3. Relevant topics in other themes:
(a) Infectious Disease:
Back to Special populations theme page
Return to Welcome page
Vers la page française
Globalization and Global Health
Globalization refers to "a process of greater integration within the world economy through movements of goods and services, capital, technology, and (to a lesser extent) labor, which lead increasingly to economic decisions being influenced by global conditions" – i.e. the emergence of a global marketplace. Our increasingly global economy influences social and cultural factors that, in turn, affect health.
- For example, the global marketing of Coca Cola or McDonald's affects diet which in turn influences obesity in the world. (See Ted Schrecker & Ron Labonté: "Globalization and social determinants of health")
The growing interconnectedness of countries via worldwide economic markets has shifted attention from comparing health between nations (i.e., internationally) toward reviewing global influences on health. Global issues are seen as “determinants of the determinants of health”.
- Economic progress has not been evenly spread, but benefits those countries that already have productive assets (capital, industry, knowledge, land).
- There is a growing net capital flow from developing to developed countries (estimated at around 500 billion US$ in 2005).
- This has increased economic inequalities between nations; increased market integration does not seem to have reduced poverty.
- Global governance systems are weak; companies can move their production sites elsewhere and so threaten local governments into tolerating low wage levels and exploitation of labour - often of women.
- Economic insecurity increases, and labour's share of wealth has fallen.
- Of the low income of poor countries (around $350 per person per year in Sub-Saharan Africa), much income is in-kind food production, rather than actual cash. This means that government can only raise a tiny amount in taxation - perhaps $50 per person per year, to support the entire government. Of this, perhaps only $10 goes to health, completely insufficient to support even a rudimentary health care system.
- Globalization contributes to the drain of trained professionals from developing to richer countries. Over 13,600 physicians in Canada come from developing countries (26% of our total supply); we also have 19,000 nurses from developing nations. However, don't automatically blame the health professionals: sometimes they train here and attempt to return home, only to find that there is no job for them because of the economic difficulties in their home country.
Global health refers to "Health problems, issues and concerns that transcend national boundaries, may be influenced by circumstances or experiences in other countries, and are best addressed by cooperative actions and solutions" (U.S. Institute of Medicine, 1997).
The following examples illustrate a global health perspective:
Health Issue Global Perspective Cigarette smoking Tobacco is ranked as the second major cause of death in the world Tobacco is a multinational business with global marketing strategies. Illicit tobacco marketing is also important Obesity One billion adults worldwide are overweight; 300 million are clinically obese Food retailing and marketing is a multinational business STIs 340 million new cases of sexually transmitted infections occur world wide each year Increased travel and migration contribute to the spread of STIs; global action is required to coordinate containment efforts Mental health 450 million people worldwide are affected by mental illness at any one time Conflict and poverty are major contributors; these generally involve more than a single country and intervention strategies require multinational collaboration Alcohol 76.3 million people worldwide have alcohol use disorders Alcohol marketing and distribution is a global business; lessons can be learned from other countries Inequities A major driving force that underlies most health patterns is the level of inequality between people. Disparities in power and wealth directly influence health While inequalities and inequities in societies are great, there are much greater disparities between countries. Life expectancy in Sierra Leone is less than half that in Japan
Adapted from "Health is Global", a UK Government Report, 2007.
Millennium development goals: Hans Rosling's (video review).
A discussion from UBC of the Ethics of Engagement Abroad: ethical guidelines for those who volunteer, work or research abroad.
Dr. Kevin Pottie's article on ways an MD can contribute to international health care (pdf)
Stages of the Transition
This is a theoretical model describing changes in the structure of human populations over time. The central idea is that with economic development and improvements in health care, populations tend to move from a situation of high birth rates, high death rates and a short life span, towards a situation of low birth rates and low death rates, giving a longer life expectancy.
In Stage 1 of the transition, birth and death rates are high and roughly in balance, giving a stable population. A population pyramid diagram forms a triangle, showing large numbers of children, few elderly people, and deaths (typically from communicable diseases) occurring at all ages.
In Stage 2, death rates drop due to improving food supply and sanitation; if birth rates remain high, the population increases rapidly and people live longer.
