Public health issues in global context

Environmental sustainability

2009-11-22T11:37:00.000-08:00

Ionizing radiation

There was one sort of pollution that wasn´t mentioned in the material - radiation. Because I didn´t find any districtions I decided to choose this topic as one of my special interests. So I want to write about radiation and especially about ionizing radiation related to nuclear activity. I think this topic is also very relevant when considering life on the earth in the future because in highly radioactive environment it´s impossible to live in and world contains numbers of sources of potential radioactive pollution which can globally influence on lives of all of us with no regard of state of wealth. Radiation doesn´t know the borders of countries or even continents and damages everyone who it reaches.

I chose WHO pages about radiation to be my source. There I chose as an example of radiation hazard one article about the Chernobyl accident and then two articles where were explained more commonly about ionizing radiation. Here are the links:

http://www.who.int/ionizing_radiation/en/

http://www.who.int/ionizing_radiation/env/en/

http://www.who.int/mediacentre/factsheets/fs303/en/index.html

The most important message of that information:

There is natural radiation in the environment in the soil, water and air(natural backround radiation) and has always occurred in the earth. Below is picture where is a distribution of different sources of radiation.

Kuvan lähde WHO

Like picture tells the most of radiation comes from natural Radon from ground which can cause lung cancer when inhaled. Other natural sources are radioactive minerals in ground, for example Uranium that is mined to be a fuel in nuclear plants, and cosmic radiation from space. Then there are a lot of man-made contribution to radiation exposure to human beings including use of this natural radiation sources. Radioactive waste comes from nuclear plants, nuclear weapons testing, accidents in nuclear plants and from misuse of radioactive stuff. Also other industry and medicine use radioactive components.

WHO has program, The Radiation and Environmental Health Programme, focused on evaluating health risks and public health issues related to environmental and occupational radiation exposure. It´s included in Sustainable Development and Healthy Environments Cluster.

The most serious accident in history happened 26.4.1986 in Chernobyl, Ukraine. One of the reactors of nuclear plant exploded and radioactive material spreaded into atmosphere. It was spreading over the Europe but mostly to Belarus, Russian Federation and Ukraine.

The accident resulted in large displacement of populations(116000) and contamination of environment. It caused severe harm to the population living in the area by serious health effects, mental traumas and lose their homes and social networks. About 5 million people are still living in the area where they are exposed to the radiation levels more than limit dose.

There were ordered 350000 liquidators to clean up the area and they were exposed to huge amounts of radiation and especially in the beginning they didn´t have proper protection or even awareness of the dangerous work they were doing. Soviet Union officials were hiding the truth from people living in the area so that also they couldn´t protect themselves from exposure. It took few years before people could get appropriate information about the accident and were suffering from stigma.

WHO experts conducted study to get scientific unbiased information about the health effects of the accident and radiation exposure. The result told the following:

-"A large increase in the incidence of thyroid cancer has occurred among people who were young children and adolescents at the time of the accident and lived in the most contaminated areas of Belarus, the Russian Federation and Ukraine" This was result of drinking milk from local cows and it would have been possible to avoid by giving a guidance of stopping giving local milk to children. After few months the danger would have been over because radioactive iodine(the cause of this cancer) is not living longer than that.

- "Ionizing radiation is a known cause of certain types of leukaemia (a malignancy of blood cells)." It seems that this sort of leukaemia insident rates are double among those who were cleaning the accident area and received the most dangerous doses of radiation.

- "According to UNSCEAR (2000), 134 liquidators received radiation doses high enough to be diagnosed with acute radiation sickness (ARS). Among them, 28 persons died in 1986 due to ARS. Other liquidators have since died but their deaths could not necessarily be attributed to radiation exposure." There is also expectation that accident would have been increasing overall cancer mortality but it has been very difficult to prove scientifically excluding those mentioned above. "The Expert Group concluded that there may be up to 4 000 additional cancer deaths among the three highest exposed groups over their lifetime (240 000 liquidators; 116 000 evacuees and the 270 000 residents of the SCZs)."

- "The lens of the eye is very sensitive to ionizing radiation and cataracts are known to result from effective doses of about 2 Sv."

- "A large Russian study among emergency workers has suggested an increased risk of death from cardiovascular disease in highly exposed individuals"

- "High levels of stress, anxiety and medically unexplained physical symptoms continue to be reported among those affected by the accident."

