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Global Health Issues

Global Health: A Gordian Knot?

Integration & Cooperation to Achieve Health for All

Remarkable improvements have been made in health status worldwide over the last century, but these improvements have not been shared equally. The gap between rich and poor nations has widened, as have inequities within countries, between urban and rural, men and women, and young and old. Those most vulnerable to existing and evolving health crises tend to be those beholden to social determinants proven to adversely affect population health (eg, poverty, unsafe living and working conditions, racial and gender discrimination, etc).[2]

Deconstructing the complex, interrelated factors determining this troubling state of global health is a daunting task. Weak health systems, worldwide shortages and imbalances in the health workforce, research and vaccine development for diseases that disproportionately affect high-income countries, new and re-emerging diseases, and a lack of political will are among the most glaring causes of the current global health morass. Compounding the situation is the economics of health, with under-investment in health infrastructures, inefficient use of health care dollars, and spending restrictions placed on governments by international funding mechanisms like the World Bank and the International Monetary Fund.

Yet, knowing the causes allows stakeholders to design solutions. Governments prioritizing population health through policy and resource allocation, scaling up of sustainable human resources for health, problem-based learning and community-based education for health professionals, and importantly, the availability of vaccines and potable water (which are two highly effective ways to prevent disease), are all proven approaches to health problems plaguing the globe. Complementary strategies including coordinated international cooperation, integration of services and agencies dedicated to health and well-being, and equitable access to care and medicine, also work towards converting health from a privilege for the few, to a right exercised by all.

Maternal and Child Health

Considering that the number of infants in the developing world dying in their first month of life equals the total number born in the United States in a year,[3] it's fair to say that maternal and infant mortality rates are some of global health's most dramatic indicators. In addition, a woman in sub-Saharan Africa has a 1 in 16 chance of dying in childbirth, while a woman in North America has only a 1 in 3,700 chance of facing the same fate.[4] Similarly dismal comparisons abound for low birthweight infants, mortality in children under 5, and children who are under weight and height for their age.[5]

Unfortunately, the majority of maternal and infant deaths occur in the poorest, most disadvantaged places, where health services are inaccessible or nonexistent, food and transportation are scarce, and other structural determinants work against population health. Representative of the imbalance between countries is the fact that almost 99% of all neonatal deaths occur in low- and middle-income countries, yet the majority of research focuses on the 1% of these deaths occurring in rich countries.[6]

More disturbing still is the fact that evidence-based research shows the majority of maternal and infant deaths result from preventable causes such as infections, complications at birth, and low birth weight. Prenatal care, maternal nutrition, preventive medicine, reproductive health information, and attendance of births by skilled health personnel have all shown to have a positive impact on maternal and infant health outcomes.  

Infectious Diseases

Tuberculosis (TB), malaria, and HIV/AIDS together kill 6 million people a year.[7] Of the three, HIV is the most deadly, with 2.9 million people dying from AIDS-related causes in 2006, an alarming 2.1 million of them in sub-Saharan Africa.  Even more alarmingly, an astounding 6% of all sub-Saharan adults are infected with HIV, making it the region with the world's highest prevalence of the disease. The next closest is the Caribbean, with an adult prevalence rate of 1.2%.[8]

Women and young people are increasingly affected by HIV/AIDS. Globally, almost half of all adults living with HIV/AIDS are women, and young people ages 15-24 accounted for 40% of new HIV infections in 2006.[9]  Although East and Central Asia and Eastern Europe accounted for the largest increase (21%) in new infections between 2004 and 2006, every region in the world recorded increases during the same two-year period.[10]  

Being orphaned to AIDS directly contributes to the fragility of communities as it usually initiates a downward spiral of discrimination, neglect, and adverse social determinants which affect the health and well being of the child and family as a whole. The numbers are staggering: more than 15 million children under the age of 18 have lost one or both parents to HIV/AIDS[11]. Compounding the problem is that the vast majority of people living with HIV/AIDS in the developing world do not have access to treatment due to fragile health systems, lack of health service providers who themselves are succumbing to the disease, and the high cost of many medications.

The next deadliest is TB, one of the world's leading infectious causes of death, killing 2 million people a year.[12]  Poverty, a lack of basic health services, poor nutrition, and inadequate living conditions all contribute to the spread of TB.  In turn, illness and death from TB reinforces and deepens poverty in many communities. The regions most affected by TB include Southeast Asia (the world’s hardest-hit region), Eastern Europe (where TB deaths are increasing after almost 40 years of steady decline), and sub-Saharan Africa.  Combatting the rise of TB is also complicated by the insufficient application of TB control measures, the spread of HIV/AIDS, and the emergence of multidrug-resistant TB (MDR-TB)[13].