In Stage 3, birth rates fall (contraception; urban living; education and employment of women; restrictions on child labour) and population gradually levels off and the population pyramid becomes more rectangular in form.
In Stage 4, birth rates may drop below replacement levels, so that the pyramid becomes top heavy. The large population of now elderly people who were born during stage 2 threaten to overwhelm the shrinking working population.
Note that this is an idealized version of events, and applies more or less well to different countries. It focuses on natural increase of a population and does not consider immigration or emigration.
Linked to the demographic transition, dependency ratios refer to how many people are working, compared to those who are being supported by the workers (dependants). This is relevant because it describes the population's ability to generate the wealth and resources to sustain itself: workers pay taxes and children + retired people benefit from the taxation.
The total dependency ratio compares the numbers of working age (usually, 19 - 65) to those too young to work (0-18), plus those deemed too old to work (65+).
If you like equations:
Of course this is crude, as many older people work, child labour exists, and many people of working age may not be gainfully employed. A high dependency ratio is of concern as it implies high taxation on the (relatively small) working population to pay for social security and health care for those not working.
Population aging is often presented as a threat to dependency ratios: all those old folks who need expensive care funded by taxpayers, and few working-age people to earn wages and pay the taxes. However, things are perhaps not as simple as that. Falling birth rates in most countries will mean fewer dependent children, somewhat counter-balancing the growing numbers of elderly dependants. In addition, more women are working, and there will likely be migration from countries with an excess of workers to countries with too few. The more we can keep our elderly population fit and healthy, and the more we can come to grips with the challenge of allowing for natural deaths, perhaps the aging population will not have a devastating effect on our health care resources.
Click here to learn more about the current Canadian population demographic in the page “Aging Canadian Population”
Statistics Canada page on Dependency ratio
The Epidemiological Transition: The dominant causes of morbidity and mortality change in a consistent pattern as countries develop economically, and this is reflected in typical life expectancy as countries cross through various disease eras.
(Omran A. The epidemiological transition: a theory of the epidemiology of population change. Milbank Quarterly, 1971; 64: 475-489).
Stage Description Typical Life Expectancy % of deaths due to CVD Examples of contemporary countries Pestilence and famine Malnutrition and infectious diseases predominate 35 5-10 Sub-Saharan Africa Receding pandemics Improved nutrition and public health measures lead to reduction in infectious disease. People live long enough to experience chronic disease 50 15-35 South Asia; parts of Latin America & Caribbean Degenerative and man-made diseases Due to increased tobacco and alcohol use and subsequently fat & caloric intake, deaths due to chronic conditions overtake infectious diseases 60 >50 Europe and central Asia; Latin America; Middle East; North Africa; Urban parts of India Delayed degenerative diseases CVD and cancer are leading causes of death. Prevention delays onset and treatment prolongs survival so that age-adjusted rates decline. Increase in aging-related conditions such as Alzheimer's > 70 <50 High income countries
Our current concern is that we may be transitioning into an era in which, due to increases in diseases such as obesity and diabetes, life expectancy may actually decline.
Additional Information on the Epidemiologic Transition
The "epidemiologic transition" refers to relatively constant patterns of changes in patterns of disease as societies develop.
Many presentations contrast three main stages. With a somewhat Biblical turn of phrase, Omran named these the "age of pestilence and famine," the "age of receding pandemics," and the "age of degenerative and man-made diseases."
Age of pestilence & famine Age of receding pandemics Age of degenerative diseases Disease Patterns:
Frequent epidemics; famines;
Endemic infections & parasitic diseases;
Maternal & child health problems;
Serious environmental health problems: unsafe water, fecal waste contamination, insects & rodents, poor housing.
Epidemics & famines somewhat reduced in frequency;
People live long enough for heart disease & cancer to occur;
Infection & parasitism somewhat reduced;
Occupational health problems rise;
Sanitation begins to improve;
Urban health problems become acute
Accidents at home & in industry.
Morbidity overshadows mortality as the main issue;
Chronic disease, mental illness, drug addiction, pollution rise in importance;
Infectious disease mainly in certain pockets of population;
Geriatric problems take over from MCH;
Electrical or chemical hazards become main occupational health dangers;
Rising cost of medical care.
