Global Health Practice, Policy, and Solutions

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, or on the Web at www.copyright .com. Requests to the publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, 201-748-6011, fax 201-748-6008, or online at www.wiley.com/go/permissions.
Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional where appropriate. Neither the publisher nor author shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. Readers should be aware that Internet Web sites offered as citations and/or sources for further information may have changed or disappeared between the time this was written and when it is read.
Jossey-Bass books and products are available through most bookstores. To contact Jossey-Bass directly call our Customer Care Department within the U.S. at 800-956-7739, outside the U.S. at 317-572-3986, or fax 317-572-4002.
Wiley publishes in a variety of print and electronic formats and by print-on-demand. Some material included with standard print versions of this book may not be included in e-books or in print-on-demand. If this book refers to media such as a CD or DVD that is not included in the version you purchased, you may download this material at http://booksupport.wiley.com. For more information about Wiley products, visit www.wiley.com.
Library of Congress Cataloging-in-Publication Data
Muennig, Peter, author. Introducing global health : practice, policy, and solutions / Peter Muennig, Celina Su. –First edition. p. ; cm. Includes bibliographical references and index. ISBN 978-0-470-53328-4 (pbk.); ISBN 978-1-118-22041-2 (ebk.); ISBN 978-1-118-23399-3 (ebk.) I. Su, Celina, author. II. Title. [DNLM: 1. World Health. 2. Health Policy. WA 530.1] RA418 362.1–dc23 2013012274
Printed in the United States of America first edition PB Printing 10 9 8 7 6 5 4 3 2 1

