Determinants of nations
Where countries were in the health olympics starting blocks
Provided basic needs (food) Forager-Hunters, UK (WWII)
How much they support early life SWEDEN
How much they support ALL (societal welfare systems)
CUBA
Sense of community, social capital OKINAWA
Culture, values, ethos JAPAN
Political systems: especially redistributive policies
NORDIC, KERALA, USA
– "educated, capable, and demanding public"
Economic growth (up to ~1850 ↑living standards), then whether
rapid & shared or not, if not shared, can worsen health
Hierarchy details: economic, societal
Access to health care, Public health programs

97. (Advertisement)

99. (first paragraph)
"There is no known
biological reason wh
every population
should not be as
healthy as the best."
(last paragraph) "The primary determinants of disease
mainly economic and social, and therefore its remedi
must also be economic and social. Medicine and poli
cannot and should not be kept apart."