Diseases of poverty

From Wikipedia, the free encyclopedia

Diseases of poverty (also known as poverty related diseases) is the term used to describe diseases that are more prevalent in the low-income population. It includes infectious diseases as well as diseases related to malnutrition and poor health behaviors. Poverty is one of the 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 exciting interventions. Diseases of poverty are often co-morbid and ubiquitous with malnutrition.

Poverty and diseases are a ramification of each other. Poverty increases chances of having these diseases as the deprivation of safe shelter, drinking water and food, poor sanitation, lack of knowledge and access to health services contributes towards poor health behaviors which often results into diseases of poverty. 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 triggered in part by poverty are in contrast to so-called "diseases of affluence", which are diseases thought to be a result of increasing wealth in a society.

Contributing factors

For many environmental and social factors, including poor housing conditions and poor working conditions, inadequate sanitation, and disproportionate occupation as sex workers, the poor are more likely to be exposed to infectious diseases. Malnutrition, mental stress, overwork, inadequate knowledge, and minimal health care can hinder recovery and exacerbate the disease. Malnutrition is associated with 54% of childhood deaths from diseases of poverty, and lack of skilled attendants during childbirth is primarily responsible for the high maternal and infant death rates among the poor.

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 such as diarrhea acquire and spread as a result of inadequate access to clean drinking water. 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. Though access to water has improved for some, it continues to be especially difficult for women and children. Women and girls 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.

There have been further 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.

An ongoing issue of contaminated water in the United States has been taking place in Flint, Michigan. On September 4, 2018, evidence of E Coli and other organisms that can cause disease were found in the water. The issue of contaminated water in Flint, Michigan started when the source for drinking water in Flint was changed from the Lake Huron and the Detroit River to the very cheap Flint River.

Inadequate sanitation

Contaminated water and inadequate sanitation are related to diseases of poverty such as malaria, parasitic diseases, and schistosomiasis. These infections act as cofactors that increase the risk of HIV transmission.

Standpipes and sanitation are provided in most developing areas, but the death rates are not significantly reduced. One of the reasons that water-related diseases are still occurring is because water supplies can be contacted by contaminated surface water. To effectively decrease the morbidity and mortality of diseases, the population should get access to water from home instead from outside. Therefore, in addition to the installation of standpipes, water supplies and sanitation should be provided within houses.

Poor nutrition

Malnutrition disproportionately affect 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

Quality and affordability of housing are one of the major concerns in public health. Poor housing conditions can be described as leaks, molds, indoor air pollutant, overcrowding, hazardous structures, affordability of home heating, and poor ergonomics. Housing insecurities are very common among the poor. It is often associated with infectious diseases, lead exposure, injuries, and mental health.

Lack of access to health services

According to WHO, medical strategies report, approximately 30% of the global population does not have regular access to exciting 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.

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 sub-Saharan Africa. 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

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 hookworms, roundworms, and other amoebas. 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 suffer from malnutrition, 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.

Asthma

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 suffer from 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 disproportionately 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.

Obstetrical fistula

Obstetric fistula or vaginal fistula is a medical condition in which a fistula (hole) develops between either the rectum and vagina or between the bladder and vagina 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.

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.

Diseases of affluence

From Wikipedia, the free encyclopedia

Diseases of affluence is a term sometimes given to selected diseases and other health conditions which are commonly thought to be a result of increasing wealth in a society. Also referred to as the "Western disease" paradigm, these diseases are in contrast to so-called "diseases of poverty", which largely result from and contribute to human impoverishment. These diseases of affluence have vastly increased in prevalence since the end of World War II.

Examples of diseases of affluence include mostly chronic non-communicable diseases (NCDs) and other physical health conditions for which personal lifestyles and societal conditions associated with economic development are believed to be an important risk factor — such as type 2 diabetes, asthma, coronary heart disease, cerebrovascular disease, peripheral vascular disease, obesity, hypertension, cancer, alcoholism, gout, and some types of allergy. They may also be considered to include depression and other mental health conditions associated with increased social isolation and lower levels of psychological well being observed in many developed countries. Many of these conditions are interrelated, for example obesity is thought to be a partial cause of many other illnesses.

In contrast, the diseases of poverty have tended to be largely infectious diseases, or the result of poor living conditions. These include tuberculosis, malaria, and intestinal diseases. Increasingly, research is finding that diseases thought to be diseases of affluence also appear in large part in the poor. These diseases include obesity and cardiovascular disease and, coupled with infectious diseases, these further increase global health inequalities.

Diseases of affluence started to become more prevalent in developing countries as diseases of poverty decline, longevity increases, and lifestyles change. In 2008, nearly 80% of deaths due to NCDs — including heart disease, strokes, chronic lung diseases, cancers and diabetes — occurred in low- and middle-income countries.

Top ten causes of death in high income/affluent countries

According to World Health Organization (WHO) the top 10 causes of deaths in the high income countries/ affluent countries in 2016 were from

1. Ischemic heart diseases
2. Stroke
3. Alzheimer disease and other dementia
4. Trachea, bronchus and lung cancer
5. Chronic obstructive pulmonary disease
6. Lower respiratory infections
7. Colon and rectum cancers
8. Diabetes
9. Kidney diseases
10. Breast cancer

Except for the lower respiratory infections all of them are non-communicable diseases. In 2016 WHO reported 56.9 million deaths worldwide, and more than half (54%), were due to the top causes of death previously mentioned.

Causes

Factors associated with the increase of these conditions and illnesses appear to be things that are a direct result of technological advances. They include:

• Less strenuous physical exercise, often through increased use of motor vehicles
• Irregular exercise as a result of office jobs involving no physical labor.
• Easy accessibility in society to large amounts of low-cost food (relative to the much-lower caloric food availability in a subsistence economy)
  • More food generally, with much less physical exertion expended to obtain a moderate amount of food
  • Higher consumption of vegetable oils and high sugar-containing foods
  • Higher consumption of meat and dairy products
  • Higher consumption of refined flours and products made of such, like white bread or white noodles
  • More foods which are processed, cooked, and commercially provided (rather than seasonal, fresh foods prepared locally at time of eating)
• Prolonged periods of little activity
• Greater use of alcohol and tobacco
• Longer life-spans
  • Reduced exposure to infectious agents throughout life (this can result in a more idle and inexperienced immune system as compared to an individual who experienced relatively frequent exposure to certain pathogens in their time of life)
• Increased cleanliness. The hygiene hypothesis postulates that children of affluent families are now exposed to fewer antigens than has been normal in the past, giving rise to increased prevalence of allergy and autoimmune diseases.

Diabetes mellitus

Diabetes is a chronic metabolic disease characterized by increase blood glucose level. Type 2 diabetes is the most common form of diabetes. It is caused by resistance to insulin or the lack of production of insulin. It is seen most commonly in adults. Type 1 diabetes or juvenile diabetes affects mostly children. This condition is due to little or lack of insulin production from the pancreas.

According to WHO the prevalence of diabetes has quadrupled from 1980 to 422 million adults. The global prevalence of diabetes has increased from 4.7% in 1980 to 8.5% in 2014. Diabetes has been a major cause for blindness, kidney failure, heart attack, stroke and lower limb amputation.

Prevalence in countries of affluence

The Centers of Disease Control and Prevention (CDC) released a report in 2015 indicating that more than 100 million Americans have diabetes or pre-diabetes. Diabetes was the seventh leading cause of death in United States in 2015. In developed countries like the United States, the risk for diabetes is seen in people with low socioeconomic status (SES). Socioeconomic status is defined by the education and the income level of a person. The prevalence of diabetes varies by education level. Of those diagnosed with diabetes:12.6% of adults had less than a high school education, 9.5% had a high school education and 7.2% had more than high school education.