Contents
Figures and Tables ………………………………………………………………………………….. ix The Authors ………………………………………………………………………………………….xiii Introduction: An Overview of Global Health ………………………………………………. xv
Part 1 The Basics of Global Health ……………………………………. 1 1 A Very Brief History of Global Health Policy …………………………….. 3
Key Ideas …………………………………………………………………………….. 3 Health and Public Policy Through the Twentieth Century ………………. 4 The Age of Global Health Policy ……………………………………………….11 The Fall of Global Governance ……………………………………………….. 16 The Millennium Development Goals ………………………………………… 19 An Alternative History ……………………………………………………………21 Love and Health in Modern Times ………………………………………….. 25 Summary ……………………………………………………………………………. 27 Key Terms ………………………………………………………………………….. 27 Discussion Questions ……………………………………………………………. 27 Further Reading …………………………………………………………………… 28 References ………………………………………………………………………….. 28
2 Case Studies in Development and Health …………………………………31 Key Ideas …………………………………………………………………………….31 The Puzzle of “Good” Development for Health ………………………….. 33 The Next Superpowers? Taking a Closer Look at Middle-Income Countries ……………………………………………………………………………. 37 Growth-Mediated Models ………………………………………………………. 40 Support-Led Models ……………………………………………………………….41 Toward a Happy Medium? ……………………………………………………… 43 China’s Explosive Growth ……………………………………………………… 45 Kerala’s Quality of Life………………………………………………………….. 49 Chile Aims for a Balancing Act ……………………………………………….. 52 Summary ……………………………………………………………………………. 56 Key Terms ………………………………………………………………………….. 56 Discussion Questions ……………………………………………………………. 56 Further Reading …………………………………………………………………… 57 References ………………………………………………………………………….. 57
Part 2 Global Health and the Art of Policy Making ……………. 61 3 The Global Burden of Disease ………………………………………………. 63
Key Ideas …………………………………………………………………………… 63 Who Dies Where? ………………………………………………………………… 64
v
vi C O N T E N T S
Counting Global Deaths (with an Eye Toward Saving Lives) …………. 69 Dead Children Make for Bad Statistics ……………………………………… 73 The Health Effects of Evil Genies ……………………………………………. 74 Quantifying the Global Burden of Disease …………………………………. 77 Cost-Effectiveness Analysis ………………………………………………………81 Summary ……………………………………………………………………………. 83 Key Terms ………………………………………………………………………….. 84 Discussion Questions ……………………………………………………………. 84 Further Reading …………………………………………………………………… 84 References ………………………………………………………………………….. 84
4 Aid …………………………………………………………………………………… 87 Key Ideas …………………………………………………………………………… 87 Different Types of Aid …………………………………………………………… 88 The Aid Controversy ………………………………………………………………91 Models of Global Aid for Public Health ……………………………………. 92 Argument: Aid Is Harmful ……………………………………………………… 95 Argument: Aid Is Poorly Managed …………………………………………… 97 Argument: Aid Is Misused ……………………………………………………… 99 Argument: “Aid” Further Consolidates Power for the Powerful …….. 101 Argument: All Is Well, Just Send More ……………………………………. 102 Argument: We Are Making Progress, But the Hurdles Are High ……. 102 Summary ……………………………………………………………………………104 Key Terms …………………………………………………………………………. 105 Discussion Questions …………………………………………………………… 105 Further Reading …………………………………………………………………..106 References ………………………………………………………………………….106
5 Health Systems …………………………………………………………………..109 Key Ideas …………………………………………………………………………..109 Health Care Delivery Systems ………………………………………………….111 Health Care Payments ………………………………………………………….. 114 Health Care Markets ……………………………………………………………. 116 Health Care Delivery Systems in High-Income Countries …………….. 117 Health Care Delivery Systems in Low- and Middle-Income Countries ……………………………………………………………………………124 Pharmaceutical Spending ………………………………………………………132 What Makes Us Healthy? ………………………………………………………134 Summary ……………………………………………………………………………138 Key Terms ………………………………………………………………………….138 Discussion Questions ……………………………………………………………139 Further Reading …………………………………………………………………..139 References ………………………………………………………………………….139
6 Social Policy and Global Health …………………………………………… 143 Key Ideas …………………………………………………………………………..143 How Policies Are Made …………………………………………………………144 Political Economy and Health ………………………………………………… 151 Lessons for Health-Optimizing Social Policies ……………………………164
C O N T E N T S vii
Summary ……………………………………………………………………………165 Key Terms ………………………………………………………………………….166 Discussion Questions ……………………………………………………………166 Further Reading …………………………………………………………………..166 References ………………………………………………………………………….166
7 A Closer Look at Three Political Economies: China, Kerala, and Chile …………………………………………………………………………. 169 Key Ideas …………………………………………………………………………..169 China: Sustainable State of Development? …………………………………170 Kerala: Experiments with Radical Decentralization ……………………..176 Chile: A Precarious Third Way ……………………………………………….181 Summary ……………………………………………………………………………190 Discussion Questions ……………………………………………………………190 Further Reading …………………………………………………………………..191 References ………………………………………………………………………….191
8 Global Governance and Health ……………………………………………. 193 Key Ideas …………………………………………………………………………..193 The World Health Organization ………………………………………………194 The World Trade Organization ………………………………………………..197 An Evolution of Global Governance …………………………………………200 Summary ……………………………………………………………………………208 Key Terms ………………………………………………………………………….209 Discussion Questions ……………………………………………………………209 Further Reading …………………………………………………………………..209 References …………………………………………………………………………. 210
Part 3 Key Challenges in Global Health …………………………. 213 9 Poverty ……………………………………………………………………………..215
Key Ideas ………………………………………………………………………….. 215 Income and Health Across Nations …………………………………………. 216 Definitions of Poverty ………………………………………………………….. 218 Why Do We Worry About Poverty in Public Health? …………………..222 Poverty in Less-Developed Nations ………………………………………….228 Poverty and Health Among Wealthy Nations ……………………………..232 The Complexities of Poverty …………………………………………………..240 Summary ……………………………………………………………………………240 Key Terms ………………………………………………………………………….241 Discussion Questions ……………………………………………………………241 Further Reading …………………………………………………………………..241 References ………………………………………………………………………….241
10 The Physical Environment and Disease ………………………………… 245 Key Ideas …………………………………………………………………………..245 Infectious Disease and Development ………………………………………..246 Malaria and Other Mosquito-Borne Illnesses …………………………….. 251 Air Pollution and Health ……………………………………………………….255 Outer-Ring Development and Health………………………………………..259
viii C O N T E N T S
Climate Change and Health ……………………………………………………262 Summary ……………………………………………………………………………267 Key Terms ………………………………………………………………………….267 Discussion Questions ……………………………………………………………267 Further Reading …………………………………………………………………..268 References ………………………………………………………………………….268
11 The Social Environment and Disease …………………………………….271 Key Ideas …………………………………………………………………………..271 The Ultimate Trifecta: Race, Class, and Gender ………………………….272 The Human Immunodeficiency Virus (HIV) ………………………………282 Tuberculosis ……………………………………………………………………….286 Social Networks and Chronic Disease ………………………………………289 Individual Risk Behaviors, Urban Planning, and Health ……………….292 Summary ……………………………………………………………………………297 Key Terms ………………………………………………………………………….297 Discussion Questions ……………………………………………………………298 Further Reading …………………………………………………………………..298 References ………………………………………………………………………….298
12 Globalization, Internal Conflict, and the Resource Curse ………… 303 Key Ideas …………………………………………………………………………..303 Globalization and Health ……………………………………………………….303 Spillover Effects of Poor Global Governance ………………………………307 Civil Conflict as a Public Health Problem …………………………………308 Resource Curses and Civil Conflict …………………………………………. 310 Natural Resources and Civil War ……………………………………………. 316 Summary …………………………………………………………………………… 319 Key Terms ………………………………………………………………………….320 Discussion Questions ……………………………………………………………320 Further Reading ………………………………………………………………….. 321 References …………………………………………………………………………. 321
13 Frontiers in Global Health ………………………………………………….. 325 Key Ideas …………………………………………………………………………..325 The Many Levels of Health ……………………………………………………328 Tidings, Good or Bad, Come in Clusters ………………………………….. 331 Working with the System ………………………………………………………333 A Rise in Targeted Social Policy Interventions ……………………………338 Innovations in Administration and Governance ………………………….347 Lessons on Social Policy Interventions ……………………………………..349 Summary ……………………………………………………………………………349 Key Terms ………………………………………………………………………….350 Discussion Questions ……………………………………………………………350 Further Reading …………………………………………………………………..350 References …………………………………………………………………………. 351
Index ………………………………………………………………………………………………….. 357
Figures and Tables
FIGURES
I.1. This river makes finding recyclables easy. xx 1.1. Changes in life expectancy from 1940 to 2009 in some of the nations
that we discuss extensively in this book. 4 1.2. Residents live near a waterway containing raw sewage and trash in
Chennai, India, 2013. 7 1.3. During the Industrial Revolution, the advent of coal and steam use as
energy sources became widespread. 8 1.4. In 2005, a chemical plant explosion in Jilin, a province in northern
China, led to a massive release of nitrobenzene into the Songhua River. The water became foamy and was too dangerous to drink. The spill at first was covered up by the Chinese government, but the truth was disclosed after large numbers of dead fish washed ashore in the large northern city of Harbin and residents began to panic. 10
1.5. President Reagan meeting with Prime Minister Margaret Thatcher at the Hotel Cipriani in Venice, Italy, 6/9/1987. 17
1.6. Population pyramids typical in various stages of development. 26 2.1. The Preston curve: Life expectancy versus GDP per capita. 34 2.2. In China, the export revolution started during the transition to a
predominantly capitalist economy led to massive environmental destruction, causing broad effects on ecosystems and adversely affecting the quality of life of hundreds of millions of Chinese citizens. 44
2.3. A woman helps one of China’s barefoot doctors with nursing duties in Luo Quan Wan village. 46
2.4. Children outside a school in Kerala. 51 2.5. Life expectancy of women in Chile relative to Japan, the United States,
New Zealand, and Norway. 52 3.1. Death by broad cause group. 65 3.2. Child mortality rates by cause and region. 68 3.3. A chulla, or a traditional outdoor cook stove used in India. This
particular chulla is going to be lit using branches, scrap wood, dried dung cakes, and coconut shells. 70
ix
x F I G U R E S A N D T A B L E S
3.4. A lack of access to clean water and adequate sanitation severely inhibits many countries, especially those in sub-Saharan Africa. This problem inhibits their ability to accelerate their development. 78
3.5. A member of a local relief committee in a village in East Africa builds a latrine. This particular village has chosen to use aid provided by the organization Oxfam to build latrines. 79
4.1. Many in international development make the same mistake that this food shop in Chongqing, China, makes. It is important to have a grasp of local and international knowledge before implementation (in this case, a sign suggesting that the snack shack is selling feces). 88
4.2. Aid is delivered to Port Au Prince, Haiti, following the magnitude 7 earthquake that hit the city in 2010. 90
5.1. One of the many EMRs available from commercial vendors. Nations that are now converting to EMR systems face the challenge of either navigating the many systems that were in place prior to implementing a mandate for providers to use such records or forcing providers to drop their existing systems in favor of a universal system. 114
5.2. The chances that a forty-five-year-old woman will survive to her sixtieth birthday (fifteen-year survival) in twelve nations in 1975 (left half) and 2005 (right half). These fifteen-year survival estimates are plotted against health expenditures (y-axis). 119
5.3. Trends in self-reported health status and total household income after accounting for medical expenditures (from the General Social Survey, 1972–2008, provided by the author). 119
5.4. Global health expenditures, average number of doctor visits per year, and life expectancy. 128
5.5. An Ayurvedic medicine shop in India. 130 6.1. The percentage of women who feel that husbands are justified in
hitting their wives under certain circumstances by selected nations. The data for each country are broken down by wealth so that we see that poorer women are more likely to favor beatings than wealthier women. 147
6.2. A man appears to collect fish for human consumption after extreme river pollution and high temperatures lead to large numbers of fish dying in the river in Wuhan, China. 160
8.1. Citizens of Mexico City wear masks to prevent the spread of influenza. 197
8.2. An anti-WTO protestor demonstrates in Hong Kong in 2005. 198 9.1. This child, like millions of others in India, suffers from extreme
poverty and hunger. 221 9.2. A Nigerian girl suffers from kwashiorkor. 224 9.3. In India, a father and child suffering from marasmus. 225 9.4. The life cycle of the hookworm parasite. 226
F I G U R E S A N D T A B L E S xi
9.5. A diagram outlining the potential connections between poverty and health. We see that inadequate resources are linked to poor education, low wages, and poor environmental conditions (boxes). However, these factors are in turn caused by a confluence of poor governance and historic circumstances (among other factors). 229
10.1. Hookworm is one of the most frequently encountered parasitic infections in the world. 250
10.2. A factory in China on the Yangtze River. 257 10.3. Slash-and-burn agriculture is a common form of farming in developing
countries. It is also a major contributor to air pollution. 258 10.4. Slum upgrade in India. One approach to improving the quality of life
in slums is to formally recognize them as neighborhoods within urban centers and to then install critical infrastructure, such as sewage, sidewalks, electricity, and in some cases, even improving the quality of the housing itself. 261
10.5. Potential land loss due to polar melting. The black outline represents the current landmass above sea level. With sufficient global warming, we can expect New York, Washington, DC, Baltimore, and Philadelphia to be under water. 263
11.1. From a purely economic perspective, it makes more sense to invest scarce aid dollars in women rather than men because women are more likely to comply with interventions, pass on information to their children, and are less likely to squander income on alcohol or other drugs than are men. 278
11.2. The missing women phenomenon. Some nations have many more boys than would be expected by natural sex ratios at birth. 280
11.3. A public communications campaign from the New York City Department of Health and Mental Hygiene. Top panel: An advertisement frequently seen on the subway. Bottom panel: Still from an accompanying YouTube video. 291
11.4. Adbusters is an organization stocked with disenfranchised advertisers that seeks in part to counter the harmful effects of consumer advertising in a process called culture jamming. This ad attempts to delink male virility and alcohol. It might be particularly effective at reducing alcohol consumption because most men know what alcohol can do when they actually do get lucky with their bar date. 292
11.5. A bike lane in Kunming, China. Sophisticated bike lanes are a regular feature of mainstream Chinese urban planning. 294
12.1. This map shows six special economic zones set up by the Chinese government in areas of Africa. 312
12.2. Natural resources in poorly governed nations not only encourage dangerous mining conditions, but also can lead to civil war. 318
13.1. How the concept of herd immunity works. 329
xii F I G U R E S A N D T A B L E S
13.2. The different levels of disease causation or prevention. 330 13.3. The life cycle of the Onchocerca volvulus. This is a parasitic worm that
is the cause of river blindness. 334 13.4. A Bolsa Família center in Feira de Santana, Brazil. 343
TABLES
3.1. Counting Deaths Worldwide, by Disease 64 3.2. Leading Causes of Death for the World Overall and by Level of
Economic Development 67 3.3. Counting Deaths Worldwide by Disease and the Most Relevant Policy
for Addressing the Disease 69 3.4. Counting Deaths Worldwide by Preventive Policy Needed 72 3.5. Burden of Disease Worldwide in DALYs 77 3.6. DALYs Ranked by Country Categories 79 3.7. A Hypothetical Cost-Effectiveness League Table 82 5.1. Health Care Spending in 2009, per Person, in US Dollars 127 6.1. Three Forms of Social Democracy in Low- and Middle-Income
Countries 158 6.2. Two Types of Nondemocratic Governance 161 6.3. Main Political Economy Types in Industrialized Countries 164
xiii
The Authors
Peter Muennig is an associate professor at Columbia University’s Mailman School of Public Health, where he teaches global health policy, comparative health systems, and health disparities to graduate students in public health. He has consulted for numerous foreign governments and has run a nongov- ernmental organization, the Burmese Refugee Project (which he cofounded while still a student), for twelve years. He has published more than sixty peer- reviewed articles, two books, and many chapters and government reports. He or his work has appeared in many media outlets, including the New York Times, the Washington Post, Slate, the Wall Street Journal, NPR, and CNN.
Celina Su is an associate professor of political science at the City University of New York. Her research concerns civil society, political participation, and social policy, especially health and education. Her publications include Street- wise for Book Smarts: Grassroots Organizing and Education Reform in the Bronx (Cornell University Press, 2009) and Our Schools Suck: Young People Talk Back to a Segregated Nation on the Failures of Urban Education (coauthored, New York University Press, 2009). Her honors include the Berlin Prize and the Whiting Award for Excellence in Teaching. Su was cofounding executive direc- tor of the Burmese Refugee Project from 2001 to 2013. She earned her PhD from the Massachusetts Institute of Technology.
Introduction: An Overview of Global Health
Before we can begin to think about global health, we must understand how institutions work. One example of an institution is a bank. Most of us deposit our money in banks because we are confident that we can retrieve our money whenever we want—that is, that the money will still be there and accessible to us, plus interest and minus fees. Banking is an institution, just as banks themselves are institutions. One way of thinking about an institution is that it constitutes the habits, cooperation, and behavior of large numbers of people. It is something that we as humans, within a given culture, collectively believe in. It is real and trustworthy because everyone believes it to be. When customers lose confidence in an institution, it collapses. This is because institutions must exist in our minds for them to exist in the real world. Just think of all the banks that went under worldwide during the Great Depres- sion. When the banks’ ability to securely hold deposits became precarious, thousands of average citizens participated in bank runs and attempted to withdraw their funds from banks and place their cash under their mattresses instead.
This, in turn, exacerbated the banks’ already fragile accounting books and reserves. Many of the banking laws the United States has today stemmed from lessons learned from institutional failures in the Great Depression. The government stepped in to reinforce our collective belief in US banks and other financial institutions, or—at a bare minimum—in the existence of the currency we deposit there. If we deposit US$10,000 and the bank goes out of business, the government promises to pay that money back to us. It will do so even though this money is held only as zeros and ones on some accounting database somewhere and not in any tangible form, such as gold or even paper currency. The trust that we have in the institution, therefore, extends to a trust that we have in our nation’s government.
As long as (almost) everyone in your society has agreed that a US$1 bill is worth $1 and a $100 bill is worth $100, the money has value even though each bill is nothing more than a piece of paper and ink with an actual worth of just pennies. Under this system, you can contribute a portion of your life to performing a task in a factory or office and be confident that the money
xv
xvi I N T R O D U C T I O N
you receive in return for your labors will always buy you a known quantity of avocados.
During times of financial stress, investors go to the currency that most people believe in most firmly. This way, despite the fact of the Great Recession that began in the United States in 2007, global investors bought US dollars. This sent the value of the dollar soaring relative to that of other currencies. Investors bought dollars precisely because the US dollar is widely recognized as the most reliable of the global currencies—at the time that we went to press, at least.
Institutions vary by geographical and historical context. Slavery was an accepted social institution in ancient Greece and Egypt. It was the rare leader who thought that people should not be owned by others. Now, slave-holding is rare. (The absolute number of slaves held is larger than at any point in history, but as a proportion of all inhabitants on earth, it is quite small [Bales, 2004].) Arranged marriage is a social institution in some places but not in others. Thus, institutions can be social or cultural in nature. They do not have to be inscribed into law or have official governmental agencies or buildings representing them.
Institutions—even ones that, at first glance, have little to do with an indi- vidual’s health, such as banking or marriage—are important in global health in several key ways. First, much of what shapes population health around the world lies outside of the official medical and health care systems. As one example, traffic accidents are a leading cause of death globally, and whether we obey traffic light signals or drive into oncoming traffic is determined by institutions within each country. Another example might be whether we wash our hands after using the bathroom or a surgeon washes her hands before a surgery. Second, many areas around the world currently do not have rules and regulations that explicitly promote healthy institutions (such as ensuring affordable access to safe drinking water) and prohibit unhealthy ones (such as tobacco advertisements aimed at children). This is partly because some institutions that are considered “normal” in some settings—such as access to family planning, including condoms and safe early-term abortions—are quite contentious in others. Third, even if governments attempt to develop helpful public policies and programs, they may not be successful because corruption is often endemic in governmental agencies.
This last point is important for global health. Many institutions in many low-income countries—banks, currencies, or even rules of conduct, such as everyone driving in the same direction on an agreed-on side of the road—are weak. In fact, it might be argued that such nations have a low income and low life expectancy precisely because these institutions are weak. When the trust in institutions breaks down, it becomes difficult to build social infrastruc- ture, such as roads and schools. That is, the banks can be too weak to lend
I N T R O D U C T I O N xvii
money for such projects. If the money is acquired, institutionalized corruption may make it impossible to successfully pay for such programs. At every step of development, what we believe to be acceptable behaviors matters.
In extreme cases, when trust disappears, it becomes difficult to perform basic, everyday activities, such as buying basic goods by any means other than bartering or using some other nation’s currency. At the time of this writing, the cost of a medical examination in most clinics in Zimbabwe was listed in terms of units of grain or livestock. This is because people had lost all faith in the value of their currency.
These institutions sometimes break down when individual self-interest overrides collective interest—this is sometimes known as the “tragedy of the commons.” Those who take bribes in exchange for a road project break down the notion of trust that we hold in the overall institution.
In nations with weak institutions, it becomes not only almost impossible to run government programs but also to deliver aid. Thus, the real challenge of global health is to figure out how to make institutions work to get global agencies and individual countries functioning to improve health.
This is partly challenging because the needs of one region are so very different from those of another. In some areas, the average person can expect to live only thirty to forty years because there is no clean water to drink, and the soil is contaminated with feces because there are no toilets. This, in turn, leads to high rates of mortality, especially among children, because of diarrhea. At this level of health development, small sums of money can go a long way because the leading health problems—lack of clean water and sanitation—are so basic and cheap to fix. But this is precisely also the context in which insti- tutions are often weakest. In fact, these problems still exist precisely because it is so difficult to get anything done.
In a wealthy country such as the United States, however, problems such as poor access to medical care, reliance on the automobile for transit, poverty, and weak pollution controls form the major institutional challenges. Nations solve these problems in different ways. For instance, the United Kingdom has a centralized, socialized medical system. Switzerland, however, relies on highly regulated private health insurance to get the job done. In both cases, these nations are successful because their institutions work well—there is logic to how their systems run, in a way that seems to reflect many of their respective peoples’ overall wishes and reasoning.
This textbook focuses on institutions and the policies that might help government to develop them if they do not exist and to reform them if they are not running well. It covers most of the pressing global health problems from this angle. This way, the student not only will learn about the leading health concerns but also will get a sense of some of the ways that these prob- lems might be fixed at the international, national, and local levels. As such
xviii I N T R O D U C T I O N
we emphasize policies that either shape or bypass existing institutions. At a minimum, we point out the difficulties in doing so (as in our discussion of international aid in chapter 3).
At a very local level, if we wish to build latrines in a poor village, for example, we attempt to get buy-in, that is, we attempt to get the people in the village to believe in the idea of latrines. At a global level, the challenge is to build institutions that a much wider range of people (or at least their political representatives) view as legitimate and worthy of respect. Neither the World Health Organization (WHO) nor its parent, the United Nations (UN), has always instilled a great amount of trust among those who are aware of their existence.
Building stronger institutions at the global level, though, is not a straight- forward process. This is difficult when the UN has few regulatory powers to punish nation-states and agencies that flout its rules and recommendations. Then, for every recommendation that the UN or the WHO writes but is sub- sequently ignored, the institution becomes weaker, provoking a vicious cycle. The institutions fail because people believe they are ineffective, and people believe they are ineffective when they fail. Organizations work best when local branches are built around a central list of priorities and each arm is staffed with an outstanding manager who is accountable for his or her department’s performance and who can operate with relative independence and agency.
Of course, getting everyone to collectively believe in a solution—to insti- tutionalize a solution—is very challenging. Moreover, “solutions” can backfire. These unintended consequences of our policies frequently arise when we fail to fully consider the systems that gave rise to the problem in the first place. Our world is a world of paradoxes. Building a healthier world requires at best an understanding that these paradoxes are possible and concurrently and sys- tematically thinking about public health at the individual, social, local, regional, national, and global levels.
WHY A PUBLIC HEALTH PERSPECTIVE?
The place you live is the single most important determinant of how healthy you will be and how long you will live. Imagine that you are a fetus nestled comfortably in your mother’s womb. If you are borne in rural eastern parts of the Democratic People’s Republic of the Congo (DPRC), the chances of you or your mother dying during your birth or shortly thereafter can be as high as 50 percent (WHO, 2012). Bleeding, infection, or other labor complications are easily managed by a health worker with just a few months of training, but chances are that your mother was never able to get these services (Kruk, Galea, Prescott, & Freedman, 2007). If you make it out of the womb, your chances of seeing your fifth birthday are also low, with about a 20 percent chance of
I N T R O D U C T I O N xix
death in many areas (WHO, 2012). The lack of basic sanitation or clean water means that you are almost certainly likely to be exposed to bacteria and para- sites that cause diarrhea and intestinal bleeding. Poor mosquito control means that you are also likely to contract malaria. You mother probably does not make much in a day, and lacking access to basics such as fertilizers and seeds, local farmers are unlikely to produce food at a cost that your mother can afford. Weak from poor nutrition, you immune system probably cannot fight off all these infectious diseases.
Now imagine that you were born in Malmo, Sweden. Your mother not only has free access to high-quality medical care at birth, but she also started receiv- ing care as soon as she discovered that she was pregnant, including free essential vitamins, such as folate. After a carefully monitored birth in a cutting- edge hospital, you are discharged into a comfortable home. Even if your mother is single and unemployed, the government ensures that she has access to high- quality housing, health care, and nutrition. There are no infectious agents in the water, no mosquitoes infected with malaria, and no West Nile virus. Your chances of making it to your seventieth birthday are greater than your chances of making it to age five in the DPRC (CIA, 2012; Oeppen & Vaupel, 2002; WHO, 2012).
You might see this Congo-born you as having low chances of survival because there is lousy medical care and bad economic circumstances. That is true. But where do the bad economy and lousy health system come from? Health systems cannot be repaired unless political institutions are repaired as well.
THE GLOBAL HEALTH LANDSCAPE
Water, water, everywhere, Nor any drop to drink.
—Samuel Taylor Coleridge, “The Rime of the Ancient Mariner”
With global climate change and the human destruction of natural protective barriers, such as mangrove forests, many of the world’s coastal regions are now exposed to cyclical flooding. This, in turn, leads to destruction of homes and livelihoods. Many of these areas will one day be permanently under water because global warming exacerbates the destruction already done by human habitation (Bush et al., 2011).
The Polynesian island nation of Tuvalu, for example, is only 4.5 meters above sea level, and it will be uninhabitable by 2050 (Connell, 2003). It is one of twenty-two Pacific island nations. Together, these nations contain seven million inhabitants that, altogether, contribute 0.06 percent of global green- house gas emissions. But these nations will suffer a disproportionate blow
xx I N T R O D U C T I O N
from the climate changes caused by their wealthy, industrialized neighbors, particularly China and the United States. On Tuvalu, the government is arrang- ing to move the remaining ten thousand residents off the island. The residents will try to establish themselves and earn their living in countries such as New Zealand and Australia. They will disperse, and linguists expect the Tuvalu language to disappear within two or three generations (Farbotko, 2005; Hammond, 2009).
Even without forced migration and displacement, flooding greatly increases human exposure to infectious agents. Sanitation systems become useless as sewer water mixes with rising ocean waters. On a planet with an expanding population, there is too much water.
Perhaps an even bigger problem arises from the damming of rivers and water pollution from industry and human settlement, choking off vital inter- national waterways. With irrigation and damming, many major rivers fail to reach the sea at all. Those that do are often contaminated with salt, lead, mercury, pesticides, trash, and sometimes with thick black toxic sludge that no one dares to test. Some inland seas and lakes, such as the Aral Sea, have become either too dry or too polluted to sustain life, let alone use as a source of drinking water (figure I.1.). This water shortage problem is only getting worse with climate change. There is too little water to sustain the rising human population.
Figure I.1. This river makes finding recyclables easy.
Source: Copyright © Jurnasyanto Sukarno/epa/Corbis.
I N T R O D U C T I O N xxi
Thus, the global water supply presents major public health challenges not only because there is massive flooding resulting from human activities, but also drought resulting from human activities. There is simultaneously too much water in some places and too little water in others.
Low-income nations are growing at a blinding pace, even as they are having trouble supporting the people that are already there with their already weak institutions. Rising populations lead to poverty, pollution, human waste, and overcrowded schools. Sub-Saharan Africa and India are growing at such a rapid pace that it seems that many regions cannot overcome the poverty trap. A poverty trap occurs when the conditions underlying poverty prevent poor people (or their children) from escaping poverty. In this case, they cannot eat, and without adequate nutrition they cannot fight off infectious diseases or learn in school. This combination of disease and undereducation makes it almost impossible for future generations of children to escape poverty, thus perpetuating the trap from one generation to the next. There are too many people.
At the same time, rich nations are in stark population decline. Japan’s birthrate is so low that, by 2050, the country is projected to be half the size it was in 2004 and its social services will be straining under the load of one million people over the age of one hundred. If trends continue, most European nations, along with Chile, Singapore, South Korea, and China, will soon follow in Japan’s footsteps. There are too few people.
Thus, there are no simple trends in public health. We do not simply have too much water or too little, too many people or too few. The fundamental questions in public health are complex and sometimes paradoxical. Most common health problems are local. Nevertheless, there is emphasis on the global, the buzzword of the early twenty-first century. This suggests that our policies are best directed transnationally.
Economic and public health projects fail time and again because global institutions tend to take one policy and apply it to all localities as one giant bandage. Many of the misadventures of global health agencies can be attrib- uted to thinking globally rather than locally. For instance, the International Monetary Fund (IMF) and World Bank got together in the 1980s and contrib- uted to the “Washington Consensus,” or the idea that rising debt in low- income countries can be addressed only by tough love. (This is a simplification of a very complicated and controversial topic. We will keep it at this simple level for now and expand later.) The Washington Consensus probably worked in some places, but in others it probably set the development agenda back a few decades.
The structural adjustment programs recommended by the IMF and World Bank (described in more detail in chapter 1) essentially led to the wholesale destruction of the middle class in sub-Saharan Africa. These “programs” required cuts to nations’ social programs, such as health, education, and
xxii I N T R O D U C T I O N
transportation, along with other economic changes. As a result, sub-Saharan Africa has never really recovered. The WHO’s recommended tuberculosis treat- ment program did not take into account local patterns of drug resistance (Khan, Muennig, Behta, & Zivin, 2002). People living in areas where the drugs simply did not work were treated so many times they sometimes died from the treat- ment rather than the disease (Farmer, 2004).
Although there is no such thing as a one-size-fits-all solution to economic, health, or education policies, global public health does exist. Pollution, infec- tious disease, people, and products all cross borders. These problems exist because countries with weak pollution controls and cheap labor tend to be more attractive for business investors. Global environmental regulations would go a long way toward solving problems like these.
A more nuanced vision of health is needed to solve “global” problems. Poverty might be viewed as a global phenomenon, but if so, it is certainly very different in Germany than it is in Sierra Leone. Despite a proliferation of doctors, journalists, and even clowns “without borders,” borders most defi- nitely exist, with very real consequences to the lives of those who live within them. Habits, laws, social networks, means of grievance, economic stability, and stratification and mobility by class, race, space, caste, and language— institutions—vary profoundly from one place to the next. So, why would a one-sized formula for development or public health fit all?
If global is such a misused word, why is it in the title of this book? Ulti- mately, policy responses to most local public health problems are shaped by and require global governance. And this brings us to the focus of this book. We ask, “How can we better understand global health problems and strengthen the institutions that fix these problems?” We do our best to teach students the status quo and then try to tear it apart. We ask whether the current set of buzzwords and policies are really going to address the problems that they set out to fix. By dissecting these problems as critically as possible, we hope that the student can come to a better understanding of the issues altering the world’s health and well-being.
ABOUT THE BOOK
The remainder of the book is organized as follows. Part 1, which consists of chapters 1 and 2, focuses on the foundational basics of global health. In chapter 1, we give a brief history of major historical forces, such as industri- alization and urbanization, that helped to shape the major epidemiologic trends and public health challenges we face today. Because population health outcomes are integrally tied to economic and human development overall, and because they increasingly cross national borders, we emphasize the ways in
I N T R O D U C T I O N xxiii
which intergovernmental institutions and international actors have struggled to implement policies that are coordinated and appropriately contextualized.
In chapter 2, we introduce China, Chile, and a state in India called Kerala as case studies. We use these case studies to explore how different types or sets of social and economic investments influence health and why. We chose these case studies because they represent different types of governance (demo- cratic and nondemocratic) and different types of social investments (social investments versus free market). Kerala has generally been democratic in gov- ernance but has elected communists to power for long stints punctuated by more market-leaning officials. Chile has experienced periods of heavy social investment and periods of heavy social divestment. We revisit these three political economies again in chapter 7.
For instance, some nations that make effective investments in basic educa- tion might gain more in longevity than nations that invest in universal medical care. Although medical care treats disease after it has already struck, basic education provides a survival toolkit. In Darwinian terms, education can be used to optimize one’s environmental niche for survival over the course of an entire life. This way, in some cases, education can prevent disease before it has a chance to strike.
Part 2, “Global Health and the Art of Policy Making,” will help students to identify the major policies shaping global health and will critically investi- gate how these policies might be improved or better implemented. Chapter 3 presents the predominating diseases in different development contexts. Chap- ter 4 looks at the aid that is delivered to address this burden of disease. Chapter 5 explores health delivery systems that are charged with using this aid to reduce the burden of disease, and chapters 6 and 8 investigate how effective global governance is at helping low-income nations stem disease and to pre- vent it from spreading between nations (first examining social policies and then the global governance institutions that implement these policies).
Finally, part 3 takes a look at some of the issues and cutting-edge solutions in global health today. Chapter 9 discusses poverty as the central node in a complex web of public health challenges, the ways in which poverty manifests differently in low- versus high-income countries, and what antipoverty pro- grams should look like. Chapter 10 reviews some of the ways in which poor physical environments—especially lack of sanitation, air pollution, and outer- ring development and urbanization—lead to poor population health. Chapter 11 takes a look at how our social environments, especially social forces such as race and gender, shape patterns in health outcomes. Chapter 12 examines challenges in trade liberalization, especially nations’ attempts to avoid the so-called resource curse, whereby countries with great natural resources sur- prisingly do worse in terms of economic, social, and human development. Chapter 13 focuses on cutting-edge solutions to addressing these problems.
xxiv I N T R O D U C T I O N
These include changes in how we think about the cities we live in, innovative ways of incentivizing people to be healthier, and radical reshaping of our drug and immigration policies. As these chapters suggest, students studying global health need to analyze problems and potential solutions on many levels— individual, local, national, and international—at once. Chapter 13, our conclu- sion, attempts to articulate emerging trends and next steps in global health by presenting several prominent case studies of social policy interventions.
As a final word, we should note that instead of listing key concepts in sequential order, we try to revisit and discuss certain complex themes through- out the book. So, for example, we do not have a chapter on epidemiology (the study of health problems in populations). Such a chapter would be full of information on how to calculate disease rates and how to conduct public health studies. Instead, we mention the major bits of epidemiology that you will need to understand how to study global health as they arise in real-life situations or in the news. For example, when we discuss the politics of making policies, we talk about how to understand how policies are tested and improved. It is here that the relevant concept in epidemiology is briefly discussed, and always within the context of a real-world example. In social environments and health in chapter 13, for instance, we discuss how, from the standpoint of maximizing health, girls tend to benefit more from education than boys. This is because girls respond to education by having fewer children when they become women (partly because it may allow them to make better-informed decisions and to participate in the workforce). Many researchers believe that educated women also tend to pass their knowledge on to their children and thereby help increase their children’s survival to a much greater extent than educated men. But in some nations, such as India, boys tend to be favored over girls. This is true not only when it comes to deciding which children go to school but also which children get fed when food is scarce. Because food is needed for education, girls lose out twice over. In fact, in India, China, and parts of the Middle East, there are many fewer girls than boys because some families abort female fetuses and some starve or otherwise neglect female children in order to better provide for males. This has led to massive gender imbalances, a phenomenon known as missing women. Although this has been a long-standing problem, it may have been made worse by the advent of low- cost ultrasound machines that allow for the quick determination of fetal sex and sex-selective abortions. This section builds on discussions on the root causes of health, governance structures, and disparities in outcomes from previous chapters.
Because of the pedagogical approach we use, readers who read this book front to back will benefit most. It also helps to read it completely through because, after introducing a concept, we try to revisit it, building on it in a fresh way. This allows the mind to naturally learn and absorb the material
I N T R O D U C T I O N xxv
without the need for notes. Although readers who skip around may occasion- ally encounter unfamiliar concepts, the good thing about our approach is that we redefine and reintroduce more-complex ideas as they arise and let less- complex ideas relax comfortably where they first appear.
One consideration that readers should keep in mind is that all works in the social sciences—be they works of journalism or academic articles—are influenced by the opinions of their authors. Researchers tend to focus on topics and concerns that they believe in or feel emotionally compelled by and—often unwittingly—interject their beliefs in a search for truth in numbers. Negative findings often go unpublished in the academic literature because editors do not see them as likely to promote their journals. Few fields are as rife for editorials presented as fact than global health. Authors of textbooks are no different. We attempt to bring you informed opinion that covers multiple sides of the issues we present.
ACKNOWLEDGMENTS
Elly Schofield, who worked hard to smooth and unify the text, and Jana Smith, who wrote most of the class exercises, were graduate students at Columbia University at the time of writing. Muhiuddin Haider, Marilyn Massey-Stokes, and Joyce Pulcini provided thoughtful and constructive comments on the complete draft manuscript. Javeria Hashmi and Amira Ahmed, then students at Brooklyn College, provided invaluable research assistance.
KEY TERMS epidemiology poverty trap
structural adjustment programs
Washington Consensus
REFERENCES
Bales, K. (2004). Disposable people: New slavery in the global economy. Berkeley: University of California Press.
Bush, K. F., Luber, G., Kotha, S. R., Dhaliwal, R. S., Kapil, V., Pascual, M., et al. (2011). Impacts of climate change on public health in India: Future research directions. Environmental Health Perspective, 119(6), 765–770. doi: 10.1289/ ehp.1003000.
CIA. (2009). Life expectancy at birth. Available online at www.cia.gov/library/ publications/the-world-factbook/rankorder/2102rank.html
Connell, J. (2003). Losing ground? Tuvalu, the greenhouse effect and the garbage can. Asia Pacific Viewpoint, 44(2), 89–107.

