Can Global Wealth Lead To Global Health?
Global Health or International Health has become a trendy term and many academic centres have evolved around this ‘Global’ theme. Is it the emergence of new infectious diseases such as SARS, or the re-emergence of old infectious diseases such as Avian Flu (H5N1) and Swine Flu (H1N1) that drives this global action on health? Should global health focus on the provision of medical aid to low-income countries? And finally, is the training of health care workers in low-income countries a priority area, as it helps to build the capacity of health care systems to respond to various health challenges more effectively and efficiently?
There is no doubt that such initiatives are essential components of global health, and in fact, they have been ongoing for decades with support for developing countries coming from developed countries. However, we still witness major disparities in health standards across the continents. More worryingly, developing countries of either high or low mortality rates nonetheless show the ‘double health burden’ of traditional and modern health risks. The latter set of health risks manifest themselves in diseases including hypertension, high cholesterol, obesity, and problems arising from alcohol and tobacco; the former burden covers traditional risks such as malnutrition, iron deficiency, unsafe water and poor sanitation and hygiene conditions.
There is a tendency for people to think that economic growth alone would result in an improvement in health standards, and that a global health strategy should emphasize economic development leading to rapid urbanisation. Yet does global wealth really lead to better global health? Although countries with high economic growth have shown improvement of health in terms of infant mortality, maternal mortality and longevity, a rapid rise of non-communicable diseases – such as hypertension and diabetes – has been observed in these countries. A review of countries/regions with rapid urbanisation and economic development such as mainland China and Taiwan shows that the prevalence of chronic illnesses is rising at an alarming rate.
Closely Packed Spaces
We have witnessed tremendous growth of the global economy since World War II, but a parallel improvement of global health was not observed. For example, the detrimental effects of urbanisation on health have been underestimated. Without doubt, urbanisation creates opportunities for better housing and living conditions, access to safe water and good sanitation, more employment opportunities, access to health and community service and recreational facilities. However, unplanned and uncontrolled urbanisation can strain health services, damage the environment and exacerbate poverty and inequality.
A recent WHO report in 2009 entitled ‘City and Public Health Crisis’ points out that urbanisation would enhance the spread of disease in today’s world. In a city an outbreak could soon become an epidemic, and with better road, rail and air links to other cities, such an epidemic would soon become a pandemic. In high-rise buildings with multiple apartments and with floor levels linked by elevators, infections are likely to spread faster than down a residential street with a row of separate single-family homes. The 2003 outbreak of SARS in Hong Kong is a striking example, where within just two months there were over 1,800 patients across a dozen countries in Asia, Europe and North America. A similar example was the H1N1 virus, where the first case identified on 23 April 2009 in Mexico spread very quickly to many cities in USA. Within nine weeks, all six WHO regions of the world were affected. It is now impossible to say that any particular part of a city is safe. As such, the inherent nature of a city makes it susceptible to epidemics.
There is less emphasis on the impact of globalization on non-communicable diseases and mental health in low-income countries. Most vulnerable individuals with mental disorders are poor and living with disabling conditions. Rapid economic growth and urbanisation, changes of family structure, loss of neighbourhood relationships, and lack of time for communication and inter-personal interactions exposes vulnerable individuals to mental distress. This effectively reduces the size of the productive workforce, an issue to be tackeled by the WHO Mental Health Global Action Program.
There is also a tendency to over-emphasize the importance of subsidized or free health care services for low-income countries as a key strategy in the resolution of health issues – ignoring the local culture and social context, the inequitable distribution of health, as well as the system of governance. In an editorial in the British Medical Journal, the then Editor, Dr. Richard Smith, pointed out that global public health should reorientate services, strengthening public health within both developed and developing societies as a joint endeavour, and advocated a resilient system of global governance for health.
The protection and improvement of global health requires prioritizing health across all public policy agendas, along with developing a system of governance for putting such policies into practice. The European Commission has stated three core objectives for promotion of healthier and safer citizens, and these objectives could serve as the framework for an effective global health policy:
To protect citizens from risks and threats that are beyond the control of individual and cannot be effectively tackled alone, e.g. unsafe commercial practice, unsafe
To enhance the ability of citizens to take better decisions about their health.