Health Care Systems: Indigenous systems; traditional healers;
Isolation & quarantine only effective therapies against infectious disease;
No environmental sanitation.
Improving nutrition & rising living standards;
Sanitary revolution begins (refuse removal, sewers, cleaner wells, etc.);
Quarantine more strictly enforced;
Antiseptic practice makes operations possible;
Organized health services.
Comprehensive, organized health services; curative + preventive;
Rigorous sanitary measures;
Screening for certain diseases introduced;
Widespread measures to prevent infectious diseases (pesticide use, immunization, etc);
Health system improvements.
These stages coincide with different demographic patterns:
Age of pestilence & famine Age of receding pandemics Age of degenerative diseases Population growth Pattern of cyclic growth until about 1650. Mortality dominates, with crude death rates between 30 and 50 per 1,000. Fertility high, at 40+ per 1,000 population Mortality continues high but peaks less frequent and general level begins to decline to about 30 per 1,000. Fertility remains high until several decades after mortality declines. Population growth explosive. Mortality declines rapidly to < 20 per 1,000; then decline slows. Fertility falls below 20 per 1,000 (but occasional rises, as after 1945). Population growth small but persistent. Population composition Predominantly young. Large young, and small old dependency ratios. Slight excess of males. Mainly rural, but a few crowded, unsanitary, epidemic ridden cities. Population still young, but proportion of older people begins to increase. Male to female ration near unity, but improved female health leads to excess of females. Exodus from farm to factory. Migration to new colonies relieves population pressures in some countries, but upsets age-sex composition. Progressive aging of the population as fertility declines and more people (especially females) survive to old age. Male : Female ratio decreases. Increasing old age dependency ratio. Urban residence; rapid growth of cities and alarming formation of slums, environmental pollution, with social & political problems.
Omran then goes on to link each pattern of disease to prevailing social circumstances:
Age of pestilence & famine Age of receding pandemics Age of degenerative diseases Society Traditional society; fatalistic orientation; rigid hierarchical social structures Traditional or provincial outlook continues among lower classes; emerging middle classes develop faith in reason. Era of rising expectations Rational, purposive lifestyles prevail. Bureaucracy & depersonalization foster anomic groups Family & Women Clan or extended family structures; large families; home centered lifestyles. Women in mother role with few rights or responsibilities outside the home Extended family systems and large families prevail, especially in rural areas. Nuclear families become common in the growing urban centres. Women begin to have modest involvement outside the home Nuclear families and small family size become the norm. Women increasingly emancipated from traditional roles and become better educated and develop careers Living standards Standards are low; unsanitary conditions; comforts & luxuries limited to the elite Standards still quite low, but hygiene and sanitation improve, except in city slums where bad conditions grow worse Progressive rises in living standards enjoyed by large segments of the population Nutrition Food for the masses is of poor quality; chronic shortages. Children and women most affected Early improvements in agriculture & crop rotation improve availability of food. Women & children still at nutritional disadvantage
People become conscious of nutrition, especially for women and children. Tendency toward over-nutrition, including high fat foods
Economic profile Subsistence economies; agrarian societies that depend on manual, labour-intensive cultivation. Sporadic rises in wages undermined by low incentives to work; labour sapped by debilitating diseases Preconditions for economic 'take-off'. Improvements in agriculture, combined with development of transportation and communication networks encourage industrialization. New economic sectors, such as textiles, emerge Scientific expertise & applied technology produce rapid rise in productivity. High mass consumption leads to switch in production to consumer goods & services. Welfare spending rises
Source: Omran AR. Changing patterns of health and disease during the process of national development. Chapter 5 in: Albrecht GL, Higgins PC (eds.) Health, illness and medicine: a reader in medical sociology. Chicago, Rand McNally, 1979.
The United Nations is an international organization founded in 1945, following World War II. On its web site, the UN states that it takes action on “the issues confronting humanity in the 21st century, such as peace and security, climate change, sustainable development, human rights, disarmament, terrorism, humanitarian and health emergencies, gender equality, governance, food production, and more.”
The UN system is made up of the UN’s main organs (the General Assembly, the Security Council, the Economic and Social Council, the Trusteeship Council, the International Court of Justice, and the UN Secretariat) as well as affiliated programs and agencies. One of the organizations in the UN system is the World Health Organization.
