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Friday, February 24, 2023

Diseases of poverty

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Diseases_of_poverty 

Diseases of poverty (also known as poverty-related diseases) are diseases that are more prevalent in low-income populations. They include infectious diseases, as well as diseases related to malnutrition and poor health behaviour. Poverty is one of the major social determinants of health. The World Health Report (2002) states that diseases of poverty account for 45% of the disease burden in the countries with high poverty rate which are preventable or treatable with existing interventions. Diseases of poverty are often co-morbid and ubiquitous with malnutrition. Poverty increases the chances of having these diseases as the deprivation of shelter, safe drinking water, nutritious food, sanitation, and access to health services contributes towards poor health behaviour. At the same time, these diseases act as a barrier for economic growth to affected people and families caring for them which in turn results into increased poverty in the community. These diseases produced in part by poverty are in contrast to diseases of affluence, which are diseases thought to be a result of increasing wealth in a society.

Poverty and infectious diseases are causally related. Even before the time of vaccines and antibiotics, before 1796, it can be speculated that, leaders were adequately protected in their castles with decent food and standard accommodation, conversely the vast majority of people were living in modest, unsanitary homes; cohabiting with their animals. During this time people were unknowingly dying of infectious diseases in an event that; they touched their sick animals, had cuts in their skins, drank something that was not boiled or ate food that was contaminated by microbes. To exacerbate the situation, epidemics known as plagues then would emerge and wipe out the whole community. During this time, people had no knowledge on the cause of these unfavourable series of events. After speculations that their illnesses were being caused by an invisible army of tiny living beings, microorganisms, Antonie van Leeuwenhoek invented the first microscope that confirmed the existence of microorganisms that cannot be visualised with the naked eye (around the 17th century).

Human Immunodeficiency Virus (HIV), Malaria and Tuberculosis (TB) also known as “the big three” have been acknowledged as infectious diseases that disproportionately affect developing countries. HIV is a viral illness that can be transmitted sexually, by transfusion, shared needles and during child birth from mother to child. Due to its long latent period, there is a danger of its spread without action. It affects the human body by targeting T-cells, that are responsible for protection from uncommon infections and cancers. It is managed by life prolonging drugs known as Antiretroviral drugs (ARVs). TB was discovered by Robert Koch in 1882. It is characterised by fever, weight loss, poor appetite and night sweats. Throughout the years, there has been an improvement in mortality and morbidity caused by TB. This improvement has been attributed to the introduction of the TB vaccine in 1906. Despite this, each year the majority infected by TB are the poor. Finally, Malaria used to be prevalent throughout the world. It is now limited to developing and warm regions; Africa, Asia and South America.

Contributing factors

The prevalence of unfavorable environmental and social factors that contribute to disease are highest among individuals living in poverty. These communities are at a higher risk of adverse health outcomes, particularly with infectious diseases and noncommunicable diseases.

Physical Activity

Physical activity is a protective factor against chronic conditions such as type 2 diabetes, high blood pressure, and coronary heart disease. Lack of physical activity is related to socioeconomic status, with a higher prevalence of sedentary lifestyles among less affluent groups. There are several factors which contribute to the barriers of exercise among these groups.

Within low-income communities in the US, there is reduced access to environments that promote physical activity including parks, recreational facilities, and gyms. Only about one in five homes in low-income areas have parks within a half-mile distance, and about the same number have a fitness or recreation center within that distance. Expanded availability of local environments enabling exercise is associated with an increase in physical activity and a decrease in individuals with an overweight status.

In addition, concerns of unsafe neighborhoods in low-income areas may result in reduced physical activity in both adults and children. Children from low-income families are more likely to engage in sedentary, indoor activities due to challenges in obtaining adult supervision of outdoor play and parental concern for noise complaints. One in three children are physically active on a daily basis, and children spend seven or more hours a day is spent in front of a screen whether it be a computer, a TV, or video games. Children and adults who do not exercise frequently lower their quality of life, which will impact them as they age.

Mental Health

Mental health is “a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity”. Poverty has a profound effect on a person's mental health. According to Alyssa Brown of the Washington D.C. Gallup, 31% of people living in poverty have reported at some point been diagnosed with depression compared with 15.8% of those not in poverty. There is evidence that low income or loss of income are associated with worsening mental health while wealth and gain of income are linked with improvements in mental health. Furthermore, individuals living in poverty are disproportionally exposed to air pollution, temperature extremes, and violence, which all negatively impact mental health. These factors can induce chronic stress, which result in high cortisol levels. Excess cortisol is associated with unfavorable health outcomes, such as hypertension, diabetes, osteoporosis, and increased risk of infections.

It is uncertain whether poverty induces depression or depression causes poverty. What is certain is that the two are closely linked. A reason for this link could be due to the lack of support groups such as community centers. Isolation plays an integral role in depression. Results from a cohort study of approximately 2,000 older adults aged 65 years and older from the New Haven Established Populations for the Epidemiological Study of the Elderly found that social engagement was associated with lower depression scores after adjustment for various demographic characteristics, physical activity and functional status.

Contaminated Water

Each year many children and adults die as a result of a lack of access to clean drinking water and poor sanitation. Many poverty related diseases are spread as a result of inadequate access to clean drinking water. Contaminated water enables the spread of various waterborne-pathogens, including bacteria (E. coli, cholera), viruses (hepatitis A, norovirus), and protozoa (schistosomiasis). According to UNICEF, 3,000 children die every day, worldwide due to contaminated drinking water and poor sanitation.

Although the Millennium Development Goal (MDG) of halving the number of people who did not have access to clean water by 2015 was reached five years ahead of schedule in 2010, there are still 783 million people who rely on unimproved water sources. In 2010 the United Nations declared access to clean water a fundamental human right, integral to the achievement of other rights. This made it enforceable and justifiable to permit governments to ensure their populations access to clean water. There have been efforts to improve water quality using new technology, which allows water to be disinfected immediately upon collection and during the storage process. Clean water is necessary for cooking, cleaning, and laundry because many people come into contact with disease-causing pathogens through their food, or while bathing or washing.

Though access to water has improved for some, it continues to be especially difficult for women and children as they bear most of the burden for accessing water and supplying it to their households. In India, Sub-Saharan Africa, and parts of Latin America, women are required to travel long distances in order to access a clean water source and then bring some water home. This has a significant impact on girls' educational attainment.

An ongoing issue of contaminated water in the United States has been taking place in Flint, Michigan since 2014. The issue of lead-contaminated water began after the source of drinking water was changed from Lake Huron to the Flint River, resulting in corrosion of supply pipes and lead leaching into the city's water supply. Exposure to lead has serious health complications in developing fetuses, children, and adults. Children are particularly vulnerable to low levels of lead, and can display behavioral changes, hearing problems, and other neurologic consequences as a result of lead ingestion.

Air Pollution

Studies show that there is an association between low socioeconomic status and exposure to higher concentrations of air pollution. This relationship is especially apparent in North America, New Zealand, Asia, and Africa. Exposure to environmental toxins, like ambient particulate matter (or air pollution), has been linked to the development of diseases like cancer, immune system impairment, and reproductive dysfunction.

According to the World Health Organization, 2.4 billion people are exposed to household air pollution through the use of open fire cooking and inefficient stoves. This resulted in 3.2 million deaths per year in 2020 and countless cases of stroke, heart disease, and lung cancer. Exposure to household air pollution is especially prevalent in lower-resourced areas, contributing to the high burden of air pollution-related disease in locations considered "impoverished." Women and children, especially those who bear the burden of household chores in under-resourced areas, face increased risks of household air pollution associated complications because they are the most exposed to cooking, burning, and other household pollution emitting chores.

Education

Education is affected by poverty, which is known as the income achievement gap. This gap shows that children living in poverty or have lower-income are less likely to have the cognitive development and early literacy levels of those who do not. The amount of income affects the amount of extra money a family has to spend on additional educational programs; including summer camps and out of school assistance. In addition to finances, environmental toxins, including lead and stress and lack of nutritious food can diminish cognitive development. In later education, low-income individuals or those living in poverty are more likely to dropout of school or only receive a high school diploma. The failure to achieve higher levels of education attributes to the cycle of poverty which can continue for generations in the same family and even in the community. Studies have linked adults with low educational achievement to worse general health and increases in chronic conditions and disabilities. These individuals are more likely to engage in behaviors that worsen health, such as smoke, have an unhealthy diet, and are less likely to exercise. Higher educational achievement correlates with more opportunities for secure jobs, which enables individuals to generate wealth that can be used to improve factors that impact health outcomes.

Sanitation and Hygiene

Inadequate sanitation is attributed to approximately 432,000 deaths in LMIC each year. Poor sanitation can lead to diarrheal disease and malnutrition, which can result in serious illness. Globally, 2.3 billion people do not have access to basic sanitation services, which include access to unshared facilities for disposal of human waste and waste management services. These inequalities in access result in open defecation and improperly treated wastewater that is used for food production. Countries where open defecation is seen have higher levels of poverty, adverse health outcomes, and death in children due to diarrheal disease.

