Global Health Project Discussion

A nation’s political and economic structures help shape the way social services including health care are delivered

Nations commonly are grouped according to the way they pay for social services

Democracy plays an important role in health but some authoritarian governments also maintain good health among their people

Traditional Policy Making Cycle

China’s authoritarian government has been impressive in its ability to lift millions out of poverty and quickly implement policies and programs but it does not always choose the right ones to implement.

Kerala has been able to achieve impressive health outcomes and a high quality of living with a long history of public governance aimed at social equality.

Chile has combined support-led social policies with market-oriented economic policies and is attempting to achieve improved health outcomes incrementally. Global Health Project Discussion

National Development

Introducing Global Health

Introducing Global Health

Practice, Policy, and Solutions

Peter Muennig

Celina Su

Cover design by: Michael Rutkowski Cover images: © Kamran Khan

Copyright © 2013 by John Wiley & Sons, Inc. All rights reserved. Published by Jossey-Bass A Wiley Brand One Montgomery Street, Suite 1200, San Francisco, CA 94104-4594—www.josseybass.com

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Library of Congress Cataloging-in-Publication Data

Muennig, Peter, author. Introducing global health : practice, policy, and solutions / Peter Muennig, Celina Su. –First edition. p. ; cm. Includes bibliographical references and index. ISBN 978-0-470-53328-4 (pbk.); ISBN 978-1-118-22041-2 (ebk.); ISBN 978-1-118-23399-3 (ebk.) I. Su, Celina, author. II. Title. [DNLM: 1. World Health. 2. Health Policy. WA 530.1] RA418 362.1–dc23 2013012274

Printed in the United States of America first edition PB Printing 10 9 8 7 6 5 4 3 2 1

Contents

Figures and Tables ………………………………………………………………………………….. ix The Authors ………………………………………………………………………………………….xiii Introduction: An Overview of Global Health ………………………………………………. xv

Part 1 The Basics of Global Health ……………………………………. 1 1 A Very Brief History of Global Health Policy …………………………….. 3

Key Ideas …………………………………………………………………………….. 3 Health and Public Policy Through the Twentieth Century ………………. 4 The Age of Global Health Policy ……………………………………………….11 The Fall of Global Governance ……………………………………………….. 16 The Millennium Development Goals ………………………………………… 19 An Alternative History ……………………………………………………………21 Love and Health in Modern Times ………………………………………….. 25 Summary ……………………………………………………………………………. 27 Key Terms ………………………………………………………………………….. 27 Discussion Questions ……………………………………………………………. 27 Further Reading …………………………………………………………………… 28 References ………………………………………………………………………….. 28

2 Case Studies in Development and Health …………………………………31 Key Ideas …………………………………………………………………………….31 The Puzzle of “Good” Development for Health ………………………….. 33 The Next Superpowers? Taking a Closer Look at Middle-Income Countries ……………………………………………………………………………. 37 Growth-Mediated Models ………………………………………………………. 40 Support-Led Models ……………………………………………………………….41 Toward a Happy Medium? ……………………………………………………… 43 China’s Explosive Growth ……………………………………………………… 45 Kerala’s Quality of Life………………………………………………………….. 49 Chile Aims for a Balancing Act ……………………………………………….. 52 Summary ……………………………………………………………………………. 56 Key Terms ………………………………………………………………………….. 56 Discussion Questions ……………………………………………………………. 56 Further Reading …………………………………………………………………… 57 References ………………………………………………………………………….. 57

Part 2 Global Health and the Art of Policy Making ……………. 61 3 The Global Burden of Disease ………………………………………………. 63

Key Ideas …………………………………………………………………………… 63 Who Dies Where? ………………………………………………………………… 64

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vi C O N T E N T S

Counting Global Deaths (with an Eye Toward Saving Lives) …………. 69 Dead Children Make for Bad Statistics ……………………………………… 73 The Health Effects of Evil Genies ……………………………………………. 74 Quantifying the Global Burden of Disease …………………………………. 77 Cost-Effectiveness Analysis ………………………………………………………81 Summary ……………………………………………………………………………. 83 Key Terms ………………………………………………………………………….. 84 Discussion Questions ……………………………………………………………. 84 Further Reading …………………………………………………………………… 84 References ………………………………………………………………………….. 84

