International Health Concepts 2024_Final.pdf

International Health concepts Hans-Friedemann Kinkel Coordinator, Postgraduate Study Programme International Health  The Typhus Epidemic Groupwork: How did the author get involved? What did he find in Upperland? What causes of the epidemic did he id...

International Health concepts Hans-Friedemann Kinkel Coordinator, Postgraduate Study Programme International Health  The Typhus Epidemic Groupwork: How did the author get involved? What did he find in Upperland? What causes of the epidemic did he identify? What solutions did he suggest?  The Typhus Epidemic For the chat: Which country do you think did this happen? The Typhus Epidemic  The author Rudolf Ludwig Carl Virchow 1821 Born in Schivelbein (today Poland), died 1902 (Berlin) 1839 Graduated in theology 1843 Graduated in medicine 1847 Founded the journal: Virchow‘s Archive 1848 „Report on the Typhus Epidemic in Upper Silesia“ 1848 Participated in the revolution, foundet the newspaper Medical Reform „Medicine is a social science“ „The physician is the natural attorney of the poor“ 1848 Karl Marx/ Friedrich Engels: „The communist manifesto“ 1849 Expelled from his positions in Berlin 1849 – 1854 Würzburg, called to Berlin 1854 John Snow: "On the Mode of Communication of Cholera” 1855 „Omnis cellula e cellula“ 1862 – 1893 Member of Prussian Diet (leader of the Progressive Party) and later member of the Reichtag – opposed opposed Bismarck‘s miliary politics, fought for proper sewage/sanitation systems in Berlin 1870s Opposed Darwinism 1880s Opposed upcoming racial theories and antisemitism 1890s Opposed germ theory (Pasteur, Koch) 1899 – 1906 Construction of the Rudolf-Virchow Klinikum His ideas live on… Salvador Allende etc.  Rudolf Virchow “Medicine is a social science, and politics is nothing else but medicine on a large scale.” Meckenbach. J Epidemiol Community Health, 2009; 63: 181-184 Rudolf Virchow Klinikum 1910 Life expectancy 1850 Life expectancy 1850  Definitions Planetary International One Health Global Health Public Health Health Health Human civilisation Global population (Geographic) Low- and Middle- Environment Animal Health Global population National population focus income countries Planet Earth Environment Bilateral Level of „Development aid“ Transnational Transnational Global solidarity (Dependence) cooperation Across all sectors Across all sectors (Interdependence) „International National (nation related) collaboration“ (Independence) Individuals Prevention in Prevention in Prevention in Prevention in Protection and populations & populations & populations & populations & and/or preservation of Earth‘s Veteriniary Care & Clinical care of Clinical care of Clinical care of Population natural systems Ecology individuals individuals individuals Access to Human and Veterinary Health equity among Seeks to help people Health equity Human sustainability Healthcare Health nations of other nations within a nation Transdisciplinary (Imaginary challenges, Highly Highly Few disciplines, no Range of Research & Encourages interdisciplinary and interdisciplinary and explicit emphasis on Disciplines information multidiciplinary multidisciplinary multidisciplinary multidisciplinary challenges, governance challenge) Koplan, Lancet 2009; 373: 1993–95  Definitions Planetary International One Health Global Health Public Health Health Health Human civilisation Global population (Geographic) Low- and Middle- Environment Animal Health Global population National population focus income countries Planet Earth Environment Bilateral Level of „Development aid“ Transnational Transnational Global solidarity (Dependence) cooperation Across all sectors Across all sectors (Interdependence) „International National (nation related) collaboration“ (Independence) Individuals Prevention in Prevention in Prevention in Prevention in Protection and populations & populations & populations & populations & and/or preservation of Earth‘s Veteriniary Care & Clinical care of Clinical care of Clinical care of Population natural systems Ecology individuals individuals individuals Access to Human and Veterinary Health equity among Seeks to help people Health equity Human sustainability Healthcare Health nations of other nations within a nation Transdisciplinary (Imaginary challenges, Highly Highly Few disciplines, no Range of Research & Encourages interdisciplinary and interdisciplinary and explicit emphasis on Disciplines information multidiciplinary multidisciplinary multidisciplinary multidisciplinary challenges, governance challenge) Koplan, Lancet 2009; 373: 1993–95  A brief history of global health exploitation The „age of exploration“ (15th and 18th century) European empires sail the world and begin of colonialisation (Columbus, Da