Solutions for radiation exposures:

Firts of all controlling radiation threat needs attention and will to take it seriously. It needs international co-operation and awareness. Luckily there already are several associations and projects that have been meant to consider this problem. One of them was introduced on the WHO pages in the following way:

"The aim of the Radiation and Environmental Health Programme is to look for solutions to protect human health from ionizing radiation hazards by raising people's awareness of the potential health risks associated with ionizing radiation, and the importance of its safe and rational management."

Also international rules and recommendations are needed to make sure on the one hand safe and responsible use and handling of radioactive material and on the other hand proper and effective way to act in possible emergencies and accident situations so that the caused harm is as small as possible to humans and environment.

There must be done also more research on the adverse health effects of radiation and new technologies to deal with them. Awareness of medical staff and public health workers in a case of accidents or terrorism attacks etc. is important to relevant response.

Chernobyl example showed in many sense what is the worst possible way to act in a emergency. Hopefully in the future whole world has been learning from it. I list some of the most important things that should be taken care in commensurate situation. First of all is information that should be given properly and to all people in danger and it should contain facts about what has happened and how to get protection(also clear international publicity reduces confusion in other countries). Second thing is to provide necessary protection(shelter, clothing etc.) to people and workers. Trauma therapy is also necessary and now WHO has been supporting people involved in the accident to get knowledge about the accident and its health effects.

Infectious Diseases

2009-11-14T03:45:00.000-08:00

1. How to prevent malaria?

- The most important(and probably cost-effective) issue introduced in the video above others were insecticide-treated nets that should be for free and used by everyone but especially by kids and pregnant women.

- Second thing mentioned was demonstrations how to use nets because people can often skip the use if they don´t know exactly how to use or what for.

- The third thing mentioned related also to the issues above was spreading awareness and knowledge about malaria so that parents and people know the danger that comes from it and also they can recognize the symptoms.

- From other sources I could find some other issues like early treatment will shorten the duration of disease, prevent complications and avoid deaths(the most important drugs are ACT- artemisinin-based combination therapies).

- In highly endemic areas to pregnant women can be given IPT/SP(sufadoxine-pyrimethamine) to clear the placenta of parasites.

- There are also sprays to kill mosquitos indoor spaces

- Reducing standing water in order to prevent mosquito breeding

- Good monitoring and epidemic forecasting, prevention and response

- Research on new medicine, diagnosis, insecticides and prevention ways

- Preventing drug resistance by using medicine properly and efficiently

(Btw, an extra comment in the end - I was so surprised to read that DDT is still used and even recommended somewhere without any mention of possible harm it can cause)

2. Preventing Tuberculosis and HIV/AIDS at the global level

There are some common factors to prevent these diseases as well as others like malaria. At the global level the most important factors are different partners who promote and donate help to developing countries. They can be either private(associations, companies) or public(official governance and health care). The amount of support and money they give is important. Spreading knowledge is also important work like in HIV prevention where campaigns and new policies(women rights as an example) and condom distribution can have big meaning.

Anyway one of the most important global challenge that was given in our material was to make these all participants to work together and coordinate their work well so that strenght of the health systems and treatment coverage would be better. Programs with common interestests should engaged more(like TB and HIV and different TB programs and associations). In countries their health care systems should be strenghtened and managed better and also developing countries should be interested by themselves in investing to the health of their population. Help and donation from developed countries should be long-term, predictable, focused and well coordinated which is not nowadays always the case.

Access to drugs was emphasized too. It means that they have to be affordable to all and their supply should be guaranteed where wider systems have their own impact through international and regional trade agreements and to national governance(for example the Agreement on Trade Related Aspects of Intellectual Property). One factor where also developed countries can influence a lot to is research and monitoring. The problem is that there isn´t that much interest to make research and invent new medicine, vaccines and diagnosis to the diseases that are mostly concerning poor countries and poor people. There is also need for monitoring the already implemented programs and their efficiency and the behavior and spread of those diseases. The problem isn´t there wouldn´t be means and technology to cure diseases but the unfair distribution of them so that people who the most would need then often lack them.

Especially regarding tuberculosis there is drug resistance problem that comes from careless and incomplete use of drugs. Drug resistance situation needs monitoring and addressed attention because it can be more global problem in the future. DOTS program has been developed to control TB and its treatment with globally planned policy. Global policies and standards are important from many aspects to make sure that medicines are properly stored and transported and they are safe and effective. Global community should also support national governments to create judicial system that can enforce the implementation of those regulations and take actions against corruption and diversion.