4 Aid …………………………………………………………………………………… 87 Key Ideas …………………………………………………………………………… 87 Different Types of Aid …………………………………………………………… 88 The Aid Controversy ………………………………………………………………91 Models of Global Aid for Public Health ……………………………………. 92 Argument: Aid Is Harmful ……………………………………………………… 95 Argument: Aid Is Poorly Managed …………………………………………… 97 Argument: Aid Is Misused ……………………………………………………… 99 Argument: “Aid” Further Consolidates Power for the Powerful …….. 101 Argument: All Is Well, Just Send More ……………………………………. 102 Argument: We Are Making Progress, But the Hurdles Are High ……. 102 Summary ……………………………………………………………………………104 Key Terms …………………………………………………………………………. 105 Discussion Questions …………………………………………………………… 105 Further Reading …………………………………………………………………..106 References ………………………………………………………………………….106

5 Health Systems …………………………………………………………………..109 Key Ideas …………………………………………………………………………..109 Health Care Delivery Systems ………………………………………………….111 Health Care Payments ………………………………………………………….. 114 Health Care Markets ……………………………………………………………. 116 Health Care Delivery Systems in High-Income Countries …………….. 117 Health Care Delivery Systems in Low- and Middle-Income Countries ……………………………………………………………………………124 Pharmaceutical Spending ………………………………………………………132 What Makes Us Healthy? ………………………………………………………134 Summary ……………………………………………………………………………138 Key Terms ………………………………………………………………………….138 Discussion Questions ……………………………………………………………139 Further Reading …………………………………………………………………..139 References ………………………………………………………………………….139

6 Social Policy and Global Health …………………………………………… 143 Key Ideas …………………………………………………………………………..143 How Policies Are Made …………………………………………………………144 Political Economy and Health ………………………………………………… 151 Lessons for Health-Optimizing Social Policies ……………………………164

C O N T E N T S vii

Summary ……………………………………………………………………………165 Key Terms ………………………………………………………………………….166 Discussion Questions ……………………………………………………………166 Further Reading …………………………………………………………………..166 References ………………………………………………………………………….166

7 A Closer Look at Three Political Economies: China, Kerala, and Chile …………………………………………………………………………. 169 Key Ideas …………………………………………………………………………..169 China: Sustainable State of Development? …………………………………170 Kerala: Experiments with Radical Decentralization ……………………..176 Chile: A Precarious Third Way ……………………………………………….181 Summary ……………………………………………………………………………190 Discussion Questions ……………………………………………………………190 Further Reading …………………………………………………………………..191 References ………………………………………………………………………….191

8 Global Governance and Health ……………………………………………. 193 Key Ideas …………………………………………………………………………..193 The World Health Organization ………………………………………………194 The World Trade Organization ………………………………………………..197 An Evolution of Global Governance …………………………………………200 Summary ……………………………………………………………………………208 Key Terms ………………………………………………………………………….209 Discussion Questions ……………………………………………………………209 Further Reading …………………………………………………………………..209 References …………………………………………………………………………. 210

Part 3 Key Challenges in Global Health …………………………. 213 9 Poverty ……………………………………………………………………………..215

Key Ideas ………………………………………………………………………….. 215 Income and Health Across Nations …………………………………………. 216 Definitions of Poverty ………………………………………………………….. 218 Why Do We Worry About Poverty in Public Health? …………………..222 Poverty in Less-Developed Nations ………………………………………….228 Poverty and Health Among Wealthy Nations ……………………………..232 The Complexities of Poverty …………………………………………………..240 Summary ……………………………………………………………………………240 Key Terms ………………………………………………………………………….241 Discussion Questions ……………………………………………………………241 Further Reading …………………………………………………………………..241 References ………………………………………………………………………….241

10 The Physical Environment and Disease ………………………………… 245 Key Ideas …………………………………………………………………………..245 Infectious Disease and Development ………………………………………..246 Malaria and Other Mosquito-Borne Illnesses …………………………….. 251 Air Pollution and Health ……………………………………………………….255 Outer-Ring Development and Health………………………………………..259

viii C O N T E N T S

Climate Change and Health ……………………………………………………262 Summary ……………………………………………………………………………267 Key Terms ………………………………………………………………………….267 Discussion Questions ……………………………………………………………267 Further Reading …………………………………………………………………..268 References ………………………………………………………………………….268

