Transcript Health and Economic Transitions HT09

Health in Times of Economic
Transitions
Proochista Ariana
International Development & Health
Hilary Term 2009
Outline
What have we learned thus far
Policy Case
Revisiting the Preston Curve
Empirical examination of EG & health
-Historical example of England/Wales
-Contemporary examples
• Mechanisms
• Methodological considerations
• Case of Poland
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Points for Reflection
• What are the intervening factors that relate
economic growth to health?
• Is EG necessary to achieve health?
• What are the policy implications of how
we understand the relationship?
Review
• Examined how development processes
relate to health at the macro-level
• Evolution of development theory & practice
• Expanded our notion of health
• Understanding of how policies mediate the
relationship between development and
health
• Examples, the intended and unintended,
positive and negative health consequences
of development
Preston Curve
Key Features
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Upward shifts
Diminishing Returns
Positive outliers
Negative outliers
Why is health improving
• Advancements in scientific and public health
knowledge (e.g. Germ theory of disease)
• International transmission of knowledge
• Public health programmes (vector control,
vaccinations, water and sanitation, housing
conditions)
• Healthcare services and medicines
• Education
• Governance (water, sanitation, housing, etc)
Medical Technology
• Scientific discoveries on aetiology of
disease and development of modes of
prevention and cures
• Development of vaccines
• Discovery of antibiotics
• Diagnostic equipment
• Pharmaceuticals
McKeown’s Evidence
• contribution of public health knowledge
and technology to health is not limited to
medical technologies in prevention and
cure (i.e. vaccines and antibiotics)
• much of the decline in mortality at the
turn of the century in England and Wales
preceded the introduction of such
technologies
Tuberculosis
Measles
Whooping Cough
Poliomyelitis
McKeown’s Conclusion
• McKeown suggested that (at least for
England and Wales at the turn of the
century) important factors for health
related to improvements in nutrition and
household conditions
• Factors which he attributed to the general
economic growth of the time
Szreter’s Retort
• comprehensive historical review of
economic growth and health in Britain
between 1750-1870
• not economic growth but rather social and
political action that motivated the
improvements in housing and nutrition
which benefited the health of the
population
4 D’s of Economic Growth
• economic growth, “… if given free rein,
may lead directly to the four Ds
[disruption, deprivation, disease, and
death]” (Szreter, 1997).
• Exemplified by urban centres where
income and real wages were growing
rapidly but life expectancy was either
declining or remaining stagnant.
Szreter’s Evidence
Social Mobilisation
& Political Will
• economic growth often brings with it
political and social disruption which can
readily lead to deprivation, disease and
death if not actively countered by political
and social systems
• Counter efforts may take the form of
redistribution of wealth, provision of
public health resources, or mechanisms
that give political voice to the poor
Allocation of Resources
Szreter’s argument corresponds to the claim
that countries that were able to achieve
high health standards incommensurate
with their level of national income (i.e. the
positive outliers on the Preston Curves)
did so with concerted political and/or
social efforts (i.e. by allocating a larger
portion of national resources to healthcare,
disease prevention, and education)
Global Urbanisation
Urban Living Today
• Urban population has grown from 220
million to 2.8 billion over the 20th century
• As of 2008, 3.3 billion people live in urban
areas
• Of the urban dwellers, about 1 billion live
in slums
Source: Social Determinants of Health 2008
Slum Living
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Lack of running water
No drainage or sanitation
Poor or inadequate housing
Overcrowding
No electricity
Rubbish accumulation, rats and other pests
Violence/insecurity
Slum Health
• In Nairobi, where 60% of the city’s
population live in slums, child mortality
in the slums is 2.5 times greater than that
in other areas of the city
• In Manila’s slums, up to 39% of children
aged between 5 and 9 are already infected
with TB – twice the national average
(Source: Social Determinants of Health Final Report)
Slum Health
Source: McMichael et al 2004
‘defective’ modernization
• increases in trauma-related deaths, chronic
diseases, and persistent infectious diseases
resulting from defective technology
• inability to sustain the high costs associated
with maintaining the modern technology
• Adjustments of traditional lifestyles to
accommodate the technology
Mexico
“We bought a refrigerator and filled it full of meat
and milk, where once we would have dried our
beef. We bought a cooler and put it into the
kitchen window, where once there came a breeze
in summer. We filled in the outhouse and put a
flush toilet next to the kitchen. Now there is no
electricity. The meat rots in the refrigerator; the
cooler blocks the window; and the toilet won’t
flush because the pump fails without power…
Everything is modern, but nothing works. It’s
Mexican style. We are better off without it.”