To mainstream health and consumer policy objectives across all policies putting health on the agenda.
Health Promoting Setting
Global health needs investment in social systems, particularly for vulnerable groups within a society. It should move away from investing predominately in health care systems alone, to investment in health generally. The concept of ‘Health Promoting Setting’ has emerged as an effective public health intervention for global health strategy. The promotion of health is organised around settings such as schools, communities and workplaces, which provide the ‘social structures’ to reach the defined population in the context of their daily lives. Thus, the Health Promoting Setting approach is an ecological model of health improvement, in which health is determined by a complex interaction of environmental, organisational, and personal factors. It has become a global movement for health improvement and the International Union for Health Promotion and Education has established a Global Working Group in this field. This approach would facilitate healthy urbanisation as a process of conscious and judicious coordination of urban management practices, so that it can produce health benefits, strengthen social solidarity, and ensure efficient and sustainable ways of meeting basic needs of community life.
An outbreak could soon
become an epidemic, and
such an epidemic would
soon become a pandemic
Targeting schools as a Health Promoting Setting has been shown to be particularly effective in reducing behaviours leading to health risks. One recent study in Hong Kong used the model of a ‘Healthy School’ for the prevention of childhood obesity with an integrated approach. This entailed a comprehensive needs assessment, improved school eating policies and eating environment, training of teachers, parents and student ambassadors, the increased involvement of family and community with school, along with a comprehensive nutrition education programme and the active participation of students. The data analysis of students’ questionnaires showed a statistically significant improvement in nutrition knowledge – 58.7% students received a pass at baseline vs 73% at the post assessment. Longitudinal comparison showed significantly higher proportions of students reported that they were consuming adequate amount of fruits (18.4% vs 23.1%) and vegetables (24% vs 34.6%). The weighed lunch surveillance showed an overall significant increase of 63.3% in vegetable consumption at lunchtime by the students. The consumption of high fat and high sugar snacks by the students at the longitudinal comparison was reduced, and significant improvements of parents’ knowledge and consumption of fruits and vegetables were also observed. Developing countries also use schools as a setting for health promotion. For example, in Laos schools work with the local religious leader, the local education authority and local nurses to implement healthy school initiatives for health improvement of students such as mental health and helminthes control.
A sustained combination of visionary leadership and governance at the municipal level, strong inter-sectoral cooperation at the programmatic level, and active community participation is needed to achieve a healthy form of urbanisation. A society must ensure the value of health, and keep it high on the global political agenda.
Global health needs a strong global response and international collective action. During the Mayors’ Summit of 4th Global Conference of Alliance of Healthy Cities in October 2010 in Gangnam-su, Seoul, Korea, the Gangnam Declaration of Health City reaffirmed the commitment of leaders of cities, towns, communities, non-government organizations, private sectors and academia to the development of ‘Healthy Cities’ so as to address the social determinants of health and reduction of health inequity. This also empowers people’s capacity in personal health improvement, and enhances health care services – particularly preventive services to vulnerable population groups.
The term wealth refers to not just economic capital, but also includes three other forms of capital: social, natural and human capital. This is why an improved global economic situation would not solve the major problems facing health issues alone. Global health initiatives need to invest in improving health through Setting Approaches where people live, study, work and play. A comprehensive range of sectors within society is involved, rather than sole reliance on health care systems. Thus, global health can truly lead to global wealth only if we recognise the importance of contributions from non-health sectors to population health, and don’t rely solely on the WHO as the only international organization for the promotion of global health. This will lead to the creation of a healthy community with high levels of social, ecological, human and economic ‘capital’, a combination of which may be regarded as ‘community capital’ bringing wealth to the society.
Prof Albert Lee is Professor of Public Health and Primary Care at The Chinese University of Hong Kong, Adjunct Professor of Applied Health Science at Indiana University, US, and Visiting Professor of International Health Development at Brighton University, UK. He is WHO Temporary Advisor on Healthy Cities, School Health and Health Promotion.