Differences in diabetes prevalence are seen in the population and ethnic groups in USA. Diabetes is more common in non-Hispanic whites, who are less educated and have a lower income. It is also more common in less educated Hispanics. The highest prevalence of diabetes is seen in the southeast, southern and Appalachian portion of the United States. In the United States the prevalence of diabetes is increasing in children and adolescents. In 2015, 25 million people were diagnosed with diabetes, of which 193,000 were children. The total direct and indirect cost of diagnosed diabetes in US in 2012 was $245 billion.

In 2009, the Canadian Diabetes Association (CDA) estimated that diagnosed diabetes will increase from 1.3 million in 2000 to 2.5 million in 2010 and 3.7 million in 2020. Diabetes was the 7th leading cause of death in Canada in 2015. Like United States, diabetes in more prevalent in the low socioeconomic group of people in Canada.

According to the International Diabetes Federation, more than 58 million people are diagnosed with diabetes in the European Union Region (EUR), and this will go up to 66.7 million by 2045. Similar to other affluent countries like America and Canada, diabetes is more prevalent in the poorer parts of Europe like Central and Eastern Europe.

In Australia according to self-reported data, 1 in 7 adults or approximately 1.2 million people had diabetes in 2014-2015. People who were living in remote or socioeconomically disadvantaged areas were 4 times more likely to develop type 2 diabetes as compared to non-indigenous Australians. Australia incurred $20.8 million in direct costs towards hospitalization, medication, and out-patient treatment towards diabetes. In 2015, $1.2 billion were lost in Australia's Gross Domestic Product (GDP) due to diabetes.

In these countries of affluence, diabetes is prevalent in low socioeconomic groups of people as there is abundance of unhealthy food choices, high energy rich food, and decreased physical activity. More affluent people are typically more educated and have tools to counter unhealthy foods, such as access to healthy food, physical trainers, and parks and fitness centers.

Risk factors

Obesity and being overweight is one of the main risk factors of type 2 diabetes. Other risk factors include lack of physical activity, genetic predisposition, being over 45 years old, tobacco use, high blood pressure and high cholesterol. In United States, the prevalence of obesity was 39.8% in adults and 18.5% in children and adolescents in 2015-2016. In Australia in 2014-2015, 2 out 3 adults or 63% were overweight or obese. Also, 2 out of 3 adults did little or no exercise. According to the World Health Organization, Europe had the 2nd highest proportion of overweight or obese people in 2014 behind America.

In developing countries

According to WHO the prevalence of diabetes is rising more in the middle and low income countries. Over the next 25 years, the number of people with diabetes in developing countries will increase by over 150%. Diabetes is typically seen in people above the retirement age in developed countries, but in developing countries people in the age of 35-64 are mostly affected. Although, diabetes is considered a disease of affluence affecting the developed countries, there is more loss of life and premature death among people with diabetes in the developing countries. Asia accounts for 60% of the world's diabetic population. In 1980 less than 1% of Chinese adults were affected by diabetes, but by 2008 the prevalence was 10%. It is predicted that by 2030 diabetes may affect 79.4 million people in India, 42.3 million people in China and 30.3 million in United States.

These changes are the result of developing nations having rapid economic development. This rapid economic development has caused a change in the lifestyle and food habits leading to over-nutrition, increased intake of fast food causing increase in weight, and insulin resistance. Compared to the west, obesity in Asia is low. India has very low prevalence of obesity, but a very high prevalence of diabetes suggesting that diabetes may occur at a lower BMI in Indians as compared to the Europeans. Smoking increases the risk for diabetes by 45%. In developing countries around 50-60 % adult males are regular smokers, increasing their risk for diabetes. In developing countries, diabetes is more commonly seen in the more urbanized areas. The prevalence of diabetes in rural population is 1/4th that of urban population for countries like India, Bangladesh, Nepal, Bhutan and Sri Lanka.

Cardiovascular disease

Cardiovascular disease refers to a disease of the heart and blood vessels. Conditions and diseases associated with heart disease include: stoke, coronary heart disease, congenital heart disease, heart failure, peripheral vascular disease, and cardiomyopathy. Cardiovascular disease is known as the world's biggest killer. 17.5 million people die from it each year, which equals 31% of all deaths. Heart disease and stroke cause 80% of these deaths.

Risk factors

High blood pressure is the leading risk factor for cardiovascular disease and has contributed to 12% of the cardiovascular related deaths worldwide. Other significant risk factors for heart disease include high cholesterol and smoking. 47% of all Americans have one of these three risk factors. Lifestyle choices, such as poor diet and physical inactivity, and excessive alcohol use can also contribute to cardiovascular disease. Medical conditions, like diabetes and obesity can also be risk factors.

Prevalence in countries of affluence

In the United States, 610,000 people die every year from heart disease which is equal to 1 in 4 deaths. The leading cause of death for both men and women in the United States is heart disease. In Canada, heart disease is the second leading cause of death. In 2014, it was the cause of death for 51,000 people. In Australia, heart disease is also the leading cause of death. 29% of deaths in 2015, had an underlying cause of heart disease. Heart disease causes one in four premature deaths in the United Kingdom and in 2015 heart disease caused 26% of all deaths in that country.

People of lower socio-economic status are more likely to have cardiovascular disease than those who have a higher socio-economic status. This inequality gap has occurred in developed countries because people who have a lower socio-economic status often face many of the risk factors of tobacco and alcohol use, obesity as well as having a sedentary lifestyle. Further social and environmental factors such as poverty, pollution, family history, housing and employment contribute to this inequality gap and to risk of having a health condition caused by cardiovascular disease. The increasing inequality gap between the higher and lower income populations continues in countries such as Canada, despite the availability of health care for everyone.

Alzheimer's disease and other forms of dementia

Dementia is a chronic syndrome which is characterized by deterioration in the thought process beyond what is expected from normal aging. It affects the persons memory, thinking, orientation, comprehension, behavior and ability to perform everyday activity. There are many different forms of dementia . Alzheimer is the most common form which contributes to 60-70 % of the dementia cases. Different forms of dementia can co-exist.Young onset dementia which occurs in individuals before the age of 65 contributes to 9% of the total cases. It is the major cause of disability and dependency among old people.

Worldwide, there are 50 million people who are suffering from dementia and every year 10 million new cases are being reported. The total number of people with dementia is projected to reach 82 million by 2030 and 152 million in 2050 .

Prevalence in countries of affluence

According to CDC, Alzheimer is the 6th leading cause of death in U.S adults and 5th leading cause of death in adults over the age of 65. In 2014, 5 million Americans above the age of 65 were diagnosed with Alzheimer. This number is predicted to triple by the year 2060 and reach up to 14 million. Dementia and Alzheimer has been shown to go unreported on death certificates, leading to under representation of the actual mortality caused by these diseases. Between 2000 and 2015, mortality due to cardiovascular diseases has decreased by 11%, where as death from Alzheimer has increased by 123%. 1 in 3 people over the age of 65 die from Alzheimer or other forms of dementia. Furthermore, 200,000 individuals have been affected by young onset dementia. In United States, Alzheimer affects more women than men. It is twice more common in African-Americans and Hispanics than in whites. As the number of older Americans increases rapidly, the number of new cases of Alzheimer will rise too. 

East Asia has the most people living with dementia (9.8 million) followed by Western Europe (7.5 million ), South Asia (5.1 million) and North America (4.8 million).  In 2016, the prevalence of Alzheimer was 5.05% in Europe. Like in United States, it is more prevalent in women than in men. In the European Union, Finland has the highest mortality among both men and women due to dementia. In Canada, over half a million people are living with dementia. It is projected that by 2031 the number will go up by 66% to 937,000. Every year 25,000 new cases of dementia are diagnosed. 

Dementia is the second leading cause of death in Australia. In 2016, it was the leading cause of deaths in females. In Australia 436,366 people are living with dementia in 2018. 3 in 10 people over the age of 85 and 1 in 10 people over the age of 65 have dementia. It is the single greatest cause of disability in older Australians. Rates of dementia are higher for indigenous people. In people from the northern territory and western Australia the prevalence of dementia is 26 times higher in the 45-69 year old group and about 20 times greater in 60-69 year old group.

Risk factors in countries of affluence

The risk factors for developing dementia or Alzheimer's include age, family history, genetic factors, environmental factors, brain injury, viral infections,neurotoxic chemicals, and various immunological and hormonal disorders.

A new research study has found an association between the affluence of a country, hygiene conditions and the prevalence of Alzheimer in their population. According to the Hygiene Hypothesis, affluent countries with more urbanized and industrialized areas have better hygiene, better sanitation, clean water and improved access to antibiotics. This reduces the exposure to the friendly bacteria, virus and other microorganisms that help stimulate our immune system. Decreased microbial exposure leads to immune system that is poorly developed, which exposes the brain to inflammation as is seen in Alzheimer's disease.

Countries like the UK and France that have access to clean drinking water, improved sanitation facilities and have a high GDP show a 9% increase in Alzheimer's disease as opposed to countries like Kenya and Cambodia. Also countries like UK and Australia, where three quarters of their population lives in urban areas, have a 10% higher Alzheimer's rate than in countries like Bangladesh and Nepal where less than one tenth of their population live in urban areas.

Alzheimer's risk changes with the environment. Individuals from the same ethnic background living in an area of low sanitation will have a lower risk as compared to the same individuals living in an area of high sanitation who will be exposed to a higher risk of developing Alzheimer's. An African-American in U.S. has a higher risk of developing Alzheimer's as compared to one living in Nigeria. Immigrant populations exhibit Alzheimer disease rates intermediate between their home country and adopted country. Moving from a country of high sanitation to a country of low sanitation reduces the risk associated with the disease.

Mental illness

People that face poverty have more risks related to having a mental illness and also do not have as much access to treatment. The stressful events that they face, unsafe living condition and poor physical health lead to cycle of poverty and mental illness that is seen all over the world. According to the World Health Organization 76%-85% of people living in lower and middle income countries are not treated for their mental illness. For those in higher-income counties, 35%-50% of people with mental illness do not receive treatment. It is estimated that 90% of deaths by suicide are caused by substance use disorders and mental illness in higher income countries. In lower to middle income countries, this number is lower.

Prevalence of mental illness

One in four people have experienced mental illness at one time in their lives and approximately 450 million people in the world currently have a mental illness. People that face poverty have more risks related to having a mental illness and also do not have as much access to treatment. The stressful events that they face, unsafe living condition and poor physical health lead to cycle of poverty and mental illness that is seen all over the world. India, China, and the United States are the countries with the highest levels of mental illnesses of anxiety, depression and schizophrenia according to WHO. The U.S. is reported to have the highest level of depression worldwide. In the U.S., approximately one in five adults has a mental illness or 44.7 million people. In 2016, it was estimated that 268 million people in the world had depression. The range of people that have depression by country is from 2% to 6% of the population with the United States, Greenland, and Australia having higher rates of depression. Anxiety disorders, such as generalized anxiety, Obsessive Compulsive Disorder, and Post Traumatic Stress Disorder impacted 275 million people around the world in 2016. The range of population impacted by anxiety disorders globally is from 2.5%-6.5%. Countries, such as the Australia, the United States, Brazil, Argentina, Iran, the United States and a number of countries in Western Europe appear to have a higher prevalence of anxiety disorders.

Cancer

Cancer is a generic term for a large group of disease which is characterized by rapid creation of abnormal cells that grow beyond their usual boundaries. These cells can invade adjoining parts of the body and spread to other organs causing metastases, which is a major cause of death. According to WHO, Cancer is the second leading cause of death globally. One in six deaths worldwide are caused due to cancer, accounting to a total of 9.6 million deaths in 2018.Tracheal, bronchus, and lung cancer is the leading form of cancer deaths across most high and middle-income countries.

Prevalence in countries of affluence

In United States, 1,735,350 new cases of cancer will be diagnosed in 2018. Most common forms of cancer are cancer of the breast, lung, bronchus, prostrate, colorectal cancer, melanoma of skin, Non-Hodgkin's lymphoma, renal cancer, thyroid cancer and liver cancer. Cancer mortality is higher among men than in women. African-Americans have the highest risk of mortality due to cancer. Cancer is also the leading cause of death in Australia. The most common cancers in Australia are prostrate, breast, colorectal, melanoma and lung cancer. These account for 60% of the cancer cases diagnosed in Australia.

Europe contains only 1/8 of the world population, but has around one quarter of the global cancer cases, with 3.7 million new cases each year. Lung, breast, stomach, liver, colon are the most common cancers in Europe. The overall incidences among different cancers vary across countries.

About one in two Canadians will develop cancer in their lifetime, and one in four will die of the disease. In 2017, 206,200 new cases of cancer were diagnosed. Lung, colorectal, breast, and prostate cancer accounted for about half of all cancer diagnoses and deaths.

Risk factors

High prevalence of cancer in high-income countries is attributed to lifestyle factors like obesity, smoking, physical inactivity, diet and alcohol intake. Around 40% of the cancers can be prevented by modifying these factors.

Allergy/Autoimmune diseases

The rate of allergies around the world has risen in industrialized nations over the past 50 years. A number of public health measures, such as sterilized milk, use of antibiotics and improved food production have contributed to a decrease in infections in developed countries. There is a proposed causal relationship, known as the "hygiene hypothesis" that indicates that there are more autoimmune disorders and allergies in developed countries with fewer infections. In developing countries, it is assumed that the rates of allergies are lower than developed countries. That assumption may not be accurate due to limited data on prevalence. Research has found an increase in asthma by 10% in countries such as Peru, Costa Rica, and Brazil.

Public health

From Wikipedia, the free encyclopedia

Newspaper headlines from around the world about polio vaccine tests (13 April 1955)

 

Public health is "the science and art of preventing disease, prolonging life and promoting human health through organized efforts and informed choices of society, organizations, public and private, communities and individuals". Analyzing the health of a population and the threats is the basis for public health. The "public" in question can be as small as a handful of people, an entire village or it can be as large as several continents, in the case of a pandemic. "Health" takes into account physical, mental and social well-being. It is not merely the absence of disease or infirmity, according to the World Health Organization. Public health is interdisciplinary. For example, epidemiology, biostatistics and health services are all relevant. Environmental health, community health, behavioral health, health economics, public policy, mental health and occupational safety, gender issues in health, sexual and reproductive health are other important subfields.

Public health aims to improve the quality of life through prevention and treatment of disease, including mental health. This is done through the surveillance of cases and health indicators, and through the promotion of healthy behaviors. Common public health initiatives include promoting handwashing and breastfeeding, delivery of vaccinations, suicide prevention and distribution of condoms to control the spread of sexually transmitted diseases.