Get Your Custom Essay Written From Scratch
We have worked on a similar problem. If you need help click order now button and submit your assignment instructions.
Just from $13/Page
Place an Order
xxvi I N T R O D U C T I O N
Farbotko, C. (2005). Tuvalu and climate change: Constructions of environmental displacement in the Sydney Morning Herald. Geografiska Annaler: Series B, Human Geography, 87(4), 279–293.
Farmer, P. (2004). Pathologies of power: Health, human rights, and the new war on the poor. Berkeley: University of California Press.
Hammond, R. (2009). Tuvalu: Islands on the frontline of climate change. London: Panos Pictures.
Khan, K., Muennig, P., Behta, M., & Zivin, J. G. (2002). Global drug-resistance patterns and the management of latent tuberculosis infection in immigrants to the United States. New England Journal of Medicine, 347(23), 1850–1859.
Kruk, M. E., Galea, S., Prescott, M., & Freedman, L. P. (2007). Health care financing and utilization of maternal health services in developing countries. Health Policy Plan, 22(5), 303–310. doi: 10.1093/heapol/czm027.
Oeppen, J., & Vaupel, J. W. (2002). Broken limits to life expectancy. Science, 296(5570), 1029.
WHO. (2012). World Health Organization health statistics: Mortality. Available online at www.who.int/healthinfo/statistics/mortality/en/index.html

Introducing Global Health
PART ONE
The Basics of Global Health
CHAPTER 1
A Very Brief History of Global Health Policy
3
KEY IDEAS
• Although people often think of health as a question of genetics and biology, the field of global health is now largely focused on how policies and social environments affect mortality and morbidity.
• The past century, marked by the second Industrial Revolution and economic development around the world, has brought improvements in standards of living. But industrialization in low-income countries poses new threats to human health, primarily through environmental degradation and occupational hazards.
• Better nutrition and basic infrastructure such as sanitation systems have helped many societies to experience an epidemiologic transition, when infectious diseases drops and life expectancy greatly increases.
• Global health policies are now partly shaped by intergovernmental institutions, such as the United Nations (UN), formed after World War II. These institutions are chiefly concerned with economic develop- ment, human development, and preventing war.
• Although fiscal austerity, trade liberalization, and the so-called Washington Consensus dominated many intergovernmental policies in the 1980s and 1990s, more recent policies have begun to acknowledge that multiple models for development are needed.
4 C H A P T E R 1 : A V E R y B R i E f H i s T o R y o f G l o B A l H E A l T H P o l i C y
HEALTH AND PUBLIC POLICY THROUGH THE TWENTIETH CENTURY
People tend to think of health as a question of genetics and biology but our environment, more than our genetic code, probably explains why our feet would pop out of the bottom of the Renaissance-era beds you see in current museums. Over time, the environments around us have tended to improve our health prospects. New medical technologies, access to better nutrition, and fewer life-threatening hazards in our everyday work lives have helped increase global life expectancy. In the healthiest nations, life expectancy has increased from fifty years in 1900 to sixty-five years in 1950 to eighty years in 2000. In a much more extreme trajectory, Cuba’s life expectancy moved from nineteen in 1900 to fifty-seven in 1950 to seventy-seven in 2000 (figure 1.1).
Figure 1.1. Changes in life expectancy from 1940 to 2009 in some of the nations that we discuss extensively in this book.
Source: World Health Organization. Rendered by Gapminder.org.
10
20
30
40
50
60
70
80
90
19 40
19 43
19 46
19 49
19 52
19 55
19 58
19 61
19 64
19 67
19 70
19 73
19 76
19 79
19 82
19 85
19 88
19 91
19 94
19 97
20 00
20 03
20 06
20 09
Chile
China
Cuba
India
Japan
Mexico
Sweden
United States
Zimbabwe
Li fe
e xp
ec ta
nc y
Year

H E A l T H A n d P u B l i C P o l i C y T H R o u G H T H E T w E n T i E T H C E n T u R y 5
In this chapter, we give a very brief history of some of the key trends that have shaped population health worldwide in the past few hundred years. Along the way, we will introduce some of the key public health issues that we will dive into more deeply later in the book.
Communities and Health
In the days when humans lived as hunters and gatherers, the best hunters and the best gatherers were almost certainly more likely to get the hottest partner around. But for most people, eating and being eaten were probably bigger concerns than one’s position in the social pecking order (Diamond, 1998). These two problems—finding food and fending off attacks—were greatly miti- gated by agrarian lifestyles, introduced around ten to twelve thousand years ago (Denham et al., 2003). By keeping livestock, farming, and gathering in communities large enough to scare off predators, humans greatly increased their chances of survival.
When food could be had with less physically demanding work, a sedentary lifestyle and more rapid population growth occurred. But the agrarian life also introduced new problems. For one, there was a need for division of labor and governance. Thus, formal social hierarchies were introduced. Those at the top were more or less ensured access to food, a mate, and superior protection from threats than those at the bottom.
Europe and Asia had some native plants and animals that really benefited the people there, including barley, two types of nutritious wheat, and easily domesticated goats and sheep for wool, leather, and meat. The grains could be stored for a long time without getting spoiled, unlike fruits and vegetables. European and Asian people were also lucky because their lands were contigu- ous on an east-west axis so they could reach one another and trade products by land. Donkeys and horses from the Middle East also helped these people trade and flourish. With luck, work, and trade, the people of Europe, the Middle East, and Asia cultivated a wide range of nutritious crops and domes- ticated animals. Folks in Africa, however, mostly dealt with untamable animals, such as lions and leopards; they continued to hunt and gather (Diamond, 1998).
Of course, up until relatively recently in human history, few people died of diabetes and hypertension. It is true that the automobile, television, and high-caloric food all play big roles in the predominance of heart disease as a major cause of death (Lowry, Wechsler, Galuska, Fulton, & Kann, 2002). But few people died of these conditions mostly because more often people died of infectious disease before they had a chance to get their first heart attack. Over time, the people outside of the Americas developed immunity to common pathogens. There is even evidence that they evolved by natural selection to
6 C H A P T E R 1 : A V E R y B R i E f H i s T o R y o f G l o B A l H E A l T H P o l i C y
become resistant to some diseases, such as the plague (Galvani & Slatkin, 2003). When Europeans encountered Native Americans during the colonial period, they brought diseases, such as smallpox, that cut down half or more of some tribal populations. Likewise, endemic malaria in Africa and yellow fever in parts of Asia killed many Europeans during the colonial era (Diamond, 1998).
Thus, by transitioning from hunter and gatherer lifestyles to an agrarian and feudal life, old threats to survival were conquered but new ones were introduced. These newer problems tended to require higher-scale cooperation and collective problem solving so that health policies began to evolve not just in small villages or clans but also in nation-states and civilizations.
These problems included, among many others, the need to dispose of all the feces produced by large collections of people living together and to ensure clean water to drink. Some human civilizations were able to tackle these problems quite early on. Many ancient civilizations show evidence of complex water delivery and basic sewage disposal systems. Other nations to this day cannot effectively provide these basic provisions, even though it has never been cheaper or easier to provide them. Thus, we see that a given community or nation can unambiguously benefit from new ideas and technologies only if it can govern well enough to counteract the unintended consequences of col- lective living and make full use of technology so that it does more benefit than harm. (See figure 1.2.)
National Policies and Health
In the late 1700s and 1800s, manufacturing technologies and processes gave rise to the first Industrial Revolution. This opened the door to the develop- ment of new medicines and life-saving goods. In the first Industrial Revolution, the development of refined coal and the steam engine helped create a new manufacturing sector, one in which machines helped with agriculture and transport. New tools and machine parts were also made. This, in turn, led to new machines that greatly facilitated the production of textiles (with cotton spinning machines), paper, and glass. Water was easier to pump out of mines. The advent of the coal-powered steam engine transformed trade and migration along new rail routes, and the rediscovery of concrete (which had been lost for thirteen hundred years) reinvigorated building construction techniques.
The second half of the nineteenth century brought the second Industrial Revolution, with assembly-line production of goods, the internal combustion engine, and electricity power generation. This era is renowned for the develop- ment of steel, chemical industries, petroleum refinement, the car industry, and hydroelectric power.
H E A l T H A n d P u B l i C P o l i C y T H R o u G H T H E T w E n T i E T H C E n T u R y 7
But just as agrarian living created some problems and solved others, industry posed new health threats. In England, for example, the population had remained steady at six million from 1700 to 1740. After the first Industrial Revolution, the population increased from eight million in 1800 to seventeen million in 1850 and then to almost thirty-one million in 1900 (Ashton, 1997). Yet, despite this population increase, childhood survival rates remained abys- mally low. Children were not afforded the chance to receive an education, and they were expected to work. The Industrial Revolution made the hazardous conditions of child labor a lot more visible than they were before and was documented by writers such as Charles Dickens. Children died in explosions in mines; they were burned and blinded making glass. “Matchstick girls” developed phossy jaw, or phosphorous necrosis of the jaw, and then organ failure while making matches (Myers & McGlothlin, 1996). The new, dense
Figure 1.2. Residents live near a waterway containing raw sewage and trash in Chennai, India, 2013.
Source: Flickr/McKaySavage.
8 C H A P T E R 1 : A V E R y B R i E f H i s T o R y o f G l o B A l H E A l T H P o l i C y
slums brought open sewers, polluted water and air, and persistent dampness, leading to widespread cholera, tuberculosis, lung diseases, and typhoid (Ashton, 1997). (See figure 1.3.)
Technological advances such as steel provided bold new opportunities to bring consumer goods to market that have greatly improved our quality of life, but they came at an enormous cost in terms of pollution, depreciation, and global climate change. Cancers, heart disease, neurological diseases, kidney disease, and liver disease slowly began to take center stage as infectious dis- eases were conquered and lifelong exposure to toxic hazards increased in industrializing nations (Parkin, Bray, Ferlay, & Pisani, 2005; Trichopoulos, Li, & Hunter, 1996). Mass cultivation of food products allowed society to feed its rapidly growing population, but it also allowed the tobacco industry to greatly expand production and market its product to a broader portion of the population.
In the United States, environmental degradation culminated in a number of river fires that took large crews of firefighters to extinguish. Factories along the Cuyahoga River in northeastern Ohio had been dumping flammable sol- vents into the water, which were probably ignited by a passing train. When this river caught fire in 1969, the last of many fires, it called national attention to waterway pollution in the United States.
Figure 1.3. During the Industrial Revolution, the advent of coal and steam use as energy sources became widespread.
H E A l T H A n d P u B l i C P o l i C y T H R o u G H T H E T w E n T i E T H C E n T u R y 9
Recently, many more severe incidents of waterway pollution in China have received notice. One factory spill effectively killed all life in the river that sup- plied water to Harbin, one of China’s largest and most important cities. This benzene spill turned the river into a giant foamy, frothy mess. Chinese officials told citizens that they were shutting the city’s water off for “routine mainte- nance” until the spill passed, but the water was probably still unsafe for some time (and by many accounts still is because so many pollutants were there to begin with) (see figure 1.4).
These examples highlight how industries bringing in economic growth and improvements in our standard of living also bring about new threats to human health through environmental degradation and occupational hazards. Cer- tainly, even today, and even in wealthy countries, environmental problems cause concerns. But in wealthy countries, these problems have been mitigated with national regulatory policies that allow their citizens to enjoy the benefits of these technologies while reducing their harms (Schmidheiny, 1992). For example, cleaner, more efficient forms of power generation have meant that even coal-fired power plants produce significantly less harmful pollutants today than they did just a few decades ago. China is trying to move toward more sustainable development, too, as it becomes a wealthy country, but the potential scope of the environmental destruction in a country with 1.4 billion people adds a good deal of concern. There is hope, however, because indus- trialization in the modern era of green technology also offers the opportunity to leapfrog right over the problems of the industrial revolution if China is willing to make the investments (Schmidheiny, 1992).
The Industrial Revolution is widely seen as a public health disaster by academics. It brought overpopulation, overcrowding, and pollution on a wide scale. How could it be anything else? We have to keep in mind, though, that the Industrial Revolution was the forerunner of modern industrial society. Today, its pollution continues to contribute to despecia- tion (the loss of animal and plant species), global warming, and cancer (among many other diseases) but it has also led the way for modern industrial civilization replete with its diverse food supply, nice homes, trains, hospitals, and, yes, consumer products that improve our quality and length of life. The question is not so much whether modern industrial civilization is good or bad, but rather how we reduce the harms that it produces while maximizing the benefits.
WAS THE INDUSTRIAL REVOLUTION A PUBLIC HEALTH DISASTER OR BOON?
10 C H A P T E R 1 : A V E R y B R i E f H i s T o R y o f G l o B A l H E A l T H P o l i C y
Indeed, there is a global push to use technology to solve the very prob- lems that technology creates. With advanced water and sanitation systems, it became possible to dispose of sewage and deliver clean water even in dense urban environments. These advances helped all but rid nations of diarrhea, greatly reducing the mortality of children under five (Gulland, 2012; Mayor, 2012). Greater nutrition also helped us stave off infectious disease, and mos- quito control reduced malaria and other illnesses. These advances led to what is referred to as an epidemiologic transition. This occurs when infectious disease drops to the point that death among a nation’s youth becomes a rare event and life expectancy greatly increases (Omran, 1971). This way, we see that the progress of human civilization has, in some ways and in some places, enabled the benefits of collective living—a reliable food source and protection from predators—without many of the downsides. Thanks to the epidemiologic transition, some nations enjoy average life expectancies that
Figure 1.4. In 2005, a chemical plant explosion in Jilin, a province in northern China, led to a massive release of nitrobenzene into the Songhua River. The water became foamy and was too dangerous to drink. The spill at first was covered up by the Chinese government, but the truth was disclosed after large numbers of dead fish washed ashore in the large northern city of Harbin and residents began to panic.
Source: www.greendiary.com/polluted-water-may-affect-four-million-people-in-china .html.

Get Assignment Writing Help

Our experts are ready to complete your assignment, course work. essay, test, dissertation, research paper, quiz

