Introduction to Public Health II

Multiple Determinants of Health

In this chapter we’ll be looking at the determinants of health, especially the social, ecological and political determinants. Of course biology is absolutely critical too, but that is most often dealt by clinical medicine. But we will also look at the interplay of these other determinants with human biology and ultimately how they shape health at the level of populations.

Let me start with the story of Rudolf Virchow, who was an eminent pathologist in 19th Century Germany. He was also the founder of the Anthropological Society of Germany. And he had a place in the Kaiser’s court. A highly respected academic. When he was sent off by Kaiser, or the emperor of Germany to investigate an outbreak of typhus in Silesia in Prussia. He came back with a report not looking at the biology of the disease, but on the social circumstances which caused the outbreak. He said the principle cause of that outbreak of typhus in Upper Silesia was poverty and inequity. And he recommended that there should be measures taken to reduce poverty including abolition of feudal privileges and greater levels of democracy. That did not make him popular in the court, but as a philosopher of social medicine Rudolf Virchow has a very prominent place. He said, do we not always find that diseases of the populace traceable to defects in society? If disease is an expression of individual life under unfavorable circumstances, then epidemics must be indicative of mass disturbances.

He went on to say that these mass disturbances are disturbances of culture and therefore great social changes sometimes also bring epidemics in their wake. What was true of typhus in the 19th Century is true of tobacco in the 20th Century and now we are seeing other social movements which are also resulting in the epidemic of overweight and obesity because of unhealthy foods. Even in Victorian London, poor living conditions were recognized to be responsible for ill health. The Black Death of 1655 was again, strongly related to poverty and poor living conditions. And when we had epidemics in London or the United Kingdom, then the rich left the town for their estates while the poor who were to remain, suffered. And we have seen the descriptions of this kind poverty and deprivation affecting health in the books of Charles Dickens. When we look at how sometimes social circumstances can actually change for the better and thereby bring about improvements in public health, we also see the decline of tuberculosis antedated the discovery of drugs against the tubercular bacterium, or the bacillus tuberculosis. And that is where McKeown brought about his famous thesis that it is the social conditions which actually are responsible for decline in infectious diseases in countries which are improving economically.

While it is true that science and technology are also very important allies in bringing about public health improvements, we definitely have to acknowledge the important role of socioeconomic development. But this development also has to be equitable. Now we recognize that if you actually look at populations and compare them. We also find out that some of the diseases which appear to be very common in some countries are far less common in other countries, even at the same level of economic development. For example, in Finland, in the 1960s and ’70s, coronary heart disease was extremely common. Whereas at the same time in Japan, coronary heart disease was very rare. And we find that the way the populations live in terms of their living habits, of diet, physical activity, all of them are responsible considerably for these inter-population differences.

Geoffrey Rose from the United Kingdom, a famous epidemiologist, while studying cardiovascular diseases across different countries said, sick individuals come from sick populations.

If your average cholesterol level in the population is high, the number of people who will get heart attacks because of high cholesterol is going to be high. Similarly if your average blood pressure in the population is high, the number of people with hypertension who are going to get a stroke is high. So we have to really alter the population dynamics of risk acquisition and risk reduction if you want to make an impact in public health across the population. Now we also know that migration into urban environments also accounts for a great deal of this change. When you look at Kenyan nomads who live in very rural conditions and London civil servants at the same time, this is one of the earlier studies of Geoffrey Rose, you find a marked change in the distribution of the systolic blood pressure across these two populations. In London, the entire distribution is far to the right. That means even the average blood pressure as well as the proportion of those with hypertension is far higher than those in the Kenyan nomads. And therefore the way in which we lead our lives makes a difference.

This doesn’t mean that everybody has to live in relatively primitive conditions and shun modernity, but we are to make sure that as we advance towards modernity we retain some of our healthy living habits. And that is the basis of public health. So when we look at the principles of risk and prevention we understand that since much of this is determined by the population profile of a risk factor, small reductions in risk factor levels when achieved across the whole population. That means when the whole population distribution shifts to the left, shifts to a better level, then that results in a large reduction of adverse events like strokes and heart attacks across the population. Even though the individual shifts are small, cumulatively the population benefits are large. At the same time you have to also look at people who are at the high risk end of the distribution and who at the individual level have a very high risk and we have to focus public health interventions to get them the appropriate mode of risk reduction therapies. So we need to combine both of these strategies.