Further, one in four individuals lack access to a handwashing station with soap and water, thereby enabling the transmission of respiratory and diarrheal disease. In 2016, inadequate handwashing was attributed to 370,000 respiratory deaths and 165,000 diarrheal deaths. Diarrheal diseases contribute not only to the decreased health of an individual, but also to an increase in poverty. Diseases of this nature cause an inability to attend school and work, thus directly decreasing income as well as educational development. The problem of inadequate sanitation is cyclical in nature—just as it is caused by poverty, it also worsens poverty.

Poor nutrition

Malnutrition disproportionately affects those in sub-Saharan Africa. Over 35 percent of children under the age of 5 in sub-Saharan Africa show physical signs of malnutrition. Malnutrition, the immune system, and infectious diseases operate in a cyclical manner: infectious diseases have deleterious effects on nutritional status, and nutritional deficiencies can lower the strength of the immune system which affects the body's ability to resist infections. Similarly, malnutrition of both macronutrients (such as protein and energy) and micronutrients (such as iron, zinc, and vitamins) increase susceptibility to HIV infections by interfering with the immune system and through other biological mechanisms. Depletion of macro-nutrients and micro-nutrients promotes viral replication that contributes to greater risks of HIV transmission from mother-to-child as well as those through sexual transmission. Increased mother-to-child transmission is related to specific deficiencies in micro-nutrients such as vitamin A. Further, anemia, a decrease in the number of red blood cells, increases viral shedding in the birth canal, which also increases risk of mother-to-child transmission. Without these vital nutrients, the body lacks the defense mechanisms to resist infections. At the same time, HIV lowers the body's ability to intake essential nutrients. HIV infection can affect the production of hormones that interfere with the metabolism of carbohydrates, proteins, and fats.

In the United States, 11.1 percent of households struggle with food insecurity. Food insecurity refers to the lack of access to quality food for a healthy lifestyle. The rate of hunger and malnutrition in female headed households was three times the national average at 30.2 percent. According to the Food and Agriculture Organization of the United Nations, 10 percent of the population in Latin America and the Caribbean are affected by hunger and malnutrition.

Poor housing conditions

Families living in poverty often struggle not only with housing problems, but neighborhood safety and affordability problems as well. Avoiding neighborhood safety problems often means staying home which reduces opportunity for exercise outside the home which exacerbates health issues due to lack of exercise. Staying in the home can mean exposure to lead, mold and rodents within that home that can lead to an increased risk of illness due to these inadequate housing issues.

Lack of access to health services

According to WHO, medical strategies report, approximately 30% of the global population does not have regular access to medicines. In the poorest parts of Africa and Asia, this percent goes up to 50%. The population below the poverty line lacks access due to higher retail price and unavailability of the medicines. The higher cost can be due to the higher manufacturing price or due to local or regional tax and Value Added Tax. There is a significant disparity in the research conducted in the health sector. It is claimed that only 10% of the health research conducted globally focuses on 90% disease burden. However, diseases such as cancer, cardiovascular diseases etc. that traditionally were associated with the wealthier community are now becoming more prevalent in the poor communities as well. Hence, the research conducted now is relevant to poor population. Political priority is also one of the contributing factors of inaccessibility. The government of poor countries may allocate less funding to public health due to the scarcity of resources.

Cycle of poverty

The cycle of poverty is the process through which families already in poverty are likely to remain in those circumstances unless there is an intervention of some kind. This cycle of poverty has an impact on the types of diseases that are experienced by these individuals, and will often be passed down through generations. Mental illnesses are particularly important when discussing the cycle of poverty, because these mental illnesses prevent individuals from obtaining gainful employment. The stressful experience of living in poverty can also exacerbate mental illnesses.

This cycle of poverty also impacts the familial diseases that are passed down each generation. By experiencing the same stressful situations for decades, individuals become more susceptible to diseases like cardiovascular disease, obesity, diabetes, and mental illnesses including schizophrenia and bipolar disorder.

Infectious Diseases

Together, diseases of poverty kill approximately 14 million people annually. Gastroenteritis with its associated diarrhea results in about 1.8 million deaths in children yearly with most of these in the world's poorest nations.

At the global level, the three primary PRDs are tuberculosis, AIDS/HIV and malaria. Developing countries account for 95% of the global AIDS prevalence and 98% of active tuberculosis infections. Furthermore, 90% of malaria deaths occur in African countries. Together, these three diseases account for 10% of global mortality.

Treatable childhood diseases are another set which have disproportionately higher rates in poor countries despite the availability of cures for decades. These include measles, pertussis and polio. The largest three poverty-related diseases (PRDs) — AIDS, malaria, and tuberculosis — account for 18% of diseases in poor countries. The disease burden of treatable childhood diseases in high-mortality, poor countries is 5.2% in terms of disability-adjusted life years but just 0.2% in the case of advanced countries.

In addition, infant mortality and maternal mortality are far more prevalent among the poor. For example, 98% of the 11,600 daily maternal and neonatal deaths occur in developing countries.

Three other diseases, measles, pneumonia, and diarrheal diseases, are also closely associated with poverty, and are often included with AIDS, malaria, and tuberculosis in broader definitions and discussions of diseases of poverty.

Neglected diseases

Main article: Neglected tropical diseases

Based upon the spread of research in cures for diseases, certain diseases are identified and referred to as "neglected diseases". These include the following diseases:

  • African trypanosomiasis
  • Chagas disease
  • Leishmaniasis
  • Lymphatic filariasis
  • Dracunculiasis (“Guinea worm disease”)
  • Onchocerciasis
  • Schistosomiasis
  • Trichomoniasis

Tropical diseases such as these tend to be neglected in research and development efforts. Of 1393 new drugs brought into use over a period of 25 years (1975–1999), only a total of thirteen, less than 1%, related to these diseases. Of 20 MNC drug companies surveyed for research on PRDs, only two had projects targeted towards these neglected PRDs. However, the combined total number of deaths due to these diseases is dwarfed by the enormous number of patients affected by PRDs such as respiratory infections, HIV/AIDS, diarrhea and tuberculosis, besides many others. Similar to the spread of tropical neglected diseases in developing nations, these neglected infections disproportionately affect poor and minority populations in the United States. These diseases have been identified by the Centers for Disease Control and Prevention, as priorities for public health action based on the number of people infected, the severity of the illnesses, and the ability to prevent and treat them.

Trichomoniasis

Trichomoniasis is the most common sexually transmitted infection affecting more than 200 million people worldwide. It is especially prevalent among young, poor and African American women. This infection is also common in poor communities in Sub-Saharan Africa and impoverished parts of Asia. This neglected infection is one of special concern because it is associated with a heightened risk for contracting HIV and pre-term deliveries.

In addition, availability of cures and recent advances in medicine have led to only three diseases being considered neglected diseases, namely, African trypanosomiasis, Chagas disease and Leishmaniasis.

Malaria

Africa accounts for a majority of malaria infections and deaths worldwide. Over 80 percent of the 300 to 500 million malaria infections occurring annually worldwide are in Africa. Each year, about one million children under the age of five die from malaria. Children who are poor, have mothers with little to no education, and live in rural areas are more susceptible to malaria and more likely to die from it. Malaria is directly related to the spread of HIV in sub-Saharan Africa. It increases viral load seven to ten times, which increases the chances of transmission of HIV through sexual intercourse from a patient with malaria to an uninfected partner. After the first pregnancy, HIV can also decrease the immunity to malaria. This contributes to the increase of the vulnerability to HIV and higher mortality from HIV, especially for women and infants. HIV and malaria interact in a cyclical manner—being infected with malaria increases susceptibility to HIV infection, and HIV infections increase malarial episodes. The co-existence of HIV and malaria infections helps spread both diseases, particularly in Sub-Saharan Africa. Malaria vaccines are an area of intensive research.

Intestinal parasites

Intestinal parasites are extremely prevalent in tropical areas. These include helminths like hookworms, roundworms, and flukes and protozoa like giardia, amoebas and Leishmania. They can aggravate malnutrition by depleting essential nutrients through intestinal blood loss and chronic diarrhea. Chronic worm infections can further burden the immune system. At the same time, chronic worm infections can cause immune activation that increases susceptibility of HIV infection and vulnerability to HIV replication once infected.

Schistosomiasis

Schistosomiasis (bilharzia) is a parasitic disease caused by the parasitic flatworm trematodes. Moreover, more than 80 percent of the 200 million people worldwide who have schistosomiasis live in sub-Saharan Africa. Infections often occur in contaminated water where freshwater snails release larval forms of the parasite. After penetrating the skin and eventually traveling to the intestines or the urinary tract, the parasite lays eggs and infects those organs. It damages the intestines, bladder, and other organs and can lead to anemia and protein-energy deficiency. Along with malaria, schistosomiasis is one of the most important parasitic co-factors aiding in HIV transmission. Epidemiological data shows schistosome-endemic areas coincide with areas of high HIV prevalence, suggesting that parasitic infections such as schistosomiasis increase risk of HIV transmission.

