Why is that person healthier than that person?: the roles of acculturation and population health

Why are some people healthier than others? Some determinants lie within socio-economics and other health disparities. Current population health research is focused on the association among race, ethnicity, gender, finances, geography, and even now the theory of acculturation. Acculturation, from a health perspective, is when immigrants come to the United States and their health begins to deteriorate at a faster rate than their U.S. born racial and ethnic counterparts over a certain period of time. This issue of acculturation has been seen in various metabolic conditions such as hypertension, diabetes, obesity, etc. So why does this happen? Social stress for immigrants in a new environment? Lower income per household than in their previous country? Lack of access to decent healthcare? Lack of access to resources for a healthy diet? The socio-economic reasons and health disparities behind it are infinite. The key issue to keep in mind when looking at illness is to look at the illness as a whole and what contributes to it, not just the illness itself. That is why it also so important to acknowledge the population you are dealing with when treating a patient because there are so many other factors at play that are determinants of health. This concept is surprisingly not new. Although the “population health” term was coined in the 1980’s, Hippocrates was thinking and talking about it in Ancient Greece. In On Airs, Waters, and Places, Hippocrates clearly associated the relationship between environment and illness, and how this affects the population. Essentially, it is important to know your population when diagnosing the illness and identifying the health determinants as Hippocrates did. The theory of acculturation is a new and popular trend in research because it is a new way to think about population health and why socio-economics and health disparities play a role in illness. These ideas and questions can ultimately provide some insight into the inequalities of health, but also make us realize that there are extensive possibilities as to why these inequalities exist in the first place.

If Only Ebola Outbreak Originated in U.S.

Well, in a perfect world the Ebola virus would have never reared its ugly head. But ideally, the virus would have been contained at the outset and not spread to cause a global health threat. The virus, first discovered in 1976 in the Democratic Republic of Congo (back then Zaire…oh ineffectual governments, but more on that later), has been a mainstay in the headlines since the outbreak in West Africa earlier this year. As more African countries are imposing quarantines, travel bans and health testing upon entrance into certain countries, the question comes to mind, what would have happened had, say, an American tourist traveled to a remote rainforest and was bit by a fruit bat, contracted the virus and then returned home to Ohio?

_77694455_ebola_apUnfortunately, the virus is outpacing its containment and available treatments; increasing the probability it transitions from an epidemic to pandemic. I’m in Amartya Sen’s corner in wishing that the disease of poverty were communicable. Then, perhaps, maybe the response to the Ebola outbreak would have decreased the death toll. The spread of the virus is just another reminder of the inequity between the societal determinants of health throughout Africa and the U.S.

Let’s look at a snapshot of the countries most severely affected by the virus: Guinea, Sierra Leone and Liberia compared to the United States. The societal determinants of these countries play a large part in the high incidence of poverty and effectually their limited capability to handle the epidemic.

Let’s break this down a bit more…

  • Poverty: The percentage of the population living on less than $1/day in Guinea is 43.4% and 83.7% in Liberia. In the U.S. (poverty measured >$2 a day) was 1.2% in 2011
  • Health Access: In Sierra Leone, there are 0.2 physicians per 10,000 population and 24.2 physicians in the U.S.
  • Cultural behavior: Populations using improved sanitation as of 2011: Guinea 18%, Liberia 18%, Sierra Leone 13%, U.S. 100% (transmission of Ebola linked to families and friends washing bodies of the dead, a common Muslim tradition and practiced widely throughout Africa though uncommon in the U.S.)

The World Health Organization prevention and control measures to contain the outbreak include prompt and safe burial of the dead, identifying people who may have been in contact with someone infected with Ebola, monitoring the health of contacts for 21 days, quarantine the sick to prevent further spread, promote importance of good hygiene and maintain a clean environment. Arguably one of the most important societal determinants of health is the accountability and capacity of governments to address population health, in this case a burden of the responsibility to control the virus falls on these country’s governments. However, because they lack the human and infrastructural resources to do so, multilateral aid has kicked in to fill the gap to prevent a pandemic (though some argue too little too late).

As we can see from a brief glimpse into the disparities in resources between the Ebola-stricken countries in Africa and the U.S., the societal determinants in health of these populations could be correlated to the spread of Ebola and the ability of the governments to efficiently and effectively respond to those living in high-risk areas. Back to the first question: if Ebola first appeared in the U.S. back in March, would it continue to be front-page news as an out-of-control virus that has already taken thousands of lives? Or would it be a public health success story of rapid response and confinement followed by research and development of Ebola treatments? If the disease of poverty were communicable, would the Ebola response in the U.S. be drastically different than the current situation?

