INTRODUCTION TO GLOBAL HEALTH

 Lesson 1 – The Principles and Goals of Global Health

o Health – a state of complete physical, mental and social well-being and not merely
the absence of diseases.
o Public Health – a science/art of preventing disease, prolonging life and promoting
physical and mental health/efficiency through organized community efforts
towards a sanitary environment.
o Global Health – an area for study/research/practice that prioritizes the improvement
of health and the achievement of equity in health for all people worldwide.
o Determinants of Health
 Definition: interconnected factors that determine an individual’s health
status.
 What influences health?
 Climate/weather
 Infrastructure
 Education
 Stress/trauma
 Economic/political instability
 Genetics
 Working environments
 Beliefs/values
 Access to healthy food
 Distal factors
 Governance
 Politics
 Interventions
 Proximal factors
 Socio-economic
  Access to services
 Behaviours
 Inborn factors
 Genetics
 Sex
 Age
o We NEED to shift from biomedical to social determinants of health.

 Lesson 2 – Sustainable Development Goals and Measurements

o UN Millennium Development Goals
 Eradicate extreme poverty/hunger
 Achieve universal primary education
 Promote gender equality and empower women
 Reduce child mortality
 Improve maternal health
 Combat HIV/Aids, Malaria and other diseases
 Ensure environmental sustainability
 Global partnership for development
o There are 17 goals in total to be fulfilled by 2030
o Why measure?
 Policy formation
 Program planning
 Funding allocation
 Monitoring and evaluating
o Tools for measurement:
 Vital registration: births, deaths, and causes of death.
 Uneven between countries or within countries
 Cultural barriers to registration
 Role of the health system
o Who is responsible for measuring?
 Countries keep their own vital statistics
  Demographic and Health Surveys (DHS)
 Funded by USAID and other partners
 90 countries since 1984
 Health service provision, fertility, family planning, maternal/child
health, gender, HIV/Aids and Malaria, nutrition
 Capacity building
o What should we measure?
 Key health indicators:
 Finding which diseases are people suffering from
 Determining the extent to which the disease causes death or
disability.
 Carrying out disease surveillance
 Key health indicators
 Life expectancy at birth – if no changes at survival, how long will a
baby born today live?
 Infant mortality rate – under 1 year, per 1000 live births
 Neonatal mortality rate – 28 days or younger, per 1000 live births
 Child mortality rate – children under 5 years, per 1000 live births
 Maternal mortality rate – number of women dying as a result of
pregnancy or childbirth, per 100,000 live births/year.
 Morbidity – sickness or any departure, subjective or objective, from
psychological or physiological state of well-being
 Mortality – death
 Disability – temporary or long-term reduction in people’s capacity
to function
 Prevalence – number of people suffering from a certain health
condition
 Incidence – the rate at which new cases of a disease occur in a
population
o Measuring the Burden of Disease
  Health-Adjusted Life Expectancy (HALE)
 Summarizes the expected number of years to be lived in what might
be termed as the equivalent of good health.
 A health expectancy measure
 Calculate HALE: the years of ill health are weighted according to
severity and subtracted from overall life expectancy
 Disability-Adjusted Life Year (DALY)
 The sum of years lost due to premature death and years lived with
disability
 Years of healthy life lost
 A health gap measure
 Indicates losses due to disability, death, and illness

 Lesson 3 – Global Health Trends

o Health is strongly linked to education
 Impacts an individual’s health
 Intergenerational links: parents’ health and education affect their children
 Malnutrition and disease affect children’s cognitive development and
school performance
 Education contributes to disease prevention and management
o Good health increases lifetime earnings
 Healthy workers are more productive than unhealthy workers
 When ill, many people cannot work and therefore they cannot ern money
 Illness often leads to decrease in earnings
o Ill health is expensive
 Costs of illness can cause individuals and families to dispose of assets and
fall into poverty – poverty traps
 Indirect costs, such as transportation
 Long-lasting disabilities generally require considerable expenditure on
health issues.
o Health disparities – Equity VS. Equality
  Inequity – differences in health that are not only unnecessary and avoidable,
nut also unfair and unjust.
 Inequality – differences in health status or in the distribution of health
determinants between different population groups.
 Equity is about fairness; equality is about outcomes.
 Health disparities – a type of difference in health that is closely linked with
social and economic disadvantage
 Consider equity, equality, and health disparities in terms of:
 Health status
 Access and coverage of health services – access is whether there are
or not services to be accessed; coverage is when there are services,
but the question is whether people have the resources to access these
services.
 Protection from financial risks
 Fairness of health financing
 Distribution of health benefits
 Consider how equity, equality, and health disparities vary with:
 SES – social economic status
 Ethnicity
 Gender
 Religion
 Location
 Occupation
 Social capital
o Common patterns of health disparities
 Less well-off people, with less social and political power, generally have:
 Worse health
 Fewer services available to them
 Less fairness
 Less protection for financing health
  Less well-off groups generally include:
 Indigenous people
 Ethnic and religious minorities
 Women
 LGBTQI+
 Rural areas residents
 Less educated
 Those working in the informal sector
 Intersectionality
o Health disparities exist across countries
 Enormous variation in basic indicators
 Differences reflect status of economic development, inequitable
relationships between countries, and political choices.
 Life expectancy in OECD countries is 30% higher than in Sub-Saharan
African countries
o Health disparities exist within countries
 Some countries have substantial variation in health indicators across
population groups
 Tend to be low and middle-income countries or high-income countries with
significant ethnic minorities.
o Health disparities exist across the urban/rural divide
 Urban dwellers tend to have better health status, coverage, and access to
services than rural dwellers.
 Rural people tend to have lower income, less education, less access to
services, and weaker political voice.
 Rural communities have less access to health services.
 Rural communities have more negative outcomes.
o Health disparities reflect income disparities
 Large gap in access, coverage, fairness, and benefits between less well-off
and better-off.
  Higher income is associated with better education, housing, water, access,
sanitation, hygiene, health services, and safer work environments.
 Often examined by looking at income quintiles.
o “Being born female is dangerous to your health” – E.M. Murphy
 Women face health concerns related to their diminished place un many
societies.
 E.g.: female infanticide, less food for female children, lower enrollment in
school, violence against women, etc.
 Women face unique health risks as child-bearers.
o Health disparities are greater for ethnic minorities
 Strong association between ethnicity and health status, access and coverage.
 Linked to strong association between ethnicity and power, education, and
income.
o Health disparities and financial fairness
 There are often substantial out-of-pocket costs for the poor
 Relative costs of health services are much greater for the poor, which raises
equity issues.
 Benefit of public subsidies often by better-off people.