Tuberculosis

Tuberculosis is the leading cause of death around the world for an infectious disease. This disease is especially prevalent in sub-Saharan Africa, and the Latin American and Caribbean region. While the tuberculosis rate is decreasing in the rest of the world, it is increasing by rate of 6 percent per year in Sub-Saharan Africa. It is the leading cause of death for people with HIV in Africa. Tuberculosis (TB) is closely related to lifestyles of poverty, overcrowded conditions, alcoholism, stress, drug addiction and malnutrition. This disease spreads quickly among people who are undernourished. According to the Center for Disease Control and Prevention, in the United States, tuberculosis is more prevalent among foreign born persons, and ethnic minorities. The rates are especially high among Hispanics, Blacks and Asians. HIV infection and TB are also closely tied. Being infected with HIV increases the rate of activation of latent TB infections, and having TB, increases the rate of HIV replication, therefore accelerating the progression of AIDS.

AIDS

AIDS is a disease of the human immune system caused by the human immunodeficiency virus (HIV). Primary modes of HIV transmission in sub-Saharan Africa are sexual intercourse, mother-to-child transmission (vertical transmission), and through HIV-infected blood. Since rate of HIV transmission via heterosexual intercourse is so low, it is insufficient to cause AIDS disparities between countries. Critics of AIDS policies promoting safe sexual behaviors believe that these policies miss the biological mechanisms and social risk factors that contribute to the high HIV rates in poorer countries. In these developing countries, especially those in sub-Saharan Africa, certain health factors predispose the population to HIV infections.

Many of the countries in Sub-Saharan Africa are ravaged with poverty and many people live on less than one United States dollar a day. The poverty in these countries gives rise to many other factors that explain the high prevalence of AIDS. The poorest people in most African countries are malnourished, lack of access to clean water, and have improper sanitation. Because of a lack of clean water many people are plagued by intestinal parasites that significantly increase their chances of contracting HIV due to compromised immune system. Malaria, a disease still rampant in Africa also increases the risk of contracting HIV. These parasitic diseases, affect the body's immune response to HIV, making people more susceptible to contracting the disease once exposed. Genital schistosomiasis, also prevalent in the topical areas of Sub-Saharan Africa and many countries worldwide, produces genital lesions and attract CD4 cells to the genital region which promotes HIV infection. All these factors contribute to the high rate of HIV in Sub-Saharan Africa. Many of the factors seen in Africa are also present in Latin America and the Caribbean and contribute to the high rates of infections seen in those regions. In the United States, poverty is a contributing factor to HIV infections. There is also a large racial disparity, with African Americans having a significantly higher rate of infection than their white counterparts.

Noncommunicable Diseases

Noncommunicable diseases (NCD) such as cardiovascular disease, chronic respiratory diseases, cancer, and diabetes place a significant burden of disease in low- and middle-income countries (LMIC). NCD cause 41 million deaths each year, which account for 71% of all deaths globally of which 77% are in LMIC.

Respiratory Diseases

More than 300 million people worldwide have asthma. The rate of asthma increases as countries become more urbanized and in many parts of the world those who develop asthma do not have access to medication and medical care. Within the United States, African Americans and Latinos are four times more likely to have severe asthma than whites. The disease is closely tied to poverty and poor living conditions. Asthma is also prevalent in children in low income countries. Homes with roaches and mice, as well as mold and mildew put children at risk for developing asthma as well as exposure to cigarette smoke.

Unlike many other Western countries, the mortality rate for asthma has steadily risen in the United States over the last two decades. Mortality rates for African American children due to asthma are also far higher than that of other racial groups. For African Americans, the rate of visits to the emergency room is 330 percent higher than their white counterparts. The hospitalization rate is 220 percent higher and the death rate is 190 percent higher. Among Hispanics, Puerto Ricans are disporpotionatly affected by asthma with a disease rate that is 113 percent higher than non-Hispanic Whites and 50 percent higher than non-Hispanic Blacks. Studies have shown that asthma morbidity and mortality are concentrated in inner city neighborhoods characterized by poverty and large minority populations and this affects both genders at all ages. Asthma continues to have an adverse effects on the health of the poor and school attendance rates among poor children. 10.5 million days of school are missed each year due to asthma.

Cardiovascular disease

Though heart disease is not exclusive to the poor, there are aspects of a life of poverty that contribute to its development. This category includes coronary heart disease, stroke and heart attack. Heart disease is the leading cause of death worldwide and there are disparities of morbidity between the rich and poor. Studies from around the world link heart disease to poverty. Low neighborhood income and education were associated with higher risk factors. Poor diet, lack of exercise and limited (or no) access to a specialist were all factors related to poverty, though to contribute to heart disease. Both low income and low education were predictors of coronary heart disease, a subset of cardiovascular disease. Of those admitted to hospital in the United States for heart failure, women and African Americans were more likely to reside in lower income neighborhoods. In the developing world, there is a 10 fold increase in cardiac events in the black and urban populations.

Cancer

While cancer affects all populations, certain populations are disproportionally affected by the disease due to differences in risk factor exposures. People living in poverty are at an increased risk of cancer incidence and mortality, with annual death rates being 12% higher in countries living in poverty. Globally, two out of three cancer deaths are attributed to lifestyle and behaviors such as smoking, poor diet, physical inactivity, and insufficient cancer screenings. Individuals living in LMIC have greater exposure to these risk factors in the setting of reduced access to health care services. Inadequate access to health care presents a major barrier as individuals are less likely to receive regular cancer screenings resulting in a late-stage diagnosis, which is associated with worse health outcomes. People living in poverty have also higher levels of chronic stress, which also increases an individual's risk of cancer due to inflammatory changes.

Obesity

Obesity is a chronic non-communicable disease (NCD) that is diagnosed in individuals who have Body Mass Index (BMI) greater than 30 kg/m2. Generally, low-income populations, whether they live in high-income countries or in low-middle income countries (LMIC) suffer higher disease burden for chronic conditions including obesity when compared to their higher income counterparts. Higher obesity rates tend to be observed in LMICs and it has been believed that lower socio-economic statuses (SES) leads to higher obesity rates because individuals living in poverty are limited in their abilities to engage in healthy exercising and dieting practices. In the United States, there tends to be higher obesity rates in lower SES neighborhoods, which are called food deserts. A food desert lacks supermarkets that offer healthy and fresh food options and instead have highly processed foods. Because of the limited access to healthy foods, it follows that individuals who live farther away from supermarkets tend to have higher rates of obesity. Besides food access, individuals living in poverty may also be limited in their healthcare access, leading to later diagnosis and management of chronic conditions like obesity. Conversely, chronic conditions such as obesity can also increase rates of poverty via increased healthcare expenditures, wage loss during peak productive years, and missed schooling. These points underscore the positive effect poverty alleviation has on improving health outcomes as it concerns obesity and other chronic NCDs. In spite of this data, pervasive attitudes remain that individual behavior, not SES, is responsible for obesity. These attitudes stigmatize individuals with obesity, which further hampers public health interventions to reduce obesity rates and accelerates health disparities along SES lines.

Other Health Complications

Maternal Health

Obstetric fistula or vaginal fistula is a medical condition in which a fistula (hole) develops between either the rectum and vagina (see rectovaginal fistula) or between the bladder and vagina (see vesicovaginal fistula) after severe or failed childbirth, when adequate medical care is not available. It is considered a disease of poverty because of its tendency to occur women in poor countries who do not have health resources comparable to developed nations.

Dental Decay

Dental decay or dental caries is the gradual destruction of tooth enamel. Poverty is a significant determinant for oral health. Dental caries is one of the most common chronic diseases worldwide. In the United States it is the most common chronic disease of childhood. Risk factors for dental caries includes living in poverty, poor education, low socioeconomic status, being part of an ethnic minority group, having a developmental disability, recent immigrants and people infected with HIV/AIDS. In Peru, poverty was found to be positively correlated with dental caries among children. According to a report by U.S health surveillance, tooth decay peaks earlier in life and is more severe in children with families living below the poverty line. Tooth decay is also strongly linked to dietary behaviors, and in poor rural areas where nutrient dense foods, fruits and vegetables are unavailable, the consumption of sugary and fatty food increases the risk of dental decay. Because the mouth is a gateway to the respiratory and digestive tracts, oral health has a significant impact on other health outcomes. Gum disease has been linked to diseases such as cardiovascular disease.

Societal consequences

Diseases of poverty reflect the dynamic relationship between poverty and poor health; while such diseases result directly from poverty, they also perpetuate and deepen impoverishment by sapping personal and national health and financial resources. For example, malaria decreases GDP growth by up to 1.3% in some developing nations, and by killing tens of millions in sub-Saharan Africa, AIDS alone threatens “the economies, social structures, and political stability of entire societies”.

For women

Women and children are often put at a high risk of being infected by schistosomiasis, which in turn puts them at a higher risk of acquiring HIV. Since the mode of schistosomiasis transmission is usually through contaminated water in streams and lakes, women and children who do their household chores by the water are more likely to acquire the disease. Activities that women and children often do around waterfront include washing clothes, collecting water, bathing, and swimming. Women who have schistosomiasis lesions are three times more likely to be infected with HIV.

Women also have a higher risk of HIV transmission through the use of medical equipment such as needles. Because more women than men use health services, especially during pregnancy, they are more likely to come across unsterilized needles for injections. Although statistics estimate that unsterilized needles only account for 5 to 10 percent of primary HIV infections, studies show this mode of HIV transmission may be higher than reported. This increased risk of contracting HIV through non-sexual means has social consequences for women as well. Over half of the husbands of HIV-positive women in Africa tested HIV-negative. When HIV-positive women reveal their HIV status to their HIV-negative husbands, they are often accused of infidelity and face violence and abandonment from their family and community.