Modern public health practice requires multidisciplinary teams of public health workers and professionals. Teams might include epidemiologists, biostatisticians, medical assistants, public health nurses, midwives, medical microbiologists, economists, sociologists, geneticists and data managers. Depending on the need environmental health officers or public health inspectors, bioethicists, and even veterinarians, gender experts, sexual and reproductive health specialists might be called on.

Access to health care and public health initiatives are difficult challenges in developing countries. Public health infrastructures are still forming in those countries.

Background

The focus of a public health intervention is to prevent and manage diseases, injuries and other health conditions through surveillance of cases and the promotion of healthy behaviors, communities and environments. Many diseases are preventable through simple, non-medical methods. For example, research has shown that the simple act of handwashing with soap can prevent the spread of many contagious diseases. In other cases, treating a disease or controlling a pathogen can be vital to preventing its spread to others, either during an outbreak of infectious disease or through contamination of food or water supplies. Public health communications programs, vaccination programs and distribution of condoms are examples of common preventive public health measures. Measures such as these have contributed greatly to the health of populations and increases in life expectancy. 

Public health plays an important role in disease prevention efforts in both the developing world and in developed countries through local health systems and non-governmental organizations. The World Health Organization (WHO) is the international agency that coordinates and acts on global public health issues. Most countries have their own government public health agencies, sometimes known as ministries of health, to respond to domestic health issues. For example, in the United States, the front line of public health initiatives are state and local health departments. The United States Public Health Service (PHS), led by the Surgeon General of the United States, and the Centers for Disease Control and Prevention, headquartered in Atlanta, are involved with several international health activities, in addition to their national duties. In Canada, the Public Health Agency of Canada is the national agency responsible for public health, emergency preparedness and response, and infectious and chronic disease control and prevention. The Public health system in India is managed by the Ministry of Health & Family Welfare of the government of India with state-owned health care facilities.

Current practice

Public health programs

There's a push and pull, as you know, between cheap alternatives for industry and public health concerns...We're always looking at retrospectively what the data shows...Unfortunately, for example, take tobacco: It took 50, 60 years of research before policy catches up with what the science is showing— Laura Anderko, professor at Georgetown University and director of the Mid-Atlantic Center for Children's Health and the Environment commenting on public health practices in response to proposal to ban chlorpyrifos pesticide.

Most governments recognize the importance of public health programs in reducing the incidence of disease, disability, and the effects of aging and other physical and mental health conditions. However, public health generally receives significantly less government funding compared with medicine. Public health programs providing vaccinations have made strides in promoting health, including the eradication of smallpox, a disease that plagued humanity for thousands of years. 

Three former directors of the Global Smallpox Eradication Programme read the news that smallpox had been globally eradicated, 1980

 

The World Health Organization (WHO) identifies core functions of public health programs including:

• providing leadership on matters critical to health and engaging in partnerships where joint action is needed;
• shaping a research agenda and stimulating the generation, translation and dissemination of valuable knowledge;
• setting norms and standards and promoting and monitoring their implementation;
• articulating ethical and evidence-based policy options;
• monitoring the health situation and assessing health trends.

In particular, public health surveillance programs can:

• serve as an early warning system for impending public health emergencies;
• document the impact of an intervention, or track progress towards specified goals; and
• monitor and clarify the epidemiology of health problems, allow priorities to be set, and inform health policy and strategies.
• diagnose, investigate, and monitor health problems and health hazards of the community

Public health surveillance has led to the identification and prioritization of many public health issues facing the world today, including HIV/AIDS, diabetes, waterborne diseases, zoonotic diseases, and antibiotic resistance leading to the reemergence of infectious diseases such as tuberculosis. Antibiotic resistance, also known as drug resistance, was the theme of World Health Day 2011. Although the prioritization of pressing public health issues is important, Laurie Garrett argues that there are following consequences. When foreign aid is funnelled into disease-specific programs, the importance of public health in general is disregarded. This public health problem of stovepiping is thought to create a lack of funds to combat other existing diseases in a given country.

For example, the WHO reports that at least 220 million people worldwide suffer from diabetes. Its incidence is increasing rapidly, and it is projected that the number of diabetes deaths will double by the year 2030. In a June 2010 editorial in the medical journal The Lancet, the authors opined that "The fact that type 2 diabetes, a largely preventable disorder, has reached epidemic proportion is a public health humiliation." The risk of type 2 diabetes is closely linked with the growing problem of obesity. The WHO’s latest estimates as of June 2016 highlighted that globally approximately 1.9 billion adults were overweight in 2014, and 41 million children under the age of five were overweight in 2014. The United States is the leading country with 30.6% of its population being obese. Mexico follows behind with 24.2% and the United Kingdom with 23%. Once considered a problem in high-income countries, it is now on the rise in low-income countries, especially in urban settings. Many public health programs are increasingly dedicating attention and resources to the issue of obesity, with objectives to address the underlying causes including healthy diet and physical exercise.

Some programs and policies associated with public health promotion and prevention can be controversial. One such example is programs focusing on the prevention of HIV transmission through safe sex campaigns and needle-exchange programs. Another is the control of tobacco smoking. Changing smoking behavior requires long-term strategies, unlike the fight against communicable diseases, which usually takes a shorter period for effects to be observed. Many nations have implemented major initiatives to cut smoking, such as increased taxation and bans on smoking in some or all public places. Proponents argue by presenting evidence that smoking is one of the major killers, and that therefore governments have a duty to reduce the death rate, both through limiting passive (second-hand) smoking and by providing fewer opportunities for people to smoke. Opponents say that this undermines individual freedom and personal responsibility, and worry that the state may be emboldened to remove more and more choice in the name of better population health overall.

Simultaneously, while communicable diseases have historically ranged uppermost as a global health priority, non-communicable diseases and the underlying behavior-related risk factors have been at the bottom. This is changing, however, as illustrated by the United Nations hosting its first General Assembly Special Summit on the issue of non-communicable diseases in September 2011.

Many health problems are due to maladaptive personal behaviors. From an evolutionary psychology perspective, over consumption of novel substances that are harmful is due to the activation of an evolved reward system for substances such as drugs, tobacco, alcohol, refined salt, fat, and carbohydrates. New technologies such as modern transportation also cause reduced physical activity. Research has found that behavior is more effectively changed by taking evolutionary motivations into consideration instead of only presenting information about health effects. The marketing industry has long known the importance of associating products with high status and attractiveness to others. Films are increasingly being recognized as a public health tool. In fact, film festivals and competitions have been established to specifically promote films about health. Conversely, it has been argued that emphasizing the harmful and undesirable effects of tobacco smoking on other persons and imposing smoking bans in public places have been particularly effective in reducing tobacco smoking.

Applications in health care

As well as seeking to improve population health through the implementation of specific population-level interventions, public health contributes to medical care by identifying and assessing population needs for health care services, including:

• Assessing current services and evaluating whether they are meeting the objectives of the health care system
• Ascertaining requirements as expressed by health professionals, the public and other stakeholders
• Identifying the most appropriate interventions
• Considering the effect on resources for proposed interventions and assessing their cost-effectiveness
• Supporting decision making in health care and planning health services including any necessary changes.
• Informing, educating, and empowering people about health issues

Implementing effective improvement strategies

To improve public health, one important strategy is to promote modern medicine and scientific neutrality to drive the public health policy and campaign, which is recommended by Armanda Solorzana, through a case study of the Rockefeller Foundation's hookworm campaign in Mexico in the 1920s. Soloranza argues that public health policy can't concern only politics or economics. Political concerns can lead government officials to hide the real numbers of people affected by disease in their regions, such as upcoming elections. Therefore, scientific neutrality in making public health policy is critical; it can ensure treatment needs are met regardless of political and economic conditions.