 Lesson 4 – Equity and Ethics in Global Health

o Good health promotes economic development at the societal level
 Works in the other direction too; greater economic development promotes
better health.
 Relate to improvements from education and technology
 Low and middle-income countries must adopt policies that speed the
achievements of health goals, even with constrained incomes.
o Health expenditures reflect country income level
 Most high-income countries spend 9-12% of GDP
 Most low-income countries spend 3-6% of GDP
o Health expenditures reflect health outcomes
 Important outliers: Cuba and Sri Lanka
  Cuba has higher-than-expected life expectancy for spending on health
 Cuba focuses on preventative medicine
 Cuba is the only country that has a health care system closely linked to
research and development.
o Public and Private Expenditures: Definitions
 Public expenditure – expenditure by any level of government or government
agency
 Private expenditure – expenditure by sources other than the government
such as NGOs or individuals
 Out-of-pocket expenditure – expenditure by individuals that is not covered
or reimbursed by an insurance program.
o The Cost Effectiveness of Health Interventions
 Cost-effectiveness analysis compares cost of an intervention with the
amount of health that can be purchased with that investment
 Can help to set priorities among different ways of achieving a health goal
 Can be used to compare costs and gains of different health interventions
 ***Should not be the only factor in decisions
 Cost-effectiveness analyses can be calculated using DALYs averted per
dollar spent
 WHO “thresholds” for cost-effectiveness:
 Highly cost-effective – cost per DALYs averted is less than GDP
per capita
 Cost-effective – cost is more than one to three times GDP per capita
o Many public health interventions are very cost effective – E.g. Vitamin A
Supplementation
 Background:
 Many dietary sources of Vitamin A
 Vitamin A deficiency is especially serious for young children
 Easy and inexpensive to administer
 Spin-off effects – other public health interventions are more effective
o Health disparities must be kept in mind when engaging with global health activities
  Keep equity, inequality, and disparities in mind at all times
 Consider the various dimensions of these issues
 Be careful when using averages for indicators
 Examine how each piece of key data relates to different population groups,
especially the poor and marginalized
o Sustainable development Goals recognize importance of health for development
 Targets include:
 Outcomes – maternal mortality ration, infant mortality, etc.
 Access and coverage
 Governance
o Health disparities are contrary to human rights
 Universal Declaration of Human Rights (1948), article 25.
o The rights-based approach to health
 Assess health policies, programs, practices, in terms of impact on human
rights
 Analyze and address the health impacts resulting from violation of human
rights when considering ways to improve population health.
 Prioritize the fulfillment of human rights
o There are limits to human rights with some health concerns
 Circumstances in which someone’s rights may be suspended; for example,
outbreak of an emerging or remerging disease.
 Some health conditions are stigmatized and discriminated against; those
affected require special attention. E.g. people who are HIV-positive
 Associated issues:
 Protecting the rights to employment, schooling, other social
activities
 Access to care
 Protection of confidentiality
 Policies regarding testing
o Ethical issues in Making Investment Choices in Health
  Resources will always be fewer than needed to meet all needs, so choices
must be made.
 Better that the choices be made according to explicit, publicly justified
criteria.
 Cost-effectiveness analysis is useful but rarely sufficient.
 Judgements must be made about what is fair, using a fair process.
o Principles for Distributing Scarce Resources in Health
 Health maximization
 Equality
 Priority to the worst off
 Personal responsibility

 Fair processes require

 Transparency about how decisions are made
 Representation from affected stakeholders
 Appropriate use of scientific data