Relating to human capabilities

Malnutrition associated with HIV impacts people's ability to provide for themselves and their dependents, thus limiting the human capabilities of both themselves and their dependents. HIV can negatively affect work output, which impacts the ability to generate income. This is crucial in parts of Africa where farming is the primary occupation and obtaining food is dependent on the agricultural outcome. Without adequate food production, malnutrition becomes more prevalent. Children are often collateral damage in the AIDS crisis. As dependents, they can be burdened by the illness and eventual death of one or both parents due to HIV/AIDS. Studies have shown that orphaned children are more likely to display physical symptoms of malnutrition than children whose parents are both alive.

Public policy proposals

There are a number of proposals for reducing the diseases of poverty and eliminating health disparities within and between countries. The World Health Organization proposes closing the gaps by acting on social determinants. Their first recommendation is to improve daily living conditions. This area involves improving the lives of women and girls so that their children are born in healthy environments and placing an emphasis on early childhood health. Their second recommendation is to tackle the inequitable distribution of money, power and resources. This would involve building stronger public sectors and changing the way in which society is organized. Their third recommendation is to measure and understand the problem and assess the impact of action. This would involve training policy makers and healthcare practitioners to recognize problems and form policy solutions.

Health in All Policies

The 8th Global Conference on Health Promotion held in Helsinki in June 2013 has proposed an approach termed Health in All Policies. Health inequalities are shaped by many powerful forces and social, political, and economic determinants. Governments have a responsibility to ensure that their people are able to live healthy lives and have equitable access to achieving a reasonable state of good health. Policies that governments craft and implement in all sectors have a significant and ongoing impact on public health, health equity, and the lives of their citizens. Increases in technology, medical innovation, and living conditions have led to the disappearance of diseases and other factors contributing to poor health. However, there are many diseases of poverty that still persist in developed and developing countries. Tackling these health inequalities and diseases of poverty requires a willingness to engage the whole government in health. The Helskinki Statement lays out a framework of action for countries and calls on governments to make a commitment to building health equity within their country.

Health in All Policies (HiAP) is an approach to public policies across all sectors of government that takes into account the health implications of all government and policy decisions to improve health equity across all populations residing within the borders of a country. This concept is built upon principles in line with the Universal Declaration of Human Rights, The United Nations Millennium Development Declaration, and principles of good governance: legitimacy given by national and international law, accountability of government, transparency of policy making, participation of citizens, sustainability ensuring policies meet the needs of both present and future generations, and collaboration across sectors and levels of government.

Finally the Framework lists and expands upon six steps for implementation that may be undertaken by a country in taking action towards Health in All Policies. These are components of action and not a rigid checklist of steps to adhere to. The most important aspect of this policy is that governments should adapt the policy to suit the needs of their citizens, their socioeconomic situation, and their governance system.

  1. Establish the need and priorities for HiAP
  2. Frame planned action
  3. Identify supportive structures and processes
  4. Facilitate assessment and engagement
  5. Ensure monitoring, evaluation, and reporting
  6. Build capacity.

HIV/AIDS policy

  • Nutrition Supplements: Focusing on reversing the pattern of malnutrition in sub-Saharan African and other poor countries is a one possible way of decreasing susceptibility to HIV infections. Micro-nutrients such as iron and vitamin A can be delivered and provided at a very low cost. For example, vitamin A supplements cost $0.02 per capsule if provided twice a year. Iron supplements per child cost $0.02 if provided weekly or $0.08 if provided daily.
  • Eliminating Co-factors: Tackling the very diseases that increase risk of HIV infections can help slow down the rates of HIV transmission. Co-factors such as malaria and parasitic infections can be combated in an effective and cost-efficient manner. For example, mosquito nets can be easily used to prevent malaria. Parasites can be eliminated with medication that is cost-effective and easy to administer. Twice-yearly treatments range from $0.02 to $0.25 depending on the type of worm.
at February 24, 2023
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Inequality in disease

From Wikipedia, the free encyclopedia

Social epidemiology focuses on the patterns in morbidity and mortality rates that emerge as a result of social characteristics. While an individual's lifestyle choices or family history may place him or her at an increased risk for developing certain illnesses, there are social inequalities in health that cannot be explained by individual factors. Variations in health outcomes in the United States are attributed to several social characteristics, such as gender, race, socioeconomic status, the environment, and educational attainment. Inequalities in any or all of these social categories can contribute to health disparities, with some groups placed at an increased risk for acquiring chronic diseases than others.

For example, cardiovascular disease is the leading cause of death in the United States, followed closely by cancer, with the fifth most deadly being diabetes. The general risk factors associated with these diseases include obesity and poor diet, tobacco and alcohol use, physical inactivity, and access to medical care and health information. Although it may seem that many of these risk factors arise solely from individual health choices, such a view neglects the structural patterns in the choices that individuals make. Consequently, a person's likelihood of developing heart disease, cancer, or diabetes is in part correlated with social factors. Among all racial groups, individuals who are impoverished or low income, have lower levels of educational attainment, and/or live in lower-income neighborhoods are all more likely to develop chronic diseases, such as heart disease, cancer, and diabetes.

Gender

Main article: Gender disparities in health

In the United States and Europe, up until the 19th century, women tended to die at an earlier age than men. This was largely due to the risks involved in pregnancy and childbirth. However, in the late 19th century there was a shift in life expectancy and women started to live longer than men. Notably, this is partly explained by biological factors. For instance, there is a cross-cultural trend that male fetal mortality rates are higher than female fetal mortality rates. Additionally, estrogen decreases the risk of females acquiring heart disease by lowering the amount of cholesterol in the blood, while testosterone suppresses the immune system in males and puts them at risk for acquiring serious illnesses. However, biological differences do not fully account for the large gender gap in the health outcomes of men and women. Social factors play a large role in gender disparities in health.

One of the main factors that contributes to the decreased life expectancy of males is their propensity to engage in risk-taking behaviors. Some commonly cited examples include heavy drinking, illicit drug use, violence, drunk driving, not wearing helmets, and smoking. These behaviors contribute to injuries that may lead to premature death in males. In particular, the effect of risk-taking behavior on health is especially visible in the case of smoking. As smoking rates have fallen in the United States overall, less men engage in this behavior and the life expectancy gap between men and women has slightly decreased as a result.

The behaviour of men and women also vary in regards to diet and exercise, leading to differential health outcomes . On average, men exercise more than women, but their diet is less nutritious. Consequently, men are more likely to be overweight, while women are at greater risk for obesity. Exposure to violence is another social factor that has an influence on health. In general, women have a higher likelihood of experiencing sexual and intimate partner violence, while men are twice as likely to die from suicide or homicide.

Markedly, the impact of gender on health becomes especially salient in different socioeconomic contexts. In the United States, there is a large economic gender inequality with many economically disadvantaged women occupying much fewer positions of power than men. According to the Panel Study of Income Dynamics, "among adults with the strongest attachment to the labor force, only 9.6% of women earned more than $50,000 annually, compared with 44.5% of men." This gendered economic inequality is partly responsible for the gender-health paradox: the general trend that women live longer than men, but experience a greater degree of non-life-threatening chronic illnesses over the course of a lifetime. A low socioeconomic status in women contributes to feelings of a lack of personal control over the events in their lives, increased stress, and low self-esteem. Perpetual states of stress inflict damage on the bodies and minds of women, placing them at risk for physical ailments, such as heart disease and arthritis, as well mental health disorders, such as depression.

Another significant social factor is that men and women deal with their illnesses in different ways. Women generally have strong support networks and are able to rely on others for emotional support, with the potential to improve their states of health. In contrast, men are less likely to have strong support networks, they have fewer doctor visits, and often cope with their illnesses on their own. Also, men and women express pain in different ways. Researchers have observed that women openly express feelings of pain, while men are more reserved in this regard and prefer to appear tough even when they experience severe mental or physical suffering. This finding suggests that this is due to socialization processes. Women are taught to be submissive and emotional, while men are taught to be strong, powerful figures that do not show their emotions. The social stigma associated with expressions of pain prevents men from admitting their suffering to others, making it more difficult to overcome the pain.

Moreover, neighborhood effects have a greater influence on women than men. For instance, research findings suggest that women living in impoverished neighborhoods are more likely to experience obesity, while this effect is not as strong for men. The physical environment also generally impacts a woman's self-rated health. This effect can be explained by the fact that women spend more time at home than their male counterparts, as a result of higher unemployment rates, and therefore may be more exposed to negative environmental characteristics that take a toll on their health.

Finally, gender effects also vary with race, ethnicity, and nativity status. Notably, Christy Erving conducted a study in which she examined the gender differences in the health profiles of African Americans and Caribbean blacks (immigrants and U.S. born). One of the findings from this research is that on average, African American women report lower self-rated measures of health, worse physical health, and were more likely to experience severe chronic illnesses than men. This finding contradicts the gender-health paradox in the sense that researchers would expect morbidity rates to be higher for women, but less of the illnesses that they acquire should be debilitating. In contrast, the opposite trend is observed for U.S. born Caribbean blacks, with men more likely to experience chronic, life-threatening illnesses than women. The health outcomes of Caribbean black immigrants are somewhere in-between the health outcomes of U.S. born Caribbean blacks and African Americans, wherein the females have a lower value of self-reported health but experience equal rates of life-threatening, chronic disease as men. This data illustrates that even within one racial category, there can be stark gender differences in health on the basis of social differences within the groups that compose the race.