Dear DALY: You’re tacky and I hate you

The lovable quote from School of Rock accurately reflects my sentiments of the DALY (disability adjusted life year) and series of Health Metrics in general.

Don’t get me wrong – I believe a system of metrics is quite useful. In theory, they are crucial in keeping a record of health both globally and within our societies. It’s incredibly invaluable to see what exactly is plaguing us today as opposed to a few decades ago. Metrics have the capability of serving as a nice point of reference against which we can determine if anything we’re doing in the public health sector is actually succeeding.

The DALY, while a massive step in the right direction when no alternative was being used, is now sorely obsolete; however, it still remains the standard measurement for the burden of global disease despite decades of backlash for its inaccuracy and misrepresentation.

At its core, the DALY is a numerical value designed to measure the various impacts of disease on people through mortality and morbidity. The potentially healthy years of life lost by diseases are measured, followed by the effects of non-fatal diseases, which are then factored into this ‘black box’ via a disability weight. This weight varies in accordance with an individual’s age – namely, their presumed value to society and position with respect to their ‘peak years of life’.

We can see a massive problem with this metric without having to use too much thought: it necessarily states that the deaths of individuals who are older and/or disabled contribute less to the burden of disease than those of their younger counterparts. This underrepresents diseases and conditions that affect the aging population in more developed countries; and it’s not like we’ve eradicated those afflictions! It’s a significant problem and the DALY, for all intents and purposes, ignores them.

Piggybacking on this notion of misrepresentation, the metrics reported for global health data is wildly inaccurate for most areas of the world that do not contain a vital registration system. Information of deaths and diseases are gathered through surveys and censuses that are incredibly vulnerable to manipulation. If we learned anything from the eight seasons of House, it’s that people lie. They may not even be trying to falsify information – they might simply forget or be unaware of the exact causes of a death in the family. That policy places so much weight on these certainly inaccurate measurements is terrifying. Would you want a physician operating on your body with imperfect knowledge of the actual problem?

Several scholars have made these very criticisms and have even come up with more that are not inherently so obvious. In her section in Reimagining Global Health: An Introduction, Anne Becker and her colleagues bring up two more of these criticisms against the DALY:

The first issue she raises is about the assigned disability weights of diseases. The measurement of disease burden rests on the severity and impact of various diseases, which necessarily relates to the gravity with which we view them. If the top ten most populous countries were suddenly afflicted with a rise in those affected by seasonal allergies, I think it’s safe to say that the world wouldn’t drop everything to find a solution. But that’s just the point: what will elicit such a reaction? What kind of disease and what volume does it need to hit to gain global infamy? The DALY tells us that it should be based on their system of ordering disease severity – one that is wholly arbitrary. A ‘group of independent experts’ is used to determine whether losing an arm is worse than losing a leg. They’re in charge of determining which strain of infection is really worse. While we can argue about the nuances of the science, the final decision is really just a judgement call. There is no indisputable piece of evidence that argues the fine points between what’s number ten on the list of worst diseases and what’s number eleven. Already that undermines the validity of the DALY, which calculates non-fatal diseases against this weighted value to determine global burden.

The darker criticism Becker makes naturally finds itself on the economic side of the debate. According to Becker, the DALY does not account for differences in available resources in a given community. The actual ‘burden’ of diseases and deaths is highly contextual, and will vary rapidly depending on the particular individual and resources of his or her area. While Christopher Murray altruistically defends that a premature death of a person should equally impact the global burden of disease whether he or she was from a developing country or a place like the US, Becker argues that, as unsettling as it is, the deaths are not as alike as we would hope to believe. We like to view ourselves as the apex of human and civil development in a sort of teleological sense of history, but addressing matters on the basis of the idealistic relationships between people may in fact blind us to things we should otherwise be investigating.

The relative burden of a particular disease is highly dependent on who is affected and where they are. It may be useless to keep looking for one catchall metric that will represent everything perfectly. It may instead be more productive to, as Daniel Reidpath puts it in “Measuring health in a vacuum: examining the disability weight of the DALY”, measure burden as it pertains to a particular area. A global, unified measure may not be possible due to the sheer amount of variables that are involved with each individual case.

Any unit of measurement is better than none at all, but an updated method is long overdue. Isn’t it about time we brought health metrics into the 21st century?

How healthy is the world – our past, present and future.

If I were to say that I had all the resources, the knowledge and the data to give you information on ‘how healthy the world is’, what would you really like to know? Would you like to know if we could have controlled Ebola earlier? Would you like to know how being more healthy has impacted income levels and hence standard of living in developing countries? Or does it just matter to you that we are making progress on the MDG’s?

