This document provides an introduction to global health. It defines global health as health problems that transcend national boundaries and require international cooperation. Key topics discussed include the link between water, sanitation, and health; the environmental, social, economic, and political factors influencing diseases like cholera; and the disciplines involved in global health like social sciences, economics, and environmental sciences. The document also examines determinants of health, measures of health status, the global burden of disease, and how health patterns differ in resource-poor and resource-rich countries.

1. Introduction to GlobalIntroduction to Global
HealthHealth
ByBy
A.Arputha Selvaraj APMP IIM CalcuttaA.Arputha Selvaraj APMP IIM Calcutta

2. Learning ObjectiveLearning Objective
To understandTo understand the link between water,the link between water,
sanitation and health from a globalsanitation and health from a global
perspective.perspective.
To understand the environmental,To understand the environmental,
social, economic and political factorssocial, economic and political factors
playing a role in cholera.playing a role in cholera.

3. DefinitionDefinition
 What isWhat is global healthglobal health??
• Health problems, issues, and concernsHealth problems, issues, and concerns
that transcend national boundaries,that transcend national boundaries,
which may be influenced bywhich may be influenced by
circumstances or experiences in othercircumstances or experiences in other
countries, and which are best addressedcountries, and which are best addressed
by cooperative actions and solutionsby cooperative actions and solutions
(Institute Of Medicine, USA- 1997)(Institute Of Medicine, USA- 1997)

4. Global Health IssuesGlobal Health Issues
 Refers to any health issue that concernsRefers to any health issue that concerns
many countries or is affected bymany countries or is affected by
transnational determinants such as:transnational determinants such as:
• Climate changeClimate change
• UrbanisationUrbanisation
• Malnutrition – under or over nutritionMalnutrition – under or over nutrition
Or solutions such as:Or solutions such as:
• Polio eradicationPolio eradication
• Containment of avian influenzaContainment of avian influenza
• Approaches to tobacco controlApproaches to tobacco control

5. Historical Development of TermHistorical Development of Term
 Public HealthPublic Health: Developed as a discipline in the mid: Developed as a discipline in the mid
1919thth
century in UK, Europe and US. Concerned morecentury in UK, Europe and US. Concerned more
with national issues.with national issues.
• Data and evidence to support action, focus on populations,Data and evidence to support action, focus on populations,
social justice and equity, emphasis on preventions vs cure.social justice and equity, emphasis on preventions vs cure.
 International HealthInternational Health: Developed during past: Developed during past
decades, came to be more concerned withdecades, came to be more concerned with
• the diseases (e.g. tropical diseases) andthe diseases (e.g. tropical diseases) and
• conditions (war, natural disasters) of middle and low incomeconditions (war, natural disasters) of middle and low income
countries.countries.
• Tended to denote a one way flow of ‘good ideas’.Tended to denote a one way flow of ‘good ideas’.
 Global Health:Global Health: More recent in its origin andMore recent in its origin and
emphasises a greater scope of health problems andemphasises a greater scope of health problems and
solutionssolutions
• that transcend national boundariesthat transcend national boundaries
• requiring greater inter-disciplinary approachrequiring greater inter-disciplinary approach

6. Disciplines involved in GlobalDisciplines involved in Global
HealthHealth
 Social sciencesSocial sciences
 Behavioural sciencesBehavioural sciences
 LawLaw
 EconomicsEconomics
 HistoryHistory
 EngineeringEngineering
 Biomedical sciencesBiomedical sciences
 Environmental sciencesEnvironmental sciences

7. Communicable Diseases and RiskCommunicable Diseases and Risk
FactorsFactors
 Infectious diseases are communicableInfectious diseases are communicable
But..But..
 so are elements of western lifestyles:so are elements of western lifestyles:
• Dietary changesDietary changes
• Lack of physical activityLack of physical activity
• Reliance on automobile transportReliance on automobile transport
• SmokingSmoking
• StressStress
• UrbanisationUrbanisation

8. It’s the Real ThingIt’s the Real Thing

9. Key Concepts in Relation to GlobalKey Concepts in Relation to Global
HealthHealth
1.1. The determinants of healthThe determinants of health
2.2. The measurement of health statusThe measurement of health status
3.3. The importance of culture to healthThe importance of culture to health
4.4. The global burden of diseaseThe global burden of disease
5.5. The key risk factors for variousThe key risk factors for various
health problemshealth problems
6.6. The organisation and function ofThe organisation and function of
health systemshealth systems