(Simonelli, 1987 p.23)
(In)appropriate Technology
• inter-relationship between technologies,
their availability and accessibility, and
changing lifestyles
• Sustainability & adaptability
• Unintended negative consequences
– Air conditions (Legionnaires)
– Hospitals (MRSA)
– Vehicles (traffic accidents)
Technology and Political Will
• Technological advancements in medicine and
public health may be regarded as tools which
may improve population health given
appropriate policies which lead to adequate
access
• This access requires increased public
awareness (i.e. via education), allocation of
resources toward provision of public health
measures (i.e. requiring political
commitment), and sufficient individual or
household means (i.e. resources)
Dynamic Process
• It is not only a one-time provision of
technologies which is needed, however,
but an active (re)assessment of which
technologies are most beneficial for the
particular time and place
• A lack of attention to maintenance of
infrastructure and monitoring of services
may thwart the gains in health and may
even contribute to its deterioration
EG May Facilitate
• Enhanced employment opportunities
• Infrastructural development (roads, water,
sanitation, electricity, telecommunication)
• Provision of social services
• Investments in education
• Improvements in healthcare
Effects of Economic Growth
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Changing environments
Migration/urbanisation
Changing lifestyles and behaviours
New risks and vulnerabilities
Changes in diet and activities
Changes in disease patterns
Changes in employment opportunities
China
Russian Federation
-10
-20
-30
Year
World
20
06
20
04
20
02
20
00
19
98
19
96
19
94
19
92
19
90
19
88
19
86
19
84
19
82
19
80
19
78
19
76
19
74
19
72
19
70
19
68
19
66
19
64
19
62
19
60
GDP Growth
GDP Growth (%)
30
20
10
0
Preston Curve (2000)
China GDP and LE
China GDP and LIfe Expectancy
3.5E+12
80
70
3E+12
60
2.5E+12
50
2E+12
40
1.5E+12
30
1E+12
20
5E+11
10
0
0
GDP
Life Expectancy
China Transition
Source: Liu et al 1998
China Transition
Positive Outliers
• Prioritisation of health
• Allocation of resources according to
Epidemiology
• Focus on prevention versus cure
• Prioritisation of Education
• Provision of social services
• Social mobilisation & political will
Health & Healthcare in Cuba
Source: Evans 2008
Cuban Health Paradox
Source: Evans 2008
How?
• Deliberate social action not only for
medical care but also for the social
determinants of health (education,
nutrition, housing, employment)
• Highest doctor to population ratio in the
world (5.9/1000)
• Primary healthcare teams linked to
communities “Community-Oriented
Primary Care” who address medical and
non-medical determinants of health
Preston Curve (2000)
Negative Outliers
• Conflict or natural disasters
• New and resurgent infections (HIV,
MDRTB) due to changing ecology and/or
• Breakdown of public health infrastructure
(healthcare, immunization)
• Decreased accessibility of medicines (due
to patents)
• Unhealthy behaviours
• High unemployment rates & insecurity
Deterioration of Health
Source: McMichael et al (2004)
Sub-Saharan African Outliers
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HIV/AIDS
War and internal conflicts
Famine
Increasing obesity, diabetes, and heart
disease
Low or No Gains in Health
Former Soviet Union Countries
• Resurgence of infectious diseases
• Increasing rates of obesity
• Increasing rate of deaths from diabetes,
hypertension, and heart disease
• Increased smoking
• Increased alcohol
• Increased injuries and violence
Russia GDP and LE
Russian Federation GDP and Life Expectancy
1.4E+12
70
69
1.2E+12
68
1E+12
67
8E+11
66
65
6E+11
64
4E+11
63
2E+11
62
Year
GDP
Life Expectancy
20
06
20
04
20
02
20
00
19
98
19
96
19
94
19
92
19
90
19
88
19
86
19
84
19
82
19
80
19
78
19
76
19
74
19
72
19
70
19
68
19
66
19
64
19
62
61
19
60
0
Mortality in Russia
Source: Liu et al 1998
Economic Transitions & Health
• Positives
– medical & public health technology
– Infrastructure & social supports
– Education
– Employment
• Negatives
– Changes to environment
– Changes in behaviours (smoking, alcohol, diets)
– Changes in disease patterns
In the News
How are our current modern lifestyles
negatively impacting our health?
In-flight health issues 'on rise'
• “Growing numbers of older passengers and
ever longer flights mean the likelihood of
health problems in the skies is increasing, US
researchers suggest”
• “From blood clots to flu pandemics”
• “Several outbreaks of serious infections such
as influenza, measles, severe acute
respiratory syndrome (Sars) and tuberculosis
have been reported on commercial flights”
(source: BBC online)
Online Networking
‘Harms Health’
• “People’s health could be harmed by social
networking sites because they reduce levels
of face-to-face contact”
• “websites such as facebook set out to enrich
social lives but end up keeping people apart”
• “In less than two decades, the number of
people saying there is no-one with whom
they discuss important matters nearly
tripled”
(source: BBC online)
Is the Recession
Ruining Our Health?
• “Demand for fast food is soaring”
• ‘McDonald’s reported that its “high-quality,
affordable meal options” helped generate the
company’s strongest ever year in Britain,
contributing to a 7% rise in worldwide
profits’
• “Most studies in most countries show
morbidity & mortality rates swing shrply up
in an economic downturn, especially among
those who lose (or fear losing) their jobs”
(source: The Guardian)
The Case of Poland
____THANK YOU____