It’s a monumental question and there is no dearth of information to answer all of these questions, but its important we know the scope and boundaries of what we really matters.

At the risk of oversimplifying how we may define this better, I would like to start by focusing on some very relevant data on child health from the State of the World’s Children 2014 Report – an area we have relatively the most up to date information in. What stands out to me, as part of this report is data that allows me to compare what progress really means in child health:

- ‘About 90 million children who would have died if mortality rates had stuck at their 1990 level have, instead, lived past the age of 5.’

- ‘Deaths from measles among children under 5 years of age fell from 482,000 in 2000 to 86,000 in 2012, thanks in large part to immunization coverage, which increased from 16 per cent in 1980 to 84 per cent in 2012.’

- ‘Nearly 1.9 billion people have gained access to improved sanitation since 1990.’

Similarly, The World Health Statistics 2014 report reveals very interesting comparisons:

- ‘Life Expectancy: Low-income countries have made the most significant progress, with an increase of 9 years of average life expectancy between 1990 and 2012 – from 51.2 to 60.2 years for men and 54.0 to 63.1 years for women.’

- ‘In the past decade almost every country in the world experienced a major shift away from premature deaths due to infectious diseases and towards non communicable diseases and injuries. Countries are at very different stages of this epidemiological transition. On average, in the WHO African Region, 70% of all years of life lost are due to infectious diseases and maternal, neonatal and nutritional causes. In high-income countries, these causes now account for only 8% of all years of life lost.’

These comparisons allow us to draw conclusions on how much the needle has moved and help us get a broad sense on how healthy the world is as compared to how healthy it was. If we take a closer look, the data behind this gives us more specific information on what is working well and what is not. The reason there is so much focus on the accuracy and relevancy of data is primarily what comes after that – what programs can be implemented at scale to improve child and maternal health, what best practices can we learn from polio elimination drives that can be replicated to solve similar problems and what health services must be provided in developing countries to suit life expectancy.

It’s crucial we look at historic data and track progress over decades on various efforts made to improve health, but it is also important for us to be able to predict how healthy we will be in the future. Millions of dollars are spent on predictive models where companies can somewhat accurately predict an art of choice and tastes of individuals based on a network and their interaction with the network. Big Data, predictive analysis – things we read often about enough for us to worry about our privacy settings and what we share online. Health is a science and is less abstract. It should be possible for us to tell how healthy the world will be in the next 20 – 50 years based on all the historic data we have, or at least to begin with focus on a more specific geography where we have the most relevant and recent information and where people are at the highest risk of poor health in the future – such as West Africa.

WHO released a report back in 2005 on using climate change to predict epidemics and Nicholas Christakis is his TED Talk in 2010 talks about this concept. For us to be able to respond to the question adequately on how healthy the world is, its important to know the past, the present and the future. If Google could predict how many people will be online by 2020, there has to be a way to say more about how healthy the world will be in the future.

The World is Healthy! (cough, cough, sneeze)

If I were to gauge the health of the world today based on mainstream media alone, I would probably say it’s not good.  I should apologize now because as hard as I have tried I can’t seem to blog about how healthy the world is without mentioning Ebola – as seems to be true in most of social media now too.  cartoonEven as I rewrite this post, NPR is wrapping up its 4th segment of the day covering nothing other than, Ebola. A recent opinion piece in the New York Times discussing the potential for Ebola to go airborne made the global health outlook seem rather dark also.  Although, we don’t (or shouldn’t) rely on the media alone to make determinations about world health status.  What resources should be used to determine how healthy the world is?  Unfortunately, there is no single answer.

 The Textbook of International Health defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”  So even if the world were absent of disease, the populations’ physical, mental, and social well-being would also need measurement and analysis.

mdgsThe 8 UN Millennium Development Goals (MDGs) cover areas such as poverty, hunger, education, child mortality, maternal health, and environmental sustainability.  All of them report positive progress, some well in advance of their 5-year deadline, and make a strong indication that the current health status is improving.  Statements such as:

“The target of reducing extreme poverty rate by half was met five years ahead of the 2015 deadline.”

“Enrollment in primary education in developing regions reached 90 per cent in 2010, up from 82 per cent in 1999, which means more kids than ever are attending primary school.”

“New HIV infections continue to decline in most regions.”

So would it be safe to assume based on these positive findings that world health is looking good?  The UN is not a single agency designated to make that determination and while the MDGs list positive information they also point out that a healthy world is still a work in progress.

“Comprehensive knowledge of HIV transmission remains low among young people, along with condom use.”