One big problem in poor countries is lack of skilled medical workers which is also influenced by developed countries as brain drain when salaries in poor countries are so bad that skilled staff is searching for better salaries from developed countries. In developed countries there also can be lack of skilled workers in some sectors(like in Finland where is lack of nurses and doctors in basic health care centers) so that sometimes rich countries even encourage people from developing countries to move there(like nurses from Philippines in Finland). There are also other reasons for shortage of skilled staff in developing countries like bad quality or amount of education and government´s resistance to hire enough staff or pay for it.

References:

Ruxin, J., Paluzzi, J., Wilson, P., Tosan, Y., Kruk, M. & Teklehaimanot, A. 2005. Emerging consensus in HIV/AIDS, malaria, tuberculosis, and access to essential medicines. (pdf) The Lancet, Vol. 365 (12), 618-621.
WHO Fact sheets: Malaria, 10 Facts on Malaria
WHO Fact sheets: Tuberculosis, 10 Facts about Tuberculosis
WHO Health Topics: HIV/AIDS

Maternal and Child Health

2009-11-08T08:10:00.000-08:00

1.

The main causes of child mortality:

The biggest risk of death is during the first month of the life(40% of the deaths under 5 years old). The most common reasons of newborn(neonatal period) death are:

- preterm birth
- birth asphyxia
- infections (pneumonia, sepsis)

After one month till the age of 5 the causes of death are:

- pneumonia (one factor indoor air pollution)
- diarrhoeal
- malaria
- measles
- intestinal infections(parasites)
- cholera
- HIV
- malnutrition
- direct or indirect consequences of armed conflicts and natural disasters
- female genital mutilation (FGM)

Many of these causes interact together by contributing to each other like malnutrition and many diseases. Also poverty and bad conditions like inadequate sanitation and housing are influencing on other conditions like in previous topics we have been learning. Other indirect risks are lacks of information, services and technology.

The main causes of maternal mortality:

- bleeding (haemorrhage)
- infections
- unsafe abortion
- hypertensive disorders (pre-eclampsia and eclampsia)
- anaemia
- obstructed labour
- FGM

2.

Prevention means of child and maternal mortality:

- quality care during a pregnancy
- skilled medical personnel attended in delivery
- immedeate care after delivery(breathing, warmth, hygienic cord, skin care)
- quality medical equipment and basic care facilities if complications occur (drugs, antibiotics, transfusions, Caesarean sections and other surgical interventions)
- strong health care system)
- breastfeeding unless mother has HIV/AIDS
- vaccinations, immunization
- antibiotics
- oxygen (pneumonia)
- Oral Rehydration Salts and zinc supplements (diarrhoeal)
- insecticide treated nets, anti-malarial medication (malaria)
- antiretrovirals, safe feeding practices and delivery (HIV)
- "ready-to-use therapeutic foods" (malnutrition)
- maternal education
- postponed marriage till the age of 18
- family planning and contraceptives (unsafe abortions)
- different heating system(smoke)

About 2/3 of deaths of children are preventable through basic low-cost means. Most maternal deaths can be prevented through skilled care at childbirth and access to emergency obstetric care.

3.

Overall rule is that everything that prevents maternal mortality and sickness and makes mothers healthier is also contributing to the health of children. Especially broader interventions are useful to both like reducing poverty, promoting education, and reducing pollution and gender inequality etc.

More practical basic interventions to both are better living conditions(housing, sanitation) and healthy nutrition.

References:

Childinfo 2008. Monitoring the situation of children and women. UNICEF
Statistics by area / Child Survival and Health
Statistics by area / Maternal Health
UNICEF 2008. Why are millions of children and women dying?
WHO 2008. Fact sheets. Female Genital Mutilation.
WHO 2008. 10 Facts on child health.
WHO 2008. 10 Facts on maternal health.
WHO 2008. 10 Facts about women's health.
WHO 2008. What are the key health dangers for children?

Education

2009-10-25T11:15:00.000-07:00

The table shows many differences between the countries. Either in overall percentage of education or the gap between boys´ and girls´ attendance percentages.

There can be many reasons for those differences. In some countries severe political conflict, war or natural disasters can take resources from education or then going to school is not safe or a family has to flee. This kind of countries are for example Afghanistan, Sudan and Somalia where all the figures are very low in primary school attendance. In Latin America Colombia has slower rates than others because of unstable situation.

Also extreme poverty can prevent families from sending their kids to school even if it was for free. School can be far away from rural areas and infrastructure can be bad and it´s not possible to go there. Families may need their kids to work at the agriculture or earn money somewhere else. This kind of poor countries are most of the African countries, some of the Latin American countries and many of Asian countries like India, Pakistan, Yemen and Nepal. In Europe there are problems only in the poorest countries like Moldova, Turