INTL 340 Class Notes and Final Study Guide
INTL 340 Class Notes and Final Study Guide INTL 340
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INTL 340 NOTES WINTER 2016 Week 1 Class Notes (Day 1): Syllabus and course overview Definition of Health: a state of complete physical, mental and social well being and not merely the absence of disease or infirmity Reading Notes: The AlmaAta Declaration (1978) Health is a fundamental human right, it should be a very important worldwide goal that requires the support of not only the health sector but also other social and economic sectors The current health status of people living in both developing and developed countries is unacceptable on a political, social and economic level. Therefore, it is a concern to all countries. Economic and social development is important to attain health for all and to close the gap in health status between developing and developed countries. Maintaining health benefits, the maintenance of economic status and social status → better quality of life and world peace People have the right to participate in deciding how they achieve health Governments are responsible for providing health care. A main target for governments should be to attain an overall sense of health for all people by the year 2000 that will allow them to be economically and socially productive Primary health care is the stepping stone into achieving overall health and must be maintainable Week 1 Discussion Post: The AlmaAta Declaration laid the groundwork for discussions concerning public health. The goal was to achieve a state of complete health for all people by the year 2000. While the goal is admirable it was found to be unachievable. In developed countries the idea that health care would be available was easy to conceive, however, affordability for all was the main obstacle. In developing countries just finding the resources to provide health care to all proved to be a challenge. The greatest challenge of the AlmaAta Declaration faced was that it merely proposed its goals with no plan in place to achieve it. Had the Declaration had a plan to help provide the resources to achieve their goal to countries that needed it, it could have been more successful. Class Notes (Day 2): AlmaAta principles are still relevant today: Primary health care Inequalities in health are “grossly” unacceptable Community participation in health Health as a human right Health for all (HFA 2000) Intersectoral action for health Health tied to social/economic development Disarmament/peace and health The global community’s responsibility or health *The AlmaAta declaration linked health with social and economic development Primary Health Care: Broader than “primary care” Holistic view of health Brings health care “as close as possible” to the people Decentralization of services (horizontal approach) Take health care to the people Available to those in rural areas Driven by community needs (“bottom up” approach) Popular participation is fundamental Prioritizes health promotion and prevention Comprehensive rather than categorical Why do declarations like AlmaAta matter? Shape agendas Set goals Provide frameworks Organize and mobilize resources for action Health and Development: How do they connect? An AlmaAta principle: health and socioeconomic development are interlinked Health is a social good, a product of social and political decisions An alternative hypothesis: healthy populations create development More plausible hypothesis: development creates the social conditions that offset disease and enable health and wellbeing World Health Organization (WHO): Founded in 1948 – post WWII context UN health agency, multilateral Establishes goals, priorities, frameworks for health programs and action Funds research, disease monitoring and surveillance, response Makes epidemiological data available to researchers and practitioners Priorities: fostering health security, health systems development, partnerships, performance AlmaAta: 35 years later: Historical period of neoliberalism, Washington consensus, structural adjustment, austerity Lack of funds to follow through with goals By 1980s “HFA 2000” becomes nearly unthinkable Role of state in healthcare debate Expanding role of IMF and World Bank in global health Implementation of user fees On going challenges: funding, emergent problems, conflict zones, international cooperation, state vs. non state actors, measurement and evaluation User fees: One pillar of World Bank’s privatization of global health Charging patients for health services Emerges from 1987 Bamiko initiative A means of raising resources for health programs, argument is that increases community involvement or ownership Results: reduced utilization of essential health services including immunizations etc… Selective Primary Health Care: Initiative of the Rockefeller Foundation Critiques primary health care as “unattainable” Cost effectiveness is a key concern (return on investment) Selective: trend towards categorical funding (disease specific), topdown programming Obtains support of mainstream development and health organizations (World Bank and UNICEF) UNICEF and child survival: James Grant (UNICEF director 19801995) “Selective”/ targeted primary health care program Aim: “child survival revolution”; dramatically decrease infant and child mortality Programs = GOBI: growth monitoring, oral rehydration, breast feeding, immunization Week 2 Class Notes (Day 3): Results of UNICEF child survival campaign: Increases use of ORT and immunizations Immunization rates reach 80% or more (was 15% at the start) Child malnutrition rates reduced, to almost half in some countries An estimated 12 million children’s lives saved (19801990) “Cost effective” – GOBI achieved for less than $10/child Disparities in child health persist: One problem with Specialized PHC: limited impact on overall health system/infrastructure International disparities in IMRs persist *IMRs = infant mortality rates = # of