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

2. 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

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

4. How healthy is the US? Health Olympics
Number one Gold
_______
_______
_______
_______
_______
_______
_______

8. 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

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

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

11. 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

13. Tom Mosser Harvard Magazine pg 17

14. RGW Figure
Wilkinson & Pickett 2009 Spirit Level

15. 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

16. 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

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

18. SEARCH reparations and global reparations

19. 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

20. 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

21. 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

22. 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

23. 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):

24. 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):

25. 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):
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):

26. October 4, 2010

27. Jeanne Shepard

28. how important is MEDICAL CARE?

29. 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.

30. 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