 Lesson 5 – Ethics in Health Research & Global Trends in Health

o Human rights inform research with human subjects
 Strict guidelines and requirements to protect human participants in medical
research.
 Informed consent.
 The role of independent ethical review by a research ethics committee if
human subjects are involved.
o Historical context of medical research
 Key Case: Nazi Medical Experiments
 Experiments on euthanasia victims, prisoners of war, occupants of
concentration camps.
 International Scientific Commission investigated and documented
abuses after WWII.
o Nuremberg Trials – 23 Nazi doctors
  Questions over whether it is ethical to use data the Nazis generated.
 Resulted in the Nuremberg Code – global set of research ethics
standard in the human research.
 Key Case: The Tuskegee Study
 1930s – U.S. Public Health Service conducted a study on the natural
history of syphilis in African American men.
 Study went on for 40 years.
 Subject were never given treatment.
 Eventually led to regulations for the protection of human research
subjects.
 Key Case: Nutritional studies in residential schools in Canada
 1940s and 1950s by government researchers.
 Tested effects of malnutrition, deficiencies of micronutrients.
 Withheld food and supplements from some, while supplementing
others.
 Strengthened call for reconciliation.
 Key Case: The “Short-Course’ AZT Trials
 Trials of a ‘short-course’ AZT regimen to prevent mother-to-child
transmission of HIV, mid-1990s.
 Opponents noted trials not permitted in high-income countries,
where a more complex ‘076 regimen’ was the standard of care.
 Debated ethical double standard – placebo as ‘standard of care’?
 Studies remain controversial.
o The Nuremberg Code
 First document to specify ethical principles that should guide physicians
engaged in human research.
 “Voluntary consent of the human subject is absolutely essential.”
 Human subjects should only be involved in research if it is necessary for an
important social good.
 Requires limits on and safeguards against risk to participants.
o The Declaration of Helsinki
  World Medical Association, 1967.
 Developed ethical principles to guide physicians/non-physicians
conducting biomedical research on humans.
 Most influential and most cited set of international research ethics
guidelines.
o Clinical research protocol must satisfy 6 conditions:
 Social value.
 Scientific validity.
 Fair subject selection.
 Acceptable risk//benefit ratio.
 Informed consent.
 Respect for enrolled subjects.
o Research in Low- and Middle-Income Countries
 Important issues when the subjects re likely to be poor, under-educated, and
without access to good care:
 Standard of care.
 Post-trial benefit.
 Ancillary care.
o Burden of Disease Data
 Important to gain an understanding of:
 Leading causes of illness, disability, and death in the world.
 Variations in causes by age, sex, ethnicity, and SES.
 Changes over times and how these causes might change in the
future.
o Overview of pattern and trends in the burden of disease
 On average, people are living longer and dying at lower rates.
 As people live longer, there in increase in the years people live with
disability.
 Burden of disease is predominantly noncommunicable in all regions except
Sub-Saharan Africa.
  Over the last few decades, the burden of disease has shifted increasingly
toward noncommunicable diseases.
 Shift due in part to:
 A reduction in communicable diseases.
 Aging of population.
o Trends in causes of death by region
 Higher income countries – greater burden of noncommunicable diseases.
 Lowest income countries – greater burden of communicable diseases.
 Africa and Asia have particularly high burdens of communicable diseases.
o Risk factors
 Personal behaviour
 Lifestyle
 Environmental exposure
 Inborn or inherited characteristic

 Determined to be a risk factor on the basis of epidemiological evidence.

o Demography and Health – Population Growth
 Current world population is 7.7 billion.
 Predicted to reach 9.2 billion in 2050.
 Most growth will be in low- and middle- income countries.
 This growth will put pressure on the environment and infrastructure.
o Demography and Health – Population Aging
 Population of the world is aging.
 Elderly support ratio – ratio between the number of people that are 15-64
years, compared with the number of people that are 65+.
 Affects the burden of disease.
 Affects healthcare financing.
o Demography and Health – Urbanization
 >50% of the world’s population lives in urban areas.
 Continuing urbanization, especially in low- and middle-income countries.
 Population pressure on urban infrastructure (water, sanitation, etc.)
 o The Demographic Divide
 Highest income countries – low fertility, often declining populations, aging
populations.
 Lowest income countries – relatively high fertility, growing populations.
 Demographic Transition – shift from pattern of high fertility and high
mortality to low fertility and low mortality.
o The Demographic Transition
 Mortality declines with better hygiene and nutrition.
 Population grows with gap between births and deaths.
 Fertility declines.
 Population growth slows, and older share of population increases as births
and deaths equalize.
o The Epidemiologic Transition
 Definition – shift from burden of disease dominated by communicable
diseases to noncommunicable diseases.
 Low income countries are going through it now.
 Pace of transition depends on factors related to the determinants of health.
o Progress in Health Status.
 Improvements in raising life expectancy and improving health not uniform
across countries.
 Life expectancy in South Asia and sub-Saharan Africa lags behind other
regions.
 Life expectancy in Europe and Central Asia changed little from 1990-2011,
related to break up of Soviet Union.
 Life expectancy in East Asia increased dramatically, partly due to rapid
economic Growth.