deaths per 1,000 live births in a population “excess deaths” = preventable deaths Measure of population health: Morbidity rates = disease Prevalence (total # of cases) Incidence (# of cases per year) of disease Mortality rates = death Rates: standardized for population size Life expectancy Predictor, outcome, control variables Causal models: “distal”, proximate” risk factors Social conditions as “fundamental causes” (See Link and Phelan) Whitehall Studies Findings: Predictor variable: job status Outcome variable: relative death rate o Whitehall I: higher risk of death due to cardiovascular disease for men in lower occupational grades. Men in lower grades had a higher risk of negative health behaviors. Health behaviors account for only about 1/3 of higher death risk o Whitehall II: for men and women social position strongly correlated with morbidity and mortality Week 2 Discussion Post: The concept "social gradient of health" refers to how health relates to an individual's socioeconomic status. It demonstrates how one's social and economic status affects their health status, for example how a lower social status corresponds to less adequate health. Marmot states that "In each country, the higher the socioeconomic quintile of the household, the lower the rate of child mortality. It is a gradient, not simply that the poor have high mortality and it is better for everyone else" (Marmot 561). Marmot makes the distinction that the social gradient of health does not mean that only those living in poverty suffer from not having sufficient health care. The degree of adequate health correlates to one's socioeconomic status. The relationship is relatively linear. The social gradient of health does not only take into consideration one's access to health care but rather all the resources available to those within a certain socioeconomic class such as education, job security and safe communities. Class Notes (Day 4): Whitehall I studies, findings: Higher risk of death due to CVD for men in lower occupational grades Men in lower job classes also had higher risk of negative health behaviors But even after controlling for these behaviors, risk of death among men of low social status was higher Health behaviors account for only about 1/3 of higher death risk Note: health “risk” behaviors correlate with social position, compounding risk Whitehall II studies, findings: For men and women, social position strongly correlated with morbidity and mortality Relationship holds for a wide range of health/illness conditions: pulmonary disease, heart disease, stroke, cancer, depression, pain, subjection ratings of health Health “risk” behaviors also correlate inversely with social position Whitehall StudiesImplications: If health behaviors and access to medical care don’t fully explain disparities in health and illness in populations, what does? Social Gradient of Health: Health outcomes correlate with social position all along the social hierarchy (not just at the “top” and “bottom”) Not just absolute material deprivation (poverty) but relative deprivation that impacts health Health exists on a gradient with social inequality A “doseresponse” effect, all along the social hierarchy, suggests independent effects of inequality on health Correlation demonstrated in poor and rich countries, within and between nations; for men and women While absolute rates of morbidity or mortality may improve, disparities between groups persist Mechanisms of Action?: How do we explain the strong correlation between social position, inequality, and health outcomes at the populations level? Hypotheses: empowerment, control, leading a life of value, freedom, autonomy (Marmot 2006); social comparison; social ties, belonging, engagement, cohesion, place, community supports, social networks, discrimination o Stress, but produced by social conditions; stress produced by social hierarchy; psychosocial impacts of inequality (Wilkinson) Film In Sickness and in Wealth Week 3 Reading Notes: Geronimus Racial differences in health are evident at all socioeconomic levels o Geronimus proposed the “weathering” hypothesis to this phenomenon that suggests that Blacks experience early health deterioration due to the impact of repeated marginalization socially, economically and politically. o The stress of living in a race conscious society that stigmatizes and disadvantages Blacks leads to disproportionate deterioration in health Composed a research study to determine if this hypothesis was true o Found that Blacks had a higher Allostatic load score than whites in their given age bracket o Found that women had higher Allostatic loads than both Whites and Black men Their allostatic loads were more significant than that of their male counterparts and of whites in general Week 3 Discussion Post: Geronimus proposed the “weathering” hypothesis to that suggests that Blacks experience early health deterioration due to the impact of repeated marginalization socially, economically and politically. Race is a social determinant of health, the evidence to support this is presented in Geronimus' research which found that Blacks have a higher mean allostatic load (AL) score in comparison to the whites in their given age bracket (Table 1). The data revealed that Black women in particular had a higher AL score overall and therefore suffered more health issues. This alone shows how race and gender interact to impact the health of Black people in the U.S. The evidence presented in the article showed that not only do Black people suffer more health issues due to their race but that gender and class can interact with one's race and detrimentally impact their health even further. Class Notes (Day 5) Review: social gradient of health Not just absolute material deprivation (poverty) but relative deprivation that impacts health Health exists on a gradient with social inequality A “doseresponse” effect, all along the social inequality on health Correlation has been demonstrated in poor and