More than a million people die from malaria each year and almost half of the world's population is at risk of acquiring the disease.[14] This proportion is steadily increasing due to a variety of factors including deteriorating health systems, growing drug and insecticide resistance, climate change, and war. As with many other pandemics, the overwhelming majority of cases occur in sub-Saharan Africa, and most of the thousands of people who die daily from malaria in this region are children under five. Growing resistance to the most affordable and available malaria drugs underscores the urgent need for scaled up malaria research.

Chronic Diseases
                                   
Success in infectious disease control, rapidly changing lifestyles, and demographic shifts are contributing to changes in the epidemiology of global health. Ironically, while infectious diseases receive much of the press and international aid attention, chronic diseases represent 60% of the global disease burden, with heart disease, diabetes, stroke, cancer, and other conditions killing 35 million people in 2005.[15] 

Projected Deaths Due to Chronic Diseases, 2005

Source: World Health Organization. Preventing Chronic Diseases: A Vital Investment. Geneva: World Health Organization, 2005.

The perception that these conditions are "diseases of the rich" is a fallacy: of those 35 million deaths, 80% were in low- and middle-income countries.[16] This straitjackets these countries into a 'double burden' of disease – already weak health systems strain to combat emerging chronic diseases while still struggling to contain infectious disease epidemics. Nevertheless, political will trails behind the epidemiological evidence, with few countries having implemented comprehensive, integrated policies for preventing and controlling non-communicable diseases and there is no UN Millennium Development Goal (MDG) specifically pegged to reducing chronic diseases.

10/90 Gap and Access to Medications & Treatments

Relataively few of the world’s resources for health research are allocated for solving the health problems of developing countries; the latest estimate from the Global Forum for Health Research puts total health research investment at US$105.9 billion. But there is still massive under-investment in health research relevant to the needs of low-and middle-income countries, with a mere 10% of this worldwide expenditure on health research and development devoted to the problems that primarily affect 90% of the world's population.[17]  This is known as the "10/90 Gap."

This is not to say that resources are totally bypassing the world’s poor and sick. On the contrary, more financial resources are now earmarked for the health challenges faced by the world’s poorest, and new technologies are also available. The problem is in their distribution, with funding typically weighted towards specific, high-profile diseases (e.g. influenza), outcomes measured accordingly, and by a narrow set of indicators (e.g. increasing the number of HIV-positive people with access to ARV drugs or reducing by 75% the maternal mortality rate, à la the MDGs). Indeed, health is not just a measure of mortality and morbidity, but rather "astate of complete physical, mental and social well-being...not merely the absence of disease or infirmity," according to WHO. Recent reports from the Joint Learning Initiative and the WHO itself argue that until stakeholders begin to define their goals in terms of such “healthy people” rather that specific diseases – and begin to direct  funds towards prevention, and bolstering public health systems – longterm, sustainable changes will not occur in the health picture of the world’s poor.

Closing this gap also depends on increasing access to essential drugs and vaccines, coupled with their rational use.  Despite existing treatments for diseases and conditions such as malaria, measles, tetanus, and child diarrheas, an estimated one-third of the world population lacks regular access to essential drugs, with this figure rising to over 50% in the poorest parts of Africa and Asia.[18] And even where drugs are available, weak regulations may mean that they are substandard or counterfeit.  Each year, tens of millions of children do not receive basic immunizations, and more than two million people die of vaccine-preventable diseases.[19]

Human Resources for Health

Training, supporting, and equitably distributing  human resources for health – both within and among countries – play a large role in the grander scheme of investment in public health systems, since the quality of health care workers and the density of their distribution have a causal relationship to positive health outcomes.[20]  Health systems, and therefore health outcomes, around the world suffer from aggregate workforce shortages and inequitable distribution due to internal migration from rural areas to urban, international emigration to countries with better working conditions, loss of personnel from the public to the private sector, socio-economic barriers to medical education, among other factors.   

While many wealthy nations face their own shortages of health care workers[21], indisputably, this trend is most problematic for developing nations, which bear the brunt of the brain drain as professionals leave their home countries in search of more safe, secure, and rewarding employment opportunities. For example, the United States, with just 5% the world’s population, employs 11% of the world’s physicians[22], pulling from developing regions with high emigration factors, such as sub-Saharan Africa and the Caribbean.

Medical education and training – the foundation for creating a sustainable global health workforce – is also rife with systemic shortages and shortcomings. Factors impeding the strategic scaling up of human resources for health include the quality and quantity of medical schools; imbalances in the diversity of medical education administrators, faculty, and students; cost; and lack of access to all levels of education by the world's underserved. 