These are not mutually exclusive but are synergistically complimentary. But when we look at what makes people healthy, or unhealthy, we realize that there are elements in the health system which are very important. The health workforce, are there enough doctors, nurses, allied health professionals? The infrastructure, are there well equipped health facilities? Do they have enough drugs, vaccines and technologies available and affordable across the population? How is health being financed? And what are the health information systems like? Do we get ready information on what the risk factor levels in the population are? Or what is the spread of disease across the population? How is the whole system being governed? Is it efficient? Is it suffering from corruption? Is it accountable to people? All of these matter in the health system. But over and beyond that, we also have to look at the social determinants of health and nutrition. For example, these are factors operating at the societal level. Like the availability of clean water, sanitation, food systems and agricultural systems which provide healthy nutrition across the life course to every individual. A clean environment, having as little air pollution as possible. Social stability, free from conflict and violence and having adequate degree of community participation.

Then all of these matter very much in terms of the societal forces. The level of development and distribution of incomes within society matters. At the personal level, income, education, occupation, social status, gender, participation in social networks, all of these are important social determinants of health. So when we really look at all of these, public health operates at each of these levels. But underlying all of these are political and economic systems which ultimately make choices with respect to many of these determinants. We recognize for example that as per capita income grows across countries, up to a certain level the life expectancy also increases.

Once you reach a certain level of about close to ,or beyond $3000 or $4000 per capita, then the effect starts plateauing off. And this is known as the Millennium Preston Curve. But the fact is, per capita income which means the overall income as assessed as the income per population, per unit, actually matters a lot in terms of life expectancy.

However, how this is distributed within the population also matters a lot. Like for example, in the United Kingdom, there’s a huge difference in life expectancy between one county of the United Kingdom and the other county of the United Kingdom. Almost, whereas one county has a life expectancy of 54 years, the other county has a life expectancy of 82 years. Again, even within the U.S. you have differences in life expectancy which is considerable between different counties. Where in Washington you have a predominantly black population, you have 63 years as their life expectancy. On the other hand, in Montgomery County, which has a predominantly white population, you have a life expectancy of 80 years.

Now we also know that because of income differences, but also because of educational differences and employment differences you can have substantial differences in mortality rates. For example, if you look at the mortality rates across different classes of occupation, the people who are in higher grades of employment in the Whitehall which is the secretariat in the United Kingdom, they have had much lower levels of mortality as compared to some of those in the lower professional grades who, where the stress levels are much higher. And in terms of health inequalities we also recognize that educational levels play a great role.

Even at the same levels of income, differences in education make a lot of difference. Those who have had university education have a much lower mortality as compared to those with only elementary education. So there is a growing recognition that whether, between countries or within countries, we ought to be addressing inequality much more effectively. Michael Marmot who headed the WHO Commission on Social Determinants of Health remarked that the fact that there is a spread of life expectancy of 48 years among countries and a spread of 20 years or more within countries is not inevitable. This is not something that is a given, irreversible. We can, by addressing through appropriate public health strategies and equitable socioeconomic development and distribution bring about a shrinkage of these huge gaps that lie within life expectancy across and within populations. And we see this can happen in different countries where the differences between the wealth quintiles can be substantial even in terms of the number of births that are attended by skilled birth attendants. And within countries we find that the poorest, again, have unattended births with a likelihood of higher maternal mortality. But as universal health coverage takes place across countries, even in countries with lower incomes, we find that these differences across wealth quintiles are substantially reduced or even obliterated. So we ought to be really looking at universal health coverage to reduce health inequalities brought about by income inequalities. We also recognize that by making determined efforts to bring about greater equality in society you can overcome many of the existing inequalities. Brazil is a remarkable success story in this direction. After the revolution in Brazil where the military dictatorship was overthrown, and a constitution enshrining the right to health was adopted, Brazil had a number of social initiatives which were directed against reducing income inequality and reducing poverty. And that has had its effect on health. If you look at the stunting rates across income quintiles, then we find that earlier on we had a huge gap pre-revolution in the stunting rates between the high income groups and the low income groups. But subsequently we find that in the last decade these differences have greatly narrowed and we find the stunting rates in the lower and the high income groups are virtually very similar. So by bringing about a greater degree of equality in distribution and greater access to nutrition, also other social determinants of health as well as health services we can actually reduce some of the gaping health inequalities that are a major problem in terms of inequitable development. And that is a very important mandate for global health. How best can we reduce inequalities in health across populations and within populations? We do have the knowledge, we just have to apply it political will and determination supplemented by professional skill brought about by good public health systems.