rich countries, within and between nations; for men and women While absolute rate may improve, disparities can worsen Hypotheses to explain the relationship between social position and health: Empowerment, control, leading a life of value, freedom, autonomy (Marmot 2006); social comparison; social ties, belonging, engagement, cohesion, community supports, social networks, discrimination Placebased impacts; communitylevel Stress, produced by social conditions; psychosocial impacts on inequality (Wilkinson) Macaque studies: stress of social hierarchy (monkeys) Cold studies: intergenerational effects of social position on health What can be done? Social policies are health policies Can reduce inequality through social policies Urban planning, mixedincome housing Open and green spaces Transportation Public programs that provide opportunities for well being and flourishing Intersectoral action Race: anthropological perspectives: “A culturally structured way of looking at, perceiving, and interpreting physical or phenotypic differences in humans” Embodiment of racial inequalities: Race becomes or impacts biology via: o The social and cultural reality of race and racism o Public understandings of “racial disparities in health”, defined along culturallynormative lines o Evidence form health disparities Data Analysis: US: life expectancy at birth (in years) by race/ethnicity, 2010 o White = 78.9 o African American = 74.6 o Latino = 82.8 o Asian American = 86.5 o Native American = 76.9 Genetic differences: o David and Collins’ study comparing US born blacks, African born blacks, US born whites Results: percentage of low birth weight = US born blacks = 7.5% African born blacks = 3.6% US born whites = 2.6% Explanatory models: race and health Individual health risk behaviors Inherent genetic differences by racial group Socioeconomic status – income, education Social structure, history and cultural context (e.g. residential segregation) Perceived discrimination and racism Stress/psychosocial stress Biological pathways allostatic load “Weathering” hypothesis: life course perspective Film “When the bough breaks” Week 4 Class Notes (Day 6) Review Day: Weathering Hypothesis o Posits that Blacks experience early health deterioration as a consequence of the cumulative impact of repeated experience of social and economic adversity and political marginalization o Prolonged coping with social disadvantage and prejudice “weather” on the body over time producing greater health inequality with age o Racism (and lived experiences of discrimination) negatively impact health outcomes o Allostatic load is a useful measure of “weathering” (Geronimus et al. p. 826) “If we want to improve birth outcomes of African American women we need to improve the quality of life starting generations back” For all ethnicities allostatic load increases as age increases Black women in particular have a higher allostatic load overall than any other ethnic group Black men are second, white women third, white men fourth Implications: Social experience of race structures health outcomes among African Americans Race and gender interact so that Black women suffer disproportionate health effects Racial impacts on health not fully explained by poverty “American public sentiment on race…exacts a physical price across multiple biological systems among Blacks who cope with stressful life conditions Preston Curve o Sums up relationship between development and health o Demonstrates a steep positive correlation between an increase in GDP and life expectancy up to a certain point (about 5,000 GDP) Growth in GDP has a positive impact on life expectancy. McKeown Hypothesis (Textbook Chapter 3) McKeown: physician and demographer Researched the role of three factors influencing population health (especially measured as declines in infectious disease mortality) Medical advances Reduced exposure to infectious agents Nutrition improvements Argues that declines in death rates are due to primarily to improvements in living standards Public health and biomedicine Public health Focuses on populations Disease: result of social conditions, policy decisions Services: communitybased, participatory, health promotion, social and environmental interventions Best practices: societal, populationbased interventions Aim: prevention Medicine: Focuses on individuals Disease: function of biology and pathology Best practices: clinical care of patient Services: medical interventions, pharmaceutical agents, delivered through hospitals and clinics, by professionals Aim: cure Week 4 Discussion Post: Today’s global health is the product of colonial establishments. The legacy of the colonial approach to global health is bittersweet. There are successes, such as the World Health Organization’s success in eradicating smallpox, and there are failures like the failure to eradicate malaria. The success of the WHO in eradicating smallpox can be found in the way the program was designed as well as the nature of the disease they were tackling. Smallpox is a disease that is easy to identify and to treat effectively. Even though the program was successful, controversy has arisen that it did not approach the issue in a way that was sustainable. The top down approach that the program took, while successful, compromised community based primary care initiatives. The WHO’s inability to eradicate malaria is a prime example of how colonialism fails to account for cultural differences when they implement their programs. The top down approach taken with the malaria eradication program was not as successful as it was with the smallpox eradication effort. The way the WHO underestimated the agricultural influence of the areas where they were trying to eradicate malaria led to the program’s downfall. Class Notes (Day 7) EpidemiologyHistorical roots: o John Snow and the Broad Street pump o Miasma theory: exposure to unsanitary environments and “bad air”, noxious vapor, responsible for disease spread o 1854: John