10. 1. Determinants of Health1. Determinants of Health
 Genetic make upGenetic make up
 AgeAge
 GenderGender
 Lifestyle choicesLifestyle choices
 Community influencesCommunity influences
 Income statusIncome status
 Geographical locationGeographical location
 CultureCulture
 Environmental factorsEnvironmental factors
 Work conditionsWork conditions
 EducationEducation
 Access to healthAccess to health
servicesservices
Source: Dahlgren G. and
Whitehead M. 1991

11. Determinants of HealthDeterminants of Health
PLUS MORE GENERAL FACTORSPLUS MORE GENERAL FACTORS
SUCH AS:SUCH AS:
 POLITICAL STABILITYPOLITICAL STABILITY
 CIVIL RIGHTSCIVIL RIGHTS
 ENVIRONMENTAL DEGRADATIONENVIRONMENTAL DEGRADATION
 POPULATION GROWTH/PRESSUREPOPULATION GROWTH/PRESSURE
 URBANISATIONURBANISATION
 DEVELOPMENT OF COUNTRY OFDEVELOPMENT OF COUNTRY OF
RESIDENCERESIDENCE

12. Multi-sectoral Dimension of theMulti-sectoral Dimension of the
Determinants of HealthDeterminants of Health
 Malnutrition –Malnutrition –
• more susceptible to disease and less likely tomore susceptible to disease and less likely to
recoverrecover
 Cooking with wood and coal –Cooking with wood and coal –
• lung diseaseslung diseases
 Poor sanitation –Poor sanitation –
• moremore intestinal infectionsintestinal infections
 Poor life circumstances –Poor life circumstances –
• commercial sex work and STIs, HIV/AIDScommercial sex work and STIs, HIV/AIDS
 Advertising tobacco and alcohol –Advertising tobacco and alcohol –
• addiction and related diseasesaddiction and related diseases
 Rapid growth in vehicular traffic often withRapid growth in vehicular traffic often with
untrained drivers on unsafe roads-untrained drivers on unsafe roads-
• road traffic accidentsroad traffic accidents

13. 2. The Measurement of Health Status I2. The Measurement of Health Status I
 Cause of deathCause of death
• Obtained from death certification but limitedObtained from death certification but limited
because of incomplete coveragebecause of incomplete coverage
 Life expectancy at birthLife expectancy at birth
• The average number of years a new-bornsThe average number of years a new-borns
baby could expect to live if current trends inbaby could expect to live if current trends in
mortality were to continue for the rest of themortality were to continue for the rest of the
new-born's lifenew-born's life
 Maternal mortality rateMaternal mortality rate
• The number of women who die as a result ofThe number of women who die as a result of
childbirth and pregnancy related complicationschildbirth and pregnancy related complications
per 100,000 live births in a given yearper 100,000 live births in a given year

14. The Measurement of Health Status IIThe Measurement of Health Status II
 Infant mortality rateInfant mortality rate
• The number of deaths in infants under 1 yearThe number of deaths in infants under 1 year
per 1,000 live births for a given yearper 1,000 live births for a given year
 Neonatal mortality rateNeonatal mortality rate
• The number of deaths among infants under 28The number of deaths among infants under 28
days in a given year per 1,000 live births indays in a given year per 1,000 live births in
that yearthat year
 Child mortality rateChild mortality rate
• The probability that a new-born will die beforeThe probability that a new-born will die before
reaching the age of five years, expressed as areaching the age of five years, expressed as a
number per 1,000 live birthsnumber per 1,000 live births

15. 3. Culture and Health3. Culture and Health
 Culture:Culture:
• The predominating attitudes and behaviourThe predominating attitudes and behaviour
that characterise the functioning of a group orthat characterise the functioning of a group or
organisationorganisation
 Traditional health systemsTraditional health systems
 Beliefs about healthBeliefs about health
• e.g. epilepsy – a disorder of neuronale.g. epilepsy – a disorder of neuronal
depolarisation vs a form of possession/baddepolarisation vs a form of possession/bad
omen sent by the ancestorsomen sent by the ancestors
• Psychoses – ancestral problems requiring thePsychoses – ancestral problems requiring the
assistance of traditional healer/spiritualistassistance of traditional healer/spiritualist
 Influence of culture of healthInfluence of culture of health
• Diversity, marginalisation and vulnerability dueDiversity, marginalisation and vulnerability due
to race, gender and ethnicityto race, gender and ethnicity

