Global Health Challenges Social Analysis 76: Lecture 6 Harvard University Initiative for Global Health

Harvard University Initiative for Global Health Framework for Analyzing Health Problems Why Are There Long-Term Secular Trends: Income, Education and Technology Where Can We Intervene? What Are the Barriers to Intervention? Harvard University Initiative for Global Health

Harvard University Initiative for Global Health Stylized Causal Web Many social, economic, political, cultural, individual, environmental and health system factors influence each other. Useful to simplify complex set of interactions to provide a general approach to health problems. Harvard University Initiative for Global Health

Harvard University Initiative for Global Health Societal Factors Health System Individual Attributes Behaviors Practices Physiology and Pathophysiology Functional Impairment Physical Environment Disease/Injury Death Harvard University Initiative for Global Health

Harvard University Initiative for Global Health Societal Factors Political system – income redistribution, investment in education and health, public action for health improvement etc. Economic factors – types of economic activity, economic growth, unemployment, etc. Social and cultural factors – belief systems, religion, inheritance, socially sanctioned sexual relationships, etc. Harvard University Initiative for Global Health

Individual or Household Attributes Educational attainment Income and wealth for the individual or household Preferences and beliefs Harvard University Initiative for Global Health

Behaviors and Practices Diet Physical activity Substance use – tobacco, alcohol, illicit drugs Sexual practices Use of seatbelts and other safety equipment Use of health services Harvard University Initiative for Global Health

Physiological and Pathophysiological Factors Exposure to pathogens Immunity Physiological Risks Harvard University Initiative for Global Health

Harvard University Initiative for Global Health Health System Promotive Preventive Curative Rehabilitative Palliative Harvard University Initiative for Global Health

Harvard University Initiative for Global Health Societal Factors Health System Individual Attributes Behaviors Practices Physiology and Pathophysiology Functional Impairment Physical Environment Disease/Injury Death Harvard University Initiative for Global Health

Harvard University Initiative for Global Health Framework for Analyzing Health Problems Why Are There Long-Term Secular Trends: Income, Education and Technology Where Can We Intervene? What Are the Barriers to Intervention? Harvard University Initiative for Global Health

Harvard University Initiative for Global Health 250 Years of Child and Adult Mortality Harvard University Initiative for Global Health

Explaining Long-Term Trends in Health How do we account for 250 years of child mortality decline in Sweden? Can attempt to answer this question at many levels: changes in pathogen exposure, immunity and micro-nutrient deficiencies. Or changes in societal factors that have led to increases in income/wealth and individual education. Or changes in health technology. Harvard University Initiative for Global Health

Education and Child Mortality Studies in the 1970s strengthened by birth history data collected in the World Fertility Survey consistently demonstrated that child mortality decreases as maternal education increases. The relationship for maternal education is stronger than for paternal education. The relationship appears to be continuous, higher levels of education in nearly all societies is associated ceteris paribus with lower child mortality. One of the most consistent relationships discovered in global health. Harvard University Initiative for Global Health

Low Quality Education Effects Household survey data suggest that even a single year of schooling in a low quality educational system has a detectable impact on child mortality. What is the mechanism of this effect? Harvard University Initiative for Global Health

Mechanisms for the Education Effect Knowledge of disease causation through health education in school – relatively small component. Increased probability of seeking health care when a child is sick. Increased capacity to acquire knowledge from media and other sources. Empowerment of the role of the mother in household decision-making. Changes in fertility, labor force participation and other behaviors. Harvard University Initiative for Global Health

Post-Independence Primary School Expansion With independence from colonial rule in sub-Saharan Africa, South Asia and elsewhere, many governments expanded primary school systems. Even in the poorest countries, there has been an increase in levels of educational attainment. Harvard University Initiative for Global Health

Trend in years of schooling by world region Harvard University Initiative for Global Health

Harvard University Initiative for Global Health Income Growth Rising income leads to improved nutritional status, better housing, water supply and sanitation, increased use of health services, access to more health information, etc. Increases in income over the last 2 centuries particularly in the 20th century have been an important driver of improvements in health in developed countries. Harvard University Initiative for Global Health

GDP per capita by world region Harvard University Initiative for Global Health

Harvard University Initiative for Global Health Technology At any given level of income per capita and educational attainment, the level of population health achieved by a country has been steadily rising over the last century. This improvement in health for a given level of income and education is attributed to improvements in technology, mostly health technology. Harvard University Initiative for Global Health

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Harvard University Initiative for Global Health New Technologies For each disease or risk factor, we will review recent technologies and potential new technologies that could transform the way we approach a health problem. The lag between technology development and widespread implementation can be years to decades – in a number of cases interventions that are decades old have not yet been implemented in poor populations. Harvard University Initiative for Global Health

Harvard University Initiative for Global Health Framework for Analyzing Health Problems Why Are There Long-Term Secular Trends: Income, Education and Technology Where Can We Intervene? What Are the Barriers to Intervention? Harvard University Initiative for Global Health

Past Trends vs. Future Intervention Causes of past trends in health especially in high-income countries (where they are well-documented) do not dictate the only modalities of improving health in the future. Opportunities for intervention exist at each level of the causal web: curative, preventive and promotive healthcare, policy changes to encourage behavior change, targeting education and income growth to the poor, etc. Harvard University Initiative for Global Health

Balancing Impact and Opportunity Many options for intervention – these will vary in impact in real populations. Pursuing one set of interventions such as raising tobacco taxes, legislating drug driving rules and enforcing them, or using conditional cash transfers to increase health service use all come with opportunity costs. Resources both financial, human, managerial and political are finite so there are trade-offs. Many of the most difficult debates in global health relate to how to balance or choose between different intervention options. Harvard University Initiative for Global Health

Harvard University Initiative for Global Health Framework for Analyzing Health Problems Why Are There Long-Term Secular Trends: Income, Education and Technology Where Can We Intervene? What Are the Barriers to Intervention? Harvard University Initiative for Global Health

Harvard University Initiative for Global Health Barriers Resources – financial, human and institutional Political – lack of problem recognition or willingness to spend public resources Social – individual vs societal responsibilities Cultural – alternative belief systems on disease causation Harvard University Initiative for Global Health