Snow investigated cholera outbreak in London neighborhood, cases cluster around the pump o Methods of investigation: case identification, mapping, identification of source/cause o Intervention: removal of the pump; provision of clean water Epidemiology approach: o Determining associations between some characteristic of the environment (“exposure” or “risk factor”) and some characteristic of the population (disease/illness) o Aim: determine risk or etiology of disease, use research to inform policy to address disease in populations o risk factor approach: which factors increase risk of contracting disease? o Outcome statistics: often expressed as odds ratio (e.g. what are the increase probabilities of contracting disease given X risk factor) Epidemiology: o explores association between risk factors (behavioral, environmental, social) and disease; does not provide causal explanation o to get closer to causality: engage specific study designs analyze data using statistical processes to control for possible alternative explanations a science of association at the population level Epidemiology measures: o disease burden in a population o prevalence: number of existing cases of a disease in a population at a point in time o incidence: number of new cases in a period of time o morbidity: rates of disease o mortality: rate of death o rates: standardized per population size (usually expressed per 1,000) Indicators of population health o life expectancy (LE) o Mortality rates o excess death Child and infant mortality indicators o child mortality rate: death of children in first 5 years o infant mortality rate: death to infants in first year o neonatal mortality rate: death from 028 days of life o perinatal mortality rate: from 22 weeks gestation through 7 days postbirth Causes of child death o preterm birth and low birth weight o infectious disease (malaria, measles) o diarrheal disease o respiratory infections o malnutrition o ⅔ of child deaths globally are preventable Composite Global Health Measures o statistical measure that capture impact of disease on populations, combine prevalence/incidence with impact o examples: DALY developed for 1990 WHO global burden of disease study; used in tracking global burden of disease o HALE, QALY, YYL, YPL o these measure compare actual health status with some measure of average or anticipated health o global burden of disease: WHO measure of impact of health problem on a population DALY: disability adjusted life year o 1 DALY can be thought of as 1 year of “healthy life lost” o a health gap measure which combines information on the impact of premature death, and of disability and morbidity o Sum of DALYs across a population = the burden of disease for that condition o measures gap between current health status and an ideal situation where entire population lives to advanced age, free of disease and disability DALY and QALY o DALY = YLL and YLD YLL = years of life lost to premature mortality YLD = years of life lost to disability o QALY: quality adjusted life year calculated using ideal health status metric where 1.0 = full health and 0 = death Why do we measure all of this? o one of WHO’s main functions o data collection, monitoring, surveillance o global burden of disease tracking o provides comparative information across populations, nations, regions o helps inform policy making and programs o informs allocations of resources Week 5 Reading Notes: Gandy and Zumla Tuberculosis remains the world’s leading cause of preventable illness o now more prevalent than in any previous period of human history o WHO calculated that about ⅓ of the human population has been infected with TB o About 3 million people die of TB a year o TB is the most prevalent infectious cause of death o streptomycin was discovered in 1944 (anti TB drug treatment) o Eradication of TB cannot be achieved through medical means alone must also assess the social aspect of it The ‘new’ Tuberculosis o drug resistant strains encountered soon after the discovery of antituberculosis drugs now have to use multidrug treatments In Russia mutant forms of TB, variously referred to as multidrug resistant tuberculosis (MDRTB), have been rapidly spreading in response to chronic overcrowding in the prison system and severe cutbacks in primary health care A signiﬁcant barrier to the control of MDRTB: is the lack of good epidemiological data on the prevalence and distribution of such resistance the lack of adequate laboratory facilities for its detection, evaluation and monitoring o coinfection with HIV In Africa, however, HIV is responsible for at least 20 per cent of TB cases Infection by HIV is currently the most important predisposing factor for the development of overt tuberculosis in those infected by M. tuberculosis before or after becoming HIV positive o social and economic developments affecting access to medical care Mass movements of people in response to war, economic insecurity, community disruption and other factors have been involved in the spread of TB and other infectious diseases associated with crowding, makeshift housing and poor sanitation A substantial body of evidence suggests that tuberculosis has a disproportionate impact on the economically poor: 95 per cent of all TB cases and 98 per cent of TB deaths occur in the developing world where problems of illhealth contribute towards vicious cycles of economic hardship in the context of high unemployment and weak social security and health care provision SmithNonini TB is spread by poverty o by striking men and women in their prime it also creates poverty Multidrug resistant forms of TB are not localized o studies have found that the strains are travelling sometimes through airlines The means to cure TB have been around for many years o however, now that there is MDRTB there is a need for change in public health models Eradicating TB cannot be done using only medical means If TB is to be cured the welfare of people, in all their aggregate and individual