16. 4. The global burden of disease4. The global burden of disease
 Predicted changes in burden of diseasePredicted changes in burden of disease
from communicable to non-communicablefrom communicable to non-communicable
between 2004 and 2030between 2004 and 2030
• Reductions in malaria, diarrhoeal diseases,Reductions in malaria, diarrhoeal diseases, TBTB
and HIV/AIDSand HIV/AIDS
• Increase in cardiovascular deaths, COPD, roadIncrease in cardiovascular deaths, COPD, road
traffic accidents and diabetes mellitustraffic accidents and diabetes mellitus
 Ageing populations in middle and lowAgeing populations in middle and low
income countriesincome countries
 Socioeconomic growth with increased carSocioeconomic growth with increased car
ownershipownership
 Based on a ‘business as usual’ assumptionBased on a ‘business as usual’ assumption

17. High Fertility/High MortalityHigh Fertility/High Mortality
Source: US
Census Bureau,
Population Report

18. Declining Mortality/High FertilityDeclining Mortality/High Fertility
Source: US
Census Bureau,
Population Report

19. Reduced Fertility/Reduced MortalityReduced Fertility/Reduced Mortality
Source: US
Census Bureau,
Population Report

20. 5. Key Risk Factors for Various5. Key Risk Factors for Various
Health ConditionsHealth Conditions
 Tobacco useTobacco use ––
• related to the top ten causes of mortality worldrelated to the top ten causes of mortality world
widewide
 Poor sanitation and access to clean water-Poor sanitation and access to clean water-
• related to high levels of diarrhoeal/waterrelated to high levels of diarrhoeal/water
borne diseasesborne diseases
 Low condom useLow condom use ––
• HIV/AIDS, sexually transmitted infectionsHIV/AIDS, sexually transmitted infections
 MalnutritionMalnutrition ––
• Under-nutrition (increased susceptibility toUnder-nutrition (increased susceptibility to
infectious diseases) and over-nutritioninfectious diseases) and over-nutrition
responsible for cardiovascular diseases,responsible for cardiovascular diseases,
cancers, obesity etc.cancers, obesity etc.

21. 6. The Organisation and Function6. The Organisation and Function
of Health Systemsof Health Systems
 A health systemA health system
• comprises all organizations, institutions andcomprises all organizations, institutions and
resources devoted to producing actionsresources devoted to producing actions
whose primary intent is to improve healthwhose primary intent is to improve health
(WHO)(WHO)
 Most national health systemsMost national health systems
consist:consist:
• public, private,public, private,
• traditional and informal sectors:traditional and informal sectors:

22. Source: W.H.O. Statistics
Source: WHO statistics 2008

23. Trends in Global Deaths 2002-30Trends in Global Deaths 2002-30
Source: World Health Statistics 2007

24. COMPARATIVE DATA (1)COMPARATIVE DATA (1)
IRELANDIRELAND
DEVELOPINGDEVELOPING
COUNTRIESCOUNTRIES
 INFANT MORTALITYINFANT MORTALITY 77 100-190100-190
RATERATE
 UNDER 5 MORTALITYUNDER 5 MORTALITY 1010 175-300175-300
RATERATE
 MATERNAL MORTALITYMATERNAL MORTALITY 22 600-600-
16001600
RATERATE
 LIFE EXPECTANCYLIFE EXPECTANCY F - 82F - 82 F < 50F < 50
M - 77M - 77 M < 50M < 50
but may bebut may be
= or > F= or > F

25. COMPARATIVE DATA (2)COMPARATIVE DATA (2)
IRELANDIRELAND
DEVELOPINGDEVELOPING
COUNTRIESCOUNTRIES
 POPULATION GROWTHPOPULATION GROWTH 0.3%0.3% 3%+3%+
RATERATE
 HIV +ve RATEHIV +ve RATE 0.15%0.15% 15%+15%+
 AIDS CASESAIDS CASES 20/20/ 400/400/
100,000100,000
100,000100,000
 GNP PER CAPITAGNP PER CAPITA $16,000$16,000
<$200<$200
 HEALTH EXPENDITUREHEALTH EXPENDITURE $1,600$1,600 $1-$2$1-$2
PER CAPITAPER CAPITA

26. HEALTH PATTERNSHEALTH PATTERNS
 GENETIC FACTORSGENETIC FACTORS
 ENVIRONMENTAL FACTORSENVIRONMENTAL FACTORS
 LIFESTYLE FACTORSLIFESTYLE FACTORS
 COMMUNICABLE vs NON-COMMUNICABLECOMMUNICABLE vs NON-COMMUNICABLE
DISEASESDISEASES DISEASESDISEASES