Gama, Cortez etc.) Populations are facing new diseases and epidemics (small pox, measles, diphtheria, syphillis, S. Typhi (Cocoliztli); „tropical“ diseases) Aztec population (1520), Huron Nation (1630s) etc. Transatlantic slave trade „Tropical Medicine“ (19th century) (vs. „temperated“) Encompasses health measures between imperial nations and colonised countries and regions Advances in medicine (Quinine/“Jesuit bark“, germ theory, social medicine, public health, epidemiology) (Virchow, Snow etc.) Military/Colonial Medicine (population-level health measures) To protect colonialists and to control „native“ population, imperial and commercial interests Medical Missions (individual-level health measures) To improve living condition of „native“ populations and to christianize („saving souls“)  The beautiful milkmaid "I shall never have smallpox for I have had cowpox. I shall never have an ugly pockmarked face." Johannes Vermeer ca. 1657 Edward Jenner – Smallpox vaccine  Institute of International Health 1802: Founded as Königlich-Preussisches-Schutzblattern- Impfinstitut located at the Grosses Friedrichshospital in Treptow  Institute of International Health Beginning of 1900? Move to Spandauer Damm, Charlottenburg 1965: Landesimpfanstalt mit tropenmedizinischer Beratungsstelle 1983: Landesinstitut für Tropenmedizin 1995: Institut für Tropenmedizin 2010: Institute für Tropenmedizin und Internationale Gesundheit  Institute of International Health 2015: Move to Campus Virchow Klinikum, Wedding 2023: Institute für Internationale Gesundheit  A brief history of Global Health Industrialisation and Urbanisation in Europe (colonising countries) (1750 – 1850) Transformation from feudalism (agrarian societies, peasants as serfs) to urbanised capitalist industrial economies („bourgeoisie“) based on wage laborers, private land ownership, competition, „free market“ Colonialism, exploitation, slavery, racism Advances in science & technology (machines, steam engine, mining, chemistry…) Unhealthy and dangerous living & working conditions, child labour, poverty, inequality Santitation, Hygiene & Public Health Health became an issue (productivity… question of moral and social order) Pioneers of „Hygiene“ and Public Health: Frank (1779), Villermé (1820s), Virchow (1848), Tardieu (1850s)… 1848 The Communist Manifesto  A brief history of Global Health Beginnings International Health (1850 -1950) 1851 International Sanitary Convention (Paris) Standardise quarantaine regulations (cholera epidemics). (Migration to the „New world“) Continued until WWI 1899 LSHTM was founded (Patrick Manson) 1902 Pan-American Sanitary Bureau Today: (WHO) Regional Office of the Americas To imporve health and living standards 1907: Office International d‘Hygiene Publique (Paris) Formed to protect trade (quarantining ships, prevention of spread of plague, cholera etc.) 1913: Rockefeller Foundation Single largest funder Construction of public health schools in the U.S. and Europe to train personnel to treat „Tropical diseases“ 1926: League of nations: Abolision of slavery  Milestones early 20th century Sanitation and Hygiene Water supply, Chlorination, Waste disposal, Hygiene education, TB control Vaccination Cholera, DTP, BCG, YF, Polio, MMR Antibiotics Penicillin... Serologic testing Anti-cardiolipin test (Wassermann) for syphilis Virus isolation & cell cultures Yellow Fever … World War I & II Life expectancy 1850 - 1950 Life expectancy 1950 „Development“ Theory „Developed“ countries (yellow & orange) „Developing“ countries (blue, turquoise, green, red) Life expectancy 1950  A brief history of Global Health The WHO (early years 1950 – 1970) 1946 WHO was constitutionalised 1948 WHO was launched in Geneva Definition of Health: „a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity“ Focus on immunization Small pox eradication Focus on infectious diseases (new: antibiotics!, DDT) Malaria control (little success) Vertical approach, technology-driven, limited social reform  A brief history of Global Health The WHO (early years1950 –1970) „Development“ theory Assistance and technology from outside, little participation of local populations Economic interests (new markets) Decolonialisation (1950s -1970s) Ideologic, nationalist and/or ethnic Biafra movements and conflicts „Cold war“ (1960s -1970s) Political interests Biafra War (1967 – 1970) Human Rights movement (1970s) Development aid organisations 1961 USAID (U.S.), 1963 DED (Germany), 1964 DFID (U.K.), 1974 gtz (today giz, Germany)  A brief history of Global Health The WHO (the 1970s) Failure of vertical programmes (e.g. malaria eradication) Criticism of “transplanting” the “western” hospital-based health care system to the decolonized (“developing”) countries Hospital based  Access to health care