complexities will have to be the forefront of health planning, funding, and advocacy It’s not just the problem of developing nations o The TB outbreak in New York Week 5 Discussion Post: SmithNonini classifies MDRTB as a social disease because of how one’s social standing affects their susceptibility to the disease. The article notes that MDRTB is spread by poverty. Those who are poorer tend to have a lower standard of health which makes them more susceptible to getting tuberculosis. Due to the fact that TB is a preventable disease its presence is an indicator of inadequate health resources which is why it is found to be more prevalent in poorer communities. Controlling the spread of MDRTB comes down to the resources available to communities. Poorer communities have more difficulty obtaining resources to control MDRTB outbreaks than affluent communities. Poverty stricken areas tend to be populated with people who suffer from malnutrition, HIVAIDS, and homelessness, all of which make a person more susceptible to contracting MDRTB. The disease certainly is a social one due to how it is much more of a concern for people with lower social standing than those in more affluent communities. Class Notes (Day 8): Epidemiological transition theory o Shift in global burden of disease from communicable (infectious) to noncommunicable (chronic) conditions o Communicable/ infectious diseases: transmittable to host by outside source (vectors, body fluids etc.) o Noncommunicable/ chronic conditions: conditions “within host”, usually due to degeneration (aging) o Transition occurs over centuries of human history o Health transition accompanied by demographic transition: decline in fertility rates and increase in life expectancy o “A longterm shift in mortality and disease pattern whereby pandemics of infection are gradually displaced by degeneration and manmade diseases as the main causes of morbidity and mortality” (Omran 1971) o From “diseases of poverty” to “disease of affluence” “Marks a fundamental change in main determinants of health…the point in economic development at which the vast majority…gained access to the basic material necessities of life” (Wilkinson p. 39). Explanations for the epidemiological transition o Medical advances, public health interventions o McKeown hypothesis (rising living standards lead to a decline in infectious diseases) o The impact of economic growth on health “levels off”; there is a point where absolute material standards of living no longer explain population health outcomes Health transition in critical perspective: o This transition is uneven; persistence of poverty, underdevelopment and infectious disease o Underlying assumptions are problematic, reflect linear model of “development” o The shift to chronic conditions (and the reemergence of infectious conditions) are in fact due to the conditions of “development” o In many countries the worseoff are bearing the burden of chronic diseases Measuring income inequality o Gini coefficient: a coefficient that varies between 0 and 1 Where 0 is perfect equality and 1 is perfect inequality “perfect” or complete equality is a statistical/hypothetical notion closer to 0, income distribution is more equal or egalitarian closer to 1, income distribution is more unequal or less egalitarian Class Notes (Day 9): Relative income matters: o beyond a certain level of absolute economic productivity (at GDP $5,000 per capita), economic growth (overall income) matter less to population health than economic distribution or inequality o after the epidemiological transition, population health is associated with relative income distribution o strong correlation between percent of national income held by bottom 70% of population and life expectancy in 9 OECD (developed) countries = stronger predictor than GNP per capita Relative income hypothesis: that income inequality affects health; not just absolute or individual income but relative social position o in fact, health is one of the most sensitive indicators of the social costs of inequality o “The burden of ill health, we shall argue, is a major reason why we should care as a society about the growing economic distance between the top and bottom” (Wilkinson et al. 1999) o Income inequality (distribution) impacts health of populations especially in middle income affluent nations o “The countries with the longest life expectancy are not the wealthiest but those with the smallest spread of incomes and the smallest proportion of the population in relative poverty” Possible mechanisms for the relative income hypothesis o access to opportunities o social comparison; social support, cohesion o public participation, collective efficacy o stress of relative deprivation; “social meanings of deprivation” (Wilkinson p.42) o inability to achieve social role/status and mental health consequences o less investment in public infrastructures o “competitive spending”, stress Impacts of inequality on population health? o Social cohesion, trust, civic engagement and participation o Sense of insecurity, instability, uncertainty o Loss of work loss of identity, mental health consequences (violence, depression, suicide) o Resurgence of infectious diseases/diseases of poverty (when people lack basic social determinants of health) o Popular protest and mobilization What can be done? Government action on economic policy Policies that promote employment Progressive taxation Supports for working families (child care) Higher minimum wage Global inequality o Nearly ½ of the worlds wealth is owned by 1% of the population o The wealth of the top 1% = $110 trillion = 65 X the wealth of the bottom 50% o 7/10 people worldwide live in countries where economic inequality has worsened o since the economic crisis of 2008/2009 more than 90% of economic growth has gone to the top 1% Health transitions in anthropological perspective o first epi transition: rise to infectious disease accompanying neolithic period, settlements o second