 Lesson 6 – Health Systems

o What is a health system?
 All actors, institutions and resources that undertake health actions – where
a health action is one where the primary intent is to improve health.
  The agencies that plan, fund, and regulate health care.
 The money that finances health care.
 Those who provide preventive health services.
 Those who provide clinical services.
 Those who provide specialized inputs, such as the education of the
healthcare profession.
 The production of drugs and medical devices.
o The 3 goals for every health system.
 Good health.
 Responsiveness to the expectations of the population that it serves.
 Fairness of financial contribution.
o The 4 functions of a health system.
 Provide health systems.
 Generate resources: raise money that can be spent on health.
 Financing: pay for health services.
 Stewardship: govern and regulate the health system.
o Health service organization generally differs by country income category
 Most low-income countries have fragmented health systems that include
both public and private providers.
 Many middle-income countries have a system organized around a national
insurance scheme.
 Almost all high-income countries have a national health insurance system.
o Type of care in a health system can be divided into 3 levels.
 Primary care – family planning, maternal and child, basic child and adult
ailments, malaria, TB.
 Secondary care – primary + emergency obstetrics, child and adult illnesses,
basic surgery, some emergencies.
 Tertiary – primary + secondary + complicated child and adult cases,
specialist surgeries, advanced emergency care.
o Organization of 3 levels of care differ by country income category.
 High-income and some middle-income countries:
  Primary care: “gate-keeper”.
 Secondary care: specialist physicians and general hospitals.
 Tertiary care: specialized hospitals generally located only in cities.
 Most low- and middle-income countries:
 Public primary, secondary, and tertiary level facilities determined
by geographic areas and population size.
o The Declaration of Alma-Ata (1978) established health as a human right.
 Set the goal of “health for all” by 2000.
 Emphasis on “primary health care” (different from primary care).
 Characteristics of primary health care:
 Essential and socially acceptable.
 Evidence-based.
 Universally available.
 Addresses the needs of the community.
 Affordable.
 Provides preventive, promotive, curative, and rehabilitative
services.
 Linked to health system through referral system.
o The Public, Private and NGO sectors all play roles in health care.
 The roles of the Public Sector:
 Stewardship of the system.
 Raising the funds for the health system.
 Making decisions about allocating those funds.
 Establishing approaches to health insurance.
 Disease surveillance.
 Food and drug safety regulations.
 The roles of the Private, For-Profit Sector:
 Involved in the provision of services including non-licensed
“medical practitioners”.
  Involved in the operation of health clinics, hospitals, services, and
laboratories.
 Can partner with the public sector or work under contract to the
public sector.
 Is involved in all countries.
 The roles of the NGO, Private, Not-For-Profit Sector:
 Often involved in community-based promotion of better health
through education, improved water and sanitation.
 Often carry out health services.
 Can partner with the public sector or work under contract to the
public sector.
o The Canada Health System
 “The primary objective of Canadian health care policy is to protect, promote
and restore the physical and mental well-being of residents of Canada and
to facilitate reasonable access to health services with financial or other
barriers.” – Canada Health Act.

 The federal government is responsible for:

 Setting and administering national standards for the health care
system through the Canada Health Act.
 Providing funding support for provincial and territorial health care
services.
 Health regulation for food, drugs, consumer products, etc.
 Health research, including disease surveillance.
 Supporting the delivery for health care services to specific groups:
o First Nations people living on reserves.
o Inuit.
o Serving members of the Canadian Forces and eligible
veterans.
o Inmates in federal penitentiaries.
o Some groups of refugee claimants.
  Provincial/Territorial Roles:
 Management, organization and delivery of health care services for
their residents.
 Receive federal health care funds through the Canada Health
Transfer.
 To receive full payment, provincial/territorial health care insurance
plans must meet the standards of the Canada Health Act.
 Canada has a “single payer system”. Other systems rely on privately
purchased health insurance.
 Role of the Private Sector:
 Doctors are considered “private”:
o Bill governments for their services.
o Are responsible for their own expenses.
o Are not allowed to pass along extra charges on “necessary
medical services”.
 Most hospitals are owned/operated by private non-for-profits.
o Hire nurses.
 In other systems, doctors/nurses may be hired by the state.
o The Canada Health Act standards:
 Administration
 Provincial and territorial plans must insure all medically necessary
services provided by:
o Hospitals.
o Physicians.
o Dentists, when the service must be performed in a hospital.
 “Medically Necessary Services” are defined by each provincial and
territorial health care insurance plan (NOT the Canada Health Act.
 Comprehensiveness
 For the services considered medically necessary, full cost must be
covered by the public healthcare insurance plan for all medically
necessary services, as defined by the province/territory.
  Universality
 The plan must cover all residents.
 Portability
 The plan must cover all residents when they travel within Canada.
 When a resident moves province, they can continue to use their
original health care insurance for 3 months, to give time to register
for the new plan and receive a new health insurance card.
 Accessibility
 The plan must provide all residents reasonable access to medically
necessary services.
 Access must be based on medical need and not the ability to pay.

 Lesson 7 – Culture and Health

o The concept of Culture
 Culture- "behavior and beliefs that are learned and shared".
 Culture influences family, social groups, individual growth,
communication, religion, art, politics and the economy.
 Health policies/programs must always keep culture in mind (it is usually
done automatically when working within our own culture.
o Culture is related to…
 Health behaviours.
 People’s perceptions of illness and health.
 Healthcare-seeking behaviours (who seeks healthcare, and why).
 Health practices by practitioners, including who is considered a practitioner
(who is considered part of a health system).
o Perceptions of illness vary across cultural groups
 Illness – personal, interpersonal, and cultural reactions to disease or
discomfort.
 One culture may view certain signs or symptoms as an affliction while other
consider them normal.
  Disease – malfunctioning or maladaptation of biologic and psychological
processes in the individual.
 Some cultures believe illness can be caused by:
 Bodily imbalances (too hot, cold, etc.)
 Strong emotions (anger, sorrow, envy, stress).
 Supernatural forces.
 Sex (too much, inappropriate partner)
 There is a slight truth in all these things.
 Cultural interpretations of physical states that people perceive to be illness,
but that do not have a physiological cause.
 Efforts to improve health need to consider these beliefs:
 E.g. Empacho in Mexico – when you eat too much and your stomach
hurts, it is because your food got stuck to your intestine walls, the
actual cause could be food poisoning or indigestion.
o Disease prevention strategies vary across cultural groups.
 Many cultures have taboos that concern avoiding illness.
 Wide variety or ritual practices to avoid illness:
 Use of charms or amulets.
 Many concern foods to avoid during pregnancy (many taboos around the
food)
 E.g. communities in southern Nigeria: avoid sweet foods, eggs
(becomes a thief), snails (could be born with a speech impediment).
 In Canada people don’t drink alcohol during pregnancy, while in
Germany they drink it as long as they don’t get drunk.
o Behaviours can have important impacts on health.
 Some health issues can only be addressed by changes in behaviour.
 Risk factors for leading causes of death related to culture include:
 Nutrition and eating practices.
 Tobacco use.
 Unsafe sex.
 Hygiene.
o There are various theories/models for how health behaviours can be changed.
 The ecological perspective – multiple levels of influence (interaction of
different levels in an ecosystem)
 E.g. risk for smoking.
 Levels – individual, interpersonal, institutional, community, public
policy.
 Individual behaviours influence and are influenced by the social
environment.
 The Health Believe model – behaviours depend on perceptions (how they
see the world)
 E.g. safer sex behaviours.
 Perceptions of:
o Likelihood of infection.
o Severity of illness.
o Benefits of preventive behaviour.
o Barriers to preventive behaviour (social pressures).
 Stage of Change model – behaviour is a process.
 E.g. substance abuse treatment.
 Stages – precontemplation, contemplation, decision, action,
maintenance.
 Diffusion of Innovations model – new information/technology takes times
to be adopted by a society and happens in stages.
 E.g. changes in diet.
 Stages of participants – innovators, early adopters, later adopters,
laggards.
 Depends on perceptions of ease of adoption, gains, risks, costs, fit
with values/culture.
o Changing health behaviours often involves education and cultural shifts.
 There are various told for changing health behaviours:
 Community mobilization.
 Mass media.
  Social marketing.
 Health education.
 Conditional cash transfers.
o Example: Conditional Cash Transfer
 Involve cash payments to poor families when they participate in services
that could help lift them out of poverty.
 Replace food subsidy programs.
 Response to evidence of the role of health, nutrition and education in
poverty reduction.
 In many cases, CCTs work. However, rely on quality of services.
 Receiving money is conditional on participants taking certain actions.