Inadequate care (spray guns and vaccinating syringes) Focus on cure  prevention Pharmacotherapy Specialisation  generalist approach Cost! Hubris of modern medicine Christian Medical Commission Cueto, The origins of PHC and SPHC, 2004 Bryant, Health and the Developing World, 1969 Communist models of health care K.Newell, ed, Health by the people, 1975 Illich, Medical nemesis: the expropriation of health, 1976 McKeown, The Role of Medicine: Dream, mirage or nemesis, 1976 Lalonde Report, A New Perspective on the Health of Canadians, 1974  A brief history of Global Health World Health Organisation International Conference on Primary Health Care, Alma Ata, Kazakhstan, 6-12 September 1978 Halfdan Mahler Dimitri Venediktov (helfden) (vinidiektov) A return to the Social Justice Spirit of Alma Ata. Fee, 2015. Am J Pub Health, 105(6): 1096-1097 The long and difficult road to Alma Ata: …. Litsios, 2002. Int J Health Services, 32(4): 709-732 ‘Socialising’ primary care?... Birn & Krementsov, 2018. BMJ Glob Health 3:e000992 Declaration of Alma Ata 1978  Principles of International/Global Health Declaration of Alma Ata 1978: „The conferences expresses the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world.“ Principles of International/Global Health 1. Definition of Health 2. Equity 3. Interlink between economic and social development on health 4. Participation of the people 5. Responsibility of governments - Primary health care is key 6. Primary Health Care Principles 7. Primary Health Care 8. Political committment (policies, strategies, resources) 9. International cooperation and partnership 10. International collaboration (peace, independence, détente, disarmament…) Principles of International/Global Health 6. Primary Health Care priniciples Practicability Science based Acceptance Accessiblity Affordability Central function of the health system Integral part of economic and social development Brings health care close to the people Continuum of care (vertically and timely) Principles of International/Global Health 7. Primary Health Care Specific to local context Comprehensive care (promotion, prevention, treatment, rehabilitation) Examples: health education, food/nutrition, water/sanitation, maternal/child health, immunization, locally endemic diseases, treatment/cure of diseases/injuries, essential drugs Integrating other sectors related to health Participation and utilisation of locally available resources Referral system Suitably socially and technically trained health workers to work as a team  A brief history of Global Health The eclipse of primary health care (1980s) „Selective primary health care“ - GOBI-FFF (UNICEF, 1980s) Growth monitoring, oral rehydration, breast feeding, immunization, female education, family spacing, food supplements Cost recovery/User financed Health Services (World Bank) „Structural adjustment programmes“ (World Bank, 1980/90s) „Neoliberalism“ and „austerity“ Cutback public spending, privatisation of government enterprises, freezing of wages, freeing of prizes, increased (sales) taxation, increased production (incl. food) for export, brain drain Debts raised, Dependency of Foreign Aid increased Rise of foreign NGOs  A brief history of Global Health Globalisation & „Reorganisation“ (1990s) HIV & TB ART, DOTS, UNAIDS World Bank Global burden of diseases study Investment in Health Crisis and reposition of WHO Nakajima - Brundtland Rise of wealthy donor nations and multilateral agencies (WB) dictating the agenda Embracing „Global Health“ Global Polio Eradication Campaign Doha Declaration on TRIPS Agreement GAVI, Roll-back-Malaria, Stop TB Millennium Development Goals Partners in Health/ Paul Farmer Equity… Life expectancy 1950 - 2000 Life expectancy 2000 Life expectancy 2000  A brief history of Global Health The new milennium (2000 – 2023) Social Determinants of Health Wilkinson & Marmot (1998), The solid facts Whitehead (2002), The concepts and principles of equity and health Blas & Kurup (2008), Equity, social determinants and public health programmes Commission of Social Determinants of Health - CSDH (2010), Closing the gap in a generation Weakening of WHO Crowded and complex health architecture (PEPFAR, BMGF, Global Fund, national donors, NGO‘s, Chan Zuckerberg Initiative - „Who sets the agenda?