11 The Social Environment and Disease …………………………………….271 Key Ideas …………………………………………………………………………..271 The Ultimate Trifecta: Race, Class, and Gender ………………………….272 The Human Immunodeficiency Virus (HIV) ………………………………282 Tuberculosis ……………………………………………………………………….286 Social Networks and Chronic Disease ………………………………………289 Individual Risk Behaviors, Urban Planning, and Health ……………….292 Summary ……………………………………………………………………………297 Key Terms ………………………………………………………………………….297 Discussion Questions ……………………………………………………………298 Further Reading …………………………………………………………………..298 References ………………………………………………………………………….298

12 Globalization, Internal Conflict, and the Resource Curse ………… 303 Key Ideas …………………………………………………………………………..303 Globalization and Health ……………………………………………………….303 Spillover Effects of Poor Global Governance ………………………………307 Civil Conflict as a Public Health Problem …………………………………308 Resource Curses and Civil Conflict …………………………………………. 310 Natural Resources and Civil War ……………………………………………. 316 Summary …………………………………………………………………………… 319 Key Terms ………………………………………………………………………….320 Discussion Questions ……………………………………………………………320 Further Reading ………………………………………………………………….. 321 References …………………………………………………………………………. 321

13 Frontiers in Global Health ………………………………………………….. 325 Key Ideas …………………………………………………………………………..325 The Many Levels of Health ……………………………………………………328 Tidings, Good or Bad, Come in Clusters ………………………………….. 331 Working with the System ………………………………………………………333 A Rise in Targeted Social Policy Interventions ……………………………338 Innovations in Administration and Governance ………………………….347 Lessons on Social Policy Interventions ……………………………………..349 Summary ……………………………………………………………………………349 Key Terms ………………………………………………………………………….350 Discussion Questions ……………………………………………………………350 Further Reading …………………………………………………………………..350 References …………………………………………………………………………. 351

Index ………………………………………………………………………………………………….. 357

Figures and Tables

FIGURES

I.1. This river makes finding recyclables easy. xx 1.1. Changes in life expectancy from 1940 to 2009 in some of the nations

that we discuss extensively in this book. 4 1.2. Residents live near a waterway containing raw sewage and trash in

Chennai, India, 2013. 7 1.3. During the Industrial Revolution, the advent of coal and steam use as

energy sources became widespread. 8 1.4. In 2005, a chemical plant explosion in Jilin, a province in northern

China, led to a massive release of nitrobenzene into the Songhua River. The water became foamy and was too dangerous to drink. The spill at first was covered up by the Chinese government, but the truth was disclosed after large numbers of dead fish washed ashore in the large northern city of Harbin and residents began to panic. 10

1.5. President Reagan meeting with Prime Minister Margaret Thatcher at the Hotel Cipriani in Venice, Italy, 6/9/1987. 17

1.6. Population pyramids typical in various stages of development. 26 2.1. The Preston curve: Life expectancy versus GDP per capita. 34 2.2. In China, the export revolution started during the transition to a

predominantly capitalist economy led to massive environmental destruction, causing broad effects on ecosystems and adversely affecting the quality of life of hundreds of millions of Chinese citizens. 44

2.3. A woman helps one of China’s barefoot doctors with nursing duties in Luo Quan Wan village. 46

2.4. Children outside a school in Kerala. 51 2.5. Life expectancy of women in Chile relative to Japan, the United States,

New Zealand, and Norway. 52 3.1. Death by broad cause group. 65 3.2. Child mortality rates by cause and region. 68 3.3. A chulla, or a traditional outdoor cook stove used in India. This

particular chulla is going to be lit using branches, scrap wood, dried dung cakes, and coconut shells. 70

ix

x F I G U R E S A N D T A B L E S

3.4. A lack of access to clean water and adequate sanitation severely inhibits many countries, especially those in sub-Saharan Africa. This problem inhibits their ability to accelerate their development. 78