The WHO does much of the international public health work of the UN, but other members of the UN system are involved in global health. Within the general organs, these include the General Assembly and the Economic and Social Council ; within the system, the United Nations Programme on HIV/AIDS (UNAIDS); the work of the United Nations Population Fund (UNFPA) and the United Nations Children’s Fund (UNICEF) are involved in global health.
In 2000, the UN Millennium Development Goals were established following the Millennium Summit. Through this, the signing countries and organizations committed to specific goals in development by 2015.
The eight UN Millennium Development Goals included:
- To eradicate extreme poverty and hunger
- To achieve universal primary education
- To promote gender equality and empower women
- To reduce child mortality
- To improve maternal health
- To combat HIV/AIDS, malaria, and other diseases
- To ensure environmental sustainability
- To develop a global partnership for development
The Goals each had specific targets and dates at which targets should be achieved. In 2010, it was seen that while significant strides had been made in many goals and in many countries, the Millennium Goals were not going to be met for 2015.
In 2015, 193 countries of the UN General Assembly signed onto a new set of goals: the Sustainable Development Goals. The Sustainable Development Goals are for the year 2030 and now include 17 different goals:
- No Poverty - End poverty in all its forms everywhere
- Zero Hunger - End hunger, achieve food security and improved nutrition and promote sustainable agriculture.
- Good Health and Well-being - Ensure healthy lives and promote well-being for all at all ages.
- Quality Education - Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all.
- Gender Equality - Achieve gender equality and empower all women and girls
- Clean Water and Sanitation - Ensure availability and sustainable management of water and sanitation for all.
- Affordable and Clean Energy - Ensure access to affordable, reliable, sustainable and clean energy for all.
- Decent Work and Economic Growth - Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all.
- Industry, Innovation and Infrastructure - Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation
- Reduced Inequalities - Reduce inequality within and among countries.
- Sustainable Cities and Communities - Make cities and human settlements inclusive, safe, resilient and sustainable.
- Responsible Consumption and Production - Ensure sustainable consumption and production patterns.
- Climate Action - Take urgent action to combat climate change and its impacts.
- Life Below Water - Conserve and sustainably use the oceans, seas and marine resources for sustainable development.
- Life on Land - Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss.
- Peace, Justice and Strong Institutions - Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels.
- Partnerships for the Goals - Strengthen the means of implementation and revitalize the global partnership for sustainable development.
The World Health Organization (WHO) is an organization under the UN system. It has been described as the “United Nations’ public health arm”. The constitution of the WHO was signed in 1946, following the first World Health Assembly.
The priorities of the WHO include monitoring and responding to communicable disease outbreaks, assessing the performance of health systems, sexual and reproductive health, food security and health eating, development, aging, substance use, occupational health and many others. The WHO publishes a yearly World Health Report on global health as well as many other reports on specific topics of concern.
WHO Publications (link)
While not one of the objectives of SIM, travel medicine is an important knowledge piece for medical students and doctors alike. The increase in numbers of travellers and the speed at which travel is now possible has had consequences on the spread of infections and diseases. Any doctor may run into a traveller with an infection they acquired abroad. Additionally, many doctors and medical students like to travel, either for personal vacations or with international aid work.
Travel medicine: “the branch of medicine that deals with the prevention and management of health problems of international travelers” (reference)
Public Health Agency of Canada operates an information site on Travel Health that provides updated information on new disease outbreaks. It also provides information on immunization requirements and general health advice for travellers.
Immunization guidelines for travellers are available as a chapter in the National Advisory Committee on Immunization Guidelines, Part 3, page 79 in the pdf version
A British web site provides information for GPs on assessing health needs for migrants, health and migration, and gives country health profiles.
The U.S. Centers for Disease Control (CDC) offers a very fancy travel medicine web site organized by medical condition.
The WHO provides weekly bulletins on outbreaks of disease under the International Health Regulations and on other communicable diseases of public health importance, including the newly emerging or re-emerging infections. The Weekly Epidemiologic Report is distributed every Friday in a bilingual English/French edition.
Article: “Emporiatrics: The Travellers Medicine”
Updated August 2, 2017