“) http://www.who.int/social_determinants/final_report/media/csdh_report_wrs_en.pdf  Social determinants of Health HIV prevalence Self reported HIV status (adult population), Data collected by Community Health Workers between 2011 and 2013 in eight geographically defined communities in Tshwane District (ca. 30.000 individuals) The solid facts, 2003; http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf  Equity “The term inequity has a moral and ethical dimension. It refers to differences which are unnecessary and avoidable but, in addition, are also considered as unfair and unjust. So, in order to describe a certain situation as inequitable, the cause has to be examined and judged to be unfair in the context of what is going on in the rest of the society.” Whitehead, 2002  Pathways of Determinants Downstream factors Upstream (and midstream) factors Upstream factor  Pathways of Determinants Downstream factors Upstream (and midstream) factors Upstream factor  Downstream and Upstream factors Downstream, or proximate factors refer to those risk factors that assert their effect more or less directly on biology and physical mechanisms related to the disease pathogenesis Upstream, or distant factors are those factors that cause exposure to the downstream risk factors („the causes of the causes“) Equity, social determinants and public health programmes. Blas & Kurup, 2010; http://apps.who.int/iris/bitstream/10665/44289/1/9789241563970_eng.pdf  Susceptibility and Vulnerability Susceptibility Describes a person‘s predisposition getting a disease (or not) Vulnerability Describes a person‘s vulnerability to the (socio-economic) consequences of a disease, i.e. the (individual, socio-economic) damage/ harm a disease causes TB death rates England/Wales 1900 1910 1920 1930 1940 1950 1960 1970 Entrypoints for interventions Equity, social determinants and public health programmes, Blas/Kurup ets., WHO, 2010  A brief history of Global Health Recent developments (2010s) Sustainable Milennium Goals Universal Health Coverage Health in all policies Planetary Health Climate change Migration Working conditions Growing nationalism and protectionism Undermines global collaboration and solidarity Counteracts efforts to foster equity Jeopardises human rights (freedom) New global epidemics (COVID-19, Influenza, SARS…) Wars TheSustained development Health Scotoma (“blindgoals spot”) 51 Sustained development goals Good health and well-being Ensure health and well-being for all at every stage of life Improve reproductive and maternal and child health End the epidemics of HIV/AIDS, malaria, TB and neglected tropical diseases Reduce non-communicable and environmental diseases Achieve universal health coverage Universal access to safe, affordable and effective medicines and vaccines Support research and development Increase health financing Strengthen the capacity of all countries to reduce and manage health risks  Universal Health Coverage All people have access to needed health services (including prevention, promotion, treatment, rehabilitation and  Free & universal  Free but not universal palliation)  Not free, not universal Health services to be of sufficient quality to be effective Protection from financial hardships while ill-health and from payment for services  Health in All Policies An approach to public policies Across sectors Systematically takes into account the health and health systems implications of decisions Seeks synergies Avoids harmful health impacts Is founded on health-related rights and obligations Emphasizes the consequences of public policies on health determinants Aims to improve the accountability of policy-makers for health impacts at all levels of policy-making  Rudolf Virchow “Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution.” Meckenbach. J Epidemiol Community Health, 2009; 63: 181-184 Activism The most political thing you can do is to follow your heart RuPaul  „Ladder of political activism“* Health professionals become politician theselves Health professionals try to Assad, Duvalier, Karadzic influence the political process directly: lobbying, actively engaging politicians of specific political parties Health professions actively disseminate relevant information among politicians Political passivism: health professionals only share information of health risks and opportunities if politicians asked for it Bidhan Chandra Roy, Bernard Kouchner, Che Guevara, Rudolf Virchow, Aron Motsoaledi, Salvador Allende, Von der Leyen * Meckenbach. J Epidemiol Community Health, 2009; 63: 181-184 Life expectancy 2000 - 2023 Life expectancy 2023 Life expectancy 2023 A brief history of Global Health Most recent (2020s) „There is a lot that is wrong with how global health is designed, structured, taught and practiced.“ „Just old wine in new bottles“ (Madhukar Pai, 2021, Forbes)  Global/International health Though the term „global“ connotes universality of humanity and interests… Global/International health … has its epistemological roots in „Tropical Medicine“ has a colonial legacy perpetuates colonial structures creates neocolonial structures Global/International Health Power Privilege Supremacy Pai, 2020 Liberté => Power Dynamics/Justice Égalité => Equity Fraternité => Solidarity Eugène Delacroix