epi transition: industrialization; rise in chronic disease combined with increase in public health infrastructure → infectious disease decline o third epi transition: (1980s) globalization and neoliberal restructuring → infectious disease (re)emergence Global political economy o “Washington Consensus”: economic policies est. by major development agencies and “exported” to Global South (19701990s) o Neoliberalism: economic policies associated with “open” markets, “free” trade, deregulation, denationalization, privatization, cuts to government spending (“austerity”), opening to foreign investment o policies adopted to pursue goal of growth (GDP) o despite some GDP growth, poverty and inequality increase Political economy of global health o policies: “opening” markets to foreign investment, borrowing from foreign banks, privatization of public services (including: water, energy, health care), cuts in government spending o impacts: unemployment, wage reductions, dismantling of social programs, privatization of medical systems, health care cost increases (via user fees and payment for basic primary care) Debt o Postwar and postcolonial period marked by massive accrual of national debts to foreign lenders and IFIs o Debt incurred to engage in “modernization and development” o Industrialization (roads, rail, mines, dams, cities) requires massive capital investment o National (and household) economies entangled in cycles of debt SAPs o structural adjustment policies: policies pushed by international lenders on debtor nations o require “austerity”: cuts to government spending, including education, health, social programs, reductions to public sector wages and pensions, etc. o provoke popular/civil society response/protest Third epidemiological transition o re/emergence of infectious diseases o rise in antimicrobial resistance o globalization of economy, travel, tourism, etc. o in the U.S., ageadjusted mortality due to infectious disease has increased o globally, dozens of new pathogens have emerged in past few decades o impact of climate change o patterns of disease emergence map onto patterns of poverty and inequality Tuberculosis: re/emergence o TB is among the largest contributors to global mortality and top infectious causes of death o long considered the classic “disease of poverty” o Nearly 10 million new cases and @ 20 million active cases worldwide; 1.5 million deaths (2014) o US prevalence rate: 3 per 100,000; overall declines but disparities by race/ethnicity and SES o 95% of all TB cases occur in “developing” countries o comorbidity with HIV is a large problem, 1:3 HIV deaths worldwide is due to TB o drugresistance → MDRTB o despite global fund treatment gaps persist Week 6 Class Day 10: MIDTERM 1 Week 6 Discussion Post: 1) In 1997 and 1999 the people of the Matsigenka community had a biomedical assessment. Their weights and heights measured. They also had their hemoglobin and protein levels measured. From the data obtained it was found that the 1999 community had an improvement in their health. 2) The interviews showed that there was an overall decline in mental health during the time period. 3) The Matsigenka community should have been healthier because of their strong beliefs in being selfless and having peace. However, the individual and societal indicators show that they are not healthier. In fact they were more stressed. Interestingly, the biomedical measures showed that their health improved and that the societal and individual indicators had improved. The increased health is due to better health education, better nutrition, and improved water supply. While all of this increased the biomedical indicators for health, the Matsigenka community puts more weight in their spiritual health than their physical health. Class Notes Day 11: Epidemiology/Anthropology o For social epidemiology: distributions of morbidity and mortality matter; assessments of health status of populations; demonstrate associations between risk factors and disease o For medical anthropology: cultural meaning matters; understanding illness as lived experience; associations between cultural change/disruption and sickness/illness Anthropology & Global Health o Questions of meaning, lived experience and an emic (from within the social group) perspective are central to anthropological concerns o Considering other cultural ways of understanding sickness and of being ill as rational responses to particular social histories and lived experiences o Avoiding ethnocentric assumptions or value judgements about the healthrelated behaviors or beliefs of cultural “others” o Moving beyond considerations of “risk behaviors” at the individual level o Considering risk as socially and structurally produced o Situating individuals within broader political, economic, social contexts Structural violence o A concept articulated by Paul Farmer to describe the structural, politicaleconomic, historical underpinnings of disease and illness (AIDS to TB) o Farmer: blaming culture, beliefs, or behaviors for disease is “victimblaming” – not recognizing larger socialstructural barriers to health o Health inequalities result from power in inequalities Disease/illness o Disease: biological pathology, observable, verifiable, “objective” o Illness: lived experience of illhealth, more “subjective” o Some element of “subjectivity” or “error” in all measurement; “positioned objectivity” or “situated knowledge” Belief and Difference o What to make of “traditional” (or worse, “primitive”) beliefs about health? o How to responds to the “other” especially when “others” act in ways discordant with our own cultural worldviews and values o Issues of difference/power/knowledge o How we respond to difference reflects our ethical disposition Assumptions of the “Medical Model” o Disease is universallyrecognized, biological pathology o Disease produces visible signs and symptoms; empirical observation is key to diagnosis o Medicine is thus a rational science o Evidence