Introduction to Public Health I

Introduction & History of Public Health

Welcome to this course on global public health. Quite often we are asked what is public health? How is it different from clinical medicine? Is it something to do with water and sanitation or is it something more? And for even people who have studied a bit of public health, they say, how is it different from epidemiology, which understands the causes of disease and identifies the means to prevent it. Others wonder what is global public health? How is it different from international health or public health in general? So let us start examining some of these questions. Firstly, public health looks at the determinants of health which act at the level of populations, or people has a whole in a community or a country, and then tries to influence those determinants so that ultimately the impact is on improving the health of individuals who constitute that community or that population.

So it doesn’t deal with the individual disease in terms of trying to identify what a person’s clinical complaint is or by providing treatment that one individual as clinical medicine does. On the other hand it tries to set right some of these determinants at the societal level so that people don’t get ill. It also tries to create robust health systems which will deliver health services in a manner that is effective as well as equitable so that people can get protected against diseases through preventive services as well as get a wider range of diagnostic, curative, palliative and rehabilitative services as needed through a well-functioning health system. And all of these also have to be done cost effectively in a manner that the health system doesn’t become bankrupt and individuals have to be protected against health related impoverishment. One of the main driving values of public health is not only to improve the health of people within communities and populations, but also to insure that there is greater degree of equity. Because even in countries where the health standards are considered to be generally very good, we see several population subgroups who do not enjoy the same good health. And we find wide disparities in life expectancy, in maternal mortality or infant mortality or even cardiovascular mortality, between these groups. So public health also aims to reduce those gaps and bridge the inequities. And when we apply the standard of equity across the world, public health then becomes global health and it also starts to examine the determinants which actually act across the global level, across countries in a transnational manner and also tries to provide a concerted multinational or a concerted worldwide response so that these determinants can be further modified to improve global health.

Now if you look at clinical medicine and take the example of somebody who died of a heart attack, well the clinician, the cardiologist would say that the person died because of blockages in the blood vessels to the heart. Absolutely true. But then the epidemiologist would say, the person developed those blockages because he had consumed tobacco as a cigarette smoker from the age of 16 and therefore he had a premature heart attack at the age of 42 and died suddenly. And therefore the cause of death according to the epidemiologist is smoking tobacco. But then the social scientist would say that in virtually every country of the world, now tobacco consumption is much more among the poor. And this poor person had consumed tobacco because he fell, trapped into the habit, did not have adequate information about it. And after having developed some other cardiac problem, did not have the ability to seek affordable healthcare and therefore died of it.

Therefore the social scientists would write down the cause of death as poverty. Now every one of them is correct. And therefore public health has to look at not only the immediate cause but the combination of causes and the causes of causes. And that is where public health becomes a very broad, integrative discipline which makes the understanding of health and disease much more holistic than any single branch of medicine.

Now in terms of public health, we also have to look at systems as I said, are doctors and nurses available in adequate numbers? Are for example affordable medicines available, accessible? Let us take for example a person who meets a nurse or a doctor in a clinic.

That is clinical medicine, if the blood pressure is being checked up and some drugs are being prescribed. But what happened to the person before he came to the clinical facility? Could the problem have been prevented by appropriate advice on how to protect health to the community? Could it have been detected early, before it went into the stage of established disease or complications? Could the referral system have functioned better by providing a timely referral? All of these issues are part of public health.

When the person leaves the clinic or the healthcare facility, are the drugs that have been prescribed by the doctor, are they available in the market? Are they affordable? Can they be taken on a long-term basis? Are the kind of dietary prescriptions given in terms of fruit and vegetables? Are they affordable again in the market? Or if it’s an infectious disease, are there systems for isolation? Are there rehabilitation support systems available for a person with mental illness, or with any other form of physical disability? All of these come under public health. Even what happens in the healthcare facility is also public health because we have to find out firstly, was there a doctor, was there a nurse? Were they adequately trained? Were they following standard management guidelines?

So the whole system organization is also part of public health. So if you want even clinical medicine to function well, you need a very strong public health system. And when you take it on the global scale and look at the determinants of disease and health on the global scale, and look at systems functioning on the global scale, including the production, export, import, regulation of drugs for example, all of that is part of global public health. So public health really covers health systems, services, policies and other sectors too.