27. HEALTH PATTERNS INHEALTH PATTERNS IN
RESOURCE POOR COUNTRIESRESOURCE POOR COUNTRIES
 INFECTIOUS/COMMUNICABLE DISEASESINFECTIOUS/COMMUNICABLE DISEASES
PREVALENT:PREVALENT:
 VACCINE PREVENTABLE DISEASES, e.g. measlesVACCINE PREVENTABLE DISEASES, e.g. measles
 ACUTE RESPIRATORY INFECTIONS (ARI)ACUTE RESPIRATORY INFECTIONS (ARI)
 DIARRHOEAL DISEASES (cholera)DIARRHOEAL DISEASES (cholera)
 MALARIAMALARIA
 TBTB
 HEPATITISHEPATITIS
 HIV/AIDSHIV/AIDS
 Plus:Plus:
 MALNUTRITION RELATED CONDITIONS:MALNUTRITION RELATED CONDITIONS:
 - CALORIE DEFICIENCIES- CALORIE DEFICIENCIES
 - MICRO-NUTRIENT DEFICIENCIES- MICRO-NUTRIENT DEFICIENCIES
 TRAUMA/ACCIDENTSTRAUMA/ACCIDENTS
 Many of these diseases are treatableMany of these diseases are treatable

28. HEALTH PATTERNS INHEALTH PATTERNS IN
RESOURCE RICH COUNTRIESRESOURCE RICH COUNTRIES
 NON-COMMUNICABLE DISEASES PREVALENT:NON-COMMUNICABLE DISEASES PREVALENT:
 Causes of death (all ages):Causes of death (all ages):
 40% Circulatory diseases, e.g. heart disease,40% Circulatory diseases, e.g. heart disease,
strokes, etc.strokes, etc.
 25% Cancers25% Cancers
 16% Respiratory diseases16% Respiratory diseases
 5% Injuries and Poisonings5% Injuries and Poisonings
 0.6% Infectious diseases0.6% Infectious diseases
 Premature mortality (<65):Premature mortality (<65):
 25%25% Circulatory diseasesCirculatory diseases
 33% Cancers33% Cancers
 16%16% Injuries (RTAs/Suicides) and PoisoningsInjuries (RTAs/Suicides) and Poisonings
 1% Infectious diseases1% Infectious diseases
 Many of these deaths are related to lifestyle factorsMany of these deaths are related to lifestyle factors
and are preventableand are preventable

29. HEALTH PATTERNS IN RESOURCEHEALTH PATTERNS IN RESOURCE
RICH COUNTRIESRICH COUNTRIES
 Lifestyle factors affecting physicalLifestyle factors affecting physical
and mental health:and mental health:
 Smoking – one third of cancer deathsSmoking – one third of cancer deaths
related to smokingrelated to smoking
 DrinkingDrinking
 Healthy eating/nutritionHealthy eating/nutrition
 Physical activityPhysical activity
 Substance abuseSubstance abuse

30. Cholera 1800sCholera 1800s

31. Cholera: the DiseaseCholera: the Disease
 Entry: oralEntry: oral
 ColonizationColonization: small: small
intestineintestine
 Symptoms:Symptoms:
nausea, diarrhea,nausea, diarrhea,
muscle cramps,muscle cramps,
shockshock
 Infants withInfants with
choleracholera

32. First Cholera PandemicFirst Cholera Pandemic

33. Second Cholera PandemicSecond Cholera Pandemic

34. John Snow and the Pump HandleJohn Snow and the Pump Handle
John Snow is credited byJohn Snow is credited by
many with developingmany with developing
the modern field ofthe modern field of
epidemiologyepidemiology
John Snow and cholera inJohn Snow and cholera in
1854 London1854 London
http://www.ph.ucla.edu/http://www.ph.ucla.edu/
epi/snow.htmlepi/snow.html

35. London in the 1850’sLondon in the 1850’s
• Germ theory of diseaseGerm theory of disease
not widely acceptednot widely accepted
 People lived in veryPeople lived in very
crowded conditionscrowded conditions
with water and privieswith water and privies
in yard (NY 1864: 900in yard (NY 1864: 900
people in 2 buildingspeople in 2 buildings
180’ deep x 5 stories180’ deep x 5 stories
– 1 pump a block– 1 pump a block
away, privy in yard)away, privy in yard)

36. John Snow’s ObservationsJohn Snow’s Observations
 People with cholera developedPeople with cholera developed
immediate digestive problems: cramps,immediate digestive problems: cramps,
vomiting, diarrheavomiting, diarrhea
 Face, feet, hands shriveled and turnedFace, feet, hands shriveled and turned
blue; died in less than a dayblue; died in less than a day
 Probably spread by vomiting andProbably spread by vomiting and
diarrheadiarrhea
 Comparison of pump location withComparison of pump location with
cholera deaths, first 3 days of epidemiccholera deaths, first 3 days of epidemic
in 1854in 1854