Get Started
T H E A G E o f G l o B A l H E A l T H P o l i C y 11
are approaching eighty-five years. This would have been unthinkable not too many decades ago.
Public health is built on a discipline called epidemiology, which we men- tioned in the introduction to this textbook. Epi means on top of and demos means people. Thus, epidemiology could be the study of things that sit on top of people but that would be silly. In fact, it is the study of disease in populations. This disease can have roots in infectious agents, genes, the social environment, or some combination of these factors. As a result, epidemiology, and public health more generally, tends to be a science that combines genetics, biology, medicine, sociology, economics, political science, and urban studies, just to name a few disciplines.
EPIDEMIOLOGY IN PUBLIC HEALTH
THE AGE OF GLOBAL HEALTH POLICY
The epidemiologic transition also leads to large increases in the number of people alive on earth, posing yet another challenge. Previously we mentioned that collective living brought people together into villages and then cities and nations, opening the possibility of war.
It also brings new, improved ways of killing people. In the beginning of the twentieth century, technologies enabled us to bomb people from the air, killing dozens of people at a time from a single biplane. By the end of the twentieth century, we could do this from space (in the form of an interconti- nental ballistic missile), with the potential to kill everyone on the planet. (On the bright side, there is a global treaty that keeps us from storing the weapons in space. In the event of nuclear war, this should prolong the survival of human civilization by up to six minutes.)
More people and better killing technologies, such as missiles, mean larger- scale and more violent conflicts. With dense collections of people, alliances between civilizations with similar goals were formed. This meant that wars could become quite large and devastating in scale, as evidenced by the World War I. In that conflict, new technologies such as airplanes and toxic chemicals were used as weapons with effects that were so devastating that international agreements were drafted to ban their use during warfare. These agreements gave rise to the notion of “civilized warfare,” or wars in which attempts have since been made to limit the scale of human suffering brought about by new technologies, such as germs and chemicals.
12 C H A P T E R 1 : A V E R y B R i E f H i s T o R y o f G l o B A l H E A l T H P o l i C y
Indeed, after World War I, it became apparent that global governance— the effective formation and application of policies across nations—would be needed to prevent a recurrence of the large-scale loss of life that came as a result. Still, efforts at improving governance did not go so well. The League of Nations, formed to unify the nations of the world, did not treat nations equally. Those that lost out opted out in anger. This opened the door to yet another worldwide conflict.
Well over sixty million people lost their lives during World War II, and countless others lost their homes and livelihoods as entire cities were leveled. Moreover, when atomic bombs were dropped on two cities in Japan, it became painfully clear that new technologies would outstrip our ability to regulate their use in conflict.
World War II created strong incentives for new institutions aimed at peacekeeping and financial cooperation. The leading economic powers formed new intergovernmental institutions such as the UN, which was primarily charged with creating dialogue between nations in order to stem wars. They also formed the International Bank for Reconstruction and Development, now commonly known as the World Bank, which was charged primarily with rebuilding Europe. Finally, the IMF was formed to reduce the chance of another global recession, one of the many major factors thought to precipitate the war.
The reconstruction of Europe was efficient and effective. Entire cities were rebuilt in just a few short years. To many, it seemed as if a new dawn of global governance had arrived. Once Europe was more or less completed, attention focused on poorer nations in Asia and Africa.
The thought was that global governance would be one of the final solu- tions to humankind’s perpetual public health problems. With an effective global government, poor nations could be helped to develop, war could be ended with global police actions, and global institutions would thrive in a highly regulated environment. Of course, sadly, this is one innovation in the history of humankind that did not come to pass.
Still, they gave it a good shot. Following World War II, colonial powers began a slow process of decolonization. Poor nations were given autonomy and aid but were left with little by way of social institutions. As mentioned in the introduction to this book, institutions include banks, governmental agen- cies, and enforceable laws. Without these institutions, the nations were unable to absorb development aid. That is, there was nowhere to put the money and there were no agencies to give it to. The ability of a nation to effectively use aid is referred to as absorptive capacity.
If a country receives ten million dollars but has no banks to safely put the money in, the money cannot be stored. If there is no ministry of education to build local schools, the money cannot be spent. In sum, without adequate
T H E A G E o f G l o B A l H E A l T H P o l i C y 13
economic, social, or political structures in place to absorb and distribute the money, development will happen slowly if at all.
Let’s take a look at one more example to drive the point home. To build a school, a region requires a department of education that is capable of man- aging construction, hiring teachers, and managing the schools. Efforts would be coordinated with other agencies, such as those of transportation, budgeting, and social work. For instance, the department of transportation would help ensure that there is a road to get to the school. These complex coordination efforts require top-down management. The president has to select ministers who are good managers. These ministers, in turn, have to select good manag- ers in a complex array of departments below them. And these departments must all coordinate their efforts with one another.
Of course, the alternative is to conduct all of the development from the outside, bypassing local banks and ministry offices, but that means that these social institutions never get built so that the programs must be administered by whoever is giving the money. That is a pretty suboptimal situation when the management is coming from a very different cultural framework with very little local knowledge.
Further, the effectiveness of aid programs was compromised by political concerns. In the post–World War II era, the United States was by far the world’s largest aid donor. But in that country, aid was framed in terms of national security. That is, it was mostly delivered as a counterbalance to the Union of Soviet Socialist Republics (USSR). By the 1950s, the Cold War was well under way. The United States and the USSR began to see some governments of poor nations run by sympathetic dictators as preferable to potentially unsympathetic democracies. Dictators were much easier to control and entice than democratic governments, after all. And neither the United States nor the USSR felt it could afford to lose any territory in the global struggle that pitted one political economy against the other. As one of many examples, in 1954, the United States overthrew a Jeffersonian-based democratic government in Guatemala in part because the government was left leaning (Schlesinger & Kinzer, 1982).
In 1944, Guatemala became one of the few countries in the world with a democracy styled after the United States (Schlesinger & Kinzer, 1982). This should have heralded the beginnings of a period of peace and eco- nomic prosperity that had the potential to spread to neighboring nations. In fact, despite the expected bumps along the way, Guatemala was doing
THE 1954 GUATEMALAN COUP D’ÉTAT
14 C H A P T E R 1 : A V E R y B R i E f H i s T o R y o f G l o B A l H E A l T H P o l i C y
At the start of the 1960s, the Kennedy administration in the United States set out to win the hearts and minds of people in poor nations (democratic or otherwise) with a good deal of development aid. If the problem with develop- ment was too little aid, the 1960s should have solved that problem. Wealthy nations and the citizens of wealthy nations contributed to this agenda, leading to a decade of unprecedented giving.
However, by the end of the decade, only modest economic or human development had actually taken place. It had become increasingly evident that it is difficult to impossible to speed poor nations through the cycle of develop- ment in the same way that Europe was redeveloped after World War II.
quite well as an exemplar for what can be achieved when dictators are replaced with a representative government. When he was elected in 1954, President Jacobo Árbenz Guzmán responded to the demands of his still quite poor electorate with a series of programs designed to alleviate poverty. Among these was a proposal for land reform—a policy that some communist nations have employed. Although land reform takes many different shapes, it is at its essence a program that purchases or expropri- ates land from private or government entities and then gives the land to poor people to farm. In theory, this provides low-income families with autonomy, a means to feed themselves, and a strong economic asset that can be passed down from one generation to the next. Such an asset can also be used as collateral for loans to improve farming operations, to build a house, or to start another business. With a little prodding by a major corporation that held most of the land that was to be expropriated (at its declared tax value), the US government saw this as a push for communism in its backyard. The Central Intelligence Agency therefore began a successful campaign to depose President Árbenz, installing the ironically named Colonel Carlos Castillo Armas (armas being the Spanish word for weapons). This act ultimately led to a thirty-six-year civil war that ended the lives of perhaps hundreds of thousands of Guatemalans (Gleijeses, 1992). In addition to the direct bloodshed, it greatly limited Guatemala’s ability to build a public health infrastructure or to otherwise develop economically. To this day, Guatemala is one of the poorest nations in the Americas, and its life expectancy of seventy-two years ranks it in the bottom third of all nations worldwide.
T H E A G E o f G l o B A l H E A l T H P o l i C y 15
Economic development—the growth of national economies—was slow in the 1960s. This is in part because, even after decades of development work, poor nations still had weak institutions. Thus, without the presence of good banks, even in the absence of thieving dictators, the money could not be easily spent. Another interrelated problem was that the Cold War continued on at full steam so the United States and the Soviet Union maintained strong interests in maintaining puppet governments around the world, virtually all with poor management skills.
A final possible problem, one that was only somewhat recognized at the time (and is still contentious), is that aid may itself pose challenges to devel- opment. This can occur because providing a reliable source of funding incen- tivizes corrupt people to go into government (so that they can steal it). Some also argue that aid creates dependence on outside help. This way, there is little incentive to build the complementary institutions required to ultimately form a mature and stable functioning government (e.g., a system of taxation). We will cover this hypothesis in more detail in chapter 3.
Human development was slow in part because almost none of the money given away was actually going to alleviate poverty. Human development, as measured by the UN Human Development Index (HDI), focuses on the growth in life expectancy, literacy, and standard of living (purchasing power) in a nation. (At the time of press, there were efforts to expand this measure beyond just these three measures.) Rather than focusing on schools or other institutions that directly benefited the poor, aid was mostly going to large infrastructure projects, such as dams, that were intended to help these countries move along economically. There is logic to this. Dams can provide needed electrical power for job-creating factories. But human development requires more than electric- ity. Without investing in schools, it becomes impossible to provide the educa- tion needed to ultimately transition an economy into one with skilled jobs that offers a living wage. Thus, the world of the poor entered the 1970s with only modest improvements in literacy, life expectancy, and economic growth.
The good news is that some nations, especially in Asia, did plant the seeds for future growth, investing in schools and agriculture in the post–World War II period. (Yes, a good education can be accomplished without electricity from dams.) The agricultural efforts were more or less led by a man named Norman Borlaug who helped usher in the green revolution (Evenson & Gollin, 2003). The green revolution involves investments in hearty grains and the use of cutting-edge crop technologies, particularly for poor nations. These benefits were slow to come, and, sadly, although these efforts were slowly building through the start of the 1970s, the world saw another governance setback that helped derail some of the progress in education and agriculture that had been realized up until then.
16 C H A P T E R 1 : A V E R y B R i E f H i s T o R y o f G l o B A l H E A l T H P o l i C y
THE FALL OF GLOBAL GOVERNANCE
The 1970s saw the formation of the Organization of the Petroleum Exporting Countries (OPEC) (Barsky & Kilian, 2002). These were generally poor Middle Eastern countries. However, they were able to coordinate spikes in oil prices worldwide (primarily with the intent of punishing the United States for assist- ing Israel). The plan worked, but it also hurt low-income nations that could not afford the high oil prices. Moreover, the OPEC countries did not have mature economic institutions, such as banks, and their governments had to deposit their newfound riches in the banks of the Western countries they meant to punish.
Of course, poor nations needed cash to pay for the higher fuel costs. Western banks, overflowing with petrodollars, then lent the money back to poor nations with interest. The result of this vicious cycle was skyrocketing debt in poor nations. Because fuel costs were so high, price inflation was running rampant. Central banks raised interest rates (thus encouraging people to save money instead of spend) to dampen inflation. This, in turn, meant that poor nations had to spend even more on their loan costs. Soon, it became nearly impossible for some nations just to pay the interest on all of the loans that they had taken out.
In the 1980s, Ronald Reagan and Margaret Thatcher were respectively elected to power in the United States and the United Kingdom. Their admin- istrations enacted what is now known as the Washington Consensus, or a set of economic mandates attached to aid dollars by multinational organizations, including reducing expenditures on government services (e.g., education, health, and transportation), privatizing government agencies, and removing trade barriers (Williamson, 1993) (see figure 1.5). This set of ideas was named the Washington Consensus because its two main intergovernmental actors, the IMF and the World Bank, sit across the street from one another in Washington, DC. A third important actor, the United States Treasury, is also close by.
As mentioned in the introduction, the IMF and the World Bank’s mandated structural adjustment programs (SAPs) were a set of rules (called condition- alities) that poorer countries were forced to adopt if they were to receive loans or aid from these agencies. These rules were designed to “adjust” the loan recipient country’s debt burden by reducing government regulations and expenditures. By reducing expenditures on schools, health care, transit, and other government programs, poor nations should, in theory, be better posi- tioned to pay off debt. By reducing regulations, such as environmental protec- tions, paperwork needed to do business, and so forth, business would start more easily and the economy should run more efficiently and therefore gener- ate more revenue for paying off debt. These structural adjustments often also
T H E f A l l o f G l o B A l G o V E R n A n C E 17
included currency devaluation, wage suppression, business deregulation, and lower taxes on imported goods.
Currency devaluation means that the nation’s currency becomes less valu- able than other nations’ currencies, such as the US dollar. This makes every- thing that the country produces much cheaper to those in other nations. (Those of you who have traveled to poor nations and have been awed at the purchas- ing power of your currency have reaped the benefits of some of these SAPs.) But SAPs also tended to be formulaic. So a country that relies on imports, such as Jamaica, would be expected to lower the value of its currency even though this would mean that imports would become more expensive.
Therefore, in many cases, these SAPs led to recessions and dramatic increases in poverty from which some countries have not yet fully recovered. Structural adjustment did help to reduce the debt burden, which by the 1980s led to a net flow of money from poor nations to rich nations in the form of interest payments. However, because it often forced governments to cut back on necessary public goods and spending as well as wasteful spending, it also
Figure 1.5. President Reagan meeting with Prime Minister Margaret Thatcher at the Hotel Cipriani in Venice, Italy, 6/9/1987.
Source: Photo courtesy of the Ronald Reagan Library. Available online at http:// www.reagan.utexas.edu/archives/photographs/large/C41109-27.jpg

18 C H A P T E R 1 : A V E R y B R i E f H i s T o R y o f G l o B A l H E A l T H P o l i C y
caused the virtual disappearance of the middle class, most of whom were government employees, in poor nations (Gaidzanwa, 1999; Moghadam, 1999).
The criticisms of the Washington Consensus do not end there. Joseph Stiglitz, a Nobel Prize–winning economist, points out that the economists making decisions at these institutions often saw the world in terms of math- ematical and theoretical relationships, without adequately examining what is truly happening on the ground. As a result, they recommended that countries withhold subsidies for fertilizer and seeds for their farmers, completely ignor- ing that the United States and Europe provide heavy subsidies for agriculture. Thus, for one, the Washington Consensus asked countries to compete in an idealized world. In reality, the playing field was far from level. This can result in failed crops and hungry people when agriculture is a nation’s main source of income. Most African residents live on less than US$2 a day, even as the average European cow receives approximately US$2.20 in subsidies each day (CFR, 2005).
The 1990s saw the end of the Cold War and thus there was less incentive for the United States and its allies to provide official direct assistance (ODA). This, coupled with the burgeoning HIV/AIDS epidemic (worsened by the impact of structural adjustment on public health infrastructure), resulted in declines in life expectancy in many African nations. In 1988, South Africa boasted of a per capita gross domestic product (GDP) of US$7,966, and a life expectancy of sixty-one years. Two decades later, their per capita GDP had improved a little bit and stood at US$9,429, but the average life expectancy had plunged to fifty-two years. But the decade also saw the stellar rise of formerly impoverished nations in Asia, a rise mostly attributed to investments in agriculture and education.
The 2000s saw the rise of humanitarian aid, with the world’s two richest men—Warren Buffet and Bill Gates—pooling resources to form the largest charitable organization yet, the Bill & Melinda Gates Foundation. Other forms of private giving increased, but so did government aid. China’s powerful manufacturing engine, coupled with unparalleled consumer spending in the United States, led to an enormous rise in the prices of raw materials such as oil, copper, and iron. But it also led to soaring economic growth in the places that supplied these goods, particularly Latin America and Africa. China, eager to fuel its manufacturing engine, turned to poor nations that were rich in mineral resources, often exchanging government aid for access to these resources (Michel, Beuret, & Woods, 2009). Moreover, China has been willing to go where few aid agencies dare, tapping into war-torn areas and highly corrupt governments alike. Thus it has served as a model and as an investor, ushering many nations into double-digit economic growth.
With all this money flowing into poor nations, particularly from China, the IMF—with all of its stipulations for aid—fell out of favor. In 2006, Turkey
T H E M i l l E n n i u M d E V E l o P M E n T G o A l s 19
was its main debtor, and the only large one in its portfolio. This led some to jokingly call the IMF the TMF, or Turkish Monetary Fund. Interest payments declined to the point that the fund had to sell off some of its gold assets. Then, in 2007, a real estate crisis struck wealthy nations, and they in turn became in need of structural adjustment. European nations received loans from the IMF, and the IMF was back in business. Ironically, during this crisis, few wealthy nations took up structural adjustment to the extent that they required poor nations to structurally adjust in the 1980s. Instead, they mostly printed money and embarked on economic stimulus programs. Yet it is good that they did not. Stimulation in many cases proved to be a good thing, because if wealthier nations such as China and the United States had not stimulated, the entire world economy might have ended up looking like the low-income nation economies did in the 1980s.
Despite the Great Recession, mostly the new millennium brought good news with respect to health worldwide. For one, we have witnessed effective public health campaigns directed at combating the tobacco and lead industries that have robbed humans of countless years of life and intellectual capacity. With these lessons, public health officials are moving against manufacturers of unhealthy foods, the coal industry and other heavy pollutants, and other industrial threats to human health. As with most advances, industry will move on to prey on less-developed countries, until those countries, too, can build effective institutions and regulatory agencies to address public health chal- lenges. Reductions in smoking rates in rich nations and increasing aid in very poor nations are two of the many factors contributing to the constantly bright- ening health picture worldwide at the time of the publication of this book at the end of 2013.
The improvements in global health coincided not just with the economic rise of low-income nations, innovative ways of tackling old public health prob- lems, and new investments in global health, but also with an ambitious set of goals forwarded by the UN called the Millennium Development Goals. Even with the global financial crisis of 2007, the economic rise of poor nations and improvements in basic sanitation, education, and immunization programs put some of these goals within reach.
THE MILLENNIUM DEVELOPMENT GOALS
Recognizing that modern health problems arise from policy failures, the UN set out to generate a set of goals that might be realistically achieved to move global health and development forward. These Millennium Development Goals were devised at the Millennium Summit in 2000 and were targeted at the poorest nations on earth, to be completed by 2015.
20 C H A P T E R 1 : A V E R y B R i E f H i s T o R y o f G l o B A l H E A l T H P o l i C y
The Millennium Development Goals comprise a set of eight goals:
Goal 1: Eradicate extreme poverty and hunger.
Goal 2: Achieve universal primary education.
Goal 3: Promote gender equality and empower women.
Goal 4: Reduce child mortality rates.
Goal 5: Improve maternal health.
Goal 6: Combat HIV/AIDS, malaria, and other diseases.
Goal 7: Ensure environmental sustainability.
Goal 8: Develop a global partnership for development.
Each set of goals contains a number of targets. For instance, the first goal, to eradicate extreme poverty and hunger, has the following targets:
Target 1.A: Halve, between 1990 and 2015, the proportion of people whose income is less than US$1 a day.
Target 1.B: Achieve full and productive employment and decent work for all, including women and young people.
Target 1.C: Halve, between 1990 and 2015, the proportion of people who suffer from hunger.
Although the goals may have seemed unrealistic at the time that they were formulated, progress has been made. Much of this is probably attributable to the huge economic success of China between 2000 and 2013, which lifted over four hundred million people out of extreme poverty within its borders alone. The extended reach of the Chinese miracle, with tentacles reaching as far as Africa and South America, has probably helped these nations’ economic prospects, lifting many hun- dreds of millions more out of poverty. In fact, most of the fastest eco- nomically growing nations on earth in 2013 were also among the poorest nations. A number of these poorer nations also used this windfall to implement massive social welfare and health programs in the first decade of the twenty-first century. It may well be that by the time you are reading this, extreme poverty is on track to disappear in some places. (Alterna- tively, you may be laughing at how naive that kind of a statement is. Publishing moves slowly but the world changes quickly.)
THE MILLENNIUM DEVELOPMENT GOALS
A n A l T E R n AT i V E H i s T o R y 21
AN ALTERNATIVE HISTORY
What you have read so far has been more or less told in various ways in books covering global public health (Black, 2002; Moyo, 2009). But we would like to tell an alternative history, one that looks a little rosier.
First, let us stop for a moment and imagine that after World War II devel- opment had been successful. When people spoke of development back then, they meant economic development. Imagine for a moment that sub-Saharan Africa had been as easy to build with development aid as was post-WWII France. We would now be living in a world with potentially more than six billion people with US habits—driving cars, using air-conditioning, generating a ton of trash, and eating an average of 273 pounds of meat each year (USDA, 2012).
This successful development agenda could have meant that we would have developed technologies that allowed us to survive in a world full of billions of consumers. Economic development, after all, brings unimaginable techno- logical advances that can have a positive and negative transformative effect on well-being and the environment in which we live (Schneider et al., 2011). It could also have led to slower population growth. As people urbanize and become more educated, reproduction drops dramatically (Lewis, 1955).
But this alternative development scenario could also have meant Armaged- don. Had the development agenda of the 1940s been successful worldwide, the Eastern seaboard of the United States and much of South and Southeast Asia could have been entirely underwater due to environmental change. This would not only have meant the loss of major cities, such as New York City, but it would also have meant that populations would have had to adapt very rapidly to such changes, in part by migrating across what are now mostly sealed borders.
Previously, we mentioned that human development—the growth in literacy and life expectancy—was slow in the 1960s. That is mostly true but is not entirely the case, as we alluded to previously when we mentioned the green
Indeed, many questions remain. Will China’s growth be sustained? (Many feel that this is unlikely.) Will it end up speeding up climate change to the point that many people are displaced, thus worsening misery? Will rising inequalities and authoritarian policies lead to social turmoil, as in nations that participated in the Arab Spring? Will China’s rise mean a sustained period of relative peace, as is currently the case? Will state ownership and mismanagement lead to a spectacular global financial collapse?
22 C H A P T E R 1 : A V E R y B R i E f H i s T o R y o f G l o B A l H E A l T H P o l i C y
revolution. Recall that in much of Asia and parts of Latin America, nations began investing in schooling and new agricultural techniques in the 1960s (Evenson & Gollin, 2003).
The green revolution involved the use of more hearty grains coupled with modernized farming techniques, including hybridized seeds, synthetic fertil- izers, pesticides, and new management strategies. This produced a large imme- diate payoff in terms of economic growth (from selling the crops), health (from better food supply and from eating the crops), and schooling (now govern- ments could afford schools and the children’s bellies were full). It also helped ease fears of global food shortages that might arise from the skyrocketing number of humans on earth. The investments in education then kicked in decades later, allowing many nations to greatly improve their healthy life expectancy and sustain reasonable economic growth. These changes in life expectancy can be easily visualized by visiting www.gapminder.org and explor- ing the past century’s life expectancy and GDP per capita paths in Malaysia, South Korea, and most of the other nations in the neighborhood.
Gapminder.org provides us with a sense of overall trends in the associa- tions between development indicators such as income and health over time. This is an example of correlational data. The term emphasizes the idea that we can infer and test whether some association, correlation, or relationship between two variables (such as per capita GDP and life expectancy) exists but not whether one variable causes or leads to the other, what the complex causal pathways and dynamics between these two variables are, how these variables interact, and what else might be going on. This sort of trend analysis, using large datasets, is probably the most common approach. But it is also the weakest study design in public health. Humans have a tendency to draw conclusions from what they see in data. For instance, coffee was first found to be highly cor- related with heart disease and lung cancer in early research studies. Can you guess why? Well, it was not the coffee, so you can rest assured (even if you now have the coffee jitters!). It was the fact that coffee drinkers are more likely to smoke cigarettes. Thus, the dictum “correlation is not causation” must be considered when reading studies in your local newspaper.
HOW PUBLIC HEALTH RESEARCHERS MEASURE THINGS