For example, when we look at what happens in terms of agriculture, food systems and the effect on nutrition, that again has to be aligned to the health of the people. Now you may say, why do we actually think that public health links to every single system, whether it’s urban design, urban transport, agriculture? Now is there no limiting factor for this? Then we have to really understand that is the primary intent of any measure is to protect health, then that is public health. Like for example, if we say, a seatbelt law, or a motorcycle helmet law, that is public health because the primary objective is toprotect health. If the primary measure is for some other objective, but still we need to align those policies and programs and those sectors to the objectives of health, then that is not strictly in the domain of public health, but public health needs to link up with it. The primary objective of agriculture may be to provide food security, may be to provide cash for the farmers, but even there we have to insure that agriculture and food systems are producing the kind of products that are better suited to human health. So that becomes an extension of public health into another sector. So public health is truly multidisciplinary in very many ways. Now when you look at how public health has evolved this is not a new concept. Even in the Roman times there was a diversion of human waste and the Roman civilization knew that if human waste accumulated, that would be a cause of disease. That was a good public health measure.

In the 19th Century Europe we saw the so-called miasma theory coming in where they felt that miasma was bad air caused by rotting organic matter and they attributed all kinds of diseases to miasma. We know that’s not entirely true, but we also know that it is important to have clean water and good sanitation and the beginnings of the sanitary movement in Europe actually brought about marked advancement in the health of the population and that was good public health. We also know that public health can use several technologies. For example, vaccination.

Vaccination again is applied at the population level so that individuals do not get the disease. Like for example, Jenner’s vaccine in 1796, Edward Jenner brought in the vaccine against small pox. Though it is said that the Chinese used this form of variola inoculation as early as a 1000 b.c., but anyway modern documented history attributes it to Jenner. In 1747, James Lind, an English sailing captain experimented and then proved that serving lime to sailors prevented scurvy, otherwise which was a major problem on long sea voyages. And that is why the English came to be known as limeys in slang.

The history of modern public health in London began with an act of vandalism. Yes. Somebody actually broke the handle of a water pump and carried it away. And this was John Snow.

In the Broad Street in London, where there was an outbreak of cholera, where cholera was spreading across in concentric circles and affecting a large number of people, John Snow mapped out how the outbreak was spreading. And then found that the center of the circle was a pump which was actually resulting in bad water coming out because of contamination with sewage. So John Snow broke the handle of the pump and the outbreak ceased. So it’s an important measure of public health to link sanitation and good water quality to people’s health. We have had several public health movements across the world, but at the level of global health, the World Health Organization which was established in 1948 became the principle catalyst and custodian of global health movements across the world, legitimized by the will of all nations.

And one of the success stories led by the World Health Organization in terms of public health has been the eradication of small pox. We know that this very deadly infectious disease have claimed a large number of lives and even in the beginning when people started getting inoculated, there were many people who did not believe in its effectiveness, but it was very clearly shown that those who were inoculated had very little mortality whereas those who were un-inoculated had a very high fatality. And the global eradication of small pox is one of the grandest success stories of public health.

But we have also seen public health evolving in terms of the understanding of the links between health and development. In the World Health Assembly of 1977, there was a resolution of health for all which resulted ultimately in the Alma-Ata declaration which also emphasized the importance of primary health services. Then it was decided that in the whole area of environmental sustainability health also needed to be accommodated and that came about in the Brundtland Commission of 1987. But the question was whether health would automatically benefit from economic development or investments in health also were needed for accelerated economic development. And that conversation began in terms of this bidirectional relationship in the World Development Report of 1993, investing in health. It was advanced then by the Commission of Microeconomics and Health which was formed by the World Health Organization. And recognizing that health and development are integrally related, at least three direct health related goals were accommodated in the Millennium Development Goals of 2000 which were adopted by the United Nations.

And now as we move towards 2015, when the United Nations is looking at adoption of sustainable development goals, the whole relationship of public health and global public health in to sustainable development is so abundantly clear that we see global health as one of the important points around which the SDG’s will revolve. We will find they’re in one way or the other linked to global public health objectives.


O Culto de Chu Tai Sin dos Pescadores de Macau no Museu do Oriente


A comunidade de pescadores de Macau é um grupo profissional em acentuado declínio. Dos cerca de 22 mil pescadores restam hoje cerca de 96 famílias que continuam a celebrar o culto da Chu Tai Sin.