The history of public health care clearly shows the global effort to improve health care for all. However, in modern-day medicine, real, measurable change has not been clearly seen, and critics argue that this lack of improvement is due to ineffective methods that are being implemented. As argued by Paul E. Farmer, structural interventions could possibly have a large impact, and yet there are numerous problems as to why this strategy has yet to be incorporated into the health system. One of the main reasons that he suggests could be the fact that physicians are not properly trained to carry out structural interventions, meaning that the ground level health care professionals cannot implement these improvements. While structural interventions can not be the only area for improvement, the lack of coordination between socioeconomic factors and health care for the poor could be counterproductive, and end up causing greater inequity between the health care services received by the rich and by the poor. Unless health care is no longer treated as a commodity, global public health will ultimately not be achieved. This being the case, without changing the way in which health care is delivered to those who have less access to it, the universal goal of public health care cannot be achieved.

Another reason why measurable changes may not be noticed in public health is because agencies themselves may not be measuring their programs' efficacy. Perrault et al. analyzed over 4,000 published objectives from Community Health Improvement Plans (CHIPs) of 280 local accredited and non-accredited public health agencies in the U.S., and found that the majority of objectives - around two-thirds - were focused on achieving agency outputs (e.g., developing communication plans, installing sidewalks, disseminating data to the community). Only about one-third focused on seeking measurable changes in the populations they serve (i.e., changing people's knowledge, attitudes, behaviors). What this research showcases is that if agencies are only focused on accomplishing tasks (i.e., outputs) and do not have a focus on measuring actual changes in their populations with the activities they perform, it should not be surprising when measurable changes are not reported. Perrault et al. advocate for public health agencies to work with those in the discipline of Health Communication to craft objectives that are measurable outcomes, and to assist agencies in developing tools and methods to be able to track more proximal changes in their target populations (e.g., knowledge and attitude shifts) that may be influenced by the activities the agencies are performing.

Public Health 2.0

Public Health 2.0 is a movement within public health that aims to make the field more accessible to the general public and more user-driven. The term is used in three senses. In the first sense, "Public Health 2.0" is similar to "Health 2.0" and describes the ways in which traditional public health practitioners and institutions are reaching out (or could reach out) to the public through social media and health blogs.

In the second sense, "Public Health 2.0" describes public health research that uses data gathered from social networking sites, search engine queries, cell phones, or other technologies. A recent example is the proposal of statistical framework that utilizes online user-generated content (from social media or search engine queries) to estimate the impact of an influenza vaccination campaign in the UK.

In the third sense, "Public Health 2.0" is used to describe public health activities that are completely user-driven. An example is the collection and sharing of information about environmental radiation levels after the March 2011 tsunami in Japan. In all cases, Public Health 2.0 draws on ideas from Web 2.0, such as crowdsourcing, information sharing, and user-centred design. While many individual healthcare providers have started making their own personal contributions to "Public Health 2.0" through personal blogs, social profiles, and websites, other larger organizations, such as the American Heart Association (AHA) and United Medical Education (UME), have a larger team of employees centered around online driven health education, research, and training. These private organizations recognize the need for free and easy to access health materials often building libraries of educational articles.

Low- and middle-income countries

Emergency Response Team in Burma after Cyclone Nargis in 2008

 

There is a great disparity in access to health care and public health initiatives between developed nations and developing nations. In the developing world, public health infrastructures are still forming. There may not be enough trained health workers, monetary resources or, in some cases, sufficient knowledge to provide even a basic level of medical care and disease prevention. As a result, a large majority of disease and mortality in the developing world results from and contributes to extreme poverty. For example, many African governments spend less than US$10 per person per year on health care, while, in the United States, the federal government spent approximately US$4,500 per capita in 2000. However, expenditures on health care should not be confused with spending on public health. Public health measures may not generally be considered "health care" in the strictest sense. For example, mandating the use of seat belts in cars can save countless lives and contribute to the health of a population, but typically money spent enforcing this rule would not count as money spent on health care.

Large parts of the world remained plagued by largely preventable or treatable infectious diseases. In addition to this however, many low- and middle-income countries are also experiencing an epidemiological shift and polarization in which populations are now experiencing more of the effects of chronic diseases as life expectancy increases with, the poorer communities being heavily affected by both chronic and infectious diseases. Another major public health concern in the developing world is poor maternal and child health, exacerbated by malnutrition and poverty. The WHO reports that a lack of exclusive breastfeeding during the first six months of life contributes to over a million avoidable child deaths each year. Intermittent preventive therapy aimed at treating and preventing malaria episodes among pregnant women and young children is one public health measure in endemic countries. 

Each day brings new front-page headlines about public health: emerging infectious diseases such as SARS, rapidly making its way from China (see Public health in China) to Canada, the United States and other geographically distant countries; reducing inequities in health care access through publicly funded health insurance programs; the HIV/AIDS pandemic and its spread from certain high-risk groups to the general population in many countries, such as in South Africa; the increase of childhood obesity and the concomitant increase in type II diabetes among children; the social, economic and health effects of adolescent pregnancy; and the public health challenges related to natural disasters such as the 2004 Indian Ocean tsunami, 2005's Hurricane Katrina in the United States and the 2010 Haiti earthquake. 

Since the 1980s, the growing field of population health has broadened the focus of public health from individual behaviors and risk factors to population-level issues such as inequality, poverty, and education. Modern public health is often concerned with addressing determinants of health across a population. There is a recognition that our health is affected by many factors including where we live, genetics, our income, our educational status and our social relationships; these are known as "social determinants of health". The upstream drivers such as environment, education, employment, income, food security, housing, social inclusion and many others effect the distribution of health between and within populations and are often shaped by policy. A social gradient in health runs through society. The poorest generally suffer the worst health, but even the middle classes will generally have worse health outcomes than those of a higher social stratum. The new public health advocates for population-based policies that improve health in an equitable manner.

Health aid in less developed countries

Health aid to developing countries is an important source of public health funding for many low- and middle-income countries. Health aid to developing countries has shown a significant increase after World War II as concerns over the spread of disease as a result of globalization increased and the HIV/AIDS epidemic in sub-Saharan Africa surfaced. From 1990 to 2010, total health aid from developed countries increased from 5.5 billion to 26.87 billion with wealthy countries continuously donating billions of dollars every year with the goal of improving population health. Some efforts, however, receive a significantly larger proportion of funds such as HIV which received an increase in funds of over $6 billion dollars between 2000 and 2010 which was more than twice the increase seen in any other sector during those years. Health aid has seen an expansion through multiple channels including private philanthropy, non-governmental organizations, private foundations such as the Bill & Melinda Gates Foundation, bilateral donors, and multilateral donors such as the World Bank or UNICEF. In 2009 health aid from the OECD amounted to $12.47 billion which amounted to 11.4% of its total bilateral aid. In 2009, Multilateral donors were found to spend 15.3% of their total aid on bettering public healthcare. Recent data, however, shows that international health aid has plateaued and may begin to decrease.