A n A l T E R n AT i V E H i s T o R y 23
An alternative to the correlational study design is an experimental study. In an experimental study, scientists manipulate the environment to make sure that they are measuring what they think that they are mea- suring. For instance, you might start by randomly assigning one group to drink coffee and another group to drink water every morning and follow them to see who gets heart disease and who does not. In this case, smokers are just as likely to end up in one random group as the other. So, using a randomized trial, smoking cannot be the hidden or underlying confounder, or confounding variable in the study. (In this example, smoking is the real link between coffee consumption and higher rates of heart disease.)
If we measure progress in terms of life expectancy growth, we see that, up until the AIDS epidemic, the growth in this life expectancy has been fairly steady even in parts of the world that had been completely written off by development economists. Data on literacy rates only go back a decade and a half, but even here, we have seen significant prog- ress. Between 1991 and 2002, Burkina Faso has gone from a literacy rate of around 13 percent to around 24 percent. Between 1987 and 1997, Malawi’s literacy rate has increased from 49 percent to 64 percent. Botswana has progressed from 69 percent to 81 percent between 1991 and 2003.
Recently, national governments in some countries such as Malawi have begun to ignore the international economic development experts and to instead follow their own common sense. Malawi’s government has begun to subsidize fertilizer and seeds, allowing for a miniature green revolution in that nation. These subsidies are essential for local farmers to grow crops because fertilizer and seeds would be unaffordable at market prices. (See the following box for an explanation of why subsidies might be a good or bad idea.) Internal investments, coupled with the efforts of many smaller aid agencies and nongovernmental organiza- tions (NGOs), have begun to improve educational opportunities for many poor people.
These statistics suggest that development progress is being made, just as long as we measure outcomes in terms of human development. Still, some NGOs are so poorly coordinated that they are doing more harm than good. Some of these changes in practices might not catch on, and governments can quickly go into decline. But if our ultimate goal is to improve well-being—as measured by literacy and a rising life expec- tancy—the development agenda is, and has been, on the right path even though researchers disagree on precisely how or why.
24 C H A P T E R 1 : A V E R y B R i E f H i s T o R y o f G l o B A l H E A l T H P o l i C y
The primary argument against subsidies for fertilizer, soil, crops, and so forth is that, in theory, the free market will raise all boats more quickly than government programs. Some argue that it is inefficient to take money from individuals and businesses and then spend this money on something else using inefficient and noncompetitive government agen- cies. Some of this money can disappear in paperwork, red tape, or cor- ruption, particularly in poor nations. This approach effectively wastes the money of those who are productive so that fewer goods are produced overall. Finally, by subsidizing agriculture, farmers might not do every- thing they can to become competitive; at their worst, subsidies, similar to other welfare benefits, act as a disincentive for work and a disincentive to think creatively about innovative ways of solving problems.
The arguments for these subsidies are that the existence of corrupt officials or fears of disincentives should not serve as an excuse for inter- governmental agencies to abandon aid for the poor. Some argue that in desperate situations, subsidies for food production are not the same as subsidies for luxury goods. They argue that the lives of millions of poor people should not be collateral damage in a political argument about the efficiency of their leaders. Moreover, by subsidizing seeds, it becomes possible to encourage farmers to modernize the crops to those that require less water and less fertilizer. This argument aside, the private sector will not sell fertilizer or seeds at a loss. If farmers had to buy fertilizer and seeds at market rates in places like Malawi, they wouldn’t have enough money to eat. Farmers may eventually need to learn to become more competitive, but they first need the sort of nurturing that so-called infant industries in industrialized nations received decades before. Often, farmers in poor countries barely have the funds to feed their families, especially during years when the yield is low. In short, farmers in poor countries would never become economically productive and competitive without receiving some aid and training to kick-start their efforts. And they must compete against highly subsidized and mechanized corporate farms in wealthier countries. Without fertilizer or seeds, poor farmers will rarely have a successful crop, so one bad year can lead to a downward cycle of perpetually declining yields. A more rational policy might be to make policy not by economic theory alone but via a much more participatory discussion that takes into account the situation on the ground.
WHY DO SOME DEVELOPMENT EXPERTS DISLIKE SUBSIDIES?
l o V E A n d H E A l T H i n M o d E R n T i M E s 25
LOVE AND HEALTH IN MODERN TIMES
Today, the development landscape can be thought of as a museum of the entirety of human history with exhibits arranged by geographic region. In one section of this museum, the Congo, we see some tribal societies struggling to ensure that half of all children born survive to age five. This, amid raging infectious disease, war, and hunger. However, the Congo is also surrounded by rising prosperity, as shown by sub-Saharan Africa becoming the next eco- nomic miracle. (China, now laced with high-speed rail and buildings built by some of the world’s greatest architects, looked quite similar three decades ago.) In other sections in the United States of America and China, we see struggles to overcome problems associated with human hierarchies, industrial waste, and poor regulation. In these sections, politics (in the United States) and the desire for economic growth (in the United States and China) take precedence over what others might see as “rational” social policies—those that accept slower growth in exchange for stricter pollution controls, higher taxes to pay for education, occupational safety standards, and heavy investments in public transit. (In all fairness, China has made some of the heaviest investments in public transit of any nation, and the United States has fairly decent occupa- tional safety standards.) In yet another section of this museum of human history, the Netherlands, we find reasonable work weeks, social safety nets, and previously unimaginable life expectancies, but also struggles to cope with an aging population in the face of a society resistant to allowing younger immigrants and increasing family size. Finally, in a series of strange new addi- tions to this museum, small, mostly nondemocratic societies are popping up in which highly socially regulated societies challenge Norway for dominance in world health rankings. One section, Singapore, offers not only extreme public health measures, but also heavy regulations on potentially unhealthy human behaviors, such as mandatory death penalties for drug trafficking. Here, we see that other aspects of well-being, such as democratic participation, take a back seat to social order.
In low-income nations, we await various significant health events. The first is the aforementioned epidemiologic transition, in which infectious disease and hunger are brought under control and the population’s life expectancy begins to increase. This is typically followed by a demographic transition, in which birthrates decline. These transitions are best illustrated by population pyramids, such as the ones in figure 1.6, showing different stages of popula- tion and demographic change.
The first pyramid is typical of nations prior to their epidemiologic transi- tion. The second is typical of a nation following the epidemiologic transition, the third for one undergoing a demographic transition, and the final, a country after a demographic transition.
26 C H A P T E R 1 : A V E R y B R i E f H i s T o R y o f G l o B A l H E A l T H P o l i C y
These transitions coincide with responsible governance. If industry is poorly regulated and the country becomes extremely polluted or the govern- ment fails to continue to invest in beneficial social policies, then the health and quality of life benefits associated with the epidemiologic and demographic transitions can be mitigated.
Thus, we strive for healthy development that moves nations from a low life expectancy to a high life expectancy. However, each of these sections of the world’s new museum suffers from its very presence in the same museum building. These include the widespread availability of cheap, tasty sources of empty calories, the inability to protect borders from pollution or new strains of infectious disease, and the spread of new and old war technologies. Although the process of development mostly follows historical trends, these truly global health risks transcend borders and pose new challenges for public health. They also point to a need for effective forms of global governance. These new risks are all in keeping with the notion that, as humans manage to tackle threats to health, the solutions to old problems inevitably produce new ones.
From this new landscape, new and challenging questions arise. Namely, how do we regulate human behavior but maintain freedom and quality of life? How do we deal with skyrocketing birthrates in some areas of the world and plummeting rates in others? How do we manage the increasing prevalence of floods and droughts, coupled with rising sea levels? How, exactly, do we main- tain a robust and vibrant free market economy and foster this market so that it maintains, rather than harms, human longevity at the same time? How do we cope with populations that are too young in some places and too old in others? How do we manage the massive movements of humans across borders as they seek to equilibrate economic and demographic inequalities?
The answers to some of these questions are easy. Increased immigration has not only helped solve economic problems in nations such as the United States, but it has also helped solve demographic and health problems. That is because immigrants tend to be slightly younger, have higher birthrates, and are healthier than native-born Americans (Muennig & Fahs, 2002; Muennig et al., 2012).
Figure 1.6. Population pyramids typical in various stages of development.
65
15
A ge Male Female
Stage 1 – expanding Stage 2 – expanding Stage 3 – stationary Stage 4 – contracting
d i s C u s s i o n Q u E s T i o n s 27
SUMMARY
Even this brief history holds some important lessons about global health policy. Most important, we need clear, coordinated global policies and strong leader- ship to manage global issues. This obviously has not happened at a global level. As this is being written, various large-scale conflicts are well in progress. There is a constant threat of nuclear attack, within countries such as the United States and between nuclear-armed nations such as India and Pakistan. The world remains ill-prepared for an infectious disease pandemic. There is no clear path to addressing global climate change. Industrial pollution is causing air quality problems not only for industrializing nations but also for their neighbors. Deforestation and despeciation are running rampant and unchecked. Much of this can be attributed to ineffective, toothless global institutions, such as the UN or WHO.
But even if such organizations were to transform themselves into effective governing bodies with actual political power, we still are not sure what those policies need to look like. For instance, we need to decide what we mean by development. Does development mean economic development to the point that we have replicated US GDP and consumption patterns in all 191 (or more) nations on earth? If so, then the world will face entirely new public health threats, such as massive environmental destruction. Or does it mean striving for the policies that will prolong our lives and improve our health, such as universal primary school education and vaccination? When do economic devel- opment and human development go hand in hand? When do they not?
KEY TERMS
absorptive capacity confounder demographic transition economic development epidemiologic transition experimental study
green revolution human development Industrial Revolution intergovernmental
institutions
Millennium Development Goals
nongovernmental organizations (NGOs)
social hierarchies social institutions
DISCUSSION QUESTIONS
1. How would you define global health?
2. What is the best way to achieve an epidemiologic transition?
3. Who are some of the main actors and institutions that currently help to set global health policy?
4. What are some of the key events in the late nineteenth and twentieth centuries that affected global health? How did they do so?
28 C H A P T E R 1 : A V E R y B R i E f H i s T o R y o f G l o B A l H E A l T H P o l i C y
5. What kinds of regulations should we put on markets in the name of health, if any?
6. Is global warming a public health threat? How so?
FURTHER READING
Sachs, J. D. (2012). Malawi and anti-hunger programs. New York Times, April 19. Available online at www.nytimes.com/2012/04/20/opinion/how-malawi-fed-its -own-people.html
REFERENCES
Ashton, T. S. (1997). The industrial revolution 1760–1830. Oxford: Oxford University Press.
Barsky, R. B., & Kilian, L. (2002). Oil and the macroeconomy since the 1970s. Journal of Economic Perspectives, 18(4), 115–134.
Black, M. (2002). The no-nonsense guide to international development. Scranton, PA: Verso.
CFR. (2005). The WTO’s troubled “Doha negotiations.” Available online at www.cfr.org/wto/wtos-troubled-doha-negotiations/p9385—p3
Denham, T. P., Haberle, S. G., Lentfer, C., Fullagar, R., Field, J., Therin, M., et al. (2003). Origins of agriculture at Kuk swamp in the highlands of New Guinea. Science, 301(5630), 189–193.
Diamond, J. (1998). Guns, germs, and steel. London: Random House.
Evenson, R. E., & Gollin, D. (2003). Assessing the impact of the green revolution, 1960 to 2000. Science, 300(5620), 758–762.
Gaidzanwa, R. B. (1999). Voting with their feet: Migrant Zimbabwean nurses and doctors in the era of structural adjustment. Uppsala, Sweden: Nordic Africa Institute.
Galvani, A. P., & Slatkin, M. (2003). Evaluating plague and smallpox as historical selective pressures for the CCR5-Δ32 HIV-resistance allele. Proceedings of the National Academy of Sciences of the United States of America, 100(25), 15276.
Gleijeses, P. (1992). Shattered hope: The Guatemalan revolution and the United States, 1944–1954. Princeton, NJ: Princeton University Press.
Gulland, A. (2012). Child mortality falls, but 19,000 under 5s still die every day. BMJ, 345, e6229. doi: 10.1136/bmj.e6229.
Lewis, W. A. (1955). The theory of economic growth. London: Allen & Unwin.
Lowry, R., Wechsler, H., Galuska, D. A., Fulton, J., & Kann, L. (2002). Television viewing and its associations with overweight, sedentary lifestyle, and insufficient consumption of fruits and vegetables among US high school students:

29R E f E R E n C E s
Differences by race, ethnicity, and gender. Journal of School Health, 72(10), 413–421.
Mayor, S. (2012). Child mortality is falling but some developing regions will miss millennium targets. BMJ, 345, e5801. doi: 10.1136/bmj.e5801.
Michel, S., Beuret, M., & Woods, P. (2009). China safari: On the trail of Beijing’s expansion in Africa. New York: Nation Books.
Moghadam, V. M. (1999). Gender and globalization: Female labor and women’s mobilization. Journal of World-Systems Research, 5(2), 367–388.
Moyo, D. (2009). Dead aid. New York: Farrar, Straus and Giroux.
Muennig, P., & Fahs, M. (2002). Health status and hospital utilization among immigrants to New York City. Preventive Medicine, 35, 225–229.
Muennig, P., Wang, Y., & Jakubowski, A. (2012) The health of Chinese New Yorkers: Evidence from the New York City Health and Nutrition Examination Survey. Journal of Immigrant and Refugee Studies, 10, 1–7.
Myers, M. L., & McGlothlin, J. D. (1996). Matchmakers’ “phossy jaw” eradicated. American Industrial Hygiene Association Journal, 57(4), 330–332.
Omran, A. R. (1971). The epidemiologic transition: A theory of the epidemiology of population change. The Milbank Memorial Fund Quarterly, 49(4), 509–538.
Parkin, D. M., Bray, F., Ferlay, J., & Pisani, P. (2005). Global cancer statistics, 2002. CA: A Cancer Journal for Clinicians, 55(2), 74.
Schlesinger, S., & Kinzer, S. (1982). Bitter fruit: The story of the American coup in Guatemala. New York: Doubleday.
Schmidheiny, S. (1992). Changing course: A global business perspective on development and the environment. Cambridge, MA: MIT Press.
Schneider, U. A., Havlík, P., Schmid, E., Valin, H., Mosnier, A., Obersteiner, M., et al. (2011). Impacts of population growth, economic development, and technical change on global food production and consumption. Agricultural Systems, 104(2), 204–215.
Trichopoulos, D., Li, F. P., & Hunter, D. J. (1996). What causes cancer? Scientific American, 275(3), 80–84.
USDA. (2012). Cattle and beef. Economic Research Service. Available online at www.ers.usda.gov/topics/animal-products/cattle-beef/statistics-information.aspx
Williamson, J. (1993). Democracy and the “Washington Consensus.” World Development, 21, 1329–1336.

CHAPTER 2
Case Studies in Development and Health
31
KEY IDEAS
• More money does not necessarily buy more health in international development.
• How policy makers allocate resources and use a nation’s wealth matters most.
• The case studies on China, Kerala, and Chile highlight some of the strengths and weaknesses of focusing on economic development relative to focusing on healthy development.
Wanda lives in the United States, in what is often dubbed the wealthiest country in the world. She has a good job she believes in: she is a community organizer who helps local residents work on social justice campaigns in New York City. She has many friends, lives in the neighborhood she grew up in, and is recognized as a community leader. As part of her work, she has gotten to have one-on-one meetings with policy makers such as Mayor Michael Bloomberg. Her neighbors and friends respect her.
As someone who works for an NGO (remember, this stands for nongov- ernmental organization), Wanda has a lot of knowledge about politics and bureaucracies so she knows how to get the resources she needs. She possesses quite a bit of so-called social capital, or rich networks of friends and connec- tions in her field of work with strong norms of sharing tips and resources (Putnam, 1995). She is not rich but she earns enough to care for herself, and her job provides her with ample vacation time (at least compared to most
32 C H A P T E R 2 : C A s E s T u d i E s i n d E v E l o P m E n T A n d H E A l T H
Having social capital means that you are well connected to others around you. If you are stressed or lonely, others can provide comfort. If you need money, others can give it or loan it to you. If you need a doctor, others can give a referral. For this reason, people who belong to community groups, churches, or other organizations that provide a lot of social con- nections tend to have better health (Kawachi, Subramanian, & Kim, 2010). So do people who spend time with their friends or family rather than watching television at night. But, of course, social capital can also be bad for you or for others. Take, for instance, friends with whom you go out to smoke and drink. People who belong to criminal organizations such as the Ku Klux Klan or the triad gangs of Hong Kong and China may harm themselves and others around them (Kim, Subramanian, & Kawachi, 2006). So, we have to be sure we define what we are talking about when we talk about social capital. Political scientists such as Robert Putnam, famous for his book Bowling Alone (the title refers to a decline in all sorts of group activities, including bowling leagues, in US public life after World War II), tend to emphasize more positive aspects of social capital. Sociologists such as Pierre Bourdieu, famous for books such as The Forms of Capital, tend to emphasize the ways in which nonmonetary resources such as social capital also largely reproduce and perhaps exacerbate class structures. After all, the so-called old boys’ clubs and their golf games might benefit those who are already wealthy, but such hubs of rich social capital exclude almost everyone else.
WHY IS SOCIAL CAPITAL GOOD FOR YOU?
Americans), flexibility, and benefits such as health insurance. Plus, she has all of the rich cultural resources of New York City—the famous museums, world- class universities and research centers, diverse immigrant neighborhoods, and good restaurants at all price points. As compared to the rest of the country, New York City also has a more comprehensive welfare infrastructure—with a greater constellation of public transit routes, community centers, food pro- grams for the poor, free English classes for immigrants, free outdoor concert series by musicians and orchestras from around the globe, and so on—than probably any other area in the country.
The life expectancy for Hispanic females like Wanda in the United States is eighty-one, in between the immigrant (foreign-born) Hispanic female life
T H E P u z z l E o f “ G o o d ” d E v E l o P m E n T f o R H E A l T H 33
expectancy of eighty-four and the average US female life expectancy, regard- less of race or immigrant status, of seventy-nine (Singh & Miller, 2004). But much as Wanda’s parents died at a much younger age than their parents, life expectancy among females in some local areas of the United States is declin- ing. This is an unprecedented phenomenon in a wealthy country that is not undergoing political turmoil, facing famine, or experiencing an epidemic disease. No one knows why this is, but maybe we can get some clues from other nations.
Although we mention many different nations throughout this book, we chose the examples of Chile, China, and the state of Kerala in India as case studies to highlight. We did this because each of these states provides a good example of what happens to health when a government invests heavily in social programs and what happens when the market is left to its own devices. Although China has been nondemocratic since 1949 through the time of pub- lication of this book in 2013, it made a large shift from investments in public health, medical, and other social programs to a predominantly market-based approach in 1979. Around 2000, it shifted its course back and began to once again invest in social programs. This provides us with a sort of internal com- parison group to look at the effects of less-regulated markets versus health investments. The state of Kerala in India has been democratic for a long time. However, communists were elected to power for long stints punctuated by somewhat more market-oriented governments. This has also changed the funding landscape for health and social programs over time. Finally, Chile has also experienced democratic and nondemocratic leadership over an even longer period and has had intervals of emphasis on social investment and intervals that emphasized a free market approach to development. These examples all highlight precisely why this health textbook reads so much like a policy text- book. We hope to use these examples to very clearly delineate a precise answer to the question of whether democracy matters and whether social investments matter for health. That is, we hope that each and every student reading this will emerge with a very clear and firm answer to this question. As a hint, that answer is: it depends.
THE PUZZLE OF “GOOD” DEVELOPMENT FOR HEALTH
Figure 2.1 shows what is known as a Preston curve, named after the famous demographer Sam Preston. In this figure, we see that there is a strong relation- ship between per capita GDP and life expectancy up to about US$4,000 per year (Acemoglu & Johnson, 2006). After this point, we see what economists would call diminishing returns to each marginal increase in GDP, and in general, the overall correlation between increased GDP and increased life expectancy becomes much weaker. Eventually, it disappears altogether. (This
34 C H A P T E R 2 : C A s E s T u d i E s i n d E v E l o P m E n T A n d H E A l T H
is mostly—as Wanda in the case study attests—thanks to the United States pulling down everyone else.)
Some countries down in the sub-US$4,000 earning range have life expec- tancies similar to those seen in developed nations. For instance, Costa Rica (nominal per capita GDP US$7,000 and purchasing power parity [PPP]-adjusted per capita GDP US$11,000) and Chile (US$10,000 nominal and US$15,000 after adjusting for PPP) have life expectancy values that are a bit better than the United States as a whole (per capita GDP US$47,000), despite being low GDP countries. Most notably, most citizens of Cuba earned about US$30 per month, or a dollar a day, in 2012. So, how does this island nation have a life expec- tancy similar to the United States? The answer could lie in how the money is spent.
Cuba has historically invested much of its very limited national wealth in food, water, education, and health care. This prioritization of social goods may account for why it has been able to maintain a reasonable life expectancy.
Figure 2.1. The Preston curve: Life expectancy versus GDP per capita.
Note: Circles are proportional to population, and some of the largest (or most interesting) countries are labeled. The solid line is a plot of a population-weighted nonparametric regression. Luxembourg, with per capita GDP of $50,061 and life expectancy of 77.04 years, is excluded.
Source: Deaton, A. (2003). Health, inequality, and economic development. Journal of Economic Literature, 41(1), 116, Fig. 1.
80
70
60
50
40
Li fe
e xp
ec ta
nc y,
2 00
0 China
Mexico Spain Italy
France Japan
Germany USA UK
Korea
Argentina Brazil
Russia Indonesia
India
Pakistan Bangladesh
Gabon
Nigeria Namibia
Botswana
GDP per capita, 2000, current PPP $
South Africa
0 10,000 20,000 30,000 40,000
Equatorial Guinea
T H E P u z z l E o f “ G o o d ” d E v E l o P m E n T f o R H E A l T H 35
These variables might be the only factors in global life expectancy values that raise a nation’s life expectancy into the seventies or even eighties.
Among the higher-earning countries, most of which have already made these investments, there is little to no relationship between life expectancy and per capita GDP (Preston, 1976). That big kink in the curve (right next to where Indonesia is on the graph) disrupts the so-called wealth-health gradient, whereby a higher income or GDP per capita earns you (whether an individual or a nation) a higher life expectancy. The wealth-health gradient tends to exist within nations, but not so much between them, especially among nations with more than US$5,000 a year in GDP per capita.
The Preston curve thus presents two major questions. First, why do coun- tries tend to get less bang for their buck (or peso or yen or whichever currency they hold) when per capita GDP surpasses US$4,000 per annum? Second, why are some countries below the trend line and others above it? For example, why is Mexico’s life expectancy more than twenty years longer than South Africa’s?
Wanda, the woman we interviewed for this book, is Puerto Rican and of African descent. She first moved to the mainland United States at the age of eight, after her mother caught her father cheating on her. Wanda, Wanda’s mother, and Wanda’s sister Sandra made a new home for themselves in New York. At first, this was not so easy. Wanda had an uncle who worked as a building superintendent in the Bronx, so they tried to live there at first. However, this was 1975, and the city was suffering from a massive fiscal crisis. Conditions in the borough were so bad that some landlords deliberately set buildings on fire, sometimes with tenants still in them, in order to collect insurance money. For the landlords, this was more lucrative than collecting rent. That moment in history was most famously captured when the Yankees played at their Bronx stadium during the 1977 World Series. A skyline of smoke was visible throughout the game, which was televised nationwide. The presiding sportscaster announced, “Ladies and gentlemen, the Bronx is burning.”
So, between 1975 and 1989, Wanda and her family moved eight times, eventually resettling in the Bronx. Wanda’s mother was quite strict but also incredibly loving, and she made sure that her daughters worked hard in school. Wanda recalls her high school experience with ambivalence, however. She had some good teachers, but the school was so rife with marijuana dealing that it had been nicknamed the drugstore—a term not meant to refer to a friendly, neighborhood pharmacy. After high school, Wanda got a business administra- tion certificate from a local, for-profit sixteen-month program. She then worked as an administrator for an insurance company for a while, became more involved as a volunteer in local NGOs, and eventually turned to the nonprofit
36 C H A P T E R 2 : C A s E s T u d i E s i n d E v E l o P m E n T A n d H E A l T H
sector, where she has been ever since. In 1989, when Wanda was twenty-three, Wanda’s mother passed away from a heart attack. Her mother was forty-three years old when she died. Wanda is overweight, even though she is an avid cumbia and salsa dancer. She recently bought a bicycle for US$30, but she has not gotten many chances to ride it just yet.
Wanda’s case may help us understand why the United States is relatively unhealthy despite its wealth. In one of the wealthiest cities in one of the wealthiest countries on earth, Wanda lives and works in what most people in wealthy nations consider poverty. She lives in the Bronx, where the per capita income is US$17,464, less than half of that of the city as a whole. The median family income is still just US$38,923, and the mean family income is US$52,327. In the South Bronx, where she works, 40 percent of households live below the poverty line—around US$22,000 for a family of four in 2011.
By means of comparison, Manhattan, the city’s wealthiest borough adja- cent and directly south of the Bronx, boasts a per capita income of US$60,596, a median family income of almost US$76,470, and a mean family income US$166,997. More than 84 percent of residents have completed high school and more than 56 percent are college graduates. In Manhattan, only 14.3 percent of households live below the poverty line.
In 2009, Wanda’s asthma had gotten so bad that her doctor prescribed her an inhaler. She has been trying to eat healthier, to turn away from the starch- heavy comfort foods of her Puerto Rican childhood, and to abandon the recipes she knows by heart. She got excited when she discovered that the Costco warehouse store she drives to has olive oil and produce. The local neighbor- hood stores tend to carry few vegetables, if any. Ironically, most of the city’s organic produce—especially the produce that gets served at US$40-per-entrée restaurants downtown—first stops in the South Bronx at a food distribution center. In order to access the distribution center, you have to pay an entry fee per person and per car, so Wanda doesn’t go unless she makes it a field trip for all of the neighbors.
Sometimes, it is a struggle to keep stress levels down. Community organiz- ers work long hours, and in the past, staff meetings took place at 9 PM, some- times at local bars, surrounded by smoking (until Mayor Bloomberg banned it in 2002) and drinking. On top of these work conditions, it is difficult not to draw boundaries when helping others in challenging situations. In 2010, Wanda’s half-sister (the daughter of Wanda’s recently deceased father in Puerto Rico) lost custody of her four children, ages four, five, seven, and eleven. Wanda, who is not close to this half-sister, called the government social worker in Puerto Rico to check up on the situation. To her dismay, she was immediately offered custody of the three oldest children. They arrived in the Bronx in a matter of weeks. Wanda quickly enrolled them in school and worked to provide them with a new, loving home.
T H E n E x T s u P E R P o w E R s ? TA k i n G A C l o s E R l o o k AT m i d d l E – i n C o m E C o u n T R i E s 37
“I want to make sure I’m here for the long haul,” like the elders who made a difference in her own early childhood in Puerto Rico, Wanda declared. She reminisced that, back then, she knew where everybody would be on Sundays— with their families. Her great-aunt lived until ninety-seven, her grandfather until eighty-seven, and her grandmother died of cancer at age seventy-nine. They led much longer lives than their children, outliving some of them. “Here, there are no elderly people,” she said. “And the people in my building don’t talk to one another.”
What has played, and what will play, the greatest role in shaping Wanda’s health—her personal habits, family, how she grew up, her neighborhood, her city, or her country? How does globalization shape her life now? Do Wanda’s gender, race, and ethnicity affect her health? Can we really disentangle and separate out each of these factors or are they all jumbled up together?
THE NEXT SUPERPOWERS? TAKING A CLOSER LOOK AT MIDDLE-INCOME COUNTRIES
Throughout this book, we will reference two case studies of middle-income economies and one low-income economy: China, Chile, and the state of Kerala
We talk about people going gray from stress, aging, getting sick. But is it an old wives’ tale? As it turns out, probably not. In experimental studies in animals (though we will explore the external validity problem in chapter 3) and in observational studies of humans (and we will explore the internal validity problem in chapter 3), stress seems to be harmful. For one, it seems to cause the body’s regulatory mechanisms—internal “thermostats”—to go haywire. This creates problems with the immune and endocrine systems, among others. It also seems to cause genetic changes, including damage. In one study, women in the highest stress group showed signs that their immune cells were ten years older relative to women in the normal stress group of the same age (Epel et al., 2004).
Public health researchers have also begun to differentiate among different types of stress, their effects on health, and the social policies that should be considered in response. When the basic necessities of life are covered or when systems of social insurance exist in cases of disaster, stress is short-lived. It most certainly exists in times of crisis or when an individual opts to enter a volatile occupation like that of a stockbroker but it may not take the same toll as long-term and chronic stress does on families in dire poverty.
IS STRESS REALLY BAD FOR YOU?
38 C H A P T E R 2 : C A s E s T u d i E s i n d E v E l o P m E n T A n d H E A l T H
within India, respectively. According to the World Bank, low-income countries are those where the gross national income (GNI) per capita is below about US$1,000, and high-income countries are those where the 2008 GNI per capita is above US$12,000. Middle-income countries are all those in between.
The global south, least-developed countries, and industrializing nations are the most common among terms used to refer to those coun- tries that are poorer. Some define these nations as those with a score of less than 0.8 on the UN HDI (see the website http://hdr.undp.org/en/ statistics/hdi). Others use per capita GDP (see http://data.worldbank .org/about/country-classifications). The term global south arose because most of these countries are in the southern hemisphere. Two important exceptions, Australia and New Zealand, are the only countries in the southern hemisphere with an HDI higher than 0.8. The countries with very high HDI scores are called the global north because most of them are in the northern hemisphere.
For the most part, we will try to be a bit more precise and identify whether the countries we discuss are low income, middle income, or high income. But this can be confusing, too. For instance, at the time of publication, about one-third of those living on less than US$2 per day lived in middle-income countries with relatively high per capita GDP but dramatic income disparities.
We give precise definitions for each of these categories in the main text introducing our case studies: China, Kerala, and Chile. We focus on income because it is too difficult (and problematic) to label countries more developed, underdeveloped, or less developed. How do we know what the perfect level of development is anyway? As we have already discussed, development can mean lots of things—economic development and high income and GDP, human development and high life expectancy and education rates, happiness, well-being, or something else.
You may have also heard the terms first world, second world, third world, and fourth world. These are a bit dated because they refer to Cold War–era designations. Still, you might find these terms in the global health literature, so it might be good to have these definitions in mind: the first world consists of the highly industrialized countries that also consist of the global north. The second world traditionally consisted of
A ROSE BY ANY OTHER NAME