3.5. A member of a local relief committee in a village in East Africa builds a latrine. This particular village has chosen to use aid provided by the organization Oxfam to build latrines. 79

4.1. Many in international development make the same mistake that this food shop in Chongqing, China, makes. It is important to have a grasp of local and international knowledge before implementation (in this case, a sign suggesting that the snack shack is selling feces). 88

4.2. Aid is delivered to Port Au Prince, Haiti, following the magnitude 7 earthquake that hit the city in 2010. 90

5.1. One of the many EMRs available from commercial vendors. Nations that are now converting to EMR systems face the challenge of either navigating the many systems that were in place prior to implementing a mandate for providers to use such records or forcing providers to drop their existing systems in favor of a universal system. 114

5.2. The chances that a forty-five-year-old woman will survive to her sixtieth birthday (fifteen-year survival) in twelve nations in 1975 (left half) and 2005 (right half). These fifteen-year survival estimates are plotted against health expenditures (y-axis). 119

5.3. Trends in self-reported health status and total household income after accounting for medical expenditures (from the General Social Survey, 1972–2008, provided by the author). 119

5.4. Global health expenditures, average number of doctor visits per year, and life expectancy. 128

5.5. An Ayurvedic medicine shop in India. 130 6.1. The percentage of women who feel that husbands are justified in

hitting their wives under certain circumstances by selected nations. The data for each country are broken down by wealth so that we see that poorer women are more likely to favor beatings than wealthier women. 147

6.2. A man appears to collect fish for human consumption after extreme river pollution and high temperatures lead to large numbers of fish dying in the river in Wuhan, China. 160

8.1. Citizens of Mexico City wear masks to prevent the spread of influenza. 197

8.2. An anti-WTO protestor demonstrates in Hong Kong in 2005. 198 9.1. This child, like millions of others in India, suffers from extreme

poverty and hunger. 221 9.2. A Nigerian girl suffers from kwashiorkor. 224 9.3. In India, a father and child suffering from marasmus. 225 9.4. The life cycle of the hookworm parasite. 226

F I G U R E S A N D T A B L E S xi

9.5. A diagram outlining the potential connections between poverty and health. We see that inadequate resources are linked to poor education, low wages, and poor environmental conditions (boxes). However, these factors are in turn caused by a confluence of poor governance and historic circumstances (among other factors). 229

10.1. Hookworm is one of the most frequently encountered parasitic infections in the world. 250

10.2. A factory in China on the Yangtze River. 257 10.3. Slash-and-burn agriculture is a common form of farming in developing

countries. It is also a major contributor to air pollution. 258 10.4. Slum upgrade in India. One approach to improving the quality of life

in slums is to formally recognize them as neighborhoods within urban centers and to then install critical infrastructure, such as sewage, sidewalks, electricity, and in some cases, even improving the quality of the housing itself. 261

10.5. Potential land loss due to polar melting. The black outline represents the current landmass above sea level. With sufficient global warming, we can expect New York, Washington, DC, Baltimore, and Philadelphia to be under water. 263

11.1. From a purely economic perspective, it makes more sense to invest scarce aid dollars in women rather than men because women are more likely to comply with interventions, pass on information to their children, and are less likely to squander income on alcohol or other drugs than are men. 278

11.2. The missing women phenomenon. Some nations have many more boys than would be expected by natural sex ratios at birth. 280

11.3. A public communications campaign from the New York City Department of Health and Mental Hygiene. Top panel: An advertisement frequently seen on the subway. Bottom panel: Still from an accompanying YouTube video. 291

11.4. Adbusters is an organization stocked with disenfranchised advertisers that seeks in part to counter the harmful effects of consumer advertising in a process called culture jamming. This ad attempts to delink male virility and alcohol. It might be particularly effective at reducing alcohol consumption because most men know what alcohol can do when they actually do get lucky with their bar date. 292

11.5. A bike lane in Kunming, China. Sophisticated bike lanes are a regular feature of mainstream Chinese urban planning. 294

12.1. This map shows six special economic zones set up by the Chinese government in areas of Africa. 312

12.2. Natural resources in poorly governed nations not only encourage dangerous mining conditions, but also can lead to civil war. 318