“The maternal mortality ration in developing regions is still 14 times higher than in the developed regions.”

whoStill the 2014 World Health Statistics published by the World Health Organization, produced some positive statistics, but cautions that “these estimates are subject to considerable uncertainty, especially for countries with week statistical and health information systems where the quality of underlying empirical data is limited.”  Reviewing the data reveals that life expectancy has increased in almost every country while infant mortality and under-five mortality rates have reduced in a large number of countries. So the world IS healthy, yes?

Our readings and lectures reveal there is no one resource that will give a definite answer on the health status of the world.  Even the Daily Adjust Life Year (DALY) should be used in conjunction with other sources of data and even then the accuracy of the data can be, and should be, questioned.

Ebola has brought world health back to the forefront and has shown that while some of our data signals improvements there are still icebergvulnerabilities in our systems. Ebola has revealed a breakdown in communication, leadership, trust, and education between our communities and countries. Should more emphasis be given on the social well-being of our society at large in an effort to better combat these health challenges?  At what point, if ever, will we be able to say our world is healthy?  Until we have perfect data and perfect resources compiling that data – we will always be searching and striving for better world health.  Ebola has climbed its way to the top of this global health iceberg and we should not lose focus on what’s underneath the water either.

The Future of Global Health

In the last decades, globalization of the world has rapidly changed the way people think and see the world. Lifestyle has changed as people are becoming more concerned about their health and what happens around the world. The awareness of diseases, famine, and natural disasters have become an international concern and thanks to many scholars, individual donors, and international organizations that have focused on global health, international aid is reaching an increasing number of countries in need. However, the world is still too big and humanitarian needs are too expansive to effectively measure the efforts of international aid. What is the best, or most productive, way that international aid can contribute to global health fairly, efficiently, and effectively? To what extent should we be concerned about the allocations of such aid? 

Esther Duflo, a MIT economist, shows a different approach to thinking about the future global health through her experiments. The first experiment she introduced was how immunization is carried out to children by mothers in India. By giving incentives to mothers and making immunization easily accessible, the rate of immunization increased from 6% to 38%. Another interesting experiment she conducted focused on effective ways to prevent malaria in Kenya by either offering discounts on bed nets or giving it away for free. The result showed that people who received free nets were more likely to purchase the nets a year later than those who did not previously receive any. What does this tell us? By initially providing incentives and offering necessities for free, the recipients are able to recognize the increasing value of health and its priority in life. 

There are many essential factors for the future of global health such as delivering aid with accountability and transparency and improving health systems through combination of vertical and horizontal approaches. Yet, it is foremost for us to find ways of making health a priority for every individual. Primary health services should be more accessible especially to those in developing countries. Healthier individuals will contribute better in society creating a positive humanitarian domino effect. It is not about making donors happy with their contributions but rather making the recipients become happily self-sufficient with their health and living conditions. This is the challenge that we have to solve for the future of global health. 

Climate Change and Global Health: Tropical diseases in North America?

With the year 2015 fast approaching, the time has come for a serious evaluation of the Millennium Development Goals. While it is important to learn from their successes and shortcomings when planning the post-2015 agenda, it is also important to have an imagination and think beyond existing development strategies and interventions.

Over the past few years, the planet has witnessed a surge in natural disasters, the latest of which was typhoon Haiyan, the strongest storm recorded at landfall[1]. Climate change is increasingly being considered as a framework, not only for traditionally related topics like natural disasters and agriculture, but also for pro-poor development strategies in general[2].

The problem is especially important for global health: climate change can amplify existing hazards, deficits and inequities, jeopardizing the already low status of population health and wellbeing of disadvantaged populations[3].

In addition, and similarly to largely unpredictable natural disasters, climate change can cause unprecedented and unexpected health effects for which we need to be prepared. Not to be alarmist, but tropical diseases might simply become widespread in new regions like North America. It is not only important to pay attention to the many neglected vector-borne diseases, but we also need to consider the possibility of completely new diseases, new geographies, and new landscapes of disease caused by climate change.

More resources need to be allocated for research in the field. Climate change needs to seriously be considered as framework when developing the post-2015 agenda, and special attention needs to be given to prevention of consequences that we are not even familiar with yet.

[2] Janetos, Anthony C., et al. “Linking Climate Change And Development Goals: Framing, Integrating, And Measuring.” Climate & Development 4.2 (2012): 141-156. Environment Complete. Web. 3 Nov. 2013.

[3] “Climate Change, Health, And Development Goals.” Lancet 364.9450 (2004): 2004-2006.Business Source Complete. Web. 3 Nov. 2013.