International health aid debates

Debates exist questioning the efficacy of international health aid. Proponents of aid claim that health aid from wealthy countries is necessary in order for developing countries to escape the poverty trap. Opponents of health aid claim that international health aid actually disrupts developing countries' course of development, causes dependence on aid, and in many cases the aid fails to reach its recipients. For example, recently, health aid was funneled towards initiatives such as financing new technologies like antiretroviral medication, insecticide-treated mosquito nets, and new vaccines. The positive impacts of these initiatives can be seen in the eradication of smallpox and polio; however, critics claim that misuse or misplacement of funds may cause many of these efforts to never come into fruition.

Economic modeling based on the Institute for Health Metrics and Evaluation and the World Health Organization has shown a link between international health aid in developing countries and a reduction in adult mortality rates. However, a 2014-2016 study suggests that a potential confounding variable for this outcome is the possibility that aid was directed at countries once they were already on track for improvement. That same study, however, also suggests that 1 billion dollars in health aid was associated with 364,000 fewer deaths occurring between ages 0 and 5 in 2011.

Sustainable development goals 2030

To address current and future challenges in addressing health issues in the world, the United Nations have developed the Sustainable Development Goals building off of the Millennium Development Goals of 2000 to be completed by 2030. These goals in their entirety encompass the entire spectrum of development across nations, however Goals 1-6 directly address health disparities, primarily in developing countries. These six goals address key issues in global public health: Poverty, Hunger and food security, Health, Education, Gender equality and women's empowerment, and water and sanitation. Public health officials can use these goals to set their own agenda and plan for smaller scale initiatives for their organizations. These goals hope to lessen the burden of disease and inequality faced by developing countries and lead to a healthier future. 

The links between the various sustainable development goals and public health are numerous and well established:

• Living below the poverty line is attributed to poorer health outcomes and can be even worse for persons living in developing countries where extreme poverty is more common. A child born into poverty is twice as likely to die before the age of five compared to a child from a wealthier family.
• The detrimental effects of hunger and malnutrition that can arise from systemic challenges with food security are enormous. The World Health Organization estimates that 12.9 percent of the population in developing countries is undernourished.
• Health challenges in the developing world are enormous, with "only half of the women in developing nations receiving the recommended amount of healthcare they need.
• Educational equity has yet to be reached in the world. Public health efforts are impeded by this, as a lack of education can lead to poorer health outcomes. This is shown by children of mothers who have no education having a lower survival rate compared to children born to mothers with primary or greater levels of education. Cultural differences in the role of women vary by country, many gender inequalities are found in developing nations. Combating these inequalities has shown to also lead to better public health outcome.
• In studies done by the World Bank on populations in developing countries, it was found that when women had more control over household resources, the children benefit through better access to food, healthcare, and education.
• Basic sanitation resources and access to clean sources of water are a basic human right. However, 1.8 billion people globally use a source of drinking water that is fecally contaminated, and 2.4 billion people lack access to basic sanitation facilities like toilets or pit latrines. A lack of these resources is what causes approximately 1000 children a day to die from diarrheal diseases that could have been prevented from better water and sanitation infrastructure.

U.S. initiatives

The U.S. Global Health Initiative was created in 2009 by President Obama in an attempt to have a more holistic, comprehensive approach to improving global health as opposed to previous, disease-specific interventions. The Global Health Initiative is a six-year plan, "to develop a comprehensive U.S. government strategy for global health, building on the President's Emergency Plan for AIDS Relief (PEPFAR) to combat HIV as well as U.S. efforts to address tuberculosis (TB) and malaria, and augmenting the focus on other global health priorities, including neglected tropical diseases (NTDs), maternal, newborn and child health (MNCH), family planning and reproductive health (FP/RH), nutrition, and health systems strengthening (HSS)". The GHI programs are being implemented in more than 80 countries around the world and works closely with the United States Agency for International Development, the Centers for Disease Control and Prevention, the United States Deputy Secretary of State.

There are seven core principles:

1. Women, girls, and gender equality
2. Strategic coordination and integration
3. Strengthen and leverage key multilaterals and other partners
4. Country-ownership
5. Sustainability through Health Systems
6. Improve metrics, monitoring, and evaluation
7. Promote research and innovation

The aid effectiveness agenda is a useful tool for measuring the impact of these large scale programs such as The Global Fund to Fight AIDS, Tuberculosis and Malaria and the Global Alliance for Vaccines and Immunization (GAVI) which have been successful in achieving rapid and visible results. The Global Fund claims that its efforts have provided antiretroviral treatment for over three million people worldwide. GAVI claims that its vaccination programs have prevented over 5 million deaths since it began in 2000.

Education and training

Education and training of public health professionals is available throughout the world in Schools of Public Health, Medical Schools, Veterinary Schools, Schools of Nursing, and Schools of Public Affairs. The training typically requires a university degree with a focus on core disciplines of biostatistics, epidemiology, health services administration, health policy, health education, behavioral science, gender issues, sexual and reproductive health, public health nutrition and environmental and occupational health. In the global context, the field of public health education has evolved enormously in recent decades, supported by institutions such as the World Health Organization and the World Bank, among others. Operational structures are formulated by strategic principles, with educational and career pathways guided by competency frameworks, all requiring modulation according to local, national and global realities. It is critically important for the health of populations that nations assess their public health human resource needs and develop their ability to deliver this capacity, and not depend on other countries to supply it.

Schools of public health: a US perspective

In the United States, the Welch-Rose Report of 1915 has been viewed as the basis for the critical movement in the history of the institutional schism between public health and medicine because it led to the establishment of schools of public health supported by the Rockefeller Foundation. The report was authored by William Welch, founding dean of the Johns Hopkins Bloomberg School of Public Health, and Wickliffe Rose of the Rockefeller Foundation. The report focused more on research than practical education. Some have blamed the Rockefeller Foundation's 1916 decision to support the establishment of schools of public health for creating the schism between public health and medicine and legitimizing the rift between medicine's laboratory investigation of the mechanisms of disease and public health's nonclinical concern with environmental and social influences on health and wellness.

Even though schools of public health had already been established in Canada, Europe and North Africa, the United States had still maintained the traditional system of housing faculties of public health within their medical institutions. A $25,000 donation from businessman Samuel Zemurray instituted the School of Public Health and Tropical Medicine at Tulane University in 1912 conferring its first doctor of public health degree in 1914. The Yale School of Public Health was founded by Charles-Edward Avory Winslow in 1915. The Johns Hopkins School of Hygiene and Public Health became an independent, degree-granting institution for research and training in public health, and the largest public health training facility in the United States, when it was founded in 1916. By 1922, schools of public health were established at Columbia and Harvard on the Hopkins model. By 1999 there were twenty nine schools of public health in the US, enrolling around fifteen thousand students.

Over the years, the types of students and training provided have also changed. In the beginning, students who enrolled in public health schools typically had already obtained a medical degree; public health school training was largely a second degree for medical professionals. However, in 1978, 69% of American students enrolled in public health schools had only a bachelor's degree.

Degrees in public health

Schools of public health offer a variety of degrees which generally fall into two categories: professional or academic. The two major postgraduate degrees are the Master of Public Health (MPH) or the Master of Science in Public Health (MSPH). Doctoral studies in this field include Doctor of Public Health (DrPH) and Doctor of Philosophy (PhD) in a subspeciality of greater Public Health disciplines. DrPH is regarded as a professional degree and PhD as more of an academic degree. 