Race

Studies have shown that individuals that are racially and ethnically stigmatized, not just in the U.S., but globally as well, experience health issues such as mental and physical illness, and in some cases even death, in higher rates than the average individual. There has been some controversy around "race" being a determinant of disease and health issues, since there are unmeasured forms of background history that are potential factors in this research. Geographical origins and the types of environments individual races were exposed to are huge contributes to the health of a certain race, especially when the environment that they are in now is not the same as the one their race originates from geographically.

Along with these factors, physical, psychological, social, and chemical environments are all included and accounted for. Including exposure over the course of one's life and through generations, and biological adaptation to these environmental exposures, including gene expression. An example of this is a study of hypertension between black people and whites. West Africans and people of West African descent levels of hypertension increased when they moved from Africa to the United States. Their levels of hypertension were twice as high as the levels of black people that were in Africa. While whites in the United States even had higher rates of hypertension than Black people in Africa, the black people in the United States rates of hypertension were higher than some predominately white populations in Europe. Again, this proves that when a race is taken out of their original geographic environment, they are more prone to disease and illness, because their genetic make-up was made for a specific type of environment.

Transitioning from the environmental aspect of race and disease, there is a direct correlation between race and socioeconomic status which contributes to racial disparities in health. When it comes to death rates from heart disease, the rate is about twice as high for black men vs. white men. Now, death rates from heart disease are lower for both black and white women compared to their male counterparts, but the patterns of racial disparities and education disparities for women are similar to that of the men. Death from heart disease is about three times as higher for black women than white women. For both black men and women, racial differences in deaths from heart disease at every level of education is evident, with the racial gap being larger at the higher levels of education than at the lowest levels. There are a number of reasons why race matters in terms of health after socioeconomic status has been accounted for. For one, health is affected by adversity early on in one's life, such as traumatic stress, poverty, and abuse. These factors affect the physical and mental health of an individual. As we know, most of the people living in poverty in the United States are minorities, specifically African Americans, so unfortunately there is no surprise that they are the individuals with so many health issues.

Continuously, race is relevant to health issues, because of the non-equivalence of socioeconomic status indicators across racial groups. At the same level of education, minorities (black people and non-white Hispanic people) receive less income than their Anglo-white counterparts, as well as have less wealth and purchasing power. Namely, one of the biggest reasons that race matters in terms of health is due to racism. Both personal and institutionalized racism are very prominent in today's society, maybe not as blunt and easy to notice in comparison to the past, but it still exists. Certain residential segregation by race, such as redlining, has created very distinct racial differences in terms of education, employment, and opportunities. Opportunities such as access to good healthcare/medical care. Institutional and cultural racism can even harm minorities health through stereotypes and prejudices, which contributes to socioeconomic mobility and can reduce and limit resources and opportunities required for a healthy lifestyle.

Socioeconomic status is only one part of racial disparities in health that reflect larger social inequalities in society. Racism is a system that combines with, and sometimes changes, socioeconomic status to influence health, and race still matters for health when socioeconomic status is considered.

Socioeconomic status

Socioeconomic status is a multidimensional classification, often defined using an individual's income and level of education. Other related metrics can round out this definition; for example, in a 2006 study by authors Cox, McKevitt, Rudd and Wolfe, further categories included "occupation, home and goods ownership, and area-based deprivation indices" in their determination of status.

Income inequality has risen rapidly in the United States, pushing greater amounts of the population into positions of lower socioeconomic status. A study published in 1993 examined Americans who had died between May and August 1960, and paired the mortality information with income, education and occupation data for each person. The work found an inverse correlation between socioeconomic status and mortality rate, as well as an increasing strength of this pattern and its reflection of the growth of income inequality in the United States.

These findings, although concerned with total mortality of any cause, reflect a similar relationship between socioeconomic status and disease incidence or death in the United States. Disease composes a very significant portion of U.S. mortality; as of May 2017, 6 out of 7 of the leading causes of death in America are non-communicable diseases, including heart disease, cancer, lower respiratory diseases, and cerebrovascular diseases (stroke). Indeed, these diseases have been seen to disproportionately affect the socioeconomically disadvantaged, albeit to different degrees and with differing magnitude. Mortality rates associated with cardiovascular disease (CVD), including coronary heart disease (CHD) and stroke, were assessed for individuals across areas of differing income and income inequality. The authors found that the mortality rates for each of the three respective diseases were greater by a factor of 1.36, 1.26, and 1.60, in areas of higher inequality compared to lower inequality areas of similar income. Across areas of differing income and constant income inequality, the rate of death due to CVD, CHD and stroke was increased by a factor of 1.27, 1.15, and 1.33 in the lower income areas. These trends across two measures of variation in socioeconomic status reflect the complexity and depth of the relationship between disease and economic standing. The authors are careful to state that while these patterns exist, they are not sufficiently described as related by cause and effect. While correlating, health and status have arisen in the U.S. from interrelated forces that may intricately accumulate or negate one another due to specific historical contexts.

As this lack of cause and effect simplicity indicates, exactly where disease-related health inequality arises is murky, and multiple factors likely contribute. Important to an examination of disease and health in the context of a complicated classification like socioeconomic status is the degree to which these measures are tied up with mechanisms that are dependent upon the individual, and those that are regionally variant. In the aforementioned 2006 study, the authors define individualized factors within three categories, "material (eg, income, possessions, environment), behavioural (eg, diet, smoking, exercise) and psychosocial (eg, perceived inequality, stress)", and provide two categories for external, regionally varying factors, "environmental influences (such as provision of and access to services) and psychosocial influences (such as social support)." The interactive and compounding nature of these forces can shape and be shaped by socioeconomic status, presenting a challenge to researchers to tease apart the intersecting factors of health and status. In the 2006 study, authors examined the specific drivers of the correlation between stroke occurrence and socioeconomic status. Identifying more nuanced and interlocking factors, they cited risk behaviors, early life influences, and access to care as tied to socioeconomic status and thus health inequality.

Inequality in disease is intricately tangled up with stratification of social class and economic status in the United States. Correlations, often disease-dependent, between health and socioeconomic attainment have been demonstrated in numerous studies for numerous diseases. The causes of these correlations are interlocking and often related to factors varying between regions and individuals, and design of future studies concerning inequality in disease require careful thought to the multifaceted driving mechanisms of social inequality.

Environment

The neighbourhood and areas people live in, as well as their occupation, make up the environment in which they exist. People living in poverty stricken neighborhoods are at a greater risk for heart disease, possibly because the supermarkets in their area do not sell healthy foods and there is increased availability of stores selling alcohol and tobacco than in more affluent parts of town. People living in rural areas are also more susceptible to heart disease, as well. An agriculturally based diet rich in fat and cholesterol, combined with an isolated environment in which there is limited access to health care and ways to distribute information probably creates a pattern in which people living in rural environments have higher levels of heart disease. Occupational cancer is one way in which the environment one works in can increase their rate of disease. Employees exposed to smoke, asbestos, diesel fumes, paint, and chemicals in factories can develop cancer from their workplace. All of these jobs tend to be low-paying and typically held by low income individuals. The decreased amount of healthy food in stores located in low-income areas also contributes to the increased rates of diabetes for persons living in those neighborhoods. One of the best examples of this can be seen by observing the city of Jacksonville, Florida.

Food deserts in urban Jacksonville

In Jacksonville, Florida it is hard to find groceries stores around the area because it is surrounded by fats, sugar, and high in cholesterol markets. In Duval County, there are 177,000 food insecure individuals such as children, families,senior citizens, and veterans that do not know when they will have a chance to have another meal again. Nearly 60 percent of the food that is consumed in Duval County is processed. To combat this, agencies helped distribute food and they averaged 12.3 million meals over eight counties in Northern Florida. In Duval alone, 3.5 million meals were handed out to families. The image below shows all of the hunger-relief partner agencies located within Jacksonville's food deserts that get food from Feeding Northeast Florida. In all Feeding Northeast Florida provided 4.2 million pounds of food to agencies in food deserts. These numbers were stats recorded in 2016.

Water pollution

Just like Flint Jacksonville had a water crisis and found 23 different chemicals in their water supply. It was so bad that Jacksonville was labeled top 10 in worst water in the nation. They stood at number 10 because of the 23 different chemicals. The chemicals that were most found in the water in high volumes were trihalomethanes, which is made up of four different cleaning by products such as chloroform. Trihalomethanes are confirmed to be carcinogenic. Throughout the five year testing period, unsafe levels of trihalomethanes were found during the 32 months of testing, and levels that are considered illegal by the EPA were found in 12 of those months. In one of the testing periods the trihalomethanes were found at twice the EPA legal limit. Other chemicals such as lead and arsenic that can cause health problems to people, were also found in the drinking water.

Another way that water pollution is damaged is from nutrient overload. Nutrient overload is caused by manure and fertilizers, storm water runoff, and wastewater treatment plants. This occurs in a lot of Florida rivers and the rivers are contained with blue green algae that feed on all those nutrients. All the waste that is dumped into the rivers gets fed on by other plants and animals that release toxins in the area, which makes everything surrounded by it a deadly toxin as well. The toxins that are dumped into the rivers can cause discoloration in the rivers to make a dark blue and green color. By looking at the river most people can tell how dangerous and harmful it is to be around it. If the water were to somehow get into water companies people can receive serious harm from drinking and bathing with this water.

Education

Education level is a great predictor of socioeconomic status. On average, individuals with a bachelors, associates, and high school degrees will annually earn 64.5, 50, and 41 thousand dollars respectively. This means that the average bachelor's degree earner will receive approximately $1,000,000 more over their working life than an individual with only a high school degree. Furthermore, as authors Montez, Hummer, and Hayward explained, "In 2012, unemployment was 12.4 percent among adults who did not graduate high school, compared to 8.3 percent among adults with a high school diploma and 4.5 percent among college graduates." Because the relationship between socioeconomic status and the prevalence of disease has already been well established, education is indirectly responsible for an increased prevalence of disease among the impoverished.

More directly, educational attainment is a great predictor of how likely an individual is to engage in risky, possibly disease causing, behaviors. In terms of smoking, which directly correlates to an increased risk for diseases like lung cancer, education is an important determining factor in the likelihood of an individual to smoke. As of 2009–10, 35 percent of adults who did not graduate high school were smokers, compared to 30 percent of high school graduates and just 13 percent of college graduates. High school graduates also smoked more packs, on average, each year than smokers who had graduated from college. Furthermore, individuals with a high school degree or less were 30% less likely to abstain from smoking for at least 3 months during their time as a regular smoker. Other studies have found that binge drinking is higher among those with college degrees, implying that binge drinking is a habitat developed by many during the college years.

Unhealthy dietary habits can also directly lead to diseases such as heart disease, hypertension, and type-2 diabetes. One of the leading causes of unhealthy eating habits is a lack of access to grocery stores, creating so called "food deserts." Studies have found that immediate access to a grocery store (within 1.5 mile radius) was 1.4 times less likely in areas where only 27%, or less, of the population was college graduates. The negative effects of these food deserts are exacerbated by the fact that impoverished neighborhoods also had an oversupply of liquor store, fast food restaurants, and convenience stores.

One significant risk for sexually active individuals is that of sexually transmitted diseases and infections. While studies have found that the correlation between education and carrying these is relatively low on average (and even less so for certain subsets such as Black women), there is a strong correlation between education and other risky sexual behaviors. Those with only a high school degree or less were significantly more likely to engage in risky practices such as early sexual initiation, sexual activity with those who use "shooting" street drugs such as heroin, and even prostitution. In addition, those with less education were also less likely to practice some safe sex practices such as condom use.

Studies have also found that adults with higher educational achievement were more likely to lead healthier lives. Intake of key nutrients such as Vitamins A and C, potassium, and calcium was positively correlated with education level. This is a critical statistic because those nutrients, such as Vitamin C, are critical in helping the body fight diseases and infections. There was also a correlation between education and exercise habits. A 2010 study found that while 85% of college graduates stated they exercised in the last month, only 68% of high school graduates and 61% of non-high school graduates said the same. Because exercise is so crucial to preventing diseases like hypertension and type 2 diabetes, this stark distinction between exercise habitats can have significant effects. By 2011, 15% of high school (or less) graduates had diabetes, compared to just 7% of college graduates.

Arguably the best way of seeing the true effects of education in the inequality of disease is to examine mortality levels, as Heart Disease, Cancer, and Lower Respiratory Diseases are the top three killers, respectively, of Americans every year. By age 25, if an individual does not have at least a high school degree, they will die an average of 9 years earlier than an otherwise similar college graduate. A different national study found that individuals with only bachelor's degrees were 26% more likely to die in the next 5 years than individuals of the same age with professional degrees such as a master's. Even more stark, Americans without a high school degree were almost twice as likely to die than those with a professional degree in the study's 5 year follow-up period.

at February 24, 2023
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Population health

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Population_health 
 
Income inequality and mortality in 282 metropolitan areas of the United States. Mortality is correlated with both income and inequality.

Population health has been defined as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group". It is an approach to health that aims to improve the health of an entire human population. It has been described as consisting of three components. These are "health outcomes, patterns of health determinants, and policies and interventions".

A priority considered important in achieving the aim of population health is to reduce health inequities or disparities among different population groups due to, among other factors, the social determinants of health (SDOH). The SDOH include all the factors (social, environmental, cultural and physical) that the different populations are born into, grow up and function with throughout their lifetimes which potentially have a measurable impact on the health of human populations. The population health concept represents a change in the focus from the individual-level, characteristic of most mainstream medicine. It also seeks to complement the classic efforts of public health agencies by addressing a broader range of factors shown to impact the health of different populations. The World Health Organization's Commission on Social Determinants of Health, reported in 2008, that the SDOH factors were responsible for the bulk of diseases and injuries and these were the major causes of health inequities in all countries. In the US, SDOH were estimated to account for 70% of avoidable mortality.

From a population health perspective, health has been defined not simply as a state free from disease but as "the capacity of people to adapt to, respond to, or control life's challenges and changes". The World Health Organization (WHO) defined health in its broader sense in 1946 as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity."

Healthy People 2020

Healthy People 2020 is a web site sponsored by the US Department of Health and Human Services, representing the cumulative effort of 34 years of interest by the Surgeon General's office and others. It identifies 42 topics considered social determinants of health and approximately 1200 specific goals considered to improve population health. It provides links to the current research available for selected topics and identifies and supports the need for community involvement considered essential to address these problems realistically.

Economic inequality

Recently, there has been increasing interest from epidemiologists on the subject of economic inequality and its relation to the health of populations. There is a very robust correlation between socioeconomic status and health. This correlation suggests that it is not only the poor who tend to be sick when everyone else is healthy, given that conditions such as heart disease, ulcers, type 2 diabetes, rheumatoid arthritis, certain types of cancer, and premature aging are present in all socioeconomic levels. Despite the reality of the SES Gradient, there is debate as to its cause. A number of researchers (A. Leigh, C. Jencks, A. Clarkwest—see also Russell Sage working papers) see a definite link between economic status and mortality due to the greater economic resources of the better-off, but they find little correlation due to social status differences.

Other researchers such as Richard G. Wilkinson, J. Lynch, and G.A. Kaplan have found that socioeconomic status strongly affects health even when controlling for economic resources and access to health care. Most famous for linking social status with health are the Whitehall studies—a series of studies conducted on civil servants in London. The studies found that, despite the fact that all civil servants in England have the same access to health care, there was a strong correlation between social status and health. The studies found that this relationship stayed strong even when controlling for health-affecting habits such as exercise, smoking and drinking. Furthermore, it has been noted that no amount of medical attention will help decrease the likelihood of someone getting type 1 diabetes or rheumatoid arthritis—yet both are more common among populations with lower socioeconomic status. Lastly, it has been found that amongst the wealthiest quarter of countries on earth (a set stretching from Luxembourg to Slovakia) there is no relation between a country's wealth and general population health—suggesting that past a certain level, absolute levels of wealth have little impact on population health, but relative levels within a country do. The concept of psychosocial stress attempts to explain how psychosocial phenomena such as status and social stratification can lead to the many diseases associated with the SES gradient. Higher levels of economic inequality tend to intensify social hierarchies and generally degrades the quality of social relations—leading to greater levels of stress and stress related diseases. Richard Wilkinson found this to be true not only for the poorest members of society, but also for the wealthiest. Economic inequality is bad for everyone's health. Inequality does not only affect the health of human populations. David H. Abbott at the Wisconsin National Primate Research Center found that among many primate species, less egalitarian social structures correlated with higher levels of stress hormones among socially subordinate individuals. Research by Robert Sapolsky of Stanford University provides similar findings.

Geographic Inequality

There is well-documented variation in health outcomes by geographic variation in many countries around the globe. This includes the U.S., with the addition of health care utilization & costs geographic variation, down to the level of Hospital Referral Regions (defined as a regional health care market, which may cross state boundaries, of which there are 306 in the U.S.). However, data availability of health indicators for sub-national geographies is limited in both number, data source and geographic scale. Across the 38 OECD countries, region, or equivalent large subnational entities, is the predominant geographic level for both mortality and morbidity indicators. Health indicator availability at smaller geographies was sparse, and varied considerably by geographic definition, health indicator, age range of population and years available. In all cases, geographic boundaries used only administrative definitions.

There is ongoing debate as to the relative contributions of race, gender, poverty, education level and place to these variations. The Office of Epidemiology of the Maternal and Child Health Bureau recommends using an analytic approach (Fixed Effects or hybrid Fixed Effects) to research on health disparities to reduce the confounding effects of neighborhood (geographic) variables on the outcomes.

Critiques

Population health has been subject to ongoing critiques and its assumptions.

Subfields

Family planning

Family planning programs (including contraceptives, sexuality education, and promotion of safe sex) play a major role in population health. Family planning is one of the most highly cost-effective interventions in medicine. Family planning saves lives and money by reducing unintended pregnancy and the transmission of sexually transmitted infections.