based on that which is visible, observable, replicable o Absent signs of visible pathology, patient is assumed to be “irrational” or “somaticizing” Assumptions of medical anthropology o Medical systems are cultural systems (biomedicine included) o Approach other cultural systems and beliefs on their own terms, assume the “truth” in them o Not privileging one form of knowing (The body, illness, healing) over another o Need caution around “medicalization”: converting social problems into medical problems and responding with medical intervention o Focus on lived experience, and the factors shaping that experience Example: Women’s health in Nicaragua o What is the impact of outmigration and caregiving on the health and wellbeing of women of the grandmother generation? Week 7 Class Notes Day 12: BrazilAIDS policy o 1996: first “developing” country to adopt universal access to antiretroviral (ARVs) as a public health policy o 2005: Brazil accounts for 15% of global AIDS patients receiving ARV treatment (even through only 3% of global AIDS cases) o Administered through SUS – national health system o Problem: health system is institutionally weak; AIDS programs partially strengthen but also point to limitations in public system Scaling up o Expanding locallevel health initiatives to countrylevel or internationally o Challenges: economic, administrative, political o Global expansion of AIDS treatment was pushed through global social activism o In expanding access to HIV treatment, countries were also able to expand primary health care ARV politics o In the mid1990s Brazil begins national production of ARVs via publicprivate partnerships o Brazil also imports generic ARVs from India up to 70% price reduction for these drugs o Other countries follow suit (e.g. South Africa with a “Medicines Act”) o Pharmaceutical companies react, sue, claim intellectual property rights Political economy of pharmaceuticalization o Brazilian government had to negotiate access to first line ARVs with Pharma companies o How did they do this? Why did Pharma agree? What leverage did Brazil’s government have in these negotiations with drug companies? o Brazil become a global leader & model for other developing countries at the level of the WHO, UNAIDS etc. Neoliberal AIDS policies o “far from achieving international justice in the realm of AIDS, the Brazilian response has helped expose the failures of reigning paradigms which promote publicprivate partnerships for the resolution of social problems” (Biehl p.1088) The “magic bullet approach” o Pg 1085 Biehl “Casas de Apoio” o A “proxy” family o And AIDSfriendly environment necessary to accumulate health o The right to health was groupprivatized o An intense process of individuation (of the responsibility for life/health) occurred o Moral discourse of the will to live Who is left out? o “The pharmaceuticalization of public health also promotes models of treatment inclusion that redefine some segments of the population as disposable” (p. 1086) structural factors (violence) lend some to be “better AIDS patients” than others Problem: when AIDS programs cease to be inclusive and address structural determinants of “noncompliance” Infectious/chronic disease o Infectious diseases like HIV can become chronic Survival results in chronicity Chronicity implies lack of a cure o Another critique to the epidemiological transition theory o New health care needs emerge as AIDS becomes a chronic condition Week 7 Discussion Post: Biehl uses the term “market based bio politics” to describe the way AIDS treatment was approached in Brazil. Politicians in Brazil were focused on working to bring together state and society which led to the success the country had in dealing with the AIDS epidemic. As well as the fact that politicians were taking into consideration the effect the new policies would have on the economy. Brazil now allows activist groups to determine government policy creating a social contract feel to the way the government runs. The way AIDS treatment in Brazil was handled owes much to pharmaceutical companies, social pressures, and the global market. Week 8 Week 8 Discussion Post: Eradicating smallpox was no easy task. The disease affected a myriad of people and cultures. Eradicating the disease required getting up close and personal with all of these people, making the task extremely challenging. The campaign to eradicate smallpox was molded by political, social, and ecological factors. The postcolonial era, the rise and fall of liberalism and the Cold War shaped the way the program grew. Some of the factors that made smallpox a disease that could be eradicated was its susceptibility to vaccines, the fact that it was only found in humans, and that its symptoms could be identified. The eradication of malaria assisted in the eradication of smallpox. The WHO determined that the best way to destroy the disease was through heat stable vaccines. The eradication of smallpox proved to be simpler than the eradication of malaria due to the fact that disease uses humans as the primary host and is not a virus that can be contracted from the environment like malaria can due to the way it is spread by mosquitoes. Class Notes Day 13: Guest Speaker Class Notes Day 14: Taking stock of foreign aid (Chapter 10 of textbook) o 2000’s spending in global health increases o > 22 billion annually; still a gap of @ $50 billion o in the US, foreign aid is @ 1% of budget o How efficacious is aid? o Types of organizations: multilateral, bilateral, nongovernmental, philanthropic, debt forgiveness o Tracking foreign aid for health http://vizhub.healthddata.org/fgh/ o US foreign aid is less than 2% of the gross national income the suggested amount is 7% Influences on aid’s effectiveness o Geography o Political systems, corruption o Infrastructure o Leadership and personnel o Administration and accounting o Debates: Sachs v. Easterly The accompaniment approach o Accompanying project beneficiaries o Favoring institutions that