 Lesson 8 – Indigenous Health

o Healthy communities create healthy children.
o Laenui’s 5 steps of colonization:
 Colonizers deny existence/value of indigenous cultures.
 Colonizers destroy visible evidence of indigenous cultures.
 Colonizer systems are created within indigenous societies (e.g. schools,
churches, etc.)
 Remnants of indigenous culture is superficially accommodated, mostly as
cultural curiosity, as a “show of respect.”
 Remaining aspects of indigenous culture is expropriated by colonizing
culture.
o Health systems can reinforce negative health outcomes.
o Focusing on cultural safety can make health systems safer and more effective.
o Jordan’s Principle
 Named in honour of Jordan River Anderson, a young boy from Norway
House Cree Nation (MB).
 Unique challenges in accessing healthcare for first nations children because
federal, provincial/territorial and First Nations governments share
responsibility for paying for medical services.
  Jordan’s Principle – the government department first approached should
pay for services that would ordinarily be available to other children in
Canada; the dispute over payment for services can be settled afterwards.
 Motion unanimously adopted by the House of Commons in 2007.

 Lesson 9 – Indigenous Health

o Lessons from health research in partnership with communities.
 Communities had no TRUST in Statistics Canada at the time and very little
trust in Health Canada and would be very resistant to a federally governed
survey that was asking a series of health questions in communities.
 The recommendation to Health Canada was that what was required was a
national First Nations and Inuit regional health survey that would be under
the authority of a First Nations governing body.
 Self-determination – a nation’s right to determine its own future as free as
possible from external interference or domination by another nation or
nation-state.
 Self-governance/government – the ability to asses and satisfy needs without
outside influence, permission or restriction.
o First Nations Health Authority (BC)
 Starts with nation rebuilding.
 Governance.
 Capacity building.
 Lesson 9 – Environmental Health Part 1: Climate Change and Pollution
o The Importance of Environmental Health
 Environmental factor for 1/3 of total global burden of diseases
 Communicable and noncommunicable diseases
 Leading causes of death in low- and middle-income countries.
 3rd – chronic obstructive pulmonary disease
 4th – lower respiratory infections
 5th – diarrheal disease
 Central to achieving development.
o Key Definitions
 Environment – externa, physical, chemical and microbiological exposures
and processes that impinge upon individuals and groups and are beyond the
immediate control of individuals.
 Environmental health – efforts that are concerned with preventing disease,
death, and disability by reducing exposures to adverse environmental
conditions and promoting behavior change.
o Environmental health risks are at multiple levels.
 Global
 Climate change
 Ozone depletion
 Community
 Outdoor air pollution
 Water resource
 Management
 Household
 Indoor air pollution
 Toxic materials
 Water and sanitation
o The costs and consequences of key environmental health problems
 Because of the high burden, social and economic consequences are
enormous.
 Burden falls disproportionally on relatively poor people.
 Negative consequences on productivity
 If people are sick, they are not able to contribute economically.
o Definitions and the Science of Climate Change
 Climate VS Weather
 Climate – long-term prevailing weather conditions at a given place.
 Weather – short-term, localized atmospheric conditions with regard
to heat, dryness, sunshine, wind, rain, etc.
 Climate change is those disruptions in the long term patterns of climate.
  Greenhouse Effect
 Greenhouse gases reflect infrared radiation back toward Earth.
 Warm enough to support liquid water.
 Greenhouse gases: CO2, water vapor, methane, etc.
 Important for keeping Earth’s surface at a habitable temperature.
o Causes of Climate Change
 There is better growth of forests with CO2.
 The ocean also pulls this gas.
o Converging lines of evidence of Climate Change – Role of the IPCC
 Established in 1988 by the World Meteorogical Organization (WMO; of the
UN) and the UN Environment Programme (UNEP) at the request of
member nations.
 Task – to provide policymakers with regular assessments of the scientific
basis of climate change, its impact and future risks, and options for
adaptation and mitigation.
 5th assessment report – 2013-2014, 831 experts.
 Special Report (2018) – Global Warming of 1.5*C
o Causes of Climate Change are not evenly distributed geographically
 There are not equally distributed, there is a correlation with higher income
countries and their higher production of pollution.
o Effects of Climate Change – Change in Sea Level
 Due to combination of sea ice melt, expansion of water volume due to
warmer temperatures.
 Effect are not evenly distributed geographically.
o Effects of Climate Change – Change in Hydrological Cycle
 Effects are not evenly distributed geographically.
 Implications for:
 Agriculture (drought)
 Flooding
o Climate Change and Health: Extreme Weather Events
 Storms, floods, hurricanes, forest fires.
  Increases accidental injury, long-term mental health.
o Climate Change and Health: Heat Waves
 Europe, 2003
 70% of deaths in Paris attributable to climate change.
 UK, 2018
 700+ deaths in UK during 15-day heat wave in June-July.
 India, 2015
 2300 deaths attributed over 1 week in May
 Temperature reached 44*C
 High temperatures reduce the ability to work.
o Climate Change and Health: Water-Borne Diseases
 Pathogens: Giardia, Cryptosporidium, Shigella, and verotoxigenic E. Coli,
cholera.
 Higher temperature and greater variation in precipitation likely to alter the
risk of enteric water-borne disease.
o Climate Change and Health: Vectored diseases
 E.g. Schistosomiasis
 Mosquito populations enhanced by increased temperature and precipitation.
o Climate Change and Health: Rodent-Borne Diseases
 Elevated temperature in West-Central Europe associated with more
frequent Hantavirus outbreaks.
 Changes community ecology.
 High seed production increases rodent densities.