For example, the United States Agency for International Development lists as benefits of its international family planning program:

  • "Protecting the health of women by reducing high-risk pregnancies"
  • "Protecting the health of children by allowing sufficient time between pregnancies"
  • "Fighting HIV/AIDS through providing information, counseling, and access to male and female condoms"
  • "Reducing abortions"
  • "Supporting women's rights and opportunities for education, employment, and full participation in society"
  • "Protecting the environment by stabilizing population growth"

Mental health

There are three main kinds of population-based approaches to mental health: health care system interventions; public health practice interventions; and social, economic, and environmental policy interventions. Health care system interventions are mediated by the health care system and hospital leaders. Examples of these interventions include enhancing the efficacy of clinical mental health services, providing consultations and training for community partners, and sharing aggregate health data to inform policy, practice, and planning for public mental health. Public health practice interventions are mediated by public health department officials. These interventions include advocating for policy changes, initiating public service announcements to reduce the stigma of mental illness, and conducting outreach to increase the accessibility of community mental health resources. Elected officials and administrative policy makers implement social, economic, and environmental policy interventions. These can include reducing financial and housing insecurity, changing the built environment to increase urban green space and decrease nighttime noise pollution, and reducing structural stigma directed at those with mental illness.

Population health management (PHM)

One method to improve population health is population health management (PHM), which has been defined as "the technical field of endeavor which utilizes a variety of individual, organizational and cultural interventions to help improve the morbidity patterns (i.e., the illness and injury burden) and the health care use behavior of defined populations". PHM is distinguished from disease management by including more chronic conditions and diseases, by use of "a single point of contact and coordination", and by "predictive modeling across multiple clinical conditions". PHM is considered broader than disease management in that it also includes "intensive care management for individuals at the highest level of risk" and "personal health management... for those at lower levels of predicted health risk". Many PHM-related articles are published in Population Health Management, the official journal of DMAA: The Care Continuum Alliance.

The following road map has been suggested for helping healthcare organizations navigate the path toward implementing effective population health management:

  • Establish precise patient registries
  • Determine patient-provider attribution
  • Define precise numerators in the patient registries
  • Monitor and measure clinical and cost metrics
  • Adhere to basic clinical practice guidelines
  • Engage in risk-management outreach
  • Acquire external data
  • Communicate with patients
  • Educate patients and engage with them
  • Establish and adhere to complex clinical practice guidelines
  • Coordinate effectively between care team and patient
  • Track specific outcomes

Healthcare reform and population health

Healthcare reform is driving change to traditional hospital reimbursement models. Prior to the introduction of the Patient Protection and Affordable Care Act (PPACA), hospitals were reimbursed based on the volume of procedures through fee-for-service models. Under the PPACA, reimbursement models are shifting from volume to value. New reimbursement models are built around pay for performance, a value-based reimbursement approach, which places financial incentives around patient outcomes and has drastically changed the way US hospitals must conduct business to remain financially viable. In addition to focusing on improving patient experience of care and reducing costs, hospitals must also focus on improving the health of populations (IHI Triple Aim).

As participation in value-based reimbursement models such as accountable care organizations (ACOs) increases, these initiatives will help drive population health. Within the ACO model, hospitals have to meet specific quality benchmarks, focus on prevention, and carefully manage patients with chronic diseases. Providers get paid more for keeping their patients healthy and out of the hospital. Studies have shown that inpatient admission rates have dropped over the past ten years in communities that were early adopters of the ACO model and implemented population health measures to treat "less sick" patients in the outpatient setting. A study conducted in the Chicago area showed a decline in inpatient utilization rates across all age groups, which was an average of a 5% overall drop in inpatient admissions.

Hospitals are finding it financially advantageous to focus on population health management and keeping people in the community well. The goal of population health management is to improve patient outcomes and increase health capital. Other goals include preventing disease, closing care gaps, and cost savings for providers. In the last few years, more effort has been directed towards developing telehealth services, community-based clinics in areas with high proportion of residents using the emergency department as primary care, and patient care coordinator roles to coordinate healthcare services across the care continuum.

Health can be considered a capital good; health capital is part of human capital as defined by the Grossman model. Health can be considered both an investment good and consumption good. Factors such as obesity and smoking have negative effects on health capital, while education, wage rate, and age may also impact health capital. When people are healthier through preventative care, they have the potential to live a longer and healthier life, work more and participate in the economy, and produce more based on the work done. These factors all have the potential to increase earnings. Some states, like New York, have implemented statewide initiatives to address population health. In New York state there are 11 such programs. These programs work to address the needs of the people in their region, as well as assist their local community based organizations and social services to gather data, address health disparities, and explore evidence-based interventions that will ultimately lead to better health for everyone.

at February 24, 2023
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Thursday, February 23, 2023

Banana republic

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Banana_republic
 
The phrase banana republic was coined in 1904 by the American writer O. Henry, 1862–1910.

In political science, the term banana republic describes a politically and economically unstable country with an economy dependent upon the export of natural resources. In 1904, the American author O. Henry coined the term to describe Honduras and neighbouring countries under economic exploitation by U.S. corporations, such as the United Fruit Company (now Chiquita). Typically, a banana republic has a society of extremely stratified social classes, usually a large impoverished working class and a ruling class plutocracy, composed of the business, political, and military elites. The ruling class controls the primary sector of the economy by way of the exploitation of labor; thus, the term banana republic is a pejorative descriptor for a servile oligarchy that abets and supports, for kickbacks, the exploitation of large-scale plantation agriculture, especially banana cultivation.

A banana republic is a country with an economy of state capitalism, whereby the country is operated as a private commercial enterprise for the exclusive profit of the ruling class. Such exploitation is enabled by collusion between the state and favored economic monopolies, in which the profit, derived from the private exploitation of public lands, is private property, while the debts incurred thereby are the financial responsibility of the public treasury. Such an imbalanced economy remains limited by the uneven economic development of town and country and usually reduces the national currency into devalued banknotes (paper money), rendering the country ineligible for international development credit.

Etymology

Cover of Cabbages and Kings (1904 edition).

In the 19th century, the American writer O. Henry (William Sydney Porter, 1862–1910) coined the term banana republic to describe the fictional Republic of Anchuria in the book Cabbages and Kings (1904), a collection of thematically related short stories inspired by his experiences in Honduras, whose economy was heavily dependent on the export of bananas. He lived there for six months until January 1897, hiding in a hotel while he was wanted in the U.S. for embezzlement from a bank.

In the early 20th century, the United Fruit Company, a multinational American corporation, was instrumental in the creation of the banana republic phenomenon. Together with other American corporations, such as the Cuyamel Fruit Company, and leveraging the power of the United States government, the corporations created the political, economic, and social circumstances, that led to a coup of the locally elected democratic government that established banana republics in Central American countries such as Honduras and Guatemala.

Origin

The history of the banana republic began with the introduction of the banana fruit to the U.S. in 1870, by Lorenzo Dow Baker, captain of the schooner Telegraph, who bought bananas in Jamaica and sold them in Boston at a 1,000% profit. The banana proved popular with Americans, as a nutritious tropical fruit that was less expensive than locally grown fruit in the U.S., such as apples; in 1913, 25 cents (equivalent to $6.85 in 2021) bought a dozen bananas, but only two apples. In 1873, to produce food for their railroad workers, the American railroad tycoons Henry Meiggs and his nephew, Minor C. Keith, established banana plantations along the railroads they built in Costa Rica; recognizing the profitability of exporting bananas, they began exporting the fruit to the Southeastern U.S.

The banana planter Minor C. Keith, American businessman.

In the mid-1870s, to manage the new industrial-agriculture business enterprise in the countries of Central America, Keith founded the Tropical Trading and Transport Company: one-half of what would later become the United Fruit Company (UFC), later Chiquita Brands International, created in 1899 by merger with the Boston Fruit Company, and owned by Andrew Preston. By the 1930s, the international political and economic tensions created by the United Fruit Company enabled the corporation to control 80–90% of the banana business in the U.S.

By the late 19th century, three American multinational corporations (the UFC, the Standard Fruit Company, and the Cuyamel Fruit Company) dominated the cultivation, harvesting, and exportation of bananas, and controlled the road, rail, and port infrastructure of Honduras. In the northern coastal areas near the Caribbean Sea, the Honduran government ceded to the banana companies 500 hectares per kilometre (2,000 acre/mi) of a laid railroad, despite there being neither passenger nor freight railroad service to Tegucigalpa, the capital city. Among the Honduran people, the United Fruit Company was known as El Pulpo ("The Octopus" in English), because its influence pervaded Honduran society, controlled their country's transport infrastructure, and manipulated Honduran national politics with anti-labor violence.

In 1924, despite the UFC monopoly, the Vaccaro Brothers established the Standard Fruit Company (later the Dole Food Company) to export Honduran bananas to the U.S. port of New Orleans. The fruit-exporting corporations kept U.S. prices low by legalistic manipulation of Latin American national land use laws to cheaply buy large tracts of prime agricultural land for corporate banana plantations in the republics of the Caribbean Basin, the Central American isthmus, and tropical South America; the American fruit companies then employed the dispossessed Latin American natives as low-wage employees.