Professional degrees are oriented towards practice in public health settings. The Master of Public Health, Doctor of Public Health, Doctor of Health Science (DHSc) and the Master of Health Care Administration are examples of degrees which are geared towards people who want careers as practitioners of public health in health departments, managed care and community-based organizations, hospitals and consulting firms, among others. Master of Public Health degrees broadly fall into two categories, those that put more emphasis on an understanding of epidemiology and statistics as the scientific basis of public health practice and those that include a more eclectic range of methodologies. A Master of Science of Public Health is similar to an MPH but is considered an academic degree (as opposed to a professional degree) and places more emphasis on scientific methods and research. The same distinction can be made between the DrPH and the DHSc. The DrPH is considered a professional degree and the DHSc is an academic degree.

Academic degrees are more oriented towards those with interests in the scientific basis of public health and preventive medicine who wish to pursue careers in research, university teaching in graduate programs, policy analysis and development, and other high-level public health positions. Examples of academic degrees are the Master of Science, Doctor of Philosophy, Doctor of Science (ScD), and Doctor of Health Science (DHSc). The doctoral programs are distinct from the MPH and other professional programs by the addition of advanced coursework and the nature and scope of a dissertation research project. 

In the United States, the Association of Schools of Public Health represents Council on Education for Public Health (CEPH) accredited schools of public health. Delta Omega is the honor society for graduate studies in public health. The society was founded in 1924 at the Johns Hopkins School of Hygiene and Public Health. Currently, there are approximately 68 chapters throughout the United States and Puerto Rico.

History

Early history

The primitive nature of medieval medicine rendered Europe helpless to the onslaught of the Black Death in the 14th century. Miniature from "The Chronicles of Gilles Li Muisis" (1272-1352). Bibliothèque royale de Belgique, MS 13076-77, f. 24v.

 

Public health has early roots in antiquity. From the beginnings of human civilization, it was recognized that polluted water and lack of proper waste disposal spread communicable diseases (theory of miasma). Early religions attempted to regulate behavior that specifically related to health, from types of food eaten, to regulating certain indulgent behaviors, such as drinking alcohol or sexual relations. Leaders were responsible for the health of their subjects to ensure social stability, prosperity, and maintain order. 

By Roman times, it was well understood that proper diversion of human waste was a necessary tenet of public health in urban areas. The ancient Chinese medical doctors developed the practice of variolation following a smallpox epidemic around 1000 BC. An individual without the disease could gain some measure of immunity against it by inhaling the dried crusts that formed around lesions of infected individuals. Also, children were protected by inoculating a scratch on their forearms with the pus from a lesion. 

In 1485 the Republic of Venice established a permanent Venetian Magistrate for Health comprising supervisors of health with special attention to the prevention of the spread of epidemics in the territory from abroad. The three supervisors were initially appointed by the Venetian Senate. In 1537 it was assumed by the Grand Council, and in 1556 added two judges, with the task of control, on behalf of the Republic, the efforts of the supervisors.

However, according to Michel Foucault, the plague model of governmentality was later controverted by the cholera model. A Cholera pandemic devastated Europe between 1829 and 1851, and was first fought by the use of what Foucault called "social medicine", which focused on flux, circulation of air, location of cemeteries, etc. All those concerns, born of the miasma theory of disease, were mixed with urbanistic concerns for the management of populations, which Foucault designated as the concept of "biopower". The German conceptualized this in the Polizeiwissenschaft ("Police science").

Modern public health

The 18th century saw rapid growth in voluntary hospitals in England. The latter part of the century brought the establishment of the basic pattern of improvements in public health over the next two centuries: a social evil was identified, private philanthropists brought attention to it, and changing public opinion led to government action.

1802 caricature of Edward Jenner vaccinating patients who feared it would make them sprout cowlike appendages.

 

The practice of vaccination became prevalent in the 1800s, following the pioneering work of Edward Jenner in treating smallpox. James Lind's discovery of the causes of scurvy amongst sailors and its mitigation via the introduction of fruit on lengthy voyages was published in 1754 and led to the adoption of this idea by the Royal Navy. Efforts were also made to promulgate health matters to the broader public; in 1752 the British physician Sir John Pringle published Observations on the Diseases of the Army in Camp and Garrison, in which he advocated for the importance of adequate ventilation in the military barracks and the provision of latrines for the soldiers.

With the onset of the Industrial Revolution, living standards amongst the working population began to worsen, with cramped and unsanitary urban conditions. In the first four decades of the 19th century alone, London's population doubled and even greater growth rates were recorded in the new industrial towns, such as Leeds and Manchester. This rapid urbanization exacerbated the spread of disease in the large conurbations that built up around the workhouses and factories. These settlements were cramped and primitive with no organized sanitation. Disease was inevitable and its incubation in these areas was encouraged by the poor lifestyle of the inhabitants. Unavailable housing led to the rapid growth of slums and the per capita death rate began to rise alarmingly, almost doubling in Birmingham and Liverpool. Thomas Malthus warned of the dangers of overpopulation in 1798. His ideas, as well as those of Jeremy Bentham, became very influential in government circles in the early years of the 19th century.

Public health legislation

Sir Edwin Chadwick was a pivotal influence on the early public health campaign.

 

The first attempts at sanitary reform and the establishment of public health institutions were made in the 1840s. Thomas Southwood Smith, physician at the London Fever Hospital, began to write papers on the importance of public health, and was one of the first physicians brought in to give evidence before the Poor Law Commission in the 1830s, along with Neil Arnott and James Phillips Kay. Smith advised the government on the importance of quarantine and sanitary improvement for limiting the spread of infectious diseases such as cholera and yellow fever.

The Poor Law Commission reported in 1838 that "the expenditures necessary to the adoption and maintenance of measures of prevention would ultimately amount to less than the cost of the disease now constantly engendered". It recommended the implementation of large scale government engineering projects to alleviate the conditions that allowed for the propagation of disease. The Health of Towns Association was formed in Exeter on 11 December 1844, and vigorously campaigned for the development of public health in the United Kingdom. Its formation followed the 1843 establishment of the Health of Towns Commission, chaired by Sir Edwin Chadwick, which produced a series of reports on poor and insanitary conditions in British cities.

These national and local movements led to the Public Health Act, finally passed in 1848. It aimed to improve the sanitary condition of towns and populous places in England and Wales by placing the supply of water, sewerage, drainage, cleansing and paving under a single local body with the General Board of Health as a central authority. The Act was passed by the Liberal government of Lord John Russell, in response to the urging of Edwin Chadwick. Chadwick's seminal report on The Sanitary Condition of the Labouring Population was published in 1842 and was followed up with a supplementary report a year later.

Vaccination for various diseases was made compulsory in the United Kingdom in 1851, and by 1871 legislation required a comprehensive system of registration run by appointed vaccination officers.

Further interventions were made by a series of subsequent Public Health Acts, notably the 1875 Act. Reforms included latrinization, the building of sewers, the regular collection of garbage followed by incineration or disposal in a landfill, the provision of clean water and the draining of standing water to prevent the breeding of mosquitoes.

The Infectious Disease (Notification) Act 1889 mandated the reporting of infectious diseases to the local sanitary authority, which could then pursue measures such as the removal of the patient to hospital and the disinfection of homes and properties.

In the United States, the first public health organization based on a state health department and local boards of health was founded in New York City in 1866.

Epidemiology

John Snow's dot map, showing the clusters of cholera cases in the London epidemic of 1854.

 

The science of epidemiology was founded by John Snow's identification of a polluted public water well as the source of an 1854 cholera outbreak in London. Dr. Snow believed in the germ theory of disease as opposed to the prevailing miasma theory. He first publicized his theory in an essay, On the Mode of Communication of Cholera, in 1849, followed by a more detailed treatise in 1855 incorporating the results of his investigation of the role of the water supply in the Soho epidemic of 1854.