o Climate Change and Health: Tick-Borne Diseases

 Lyme disease.
 Ecology similar to Hantavirus.
o Climate Change and Health: Air Pollution
 Air quality diminished by
 Heat
 Chemical such as methane
  Increases ground-level ozone.
o Climate Change and Health: Food Insecurity
 Risk of protein deficiency in communities dependent on fisheries.
 Extreme weather events and unpredictability in weather patterns.
o Climate Change and Nutrition: Problems that cross sectors
 Unhealthy diets currently cause more deaths and disease worldwide than
unsafe sex, alcohol, drug, and tobacco use combined.
 Diets are inextricably linked to the environment.
 Food production is the largest source of environmental degradation.
 70% of global water use is for agriculture.
 Primary source of N2O and methane.
o Climate Change and Nutrition: Solutions that cross sectors
o Air pollution
 Burden of disease of key environment-related diseases.
 Ambient air pollution
o Cause of 3.1 million deaths an 3.1% of global DALYs
(2010)
 Household air pollution
o Cause 3.5 million death and 4.3% of total DALYs (2010)
 Pollution is an environmental justice issue
 Environmental justice – all people and communities are entitled to
equal protection of environmental and public health laws and
regulations.
 Environmental injustice – inequitable exposure of poor, minority,
and disenfranchised populations to toxic chemicals, contaminated
air and water, unsafe workplaces and other forms of pollution, and
the consequence disproportionate burden among these populations
of pollution-related disease.
 Air pollution commonly comes from combustion
 Different fuels release different pollutants.
 Internal combustion engines:
 o Carbon monoxide (CO) – binds with hemoglobin in the
blood, blocking oxygen.
o Lead (from leaded gasoline) – damages digestive and
nervous system.
o NO2, NO3 – damages lungs and respiratory system.
 Burning of coal and wood.
o Sulfur dioxide (SO2) – irritates and damages lungs.
o Particular matter (PM) – irritates and damages lungs; depth
of penetration depends on size of PM
o PM10 – diameter less than 10 um
o PM2.5 – diameter less than 2.5 um
 Air pollution leads to noncommunicable diseases
 Use of certain chemicals in construction, etc.
o Volatile organic compounds (VOCs) – irritant, possibly
carcinogenic.
 Mixing and reacting pollutants
o Smog – originates from fossil fuel combustion; respiratory
and eye irritant.
o Ozone (O3) – formed low in atmosphere by reaction of
pollutants such as NO2 with Oxygen.
 Health risks from ambient air pollution
 Common effects are respiratory symptoms, including cough,
irritation of the nose and throat, and shortness of breath.
 Older and younger people tend to be more susceptible.
 Ambient air quality measured by an Air Quality Index (AQI)
 Developed by US Environment Protection Agency
 Based on PM, SO2, NO2, CO, Ozone (at ground level).
 AQI > 300: everyone should avoid outdoor exertion.
 The burden of disease from ambient air pollution can be reduced through
regulations.
 Introduce unleaded gasoline.
  Use low-smoke lubricant for or ban two-stroke engines.
 Shift to natural gas to fuel public vehicles.
 Tighten emissions inspections
 Reduce burning of garbage.