37. Water Supply London 1850’sWater Supply London 1850’s

38. Cholera EpidemiologyCholera Epidemiology
 Of 83 people, only 10 livedOf 83 people, only 10 lived
closer to a different pumpcloser to a different pump
than Broad Streetthan Broad Street
 Of these 10, 5 preferred tasteOf these 10, 5 preferred taste
of Broad Street water and 3of Broad Street water and 3
were children who went towere children who went to
nearby schoolnearby school

39. Snow Index CaseSnow Index Case
 Index caseIndex case is first person tois first person to
become illbecome ill
 40 Broad Street – husband and40 Broad Street – husband and
infant child became illinfant child became ill
 Wife soaked diapers in pail andWife soaked diapers in pail and
emptied pail into cistern next toemptied pail into cistern next to
pumppump

40. The Great ExperimentThe Great Experiment
 Two water companies suppliedTwo water companies supplied
central Londoncentral London
 Lambeth Company: waterLambeth Company: water
intake upstream of Londonintake upstream of London
sewage outfall into Thamessewage outfall into Thames
 Southwark & VauxhallSouthwark & Vauxhall
Company: water intakeCompany: water intake
downstream of sewage outfalldownstream of sewage outfall

41. The Great ExperimentThe Great Experiment
 Customers mixed in sameCustomers mixed in same
neighborhoodneighborhood
 Snow went door to doorSnow went door to door
asking which waterasking which water
company served homecompany served home
and compared locationsand compared locations
with cholera datawith cholera data

42. The Great ExperimentThe Great Experiment
# Houses # Deaths
Deaths/
100,000
S and V 40,046 1263 315
Lambeth 26,107 98 37

43. Cholera EpidemiologyCholera Epidemiology
 Snow convincedSnow convinced
neighborhood council to letneighborhood council to let
him remove handle fromhim remove handle from
water pump on Broad Streetwater pump on Broad Street
 The new cases declinedThe new cases declined
dramaticallydramatically
 Many on council notMany on council not
convinced by his evidenceconvinced by his evidence

44. Cholera in the 1990sCholera in the 1990s
 Epidemic in Peru beginningEpidemic in Peru beginning
19911991
 From 1991-1994From 1991-1994
•Cases 1,041,422Cases 1,041,422
•Deaths 9,642 (0.9%)Deaths 9,642 (0.9%)
 Originated at coast, spreadOriginated at coast, spread
inlandinland

46. World Cholera 2000-01World Cholera 2000-01

47. Why Has Cholera Re-emerged?Why Has Cholera Re-emerged?
 Deteriorating sanitary facilitiesDeteriorating sanitary facilities
as larger population moves intoas larger population moves into
shanty townsshanty towns
 Trujullo, Peru – fear of cancerTrujullo, Peru – fear of cancer
from chlorination so waterfrom chlorination so water
untreateduntreated
 Use of wastewater on cropsUse of wastewater on crops
 Africa – civil wars and droughtAfrica – civil wars and drought
caused migrations into campscaused migrations into camps

48. How Has Cholera Re-emerged?How Has Cholera Re-emerged?
 Simultaneous appearanceSimultaneous appearance
along whole coast of Perualong whole coast of Peru
 Traveled in ship ballast?Traveled in ship ballast?
 Traveled in plankton fromTraveled in plankton from
Asia?Asia?
 Always present in localAlways present in local
zooplankton (copepods) butzooplankton (copepods) but
dormant until triggered by ???dormant until triggered by ???

49. Copepod CarryingCopepod Carrying VibrioVibrio
choleraecholerae

50. Global Health ReferencesGlobal Health References
 Skolnik R.Skolnik R. Essentials of Global HealthEssentials of Global Health. Jones. Jones
& Bartlett Publishers, Sudbury MA 2008. Chapter& Bartlett Publishers, Sudbury MA 2008. Chapter
11
 Ed. Robert Beaglehole, 2003Ed. Robert Beaglehole, 2003.. Global PublicGlobal Public
Health: A new era. Chapter 1Health: A new era. Chapter 1
 Megan Landon. 2006.Megan Landon. 2006. Environment, Health andEnvironment, Health and
Sustainable DevelopmentSustainable Development
 Bonder, B. Martin L. Miracle A.Bonder, B. Martin L. Miracle A. Culture inCulture in
Clinical CareClinical Care
 Koplan J et al, 2009.Koplan J et al, 2009. Towards a commonTowards a common
definition of global healthdefinition of global health The Lancet, VolumeThe Lancet, Volume
373, Issue 9679, Pages 1993-1995373, Issue 9679, Pages 1993-1995

51. ThanksThanks
 Email me :Email me : arputhaselvaraj@gmail.com