By talking to local residents (with the help of Reverend Henry Whitehead), he identified the source of the outbreak as the public water pump on Broad Street (now Broadwick Street). Although Snow's chemical and microscope examination of a water sample from the Broad Street pump did not conclusively prove its danger, his studies of the pattern of the disease were convincing enough to persuade the local council to disable the well pump by removing its handle.

Snow later used a dot map to illustrate the cluster of cholera cases around the pump. He also used statistics to illustrate the connection between the quality of the water source and cholera cases. He showed that the Southwark and Vauxhall Waterworks Company was taking water from sewage-polluted sections of the Thames and delivering the water to homes, leading to an increased incidence of cholera. Snow's study was a major event in the history of public health and geography. It is regarded as the founding event of the science of epidemiology.

Disease control

Paul-Louis Simond injecting a plague vaccine in Karachi, 1898.

 

With the pioneering work in bacteriology of French chemist Louis Pasteur and German scientist Robert Koch, methods for isolating the bacteria responsible for a given disease and vaccines for remedy were developed at the turn of the 20th century. British physician Ronald Ross identified the mosquito as the carrier of malaria and laid the foundations for combating the disease. Joseph Lister revolutionized surgery by the introduction of antiseptic surgery to eliminate infection. French epidemiologist Paul-Louis Simond proved that plague was carried by fleas on the back of rats, and Cuban scientist Carlos J. Finlay and U.S. Americans Walter Reed and James Carroll demonstrated that mosquitoes carry the virus responsible for yellow fever. Brazilian scientist Carlos Chagas identified a tropical disease and its vector.

With onset of the epidemiological transition and as the prevalence of infectious diseases decreased through the 20th century, public health began to put more focus on chronic diseases such as cancer and heart disease. Previous efforts in many developed countries had already led to dramatic reductions in the infant mortality rate using preventative methods. In Britain, the infant mortality rate fell from over 15% in 1870 to 7% by 1930.

Country examples

France

France 1871-1914 followed well behind Bismarckian Germany, as well as Great Britain, in developing the welfare state including public health. Tuberculosis was the most dreaded disease of the day, especially striking young people in their 20s. Germany set up vigorous measures of public hygiene and public sanatoria, but France let private physicians handle the problem, which left it with a much higher death rate. The French medical profession jealously guarded its prerogatives, and public health activists were not as well organized or as influential as in Germany, Britain or the United States. For example, there was a long battle over a public health law which began in the 1880s as a campaign to reorganize the nation's health services, to require the registration of infectious diseases, to mandate quarantines, and to improve the deficient health and housing legislation of 1850. However the reformers met opposition from bureaucrats, politicians, and physicians. Because it was so threatening to so many interests, the proposal was debated and postponed for 20 years before becoming law in 1902. Success finally came when the government realized that contagious diseases had a national security impact in weakening military recruits, and keeping the population growth rate well below Germany's.

United States

The seal of the United States Public Health Service.

Modern public health began developing in the 19th century, as a response to advances in science that led to the understanding of, the source and spread of disease. As the knowledge of contagious diseases increased, means to control them and prevent infection were soon developed. Once it became understood that these strategies would require community-wide participation, disease control began being viewed as a public responsibility. Various organizations and agencies were then created to implement these disease preventing strategies.

Most of the Public health activity in the United States took place at the municipal level before the mid-20th century. There was some activity at the national and state level as well.

In the administration of the second president of the United States John Adams, the Congress authorized the creation of hospitals for mariners. As the U.S. expanded, the scope of the governmental health agency expanded. In the United States, public health worker Sara Josephine Baker, M.D. established many programs to help the poor in New York City keep their infants healthy, leading teams of nurses into the crowded neighborhoods of Hell's Kitchen and teaching mothers how to dress, feed, and bathe their babies. 

Another key pioneer of public health in the U.S. was Lillian Wald, who founded the Henry Street Settlement house in New York. The Visiting Nurse Service of New York was a significant organization for bringing health care to the urban poor. 

Dramatic increases in average life span in the late 19th century and 20th century, is widely credited to public health achievements, such as vaccination programs and control of many infectious diseases including polio, diphtheria, yellow fever and smallpox; effective health and safety policies such as road traffic safety and occupational safety; improved family planning; tobacco control measures; and programs designed to decrease non-communicable diseases by acting on known risk factors such as a person's background, lifestyle and environment. 

Another major public health improvement was the decline in the "urban penalty" brought about by improvements in sanitation. These improvements included chlorination of drinking water, filtration and sewage treatment which led to the decline in deaths caused by infectious waterborne diseases such as cholera and intestinal diseases. The federal Office of Indian Affairs (OIA) operated a large-scale field nursing program. Field nurses targeted native women for health education, emphasizing personal hygiene and infant care and nutrition.

Mexico

Logo for the Mexican Social Security Institute, a governmental agency dealing with public health.

 

Public health issues were important for the Spanish empire during the colonial era. Epidemic disease was the main factor in the decline of indigenous populations in the era immediately following the sixteenth-century conquest era and was a problem during the colonial era. The Spanish crown took steps in eighteenth-century Mexico to bring in regulations to make populations healthier.

In the late nineteenth century, Mexico was in the process of modernization, and public health issues were again tackled from a scientific point of view. Even during the Mexican Revolution (1910–20), public health was an important concern, with a text on hygiene published in 1916.^[105] During the Mexican Revolution, feminist and trained nurse Elena Arizmendi Mejia founded the Neutral White Cross, treating wounded soldiers no matter for what faction they fought. 

In the post-revolutionary period after 1920, improved public health was a revolutionary goal of the Mexican government. The Mexican state promoted the health of the Mexican population, with most resources going to cities. Concern about disease conditions and social impediments to the improvement of Mexicans' health were important in the formation of the Mexican Society for Eugenics. The movement flourished from the 1920s to the 1940s. Mexico was not alone in Latin America or the world in promoting eugenics. Government campaigns against disease and alcoholism were also seen as promoting public health.

The Mexican Social Security Institute was established in 1943, during the administration of President Manuel Avila Camacho to deal with public health, pensions, and social security.

Cuba

Since the 1959 Cuban Revolution the Cuban government has devoted extensive resources to the improvement of health conditions for its entire population via universal access to health care. Infant mortality has plummeted. Cuban medical internationalism as a policy has seen the Cuban government sent doctors as a form of aid and export to countries in need in Latin America, especially Venezuela, as well as Oceania and Africa countries.

Colombia and Bolivia

Public health was important elsewhere in Latin America in consolidating state power and integrating marginalized populations into the nation-state. In Colombia, public health was a means for creating and implementing ideas of citizenship. In Bolivia, a similar push came after their 1952 revolution.

Ghana

Though curable and preventative, malaria remains a huge public health problem and is the third leading cause of death in Ghana. In the absence of a vaccine, mosquito control, or access to anti-malaria medication, public health methods become the main strategy for reducing the prevalence and severity of malaria. These methods include reducing breeding sites, screening doors and windows, insecticide sprays, prompt treatment following infection, and usage of insecticide treated mosquito nets. Distribution and sale of insecticide-treated mosquito nets is a common, cost-effective anti-malaria public health intervention; however, barriers to use exist including cost, hosehold and family organization, access to resources, and social and behavioral determinants which have not only been shown to affect malaria prevalence rates but also mosquito net use.