T H E n E x T s u P E R P o w E R s ? TA k i n G A C l o s E R l o o k AT m i d d l E – i n C o m E C o u n T R i E s 39
Why are we focusing on middle-income countries? We do so because they represent a great hope (and a great puzzle) in global health policy. They have begun the epidemiologic and demographic transitions, but no one knows whether they will replicate the paths first traveled by current industrialized countries (such as Sweden, Japan, or Canada) or if their paths to development will be completely new ones. They have passed the turning point along the Preston curve (see figure 2.1) so we suspect that simply pouring money or increasing GDP is unlikely to guarantee anything unless the revenues from this growth are invested in human development. They could become the next power players, or even global powers, or they could stagnate as struggling economies. Middle-income countries also matter in terms of pure scale. There are forty-three low-income countries left in the world. Although there are sixty- six high-income countries, only twenty-seven are members of the Organization for Economic Co-operation and Development (OECD). Non-OECD high-income countries provide some clues for alternative models for industrial development; these mostly lie in the oil-rich Middle East. Middle-income countries constitute the biggest category of economic development right now, with 101 countries. The People’s Republic of China alone has a population of almost 1.4 billion people and India around 1.2 billion in 2012. (Together, these two countries account for more than one-third of the world’s population.) The next largest country, the high-income United States, looks like a peon by comparison, with just 310 million people. In fact, many of China’s smaller cities, such as Suzhou, have populations that are ten times as large as that of San Francisco.
It might seem odd that a state in India, Kerala, is one of our three case studies. After all, there are many countries with similarly impressive health and education outcomes, such as Cuba or Costa Rica. We partly chose to profile Kerala because it boasts a larger population than these other countries. With almost thirty-two million people, it would rank as the thirty-eighth most popu- lous country in the world if it were one, just two notches below Canada. In
centrally planned communist countries in the former Soviet Union. Some of these countries, such as Slovenia, are now classified as wealthy nations. The third world originally referred to those countries that did not align with either the United States or the Soviet Union during the Cold War, and then it referred to countries not in the first or second worlds. It became a phrase that implied “poor countries,” but this was not always well defined. The fourth world refers to the six thousand indigenous groups and roughly six hundred million people who may or may not identify with the nation-states recognized by the United Nations.
40 C H A P T E R 2 : C A s E s T u d i E s i n d E v E l o P m E n T A n d H E A l T H
contrast, Cuba has roughly eleven million residents and Costa Rica just four million. Kerala also better illustrates the complex relationship among econom- ics, governance, and health that we focus on in this book. Why has Kerala historically thrived with respect to health when almost all other states in the same country—most with much higher income—have floundered?
All three case studies have market-oriented economies, and Chile and Kerala boast of democratically elected governments. From time to time, we will include examples from other countries; it will be useful, for instance, to take a look at some of the policies that garnered Costa Rica third place on the Environmental Performance Index in 2010, after Iceland and Switzerland, which are both much wealthier countries. We will also include examples from much poorer countries, such as the Democratic Republic of the Congo. That nation underwent elections and has made some progress away from being the grave human rights disaster site it was just a few years ago.
GROWTH-MEDIATED MODELS
China provides an example of a country with what Jean Drèze and Amartya Sen call a growth-mediated economy, at least since reforms in the 1980s (Drèze & Sen, 1989). Before the 1980s, China was a communist, totalitarian country with a central political party making decisions about which goods and services should be produced and at what scale.
Deng Xiaoping, who became chairman of the Chinese National People’s Congress in 1978, launched a model of “socialism with Chinese characteristics” that year. His plan was to gradually open the internal economy to markets and increase foreign trade. Unlike countries such as Russia, China moved to a free market economy in a gradual, experimental fashion. The experiments were local and proved successful at increasing economic growth. According to free market principles, government should also stay out of the way (thus the nick- name laissez-faire economics), save for regulating against fraud and force and upholding property rights (Friedman, 1982). In an ideal free market, buyers and sellers mutually consent to prices without any coercion or government intervention so that aggregated supply meets aggregated demand, at a “general equilibrium.” Free markets work best when they meet a certain set of criteria, such as the existence of many firms competing to supply or buy goods and consumer access to good information about the costs, benefits, and potential consequences of all available options.
Of course, real-life markets—even ones that aim to be “free”—are much more complicated. Copyright laws on everything from pharmaceutical drugs to pop songs downloaded via the Internet are often considered probusiness when they extend patent rights and demand more governmental intervention, not less.
s u P P o R T- l E d m o d E l s 41
For the purposes of this book, three characteristics of “free market” poli- cies stand out because of their economic or health implications. First, they aim to reduce costs associated with participation in the market by firms and busi- nesses. For instance, “freer” markets would not only offer low taxes but also make it easy to open a business without much government interference. Second, as a result of less government interference, free markets provide rela- tively loose regulations protecting workers, consumers that buy the products produced by the free economy, and the environment. Third, they are more concerned with efficiency than with fairness in the allocation of goods. This means that large wealth inequalities are a frequent consequence of efficient free market policies.
No modern nation adheres entirely to free market principles. By “growth- led models,” we usually mean that worker, consumer, and environmental protections are less emphasized. The success (measured in terms of economic growth) of the growth-mediated model depends on wide distribution of eco- nomic activity, especially in employment. If a large enough percentage of the country’s residents participate in the economic boom, they can share the rewards and other aspects of economic development that we associate with high-income countries—public infrastructure such as good roads and bridges, hospitals, and so on—which rise alongside personal income.
SUPPORT-LED MODELS
In contrast to China, the state of Kerala in India has mostly stuck to what Drèze and Sen call a support-led model of economic development. Instead of postponing social investments until after economic growth has occurred, the state invested heavily in health care and education while placing relatively high taxes and regulatory burdens on businesses. Sen argues that although these sorts of programs feel quite expensive in industrialized countries, they are more affordable than many policy makers assume in lower-income coun- tries because schools, clinics, and so on are so labor- rather than technology- or capital-intensive (Sen, 1999). Labor tends to be cheap in poor countries so these services, in turn, are cheaper to implement than they are in rich nations. Nevertheless, support-led models are associated with less economic growth than growth-led models.
An emphasis on primary and secondary school, supplemental nutrition programs, and safe drinking water can all have huge economic benefits. In the case of China, the transition to a growth-led model came on the heels of decades of investment in these policies, making it easier to make the leap to a growth-led model.
On the pantheon of support-led policies, education holds a special and central position. It is often argued that, in a global economy, education
42 C H A P T E R 2 : C A s E s T u d i E s i n d E v E l o P m E n T A n d H E A l T H
investments are essential if future economic growth is to be maintained. For instance, it builds human capital, which can be thought of as a nation’s stockpile of knowledge, personality attributes, and skills. These goods make it possible for people to understand how to keep themselves healthy, to invest, to create jobs, and so forth. It probably also makes people better workers. Education is also essential to citizen participation in public debates, informa- tion exchanges, and goal setting. Generally, education is also the most reliable indicator of a country’s support-led policies (Evans, 2006).
Henry Kissinger referred to Bangladesh as one of development’s “basket cases.” By this, he meant countries that could never reach a full state of economic development no matter how much aid one throws at them (Economist, 2012). Although Bangladesh has remained a poor country— significantly poorer than its neighbor, India—aid does seem to be working its magic. It has achieved a steady growth in educational attainment and public health improvements, reaching higher rates of female education, female literacy, and infant immunization than India, even while falling further behind India with respect to per capita income. These improve- ments in education and public health may explain why it has been able to surpass its neighbor in life expectancy by four years.
BANGLADESH, A DEVELOPMENT “BASKET CASE”?
But support-led models also slow economic progress down in some ways by making it more difficult to start and run a business. Some entrepreneurs simply will not invest or will move to places where it is easier to do so. Although there are many poor countries with very high life expectancies because they have invested in clean water, sanitation, education, and nutrition programs, most people also want the chance to enjoy the benefits of capital- ism. Large populations in communist-era China or Cuba expressed dissent over the scarcity of consumer goods, even as they reaped the benefits of strong social infrastructure. (Cuba and China are somewhat odd cases because they are also authoritarian states. Even in democratic Kerala, constituents implore their elected officials to balance economic growth with social mandates such as good, affordable health care and worker protections.) So, in the ideal, how do policy makers decide where to draw the line between support-led and growth-led models?
T o w A R d A H A P P y m E d i u m ? 43
TOWARD A HAPPY MEDIUM?
Although there are no perfect, real-life “growth-mediated” and “support-led” models, China, Kerala, and Chile provide some perspective on the public health benefits of different development investment strategies. One point to remember is that public health policies are major determinants of the speed at which a country undergoes an epidemiologic and demographic transition. Recall that most of the gains in life expectancy globally since the mid-eighteenth century have come from tackling infectious disease and poor nutrition. This leads to an epidemiologic transition when infectious diseases are largely conquered with public health measures. The epidemiologic transition is followed by a demographic transition, which occurs when the population has a sufficiently low infant mortality rate that women bear just a few children on average, and the population begins to age until it starts to either shrink or accept immigrants from nations that have not yet undergone an epidemiologic transition. At some point in the twenty-first century, the global population may begin to decline when virtually all nations seem to be headed toward an epidemiologic transi- tion. Therefore, public health investments made by governments are probably leading to the global changes that will allow us to survive as a human race. (If we do survive, that is.) Economic development appears to be important in this regard because it allows governments and individuals alike to invest in neces- sities such as toilets, food, and vaccines.
Another point of these case studies is that, once these transitions are completed, one must ask whether they can be sustained. That is, although economic growth can help us solve our public health problems, we must be careful to ensure that the money earned from economic development is spent wisely. One definition of sustainable development is “development that meets the needs of the present without compromising the ability of future generations to meet their own needs” (WECD, 1987, p. 43). The goal behind sustainable development is to create a policy environment that allows people to lead a healthy, enjoyable life with minimal environmental impact. One assumption behind sustainable development is that, eventually, countries that focus on rapid economic growth at the expense of other social goods, such as the United States and China, will eventually be unable to support the needs of their popu- lations. In short, the thought is that nations with “unsustainable” social poli- cies will self-destruct unless broad policy changes are made (or new technologies mitigate the impact of more destructive ones) (see figure 2.2).
A final point of these case studies is to help readers understand that most social policies, not just those dealing with medical systems and food, affect one’s health. Investments in sewage systems, clean water, and vaccinations ultimately need to be accompanied by investments in schools, product safety, and occupational regulations. Further, all policies have unintended side effects,
44 C H A P T E R 2 : C A s E s T u d i E s i n d E v E l o P m E n T A n d H E A l T H
good and bad. Roads can greatly speed economic development and improve access to schools and clinics, but they also increase pollution and traffic fatali- ties and can even facilitate the spread of infectious diseases such as HIV/AIDS. (For instance, truckers can visit lovers or brothels along their regular routes.)
After three decades of growth-mediated policies, China ended up with a robust economy that raised hundreds of millions of people out of poverty, but it did so at the cost of widespread environmental destruction, massive displace- ment of its people through unregulated development projects, and rising so-called “cancer villages,” with unusually high levels of pollution and disease. Kerala achieved near universal literacy and became the envy of India with respect to indicators such as infant mortality and life expectancy, but it did so at the cost of economic stagnation and, as a result of poor job opportunities, a vast migration of its educated people out of the state. Chile invested heavily in public health and education, and also enacted market reforms that lifted its economy to enviable income and life expectancy levels, but it did so haphaz- ardly and at a great cost of lives during periods of political upheaval.
Figure 2.2. In China, the export revolution started during the transition to a predominantly capitalist economy led to massive environmental destruction, causing broad effects on ecosystems and adversely affecting the quality of life of hundreds of millions of Chinese citizens.
Source: Wikimedia Commons/Vmenkov.
C H i n A’ s E x P l o s i v E G R o w T H 45
Similar to China, Kerala also saw a massive displacement of its people. China’s families were displaced by rising waters behind dams and the bulldoz- ers of developers. Kerala’s people, however, were displaced by their own quest for skilled labor opportunities. Because their human capital skills could not be used at home, they ventured to the Middle East, the United Kingdom, the United States, and to other states within India. Still, the Kerala model may be the primary hope for the poorest countries with little or nothing to sell in the global economy because they have little in the way of natural or economic resources. In this section, we take a look at each locale’s history, governance, economic philosophy, and public health investments.
CHINA’S EXPLOSIVE GROWTH
Gleaming bullet trains bound for Shanghai whisk passengers at an average speed of 217 kilometers per hour through Wenzhou’s thick, gray skies. Through the haze, one sees extreme poverty and crumbling houses. Pristine Mercedes models dodge rusty rickshaws as they blast through intersections filled with rubble, not pausing for the red stoplight. The patchwork farms on the outskirts of Wenzhou are seeded and picked by hand by workers earning a few dollars a day, even as factory owners and real estate investors in the city join the world’s burgeoning billionaires. Today’s China paints a picture of great hope and promise interwoven with suffering and despair. It is a nation that has placed humans in outer space but has yet to ensure that its doctors have soap to wash their hands after using the hospital’s filthy bathroom. It is the perfect case study for the growth-led model in many ways. But that, like the rest of China, is changing as well. As you read this, enormous investments are being made in the health and welfare of the Chinese people.
Shortly after the Communist revolution of 1949, China embarked on experimental public health efforts. In 1965, China institutionalized these efforts, mobilizing large groups of citizens to tackle infectious diseases and installing basic medical providers in virtually every community across the unimaginably large and overpopulated nation.
These medical providers, known as barefoot doctors, tended to have just six months or so of medical training and only about seven years of education of any sort. Yet it does not take a good deal of training to set bones, to admin- ister vaccines, or to correctly diagnose and treat common ailments (see figure 2.3). Schools also received a boost from the Communist Party. In postrevolu- tionary China, literacy improved steadily from pathetically low levels.
Infectious disease was attacked with large-scale public health programs. These involved not only simple sanitation measures but also disease eradica- tion efforts. For instance, schistosomiasis, a parasite that spends part of its life
46 C H A P T E R 2 : C A s E s T u d i E s i n d E v E l o P m E n T A n d H E A l T H
in snails, was eradicated by a public works program that rid the rivers of the snail that hosts the parasite.
China’s communist years did see some of the greatest public health disas- ters in the recent history of human civilization. The “Great Leap Forward,” for instance, was a national policy aimed at mobilizing China’s massive workforce to produce large quantities of steel. Unfortunately, farmers are not steel workers and the steel was of extremely low quality. And making it required pulling workers out of agriculture and other life-sustaining industries within their largely closed economy. The massive starvation that followed caused a ten- to twenty-year drop in life expectancy. The Maoist government also tortured and
Figure 2.3. A woman helps one of China’s barefoot doctors with nursing duties in Luo Quan Wan village.
Source: Copyright © Yves Gellie/Corbis.
C H i n A’ s E x P l o s i v E G R o w T H 47
publicly humiliated entrepreneurs or suspected traitors, further endangering population health and well-being.
Still, China saw large and consistent improvements in life expectancy through the communist years. This was because the government made large investments in sewage, sanitation, education, and basic health care. As a result, it probably underwent an epidemiologic transition somewhere in the 1960s or 1970s. Interestingly, this happened despite relatively weak progress in nutrition.
In the 1980s, China began to transition to a capitalist model. This model involved creating special enterprise zones (SEZs), in which capitalism could flourish in a confined and controlled environment. The SEZ’s policies encour- aged foreign direct investment, streamlined processes for starting businesses, and implemented competitive taxation rates. The most successful of China’s five original SEZs, Shenzhen, grew from a fishing village of twenty-five thou- sand to a city of ten million in just two decades.
China’s economic reforms also dismantled the commune system, which was the source of community and health care for the average Chinese person. Under the traditional system, rural dwellers were mostly organized into small groups called communes. Each commune had one of the barefoot doctors associated with it, and the barefoot doctor was funded by local and central sources. Under the reforms, the barefoot doctors mostly disappeared (or became private doctors focused on curative rather than preventive care) along- side the communes.
Public health programs also generally went by the wayside. School fees, and even fees for vaccinations, were required in some places. The gains of the previous thirty years slowly yielded to outbreaks of infectious disease and great hardship for some of China’s poor. For the newly rich, however, it created the opportunity to move from a future of cramped dormitory life to four-story mansions, replete with koi ponds running under glass floors, tennis courts, and a pool.
Toward the end of the twentieth century, for the first time in many years, large numbers of Chinese went without health care. At the same time, the rising class of entrepreneurs enjoyed access to medical technologies previously reserved only for the highest-ranking party officials.
Local officials began to own and operate businesses. These officials worked with other business owners to build factories and power plants that spewed effluent into waterways used for drinking water. In some cases, the officials did not own the businesses, but they did receive kickbacks from polluters to skirt rules. Some of the rural poor were relegated to sifting their water from toxic sludge before boiling it and drinking it. Unsurprisingly, villagers along some of these waterways were reported to have mostly died young of cancer or other complications of industrial pollutants, such as liver failure.
48 C H A P T E R 2 : C A s E s T u d i E s i n d E v E l o P m E n T A n d H E A l T H
One classic example of one of the industrial pollutants now common in China is lead. Lead is a heavy metal that primarily causes brain damage, sapping youth of their future as professionals in China’s rising capitalist society (Muennig, 2009; Schwartz, 1994). Although regulations technically forbid human settlement around smelter plants, these were largely ignored because factory owners wanted workers in close proximity to their workplace. Child- hood lead poisoning cases soared as a result.
Air pollution has become so bad in China’s many urban centers that only rare, highly favorable atmospheric conditions yield days when it is safe to go outside. Because people essentially must go outside, lung diseases such as pneumonia have reached epidemic proportions (Xu, Gao, & Chen, 1994). Wealthier Chinese are protected by air-conditioned private cars and offices with filtered air. The poor still ride bicycles to work—something we would associate with a healthy lifestyle in industrialized nations but which is a dire threat in China’s urban centers (even more so now that cars vastly outnumber bicycles).
Important regulations, such as occupational safety or consumer protec- tions, have, in some instances, taken a backseat to economic growth. In others, they fall prey to corrupt local politicians who fear such regulations will cut into profits. In fact, such regulations do increase the cost of doing business. Some argue that they must be ignored if the nation is to maintain its 10 percent economic growth rate (an average of values between 2003 and 2013), and others argue that pollution will cost future growth prospects (BBC World Service, 2008; Neidell, 2004; Xu et al., 1994). Peasants routinely fall to their deaths from construction sites, are crushed in mining accidents, or die from tainted medicines and foods. These deaths too often go unnoticed within a country that controls what does and does not go into the media. Although some are reported, many of these incidents are picked up only by foreign journalists who happen to stumble on them or by webizens who risk prosecu- tion for reporting them.
Even with press restrictions, these ecological and safety problems have led to unrest. As more citizens risked arrest and detention in “black prisons” to protest China’s environmental, health, and public safety problems, the central government began to take notice. (“Black prisons” are extralegal centers used by Chinese security forces to detain, without trial, citizens who travel to regional or central government offices to address grievances they could not resolve at the local level.) In 2006, Hu Jintao declared a new period of “harmony,” in which social safety net programs would be reinstituted and the environment would be given serious attention. Unfortunately, these programs to date have been difficult to implement because the local officials in control of polluting factories have chosen largely to ignore them.
k E R A l A’ s Q u A l i T y o f l i f E 49
Still, the government is actively working to overcome these problems, and it is pushing ahead with a variety of national programs in health, housing, and education. One such reform surrounds an attempt to reinvest in rural health programs. Each locality has been given matching funds for health care and has been asked to design its own unique health program. These funds amount to US$2.50 per person in 2009 dollars. The state and the patient must come up with another US$2.50 and US$1.25, respectively. These programs, although totaling only US$6.25 on the high end (a figure that has since increased), have added financial relief for catastrophic illness in rural areas. Some localities, such as Daxing near Beijing, have had great success in imple- menting minimal basic health programs (personal communication).
China is fortunate in that it completed its epidemiologic and demographic transitions before undertaking market reforms. Indeed, these transitions have provided a jumping-off platform for its remarkable economic success. The question now is whether its economic growth has been so unchecked that China’s larger environment will survive. Unless there are significant break- throughs in environmental technology that China can afford to use, China’s environment might eventually collapse, creating major public health problems for its citizens.
KERALA’S QUALITY OF LIFE
Kerala is a state in southern India with around thirty million people packed into a relatively small area. It is a poor state, ranking toward the bottom of India’s per capita GDP rankings (Parayil, 1996; Ratcliffe, 1978; Veron, 2001). Nevertheless, it ranks at the top in terms of life expectancy, public health infrastructure, and literacy. It also has among the country’s (and the world’s) lowest infant mortality and birth rates.
Although most states within India are predominantly male—a combined result of sex-selective abortions and giving female children less food or resources when money runs short—Kerala has a male-to-female ratio compa- rable to most European nations. In fact, many measures of health and educa- tion are in the ballpark range of much wealthier nations.
To many, these positive statistics are shocking. After all, health and wealth are supposed to be two great things that go great together. Certainly Costa Rica, Chile, and many other low- or middle-income countries have achieved high levels of literacy and life expectancy with relatively little economic power, but these nations are by no means quite as poor. Cuba is neck and neck with the United States on measures such as life expectancy, but it devotes a huge proportion of its resources to education and health. Kerala, in contrast, is
50 C H A P T E R 2 : C A s E s T u d i E s i n d E v E l o P m E n T A n d H E A l T H
something of a miracle, at least at first glance. After all, many in Kerala lack even basic necessities, such as cooking ware or bedding.
How has Kerala achieved this? One clue lies in its long history of education funding. In the early part of the twentieth century, local royalty ceded to the demands of its people for more schools. Girls were not shunned for wanting to read or learn math. By mid-century, Kerala’s literacy, life expectancy, and male-to-female ratios were already among the best in India.
In 1959, a democratically elected communist government began wider- scale schooling programs and coupled them with public health initiatives. In 1988, early efforts culminated in a massive attempt to mobilize as many edu- cated Keralans as possible to teach even previously out-of-reach villagers how to read and write. Many texts were translated into local languages, such as Malayalam. Before long, the percentage of literate Keralans had climbed and Kerala had broken away from Indian averages, instead chasing much richer nations in terms of literacy and longevity.
Kerala makes for an interesting case study because it is poor and has achieved greatness in measures of human development. However, it is also famous because it has enacted “communist” or “socialist” policies in the context of a democracy. It even has environmental protections in place that are stronger than one typically sees in a low-income region. For these reasons, Kerala has been touted as a model for sustainable development (Heller, 2012; Parayil, 1996).
The main countries that have come close to achieving similar sustainable development goals are Scandinavian ones. Norway, for instance, ranked first on the HDI and Global Peace Index in 2007 (albeit aided by massive crude oil reserves). Scandinavian countries have invested heavily in health and educa- tion and have stringent environmental regulations. By minimizing environmen- tal degradation and maximizing the well-being of future generations, these countries are seen as much more likely to remain viable over many genera- tions. Thus, the Kerala model has been proposed as a sort of “Scandinavia light” for poor countries.
Does Kerala help us understand what makes for healthy, sustainable devel- opment? Certainly, much of Kerala’s success comes on the back of literacy and public health policies. But it also partly arose from a relatively cohesive, some- what matrilineal society dominated by aliya kattu, a property inheritance system in which female children inherit the majority of a mother’s belongings. So it may be impossible to disentangle the state’s underlying culture from its successful policies.
Indeed, political scientists have debated for years whether homogenous or more cohesive societies are more likely to enact health-producing social policy, so we will never really know for sure how much of which is responsible for health (Orloff & Skocpol, 1984; Skocpol, 1979; Weir, Orloff, & Skocpol, 1988).
k E R A l A’ s Q u A l i T y o f l i f E 51
Some researchers contend that Kerala boosters may have overstated their case (Veron, 2001). With all of the regulations in place, the Kerala government has recognized its need to improve the way that the government functions. Most of the state’s low level of environmental destruction, for example, may partly be attributed to its lack of industry. The same might be said of Kerala’s nondemocratic cousin, Cuba. In the case of Cuba, it is poverty and economic isolation more than good intentions about a green revolution or sustainable development that initially led to an uptake in organic farming. In fact, the nation’s agricultural profile is now retreating and looking toward a more capitalism-based farming model.
Nevertheless, Kerala and Cuba demonstrate that a nation does not have to be rich to be well educated and healthy (see figure 2.4). Poignantly, Kerala has been able to achieve impressive outcomes without coercion or human rights violations. As with any case study, readers should keep in mind that
Figure 2.4. Children outside a school in Kerala.
Source: Christopher Michel Photography. Available at www.flickr.com/photos/ cmichel67/4077411904/.