13.1. How the concept of herd immunity works. 329

xii F I G U R E S A N D T A B L E S

13.2. The different levels of disease causation or prevention. 330 13.3. The life cycle of the Onchocerca volvulus. This is a parasitic worm that

is the cause of river blindness. 334 13.4. A Bolsa Família center in Feira de Santana, Brazil. 343

TABLES

3.1. Counting Deaths Worldwide, by Disease 64 3.2. Leading Causes of Death for the World Overall and by Level of

Economic Development 67 3.3. Counting Deaths Worldwide by Disease and the Most Relevant Policy

for Addressing the Disease 69 3.4. Counting Deaths Worldwide by Preventive Policy Needed 72 3.5. Burden of Disease Worldwide in DALYs 77 3.6. DALYs Ranked by Country Categories 79 3.7. A Hypothetical Cost-Effectiveness League Table 82 5.1. Health Care Spending in 2009, per Person, in US Dollars 127 6.1. Three Forms of Social Democracy in Low- and Middle-Income

Countries 158 6.2. Two Types of Nondemocratic Governance 161 6.3. Main Political Economy Types in Industrialized Countries 164

xiii

The Authors

Peter Muennig is an associate professor at Columbia University’s Mailman School of Public Health, where he teaches global health policy, comparative health systems, and health disparities to graduate students in public health. He has consulted for numerous foreign governments and has run a nongov- ernmental organization, the Burmese Refugee Project (which he cofounded while still a student), for twelve years. He has published more than sixty peer- reviewed articles, two books, and many chapters and government reports. He or his work has appeared in many media outlets, including the New York Times, the Washington Post, Slate, the Wall Street Journal, NPR, and CNN. Global Health Project Discussion

Celina Su is an associate professor of political science at the City University of New York. Her research concerns civil society, political participation, and social policy, especially health and education. Her publications include Street- wise for Book Smarts: Grassroots Organizing and Education Reform in the Bronx (Cornell University Press, 2009) and Our Schools Suck: Young People Talk Back to a Segregated Nation on the Failures of Urban Education (coauthored, New York University Press, 2009). Her honors include the Berlin Prize and the Whiting Award for Excellence in Teaching. Su was cofounding executive direc- tor of the Burmese Refugee Project from 2001 to 2013. She earned her PhD from the Massachusetts Institute of Technology.

Introduction: An Overview of Global Health

Before we can begin to think about global health, we must understand how institutions work. One example of an institution is a bank. Most of us deposit our money in banks because we are confident that we can retrieve our money whenever we want—that is, that the money will still be there and accessible to us, plus interest and minus fees. Banking is an institution, just as banks themselves are institutions. One way of thinking about an institution is that it constitutes the habits, cooperation, and behavior of large numbers of people. It is something that we as humans, within a given culture, collectively believe in. It is real and trustworthy because everyone believes it to be. When customers lose confidence in an institution, it collapses. This is because institutions must exist in our minds for them to exist in the real world. Just think of all the banks that went under worldwide during the Great Depres- sion. When the banks’ ability to securely hold deposits became precarious, thousands of average citizens participated in bank runs and attempted to withdraw their funds from banks and place their cash under their mattresses instead. Global Health Project Discussion

This, in turn, exacerbated the banks’ already fragile accounting books and reserves. Many of the banking laws the United States has today stemmed from lessons learned from institutional failures in the Great Depression. The government stepped in to reinforce our collective belief in US banks and other financial institutions, or—at a bare minimum—in the existence of the currency we deposit there. If we deposit US$10,000 and the bank goes out of business, the government promises to pay that money back to us. It will do so even though this money is held only as zeros and ones on some accounting database somewhere and not in any tangible form, such as gold or even paper currency. The trust that we have in the institution, therefore, extends to a trust that we have in our nation’s government.

As long as (almost) everyone in your society has agreed that a US$1 bill is worth $1 and a $100 bill is worth $100, the money has value even though each bill is nothing more than a piece of paper and ink with an actual worth of just pennies. Under this system, you can contribute a portion of your life to performing a task in a factory or office and be confident that the money. Global Health Project Discussion