the poor favor o Fund public institutions o Coinvest with governments to build civil services o Make job creation a priority o Buy and hire locally o Use cash transfers to benefit the most poor o Regulate INGOs In class activity: values in GH o Utilitarianism: greatest good for the greatest amount of people John Stewart Mill Not a lot of space for individual freedom/ rights/ choice o Liberal cosmopolitanism: all beings belong to a single community Confidence in government Postwar mentality Veil of ignorance: we aren’t all born on the same starting line o The capabilities approach: similar to Maslow’s hierarchy of needs Freedoms Empowerment Equal opportunity Conditions in which humans can flourish o Health as a human right: people have the right to proper health care and the right to be healthy o Religious values: people try to distance themselves from religion as the reason for their “good deeds” Week 9 Class Notes Day 15: Bioethics: Methods, History and Research Historical context: o Hippocratic oath: “I will use those dietary regimens which will benefit my patients according to my greatest ability and judgment.” WWII Nazi Physicians o Unwilling victims were infected with cholera, smallpox, typhus o “Research” Nuremberg Code: part of the judicial decision condemning the atrocities of the Nazi physicians o Consent o Favorable riskbenefit ratio o Limitations: no mention of fair subject selection or independent review Declaration of Helsinki o Added the independent review o Emphasized distinction between therapeutic and non therapeutic research o Discusses the use of placebo controls Willowbrook Hospital 1956 o Study of natural course of hepatitis in institutionalized children Infected several hundred children with hepatitis and observed Tuskegee Victimhood rather than rights? Principles of bioethics: o Autonomy and beneficence o Nonmaleficence and social justice o Professional integrity Physician vs. Scientist o Best interest of the patient vs integrity of the research o Issue of equipoise: being in doubt about the relative merits of the treatments o Breach of duty to the patient o Efficacy of the treatment Women in clinical trials o Unjustly excluded o May not benefit from a trial Research in the Third World o Injustice to the control groups o Participants are coerced o Countries in question are exploited Class Notes Day 16: Ethical principles and challenges o Principles: autonomy, beneficence, justice How do these apply across cultures in international research? Informed consent o Adult participants must consent to participate in research study o Written or verbal consent? Nonliterate groups? o Vulnerable populations (pregnant women, children, prisoners)? Other vulnerabilities? o Coercion? Withholding services? o Understanding of research o Medical authority Standard of Care/ “controls” o In RCT study designs, casecontrol groups o What treatment should control groups receive? o Should there be a global standard of care? o To what extent should local conditions matter in determining treatment of control groups o To what extent should local cultural factors matter? o When does accounting for culture make research study more/less ethical? Risks and Benefits o Risk: the common rule directs IRBs to ensure that research risks are minimized through careful study design and that risks are “reasonable in relation to anticipated benefits, if any, to subjects and the importance of the knowledge that may reasonably be expected to result o Benefit: direct (therapeutic/medical); indirect (to general knowledge) Equity and social justice o The 10/90 gap o Only 10% of research resources go to address the health problems facing 90% of the world’s population Global Forum on Health Research Week 10 Week 10 Discussion Post: The global health delivery initiative in Kenya (AMPATH HIV Care) employed the use of a care delivery value chain (CDVC). A disease like HIV/AIDS requires more than a onetime treatment or vaccination, it requires constant and diligent care. The CDVC is a tool used to optimize value for patients across the various treatments they will receive. The Indiana University School of Medicine partnered with the Moi University School of Medicine in Kenya to bring HIV/AIDS treatment to the many people in Kenya affected by the disease. The program was called the Academic Model for Prevention and Treatment of HIV/AIDS (AMPATH). The program employed the use of a CDVC and targeted the disease at various points in its cycle. The program informed and engaged patients by educating them about prevention and testing them for HIV/AIDS. It then provided places where patients with the disease could receive care such as clinics and hospitals. The program also offered food and social support for those who needed it as well as antenatal care to reduce the risk of HIV transmission between mother and child. Additionally, AMPATH offered care for opportunistic diseases associated with HIV/AIDS such as Kapok's sarcoma and TB. By 2007 AMPATH extended the program to a homebased counseling and testing program so that they could reach more people in need of treatment. Overall the steps the program took definitely follow the path of a CDVC. Each piece of the chain is accessible to those who need it and very valuable to their health. Class Notes Day 17: Guest Speaker Pathology: o Diagnoses o Microscope is the primary diagnostic tool o Must often determine is it cancer? Partners in Health o Developed a cancer center in Butaro, Rwanda The cancer center services the entire country Wanted to provide quality cancer care in a rural setting Wanted to show that they could provide cancer care to poor Health center: a place for primary care Class Notes Day 18: Rwanda & GH o PIH Haiti (since the 90s) to Rwanda (2005) o Post2000 nation, postwar restructuring o Government (Kagame) ejects NGOs, sets terms and regulates their operation incountry o Goal: aidindependent by 2020 o GDP quadrupled o
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