Moving Forward

Grasping the constellation of factors influencing the current state of global health is daunting, and still more daunting is the challenge to design effective strategies to transform the situation. Challenging and daunting, but not impossible. Initiatives such as advance market commitments to improve vaccine availability, the GAVI Alliance, the Global Fund for AIDS, TB and Malaria, the work of other foundations such as the Bill & Melinda Gates Foundation, an increased focus on translational research, massive medical education programs in Cuba and Venezuela, and other cooperative undertakings, all show promise in turning the tide towards improved global health. Nevertheless, the broader structural and social determinants affecting health – secure housing, gender and racial equality, quality education – must be brought to bear if equitable, sustainable improvements are to be realized; indeed if real development is to take place on a global scale. Only by uniting all stakeholders in an integrative and cooperative approach, will the Gordian Knot of global health be transformed into a guy wire for "health for all." 

References

1. Every minute, a pregnant woman dies in the course of her pregnancy or childbirth. In that same 60 seconds, seven infants and 20 children under five die. Save the Children. State of the world’s mothers 2006: Saving the lives of mothers and children.  Westport (CT):  Save the Children; 2006.
2. For instance, see Action on the Social Determinants of Health: Learning from Previous Experiences. World Health Organization; March 2005; Social Epidemiology. Berkman LF, Kawachi I, editors. New York: Oxford University Press;2000; and Social Determinants of Health. Marmot M, Wilkinson R. editors. Oxford: Oxford University Press; 1999.
3. Save the Children.  State of the world’s mothers 2006: Saving the lives of mothers and children.  Westport (CT):  Save the Children; 2006.
4. MillenniumProject.org [homepage on the Internet].  New York:  Millennium Project; c2006 [updated 2006; cited 2007 Apr 25].  Fast Fact:  The Faces of Poverty.  Available from:  http://www.unmillenniumproject.org/resources/fastfacts_e.htm
5. For these and other current indicators, see the Human Development Report 2006: Beyond Scarcity: Power, poverty and the global water crisis. Geneva: United Nations Development Programme, 2006.
6. Lawn JE, Cousens S, Zupan J, Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: When? Where? Why?  2005.  The Lancet, 365(9462):891-900.
7. World Health Organization.  Working for Health: An introduction to the World Health Organization. Geneva: World Health Organization; 2006:16.
8. Joint United Nations Programme on HIV/AIDS; World Health Organization.  AIDS epidemic update. Geneva: UNAIDS; December 2006.
9. ibid.
10. ibid.
11. UNAIDS.org [homepage on the Internet]. Geneva: Joint United Nations Programme on HIV/AIDS and World Health Organization [cited 2007 april 27]. Orphans. Available from: http://www.unaids.org/en/Issues/Affected_communities/orphans.asp
12. World Health Organization.  Working for Health: An introduction to the World Health Organization. Geneva: World Health Organization; 2006:17.
13. World Health Organization.  Global tuberculosis control: Surveillance, planning, financing: WHO report 2007.  Geneva: World Health Organization; 2007.
14. World Health Organization.  Working for Health: An introduction to the World Health Organization. Geneva: World Health Organization; 2006:17.
15. Strong K, Mathers C, Leeder S, Beaglehole R.  Preventing chronic diseases: How many lives can we save?  The Lancet. 2005;366(9496):1578-82.
16. World Health Organization. Preventing Chronic Diseases: A Vital Investment. Geneva: World Health Organization; 2005.
17. GlobalForumHealth.org [homepage on the Internet].  Geneva:  Global Forum for Health Research [updated 2007 Mar 07; cited 2007 Apr 25].  The 10/90 Gap Now.  Available from:  http://www.globalforumhealth.org/Site/000__Home.php
18. World Health Organization. [homepage on the Internet]. Geneva: World Health Organization; c2007 [cited 2007 Apr 27]. Access and Human Rights Issues. Available from: http://www.who.int/medicines_technologies/human_rights/en/
19. Bill & Melinda Gates Foundation [homepage on the Internet].  Seattle: Bill & Melinda Gates Foundation; c1999-2007 [cited 2007 Apr 25]. Available from: http://www.gatesfoundation.org/AboutUs/OurWork/Learning/default.htm   
20. World Health Report, 2006. World Health Organization, 2006;p. xv.
21. According to the Association of American Medical Colleges, there will be an acute shortage of physicians in the US by 2020 and 20% of the population already lives in medically underserved areas. Source: Help Wanted: More U.S. Doctors. Association of American Medical Colleges, 2006.
22. Human Resources for Heath: Overcoming the Crisis. Joint Learning Initiative, 2004.

©MEDICC, 2007