GLOBAL HEALTH INEQUALITIES Stephen Bezruchka MD, MPH Departments of Global Health & Health Services School of Public Health University of Washington

United States or Sri Lanka QUIZ If you are a girl aged 15 in which country do you have a better chance of reaching age 60? United States or Sri Lanka

Adult Female Mortality 1970-2010 Sri Lanka US Adult Female Mortality 1970-2010

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

http://www.youtube.com/watch?v=Q0X2exKyC7k

POPULATION HEALTH Health has been improving most of the last century, Health improvements are not shared equally Health Inequities (poorer people have poorer health) Early Life: critical for adult health

Survival Rate on the Titanic 60 % 40 % 25 % 24 %

SOCIOECONOMIC GRADIENT IN HEALTH RGW Figure 1.3 2009 Wilkinson & Pickett 2009 Spirit Level

Spatial-temporal spectrum of human health around the globe 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

Tom Mosser Harvard Magazine pg 17

RGW Figure 1.1 2009 Wilkinson & Pickett 2009 Spirit Level

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

Countries ranking in health WHY? Theory of Global Health Where they ranked when the race started When they got out of the starting blocks (when did health begin to improve) Mix of factors influencing health improvements

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

SEARCH reparations and global reparations

Global income wealth inequality + WHAT IS THE ROLE FOR PRIMARY CARE? - evidence is accumulating that suggests of all the aspects of medical care, the one with the most significant positive impact on population health may be primary health care I want to report on some data that looks at population measures of primary care: Shi and Starfield from Johns Hopkins use a state ecological analysis with Kawachi and Kennedy from Harvard to show that

GLOBAL INCOME DISTRIBUTION BY QUINTILES Milanovic, B. (2011). The haves and the have-nots: a short and idiosyncratic history of global inequality. New York, Basic Books. Width of block proportional to people there Milanovic 2011

A girl is a mother from the time of her own conception MOTHERHOOD A girl is a mother from the time of her own conception

Poor Pregnancy Conditions Related to entire life history of woman before she become pregnant Impacted by parents Impacted by grandparents Impacted by previous generations Coall & Chisholm (2003) Flinn 1996

Poor Pregnancy Conditions Increased Risk of EARLY LATER LIFE Pre-term Delivery Low Birth Weight Caesarian Section Infant Mortality Behavioral Problems Poor School Performance Earlier reproduction Cardiovascular Disease Obesity Metabolic syndrome Diabetes Hypertension Common Cancers Early death Coall & Chisholm (2003) Flinn 1996 Seckl, J. R. and M. C. Holmes (2007). "Mechanisms of Disease: glucocorticoids, their placental metabolism and fetal'programming' of adult pathophysiology." Nature Clinical Practice Endocrinology & Metabolism 3(6): 479-488.

Poor Pregnancy Conditions Increased Risk of EARLY LATER LIFE Pre-term Delivery Low Birth Weight Caesarian Section Infant Mortality Behavioral Problems Poor School Performance Earlier reproduction Cardiovascular Disease Obesity Metabolic syndrome Diabetes Hypertension Common Cancers Early death Coall & Chisholm (2003) Flinn 1996 Seckl, J. R. and M. C. Holmes (2007). "Mechanisms of Disease: glucocorticoids, their placental metabolism and fetal'programming' of adult pathophysiology." Nature Clinical Practice Endocrinology & Metabolism 3(6): 479-488.

LBW (proxy) associated with Hypertension Type 2 diabetes Obesity, metabolic syndrome Coronary heart disease Stroke Osteoporosis Depression and psychoses (e.g. schizophrenia) Age-related cognitive impairments Chronic renal failure Altered gonadal responses Altered immune responses Overall reduced life expectancy Coall & Chisholm (2003) Flinn 1996 Seckl, J. R. and M. C. Holmes (2007). "Mechanisms of Disease: glucocorticoids, their placental metabolism and fetal'programming' of adult pathophysiology." Nature Clinical Practice Endocrinology & Metabolism 3(6): 479-488. Seckl, J. R. and M. C. Holmes (2007). "Mechanisms of Disease: glucocorticoids, their placental metabolism and fetal 'programming' of adult pathophysiology." Nature Clinical Practice Endocrinology & Metabolism 3(6): 479-488.

October 4, 2010

Jeanne Shepard

how important is MEDICAL CARE?

consequential as medical care is for individual cases "As dramatic and consequential as medical care is for individual cases and for specific conditions, 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. Schoeni, R. F., J. S. House, et al., Eds. (2008). Making Americans healthier : social and economic policy as health policy. New York :, Russell Sage Foundation.

SUMMARY WHAT WE KNOW Health Determinants of nations Where countries were in the health olympics starting blocks related to colonial and imperial era (W. Europe advantaged) Culture, values, ethos (Japan, Vietnam) How well they provided basic needs (India, SS Africa) Sense of community, social capital (Hispanics) How much they support early life (Scandinavian ) How much they support ALL (social welfare systems) China Economic growth whether rapid & shared or not Taiwan vs US Rapid economic change (India, China) Political systems, POLICIES that redistribute (culturally driven) Hierarchy details: economic, social Japan Access to primary health care Kerala, Sri Lanka