 Lesson 10 – Environmental Health Part 2: WaSH (Water, Sanitation, Hygiene)

o Fecal-orally transmitted infections are an environmental health burden.
 Unsafe sanitation, unsafe water, poor hygienic practices, and burden or
diarrheal disease are closely linked.
o Burden of disease related to sanitation, water and hygiene
 0.3 million deaths and 0.9% of DALYs (2010).
 Highest burden: children, the poor, less educated in poorer countries of
South Asia and sub-Saharan Africa.
 Waterborne pathogens associated with diarrhea, other gastrointestinal
problems.
 Other diseases:
 Parasitic worms.
 Trachoma.
 Scabies.
 Skin infections.
o Sanitation is key in reducing the burden of disease.
 Simple methods of sanitation and excreta disposal are low-cost and
relatively effective.
 Barriers include lack of knowledge, cost, construction, and local laws.
 Government subsidies and regulations for installing latrines.
 Promotion through public-private partnerships headed by NGOs.
o Night soil and greywater are important fertilizers for agriculture and aquaculture.
 Use is growing in many parts of the world.
 Driven by:
 Increasing water scarcity and stress.
 Expanding populations.
  Recognition of its resource value.
 Irrigation with waste water can often supply all the nutrients required for
crop growth.
 Health risks: spread of enteric viruses, bacteria and parasites.
 Risk to farmer and farm families; consumers.
 Solutions:
 Composting toilets.
 Wastewater settling/treatment.
 Protective equipment.
o Improved water supply is key in reducing the burden of disease.
 Potable = safe
 Improved water sources:
 House connection.
 Stand post.
 Borehole.
 Dug well.
 Rainwater collection.
 Investments in water alone do not have greatest impact on reductions in
diarrheal morbidity.
 Hygiene investments are critical to realizing water and sanitation benefits.
o Hygiene is key in reducing the burden of disease.
 Hygiene promotion can lead to a 33% reduction in diarrhea morbidity.
 Handwashing associated with significant reduction in acute respiratory
infections.
 Focus should be on simple messages about handwashing and enabling
handwashing.
o Investment in water, sanitation and hygiene must be integrated.
 In order of priority:
 (1) Hygiene: important for its own sake and to maximizing effect of
other investments.
  (2) Sanitation: government promotion of low-cost sanitation
schemes.
 (3) Water: development of low-cost water supply schemes.

 Nutrition – Part 1 – Measurement, Macronutrients, and Undernutrition

o Nutritional status has profound relationship with health status.
 Childhood underweights is the leading risk factor for death of under-5
children globally.
 45% of all deaths in children under-5 are attributable to nutrition-
related causes.
 Low-cost, highly effective interventions available
o Por children commonly suffer from inadequate nutrition and sickness at the same
time.
 Conditions of inadequate sanitation and potable water, low education
commonly occur with undernutrition.
o Undernutrition and intestinal parasites affect the same people.
o Undernutrition and infections cause a cycle of sickness.
 Lack of appetite.
 Diarrhea.
 Malabsorption of nutrients.
 Redirection of nutrients to inflammation.
 Decreased growth hormones.
 Impaired immune function – more parasites successfully develop.
 Higher parasite survival.
 More parasite reproduction.
o The cycle of undernutrition and infection reduces child growth.
o Key definitions:
 Macronutrients – carbohydrates, fats, protein.
 Micronutrients – essential vitamins and minerals.
 Malnutrition – improper nutrition (too much or too little).
 Undernutrition – insufficient intake (macro- and/or micronutrients).
o Linear growth in humans
 Growth is episodic – even in early childhood, children will go lengths of
time without growing.
 Genetics explain only 10% of variation in adult height.
o Stature of populations is a sensitive indicator of quality of life during the time of
growth.
o Time of linear growth in humans.
 4 important period of linear growth:
 Fetal.
 Infant.
 Childhood.
 Puberty.
 Growth faltering is possible during all 4 periods, including in utero.
o How is growth and size measured?
 Anthropometry – scientific study of measurements and proportions of the
human body.
 3 primary measurements:
 Weight-for-height (WHZ) – current nutritional status, independent
of age – wasting.
 Body mass index (BMI)
 Weight-for-age (WAZ) – short-term, acute hunger – underweight.
 Height-for-age (HAZ) – longer-term, chronic hunger – stunting.
 Measurement is non-invasive, simple, inexpensive, and repeatable.
o Definitions of undernutrition categories.
 Low birthweight – child’s weight at birth below 2.5 kg
 Wasting, WHZ = weight (kg) / height (m)^2  (2 z-scores below the
international reference)
 Underweight, WAZ: 2 z-scores below the international reference.
 Stunting, HAZ: low weight-for-age; 2 z-scores below the international
reference.
o Child anthropometry based on WHO Child Growth Standards
  WHO Child Growth Standards are based on the WHO Multicentre Growth
Reference Study.
 International standard based on growth data of healthy children from Brazil,
Ghana, India, Norway, Oman, and the USA.
 Children will grow similarly when their health and care needs are met.
o Anthropometry measures are statistically transformed for comparison
 Z-score – statistical transformation where the mean (=average) is set to 0.
 Measurements are given as their deviation from the mean.
 Cut-off for stunting: - 2 standard deviations (SD)
 Cut-off for severe stunting: -3 SD
o Consequences of clinical stunting in childhood.
 Short-term
 Morbidity.
 Mortality from infections.
 Medium-term
 Diminished cognitive development.
 Long-term
 Higher risk of metabolic syndrome – hypertension, cardiovascular
disease, type 2 diabetes.
 Lower earnings over lifetime.
o Key nutritional needs through the lifespan.
 Undernourished women have greatly increased risks of dying of pregnancy-
related causes.
 Undernourished fetuses have higher risk of stillbirth, mental impairment,
birth defects.