By the 1930s, the United Fruit Company owned 1,400,000 hectares (3.5 million acres) of land in Central America and the Caribbean and was the single largest landowner in Guatemala. Such holdings gave it great power over the governments of small countries, one of the factors confirming the suitability of the phrase "banana republic".

Honduras

In 1912, for the Cuyamel Fruit Company, the American mercenary "general" Lee Christmas overthrew the civil government of Honduras to install a military government friendly to foreign business.

In the early 20th century, the American businessman Sam Zemurray (founder of the Cuyamel Fruit Company) was instrumental in establishing the "banana republic" stereotype, when he entered the banana-export business by buying overripe bananas from the United Fruit Company to sell in New Orleans. In 1910, Zemurray bought 6,075 hectares (15,000 acres) in the Caribbean coast of Honduras for use by the Cuyamel Fruit Company. In 1911, Zemurray conspired with Manuel Bonilla, an ex-president of Honduras (1904–1907), and the American mercenary Gen. Lee Christmas, to overthrow the civil government of Honduras and install a military government friendly to foreign businesses.

To that end, the mercenary army of the Cuyamel Fruit Company, led by Gen. Christmas, effected a coup d'état against President Miguel R. Dávila (1907–1911) and installed General Manuel Bonilla (1912–1913). The U.S. ignored the deposition of the elected government of Honduras by a private army, justified by the U.S. State Department's misrepresenting President Dávila as too politically liberal and a poor businessman whose management had indebted Honduras to Great Britain, a geopolitically unacceptable circumstance in light of the Monroe Doctrine. The coup d'état was a consequence of the Dávila government's having slighted the Cuyamel Fruit Company by colluding with the rival United Fruit Company to award them a monopoly contract for the Honduran banana, in exchange for the UFC's brokering of U.S. government loans to Honduras.

Honduras, the quintessential banana republic.

The political instability consequent to the coup d'état stalled the Honduran economy, and the unpayable external debt (c. US$4 billion) of the Republic of Honduras was excluded from access to international investment capital. That financial deficit perpetuated Honduran economic stagnation and perpetuated the image of Honduras as a banana republic. Such a historical, inherited foreign debt functionally undermined the Honduran government, which allowed foreign corporations to manage the country and become sole employers of the Honduran people, because the American fruit companies controlled the economic infrastructure (road, rail, and port, telegraph and telephone) they had built in Honduras.

The U.S. dollar went on to become the legal-tender currency of Honduras; the mercenary Gen. Lee Christmas became commander of the Honduran army, and later was appointed U.S. Consul to the Republic of Honduras. Nonetheless, 23 years later, after much corporate intrigue among the American businessmen, by means of a hostile takeover of agricultural business interests, Sam Zemurray assumed control of the rival United Fruit Company, in 1933.

Guatemala

Location of Guatemala

Guatemala suffered the regional socio-economic legacy of a 'banana republic': inequitably distributed agricultural land and natural wealth, uneven economic development, and an economy dependent upon a few export crops—usually bananas, coffee, and sugar cane. The inequitable land distribution was an important cause of national poverty, and the accompanying sociopolitical discontent and insurrection. Almost 90% of the country's farms are too small to yield adequate subsistence harvests to the farmers, while 2% of the country's farms occupy 65% of the arable land, the property of the local oligarchy.

During the 1950s, the United Fruit Company sought to convince the governments of U.S. Presidents Harry Truman (1945–1953) and Dwight Eisenhower (1953–1961) that the popular, elected government of President Jacobo Árbenz Guzmán of Guatemala was secretly pro-Soviet for having expropriated unused "fruit company lands" to landless peasants. In the Cold War (1945–1991) context of the proactive anti-communist politics exemplified by U. S. Senator Joseph McCarthy in the years 1947–1957, geo-political concerns about the security of the Western Hemisphere facilitated President Eisenhower's ordering and authorizing Operation Success, the 1954 Guatemalan coup d'état by means of which the U.S. Central Intelligence Agency deposed the democratically elected government (1950–1954) of President Jacobo Árbenz Guzmán and installed the pro-business government of Colonel Carlos Castillo Armas (1954–1957), which lasted for three years until his assassination by a presidential guard.

A mixed history of elected presidents and puppet-master military juntas were the governments of Guatemala in the course of the 36-year Guatemalan Civil War (1960–1996). However, in 1986, at the 26-year mark, the Guatemalan people promulgated a new political constitution, and elected Vinicio Cerezo (1986–1991) president; then Jorge Serrano Elías (1991–1993).

Modern era

Chiquita bananas in a store
Chiquita bananas

Pesticides

Dole Food Company and Chiquita Brands International have shifted their focus of maintaining the environments on their plantations and making agriculture more efficient by breeding and growing more resilient versions of foods, such as Cavendish bananas. Both companies have been working to employ better farming practices, especially regarding the use of pesticides, as both companies have received heavy criticism for the amount and effects of the pesticides they have used on their products. Although the pesticides do not generally represent a safety concern for consumers abroad, they can be harmful to residents and the ecosystem in which they are used. Many banana farmers from Central America and South America were exposed to the pesticide Dibromochloropropane (DBCP) from the 1960s to 1980s, which can lead to birth defects, elevated risk of cancer, central nervous system damage, and most commonly, infertility.

Labor conditions and treatment of workers

Both Dole Food Company and Chiquita Brands International say that in the 21st century their laborers and farmers are being treated much better than they were during the height of the banana republics. It is clear that workers do have better conditions than they did during the 20th century; but these large corporations still suppress labor union movements through intimidation and harassment. Working conditions on banana plantations are dangerous, with very low wages and long hours in difficult conditions. The workers are not cared for and are often replaced as they have very little policy about job security in the case of sickness or injury. The plantation workers are also exposed to toxic pesticides on a daily basis, causing harm. Unionists who pressure these large corporations for better working conditions are commonly targeted and forced to leave their positions. The workers also receive no benefits, and as the plantations are in countries with lax safety regulations, there are minimal health policies.

Modern Honduras and Guatemala

Honduras and Guatemala have significant challenges with government corruption as a result of the dictators backed by the United States government, Effraín Ríos Montt (1982–1983) for Guatemala, and Roberto Suazo Córdova (1982–1986) for Honduras. The political instability caused by the dictators falling and being replaced with democratically elected presidents left the government with very little power, leading to corruption of the government and the rise of drug cartels. Today, the governments of Guatemala and Honduras still have very little power, as drug cartels control much of the land and are allied with corrupt officials and law enforcement officers. These drug cartels serve as the main transporters of cocaine and other drugs from Latin America to the United States. This has also caused extreme levels of violence, with Honduras having one of the highest homicide rates in the world: 38 per 100,000 people according to UNODC. Guatemala and Honduras also continue to have very low economic diversity, with their primary exports being clothing items and food items. 53% of all exports continue to be sent to the United States.

In art

Poetry

With the poem "La United Fruit Co.", Pablo Neruda denounced the corporate subjugation of Latin America.

In the book Canto General (General Song, 1950), the Chilean poet Pablo Neruda (1904–73) denounced foreign corporate political dominance of Latin American countries with the four-stanza poem "La United Fruit Co."; the second-stanza reading in part:

... The Fruit Company, Inc.
Reserved for itself the most succulent,
The central coast of my own land,
The delicate waist of the Americas.

It rechristened its territories
As the "Banana Republics",
And over the sleeping dead,
Over the restless heroes
Who brought about the greatness,
The liberty and the flags,
It established a comic opera ...

Novels

The novel One Hundred Years of Solitude (1967), by Gabriel García Márquez, depicts the imperialist capitalism of foreign fruit companies as voracious socio-economic exploitation of natural resources of the fictional South American town of Macondo and its people. Domestically, the corrupt national government of Macondo abets the business policies and labor practices of the foreign corporations, which brutally oppress the workers. In the novel, a specific scene depicts the real 1928 Banana Massacre, related to the death of workers who striked against poor conditions in the banana plantations in Colombia.

Modern interpretations

Graffiti implying "banana republic of Slovenia"

United States

The Kingdom of Hawaii, now the US state of Hawaii, was once an independent country under political pressure from American sugar plantation owners, who in 1887 forced King Kalākaua to write a new constitution that benefited American businessmen at the expense of the working class. This constitution is known as the "Bayonet Constitution" due to its threat of force. In the case of Hawaii, the US was also interested in the strategic military significance of the islands, leasing Pearl Harbor and later acquiring Hawaii as a Territory.

United Kingdom

In July 2018, a Guardian article on the resignations from the Cabinet of Boris Johnson and David Davis referred to a tweet from a Spanish correspondent, which described Britain as "officially a banana republic" when sunny weather and footballing success were combined with other attributes usually considered to be characteristic of a banana republic. The country has often been referred to as a "banana monarchy", a phrase which combines the concept of a banana republic with the United Kingdom's constitutional monarchy.

Post-colonial states

Countries that obtained independence from colonial powers in the 20th century have at times thereafter tended to share traits of banana republics due to influence of large private corporations in their politics; for example, Maldives (resort companies) and the Philippines (tobacco industry, U.S. government and corporations).

On 14 May 1986, then Australian Treasurer Paul Keating stated that Australia might become a banana republic. This has received a lot of commentary and criticism and is seen as part of a turning point in Australia's political and economic history.

at February 23, 2023
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