Numa iniciativa do Museu Marítimo de Macau e da Fundação Oriente, realizou-se entre Fevereiro e Abril deste ano de 2015 uma exposição sobre as festividades desta comunidade. Uma comunidade que viviam com as suas família em frágeis juncos, numa vida dura e incerta. A festa eram um momento de reencontro da comunidade e de adoração à divindade taoista na procura da boa sorte e saúde. A exposição exibe vários ídolos e constrói uma narrativa sobre o processo de celebração, sem esquecer a apresentação das suas origens junto da comunidade de pescadores de Macau.

A devoção data do inicio da década de 20 do século passado, quando as embarcações rumavam à província de Guandong para capturar corvinas e comercializar o sal  para conservas. Numa dessas viagens, um dos filhos dum armador adoeceu gravemente, tendo procurado num templo xaman. Curado o filho, o armador regressa a Macau e aí passa a organizar as festividades, que rapidamente se estendem a toda a comunidade.

Entre o terceiro e quarto mês lunar, as festas realizam-se em várias cerimónias, sempre no mar. Todos os anos é escolhida uma embarcação para servir de palco das celebrações desse ano. Ao longo da exposição, construída para simular o ambiento no interior da embarcação, descrevem-se os vários passos do complexo ritual das celebrações, com a participação de monges que medeiam a relação entre os espíritos e a comunidade. Entre as várias curiosidades dos rituais, encontra-se a bênção das estatuetas, que acompanham cada uma das embarcações até ao próximo ciclo de festividades.

Os ícones sagrados são uma arte complexa e enraizada na comunidade. Eles representam os antepassados e assumem diversas funções sociais na comunidade. Esta arte está classificada desse 2008 como património imaterial da China. A sua gramática permite fazer uma leitura dos papeis sociais. Por exemplo, uma estatueta sentada representa alguém que já faleceu. Uma figura feminina com o cabelo preso, representa uma mulher casada. Os funcionários administrativos são reconhecidos pela sua postura e vestuário. São um elemento poderoso para o reconhecimeSAM_4018nto social.





São Braz


São Braz é uma figura da hagiografia cristã, venerado para as doenças da Garganta. Nascido no Cáusaco, na região que é hoje a arménio no século III, foi Bispo de Sebaste. Foi decapitado pelos romanos em 316.

Iconograficamente, apresenta-se com vestes episcopais, usando mitra , e tem como atributo as cardas de ferro com que foi martirizado, dois círios entrecruzados (alusão à cura milagrosa de uma criança, engasgada com uma espinha de peixe, feita com a aplicação de duas velas cruzadas sobre a garganta). Em Espanha, apresenta a mão sobre a garganta e na Alemanha a sua trompa de caça. Tem ainda como atributos os animais que o criaram, as ovelhas, os círios em cruz ou uma tocha.

Em Portugal é venerado em diversas terras de norte a sul do país. No Algarve dá o nome à vila homónima em Alportel. foi aí que encontrei os rebuçados peitorais para a tosse. Há várias freguesias com o seu orago.

1º de Maio e a sustentabilidade

Florestas Submersas by Takashi Amano

Visitei hoje o Oceanário de Lisboa , onde está patente até ao final do verão, com nome de  “Florestas Submersas” by Takashi Amano“. Saimos de bicicleta os três e atravessamos a bela frente de Rio do Oriente desta cidade de Lisboa. A exposição realça a riqueza das florestas tropicais e dos seus sistemas associados através dum gigantesco aquário

Do laudatório diz-se “é uma celebração à simplicidade e (im)perfeição da natureza e apresenta as florestas tropicais na plenitude da sua beleza mutável, proporcionando ao visitante uma experiência sensorial e emocional que o transporta até às origens da vida”.
Palavras  que procuram chamar a atenção para uma experiência que está longe de se aproximar da do oceanário ali mesmo ao lado. É no entanto de salientar a relevância de que a musica ambiente, de Rodrigo leão ajuda a criar uma sensação de bem-estar, quase sacralidade. Tudo se conjuga para um bom momento.
A questão para pensar é no entanto outra. No final fala-se do perigo que as florestas sofrem pelo elevado ritmo do seu desaparecimento ou da destruição dos seus ecossistemas por sobre exploração. Sabemos que esta questão é sensível. O mar também está em perigo. A economia está em recessão. O mundo parece que se está a desmoronar à volta. Tem que haver uma outra solução para isto. O modo como olhamos para o mundo não nos afetará’
Saímos. Alguém tinha roubado a minha bicicleta e deixado a dos miúdos. Um larápio que anda a pé, com um alicate numa bolsa e que num momento – zás ! lá desaparece.
Lisboa submersa .