 Lesson 11 – Nutrition, Part 2

o Key Micronutrients:
 Vitamin A
 Sources: green leafy vegetables, yellow and orange fruits (not
citrus), carrots, animal-source foods.
  Deficiency associated with xeropthalmia eventually can lead to
permanent blindness.
 Important to growth and immune function; can impact severity of
illness and chance of survival of pneumonia, diarrhea and measles.
 Iodine
 Sources: some types of seafood, plants grown in soil that naturally
contains iodine.
 Deficiency associated with a growth on the thyroid called a goiter,
failure to develop full intellectual potential.
 Often occurs in people in mountainous regions where less seafood
is consumed, and soil is deficient in iodine.
 Iron
 Sources: fish, meat, poultry; also, in fruits, grains, vegetables, nuts,
and dried beans.
 Lack of iron associated with iron deficiency anemia, associated with
fatigue and weakness.
 Iron deficiency during pregnancy increases risk of premature birth,
low birthweight, hemorrhaging, and dying in child birth.
 Some limited programs to double-fortify salt with iodine and iron.
 Zinc
 Sources: red and white meat, and shellfish.
 Severe deficiency associated with growth retardation, impaired
immune function, skin disorders, hypogonadism, cognitive
dysfunction.
 Deficiency a major risk factor for morbidity and mortality from
diarrhea, pneumonia and malaria.
 Folic Acid and Calcium
 Folic acid sources: leafy green vegetables, and enriched products
such as flour.
 Calcium generally found in dairy products but also in nuts, leafy
green vegetables, fish eaten with bones such as sardines.
  Deficiencies of folic acid in pregnant women are associated with
neural tube defects in their children, such as spina bifida.
 Supplementation with calcium reduces the risk of hypertensive
disorders of pregnancy.

o Food security – “food security exists when all people, at all times, have physical
and economic access to sufficient, safe and nutritious food which meets their
dietary needs and food preferences for an active and healthy life.”
 Food security is measured in a variety of ways:
 Measurement Tool Construct Measured
 Food balance sheets National food supply/access
 Agricultural production National food supply/access
 Anthropometry Chronic undernourishment
 Food consumption Food quantity, diet quality
 Dietary diversity Diet quality
 Coping Strategies index Coping behaviours
 Income and employment indirect measure of access
 ===> rely on proxy measures
 Measurement is key but challenging.
 Measurement is required to:
o Understand problems.
o Design interventions.
o Access outcomes.
 Measurement must be valid.
o What are we measuring? Are we measuring the right thing?
 Measurement must be reliable.
o How are we measuring? Do our measurement tools work
well?
 Experience-based measures of food security:
 Radimer’s work in the US late 1980s.
  Her question: how to reliably and validly measure hunger, rather
than a proxy?
 Started with qualitative, open-ended interviews with low-income
women about their experiences of hunger.
 Questionnaire generated from the statements by these women.
 4 components: household individual
o quantity food depletion insufficient intake
o quality unsuitable food inadequate diet
o psychological food anxiety feeling deprived
o social unacceptable means disrupted eating pattern.
 Experiences of food insecurity cut across cultures:
 Worry about not having enough food. |
 Stretch food resources. |
 Diet quality declines. | SEVERITY
 Portion sizes are cut. |
 Meals are skipped. |
 Go for 1+ days without eating. V
o Children tend to be protected from the worst experiences as
parents are able to.
o With development, nutrition issues shift.
 Malnutrition shifts from a problem of undernutrition to overweight and
obesity.
 Most overweight/obesity in low- and middle- income countries.
o Global burden of overweight and obesity
 30% of global population (2.1 billion people) are obese or overweight.
 Obesity has nearly doubled since 1980.
 Childhood obesity has emerged as one of the most serious public health
challenges of the 21st century.
 Closely linked with many noncommunicable diseases.
o Measurement.
 Overweight: excess weight relative to height.
 In adults, commonly measured by body mass index (BMI)
  In children, commonly measured as weight-for-height (WHZ)
o Determinants of nutritional status: obesity and overweight.
 Immediate causes: an increase in total energy intake and a decrease in
energy expenditure.
 Genetic and cultural factors are important.
 Distal causes: global financial and trade liberalization; increased SES,
urbanization.
o The Nutrition Transition
 “obesity in the developing world can be seen as a result of a series of
changes in diet, physical activity, health and nutrition, collectively known
as the ‘nutrition transition’”
 Multiple forces account for dietary shifts:
 Increased income.
 Trends.
o Traditional diets abandoned in favour of ‘western’ foods.
o Shifts in how food is prepared.
 Timing of eating shifts as people’s times allocation to different
activities shifts.
o Eating between meals.
o Eating away from home.
 Market forces
o Producers of sugary beverages and snack foods shift to
LMIC markets.
 Concurrent decrease in physical activity patterns.
 Shifting occupations away from physical labour.
 Transportation shifts from active to non-active as income increases.
 Urbanization.
 Diet shifts
 Increased fat
o Sources: red meat, dairy products, processed food made with
partially hydrogenated oils.
 o Saturated and trans fats have been shown to be harmful to
cardiovascular health by raising cholesterol levels.
 Increased sodium
o High quantities in prepared and processed foods.
o High intake can lead to hypertension.
 Added sugar
o Dramatic increase in consumption of sugar-sweetened
beverages.
o Consumption of SSBs promotes weight gain, type 2
diabetes, and coronary heart disease.
 Lower dietary fiber intake
o Sources: whole grains, legumes, fruits, and vegetables.
o Helps prevent obesity, diabetes, cardiovascular diseases, and
various cancers.
 Refined carbs
o Whole grains are often processed to produce refined carbs,
which removes the majority of the fibers and other nutrients.
o For taste, increased shelf life.
o Case study: Street vendors in Tamil Nadu (India)
 In many developing countries, street vendors are key in feeding urban
dwellers.
 Street vending a viable option for entrepreneurial urban poor.
 Benefits:
 Can incorporate a variety of foods, including traditional foods.
 Inclusion of women.
 Livelihoods.
 Challenges:
 Food safety.
 Difficult to regulate.
o The double burden of malnutrition
 It is possible to find undernourished and overweight/obese individuals in
the same household.