52 C H A P T E R 2 : C A s E s T u d i E s i n d E v E l o P m E n T A n d H E A l T H
these examples serve to illustrate only what might be the cause of better health rather than what is the case for better health.
CHILE AIMS FOR A BALANCING ACT
Chile has a long history of having a largely bifurcated society, especially in terms of class and political ideology. On one side, there are many Chileans who oppose more expansive support-led reforms and who hope for a low-tax, high-performance economy. (Recall that “support-led” refers to policies that favor social welfare over economic growth.) On the other side are a large number of progressive Chileans who demand social investments in the name of social justice. These two competing forces have created a rich experiment in economic versus social reform that gives us a sense of how these competing investments may have affected Chilean life expectancy (figure 2.5).
Figure 2.5. Life expectancy of women in Chile relative to Japan, the United States, New Zealand, and Norway.
Source: Oeppen, J., & Vaupel, J. W. (2002). Broken limits to life expectancy. Science, 296(5570), 1029. Retrieved from www.sciencemag.org/content/296/5570/1029 .summary.
Japan Chile
New Zealand (non-Maori) Norway U.S.A.
Li fe
e xp
ec ta
nc y
(in y
ea rs
)
85
80
75
70
65
60
55
50
45
40
35
30
18 40
18 60
18 80
19 00
19 20
19 40
19 60
19 80
20 00
Year

C H i l E A i m s f o R A B A l A n C i n G A C T 53
The solid line in figure 2.5 represents the moving average of female life expectancy over time. Chile had extraordinary increases in life expectancy through around 1980, which then again started to rise quickly in the late 1990s.
In the 1920s and for much of the 1930s, right-leaning parties dominated Chilean politics (Collier & Sater, 1996). This was in no small part due to the electoral laws allowing only literate men to vote. Because the majority of the country was poor and illiterate, this meant that only the elite class, which previously held power as dictators, would be elected into office. The slow rise of a middle class did lead to a slow trickle of reformers into office, including the office of the presidency.
The right-wing dominance was interrupted, however briefly, by the Great Depression, leading to some reforms. For instance, limited suffrage was granted to women in the early 1930s (Pernet, 2000). Then, in 1938, an unsuccessful military coup by the socialists was brutally suppressed, leading to a backlash. This coup and backlash angered Chileans to the point that Pedro Aguirre Cerda was voted into office (Collier & Sater, 1996). Aguirre Cerda’s left-leaning administration focused on education reform, building thousands of schools. It also invested heavily in public health measures, slowly bringing sanitation, cleaner water, improved nutrition, and vaccination programs to the masses.
Most important, the administration enacted electoral reforms that largely entrenched left-leaning parties in the Chilean political machine. For instance, they not only removed restrictions on whether women or those with less edu- cation could vote, but they also made voting compulsory. This had the effect of bringing the poor masses into the political process and helping to ensure future leftist victories.
During this period, the government continued to make heavy investments in health, public health, and education. These investments accelerated until the welfare state consumed much of the economy. Land reforms (including expropriations of large land holdings and subsidies for small farms), coupled with heavy investments in education and health, led to dramatic increases in life expectancy among the poor. The country entered its demographic transition in the 1940s, rapidly climbing from a life expectancy of around thirty years in 1920 to sixty years by 1960—nearly one year of life expectancy gained per year of time passed.
However, all of this did little for the Chilean economy. Despite its abun- dance of health and mineral wealth (especially copper), Chile’s economic growth was quite slow. Then, in the 1970s, President Salvador Allende attempted to open clinics twenty-four hours a day and pushed through a number of far-reaching social programs. He also gave huge raises to public sector employees. This huge boost in government spending led to soaring economic growth, rapidly followed by hyperinflation, debt, and economic chaos.
54 C H A P T E R 2 : C A s E s T u d i E s i n d E v E l o P m E n T A n d H E A l T H
The economic crisis endangered the survival of the Allende administration. In addition, the US government used operatives to assassinate Allende’s sup- porters in the Chilean military and worked in conjunction with his detractors to stage a coup in 1973 (Collier & Sater, 2004).
The years between 1973 and 1989 were marked by decentralization (public schools, for instance, went from being nationally funded to being governed and funded by local municipalities) and defunding of social services. Thou- sands of people “disappeared” in the coup (and were never recorded as official deaths), tens of thousands were interned and tortured, and an additional two
Most nations are in control of how much currency is in circulation. As a result, there is a huge temptation to simply print (or create in digital form) currency to pay off a nation’s debt. When this happens, though, the supply of the nation’s currency increases. Unless the economy is shrinking and the currency is deflating anyway, printing money will lead to inflation.
Something similar happens when wages are increased. More money in people’s pockets leads to more spending, which leads to more eco- nomic growth and, ultimately, inflation. This can cause an inflationary spiral—a condition in which the cost of goods increases so it becomes necessary to raise wages, which then also contributes to increases in the cost of goods.
Inflation also reduces the value of the currency relative to other nation’s currencies (as we all learned in economics, an increase in the supply of something reduces the cost of that thing). When the value of a nation’s currency falls relative to others, it becomes cheaper to buy things that the country produces, so its exports tend to increase. This can give a huge boost to a nation’s economy, but it also makes foreign goods more expensive. The combination of economic growth (which creates inflation overall) and higher prices for imports (which creates inflation in some goods) can result in a situation that quickly spirals out of control. Therefore, reducing a currency’s value can also have a huge inflationary effect, particularly in countries that rely on critical imported goods such as food.
This is important for health because falling into poverty is not good for the average citizen. For instance, it can affect a family’s nutrition, ability to buy medicines, and quality of the housing.
A PRIMER ON THE ECONOMICS OF DEVELOPMENT
C H i l E A i m s f o R A B A l A n C i n G A C T 55
hundred thousand or so fled into exile (Ensalaco, 2000). Even setting these disappearances aside, Chile experienced a slight slowdown in life expectancy during these years (Oeppen & Vaupel, 2002), even as it realized a large boom in economic growth by the 1980s. Augusto Pinochet, the brutal dictator installed in the 1973 coup, called a general election and was defeated. In 1990, a center-left coalition was elected to office.
Chile potentially serves as a counterfactual to the Cuba, China, and Kerala examples because it has excellent health and educational outcomes coupled with low fertility but a very different history. Even though Chile is a bit better off and Chilean life expectancy data are fairly reliable over much of the twen- tieth century, it is still difficult to guess how changes in Chilean policy might have affected life expectancy. Education enhancement probably takes years to affect life expectancy or fertility rates, for instance, so any rapid changes in governance are difficult to map to either of these important outcomes.
If we humor this notion that social programs and democracy could be linked, we see that life expectancy skyrocketed after the reforms of the 1930s and leveled off after these social programs were defunded in the late 1970s and 1980s (the periods of fastest economic growth; see figure 2.5). It increased again after social democracy returned in the 1990s.
The real reason we have included the Chilean case study, though, is to show that a nation need not be a totalitarian communist state nor impoverish itself with social spending to achieve a long life expectancy. With relatively modest means, it has achieved a life expectancy that is equal to that of the United States (about seventy-eight years for both countries).
Unlike the Keralan or Cuban cases, Chile’s development has been far from environmentally sustainable. Environmental protections have only recently become front and center in Chile’s official policy. These environmental policies also tend to be a bit weak. Of course, Chile is destroying its habitat at a slower rate than China.
A note: You also may have noticed that our brief descriptions of the different models focused most on the governments’ economic policies with only short mentions of politics, even though we included labels such as capitalist, social- ist, and communist. Why? One reason is that it is really difficult to place a concise but accurate label on a country. How can China be a “communist country,” for instance, after decades of dismantling communes and public enterprises? How can a Chilean “socialist” president aggressively pursue market-oriented policies? Even Cuba is slowly giving way to a model that looks a lot like China’s. The relationship among public health, development, and politics is a complicated one, and we will hold off on focusing on that piece of the puzzle until chapter 6.
56 C H A P T E R 2 : C A s E s T u d i E s i n d E v E l o P m E n T A n d H E A l T H
SUMMARY
Although most of the world’s wealthiest nations (with respect to per capita GDP) rank among the top nations worldwide in terms of life expectancy, there are some exceptions. Likewise, although most of the poorest nations rank toward the bottom, some of these nations and states rank closer to the top. Many experts believe that health and life expectancy are less dependent on whether a nation is rich but rather on how the nation spends its money. Cuba and the state of Kerala within India provide two examples of how the right social policies may improve population health. If we take a historical perspec- tive, Chile’s story also suggests that health can be gained or lost depending on the investments made. China appears to have initially damaged its prospects for rapid gains in life expectancy during its conversion to a capitalist model of development. As of now, though, it seems to be on track to repairing this damage as it invests in transit, health care, and healthy cities. This brings us to the next unit, which focuses on policy as a means to better health.
KEY TERMS
barefoot doctors global north global south growth-mediated
economy human capital
industrializing nations inflationary spiral least-developed
countries Preston curve social capital
support-led model sustainable
development wealth-health gradient
DISCUSSION QUESTIONS
1. What is the Preston curve? What puzzles does it present for global health policy makers?
2. What does a growth-mediated model of development look like? What are some of its strengths and weaknesses?
3. What does a support-led model of development look like? What are some of its strengths and weaknesses?
4. Based on the very short summaries you have read thus far, what do you think the key characteristics of China’s current development situation might be? Its key challenges? What about for Kerala and Chile?
5. Think about another middle- or high-income country you know well. Was its development path similar to that of any of the case studies? Did it pass labor, environmental, educational, and other regulations
57R E f E R E n C E s
before, during, or after rapid economic growth? Talk about two to three specific major programs or pieces of legislation in your answer. For instance, in the case of the United States, consider pieces of legislation such as the Wagner Act, New Deal, Clean Air Act, and so on.
6. Do current middle-income countries face the same sorts of develop- ment challenges that industrialized nations such as England, Japan, and the United States did in the last century? What has changed?
FURTHER READING
Wallich, P. (1995). Mystery inside a riddle inside an enigma. Scientific American, March, 37.
REFERENCES
Acemoglu, D., & Johnson, S. (2006). Disease and development: The effect of life expectancy on economic growth. Cambridge, MA: National Bureau of Economic Research.
BBC World Service. (2008, August 11). Beijing pollution: Facts and figures. Available online at http://news.bbc.co.uk/2/hi/asia-pacific/7498198.stm
Collier, S., & Sater, W. F. (1996). A history of Chile, 1808–1994 (Vol. 82). Cambridge, UK: Cambridge University Press.
Collier, S., & Sater, W. F. (2004). A history of Chile, 1808–2002 (Vol. 82). Cambridge, UK: Cambridge University Press.
Drèze, J., & Sen, A. K. (1989). Hunger and public action. New York: Oxford University Press.
Economist. (2012, November 3). Bangladesh and development: The path through the fields. Available online at www.economist.com/news/briefing/21565617 -bangladesh-has-dysfunctional-politics-and-stunted-private-sector-yet-it-has-been -surprisingly
Ensalaco, M. (2000). Chile under Pinochet: Recovering the truth. Philadelphia: University of Pennsylvania Press.
Epel, E. S., Blackburn, E. H., Lin, J., Dhabhar, F. S., Adler, N. E., Morrow, J. D., & Cawthon, R. M. (2004). Accelerated telomere shortening in response to life stress. Proceedings of the National Academy of Science of the United States of America, 101(49), 17312–17315.
Evans, P. (2006). Population health and development: An institutional-cultural approach to capability expansion. Successful societies. Washington, DC: World Bank.

58 C H A P T E R 2 : C A s E s T u d i E s i n d E v E l o P m E n T A n d H E A l T H
Friedman, M. (1982). Capitalism and freedom. Chicago: University of Chicago Press.
Heller, P. (2012). Democracy, participatory politics and development: Some comparative lessons from Brazil, India and South Africa. Polity, 44(4), 643–665.
Kawachi, I., Subramanian, S. V., & Kim, D. (2010). Social capital and health. New York: Springer.
Kim, D., Subramanian, S. V., & Kawachi, I. (2006). Bonding versus bridging social capital and their associations with self-rated health: A multilevel analysis of 40 US communities. Journal of Epidemiology and Community Health, 60(2), 116–122.
Muennig, P. (2009). The social costs of childhood lead exposure in the post-lead regulation era. Archives of Pediatrics and Adolescent Medicine, 163(9), 844–849. doi: 163/9/844 [pii]10.1001/archpediatrics.2009.128.
Muennig, P., Cohen, A. K., Palmer, A., & Zhu, W. (February 2013). The relationship between five different measures of structural social capital, medical examination outcomes, and mortality. Social Science & Medicine, 85.
Neidell, M. J. (2004). Air pollution, health, and socio-economic status: The effect of outdoor air quality on childhood asthma. Journal of Health Economics, 23(6), 1209–1236.
Oeppen, J., & Vaupel, J. W. (2002). Broken limits to life expectancy. Science, 296(5570), 1029.
Orloff, A. S., & Skocpol, T. (1984). Why not equal protection? Explaining the politics of public social spending in Britain, 1900–1911, and the United States, 1880s– 1920. American Sociological Review, 49(6), 726–750.
Parayil, G. (1996). The “Kerala model” of development: Development and sustainability in the third world. Third World Quarterly, 17(5), 941–957.
Pernet, C. A. (2000). Chilean feminists, the international women’s movement, and suffrage, 1915–1950. Pacific Historical Review, 69(4), 663–688.
Preston, S. H. (1976). Mortality patterns in national populations: With special reference to recorded causes of death. New York: Academic Press.
Putnam, R. D. (1995). Tuning in, tuning out: The strange disappearance of social capital in America. Political Science and Politics, 28, 664–683.
Ratcliffe, J. (1978). Social justice and the demographic transition: Lessons from India’s Kerala State. International Journal Health Services, 8(1), 123–144.
Schwartz, J. (1994). Low-level lead exposure and children’s IQ: A meta-analysis and search for a threshold. Environmental Research, 65(1), 42–55. doi: S0013– 9351(84)71020–6 [pii]10.1006/enrs.1994.1020.
Sen, A. (1999). Development as freedom. New York: Knopf.
Singh, G. K., & Miller, B. A. (2004). Health, life expectancy, and mortality patterns among immigrant populations in the United States. Canadian Journal of Public Health, 95, 114–121.
59R E f E R E n C E s
Skocpol, T. (1979). States and social revolutions: Comparative analysis of France, Russia, and China. Cambridge, UK: Cambridge University Press.
Veron, R. (2001). The “new” Kerala model: Lessons for sustainable development. World Development, 29(4), 601–617.
WECD. (1987). Our common future. New York: Oxford University Press.
Weir, M., Orloff, A. S., & Skocpol, T. (1988). The politics of social policy in the United States. Princeton, NJ: Princeton University Press.
Xu, X., Gao, J., & Chen, Y. (1994). Air pollution and daily mortality in residential areas of Beijing, China. Archives of Environmental Health: An International Journal, 49(4), 216–222. doi: 10.1080/00039896.1994.9937470.
PART TWO
Global Health and the Art of Policy Making
CHAPTER 3
The Global Burden of Disease
63
KEY IDEAS
• The global health community needs to shift our focus from how many people get sick to why they get sick and what we can do about it.
• Burden of disease analysis tells us how much suffering and death there is among a given group or in a given place on earth.
• Cost-effectiveness analysis tells us how many lives we can save with a particular amount of money.
Burden of disease refers to how much disease and death are present in a given place (e.g., Zambia) or among a group of people (e.g., poor rural farmers). Once we know which health problems are present and where, we can start to do something about them. Maybe.
But just how do we figure out how to make public health investments? One approach is to look at where people are dying at much higher rates than in other places. But how do we think about what it is about the characteristics of such places that make people sick? Is it the poorest nations that need our attention? Focusing on such nations might lead us to invest in places such as Cuba, where people only earn a dollar a day. But although this might generally be a good approach, people in Cuba live longer than in many rich nations, so universal investments in the poorest nations do not make complete sense. Another way of thinking about this is by geography. Some parts of the world are sicker than others (thus the global north and global south designations) but that logic does not consistently work either. Even if we hone our criteria down to focus on regions such as Latin America, Asia, and Africa, we ignore
64 C H A P T E R 3 : T H E G l o b A l b u R d E n o f d i s E A s E
that some nations are doing well in terms of health and others not so well. It is also a problem that neither geography nor wealth really tells us much about what we should be doing to improve people’s health. Another way of thinking about health is in terms of which policies are needed and where. Burden of disease analysis can help inform these kinds of policy actions and investments.
In this chapter, we will explore the major causes of disease among adults and children. Some of these can be addressed with very simple, tried-and- true public health interventions: vitamin A supplementation for malnourished people, clean water, vaccination, and healthy meal preparation in the face of food scarcity. These are a few essential steps that will be discussed throughout this book that can be used to address leading causes of disease in low-income countries. For middle- and high-income countries, the solutions are more com- plicated but can also probably be addressed if only there were enough funding. Let us begin by asking where diseases are located.
WHO DIES WHERE?
The leading causes of death worldwide can be found in table 3.1. These numbers are not perfect. It is very difficult to tell how many people there are in many poor nations, let alone whether they are alive or dead. And if we know whether they are alive or dead, we still have to figure out what they died from. With this in mind, take a look at table 3.1.
We see that the leading causes of death are heart disease, stroke, pneu- monia, and chronic obstructive pulmonary disease (COPD), that is, most people worldwide go because either their heart or their lungs give out on them. But as we have mentioned before, the biggest threats to human health vary
Table 3.1. Counting Deaths Worldwide, by Disease
Number of deaths (in millions) Percentage of all deaths
Heart disease 7.25 12.8 Stroke 6.15 10.8 Pneumonia 3.46 6.1 COPD 3.28 5.8 Diarrhea 2.46 4.3 HIV/AIDS 1.78 3.1 Tuberculosis 1.34 2.4
Source: WHO. (2011). The top 10 causes of death. Fact sheet no. 310. Available online at http://
who.int/mediacentre/factsheets/fs310/en/.
Note: COPD is the acronym for chronic obstructive pulmonary disease.

W H o d i E s W H E R E ? 65
greatly from country to country, so knowing the overall burden of disease of stroke might be interesting to some people, but it does not help us set up poli- cies that will make people any healthier because policies to reduce stroke are usually applied at the local level.
The World Bank argues that it is possible to understand these threats according to a nation’s level of economic development. The WHO argues that global region is also important (Murray & Lopez, 1996). (The WHO does look at these problems in many different ways.) In reality, prevalent diseases and other causes of mortality and morbidity vary even within countries. At the time of writing, 30 percent of China’s population was still living on US$2 per day. (This, in a nation that has put humans into outer space.)
One way to think about the global burden of disease is to explore deaths by level of development. In figure 3.1, we see the relative number of deaths due to infectious and noninfectious causes by level of economic development. Here, we see that noncommunicable diseases dominate in wealthier nations and infectious diseases dominate in poorer nations. (Note that these traditional distinctions will probably one day soon be replaced because we are learning that many noncommunicable diseases, such as obesity, may actually be spread from person to person [Christakis & Fowler, 2007]). At any rate, behaviors such

Needs help with similar assignment?

We are available 24x7 to deliver the best services and assignment ready within 3-4 hours? Order a custom-written, plagiarism-free paper

Order Over WhatsApp Place an Order Online

"Do you have an upcoming essay or assignment due?


Get any topic done in as little as 6 hours

If yes Order Similar Paper

All of our assignments are originally produced, unique, and free of plagiarism.

Stuck with a Question?

Get it solved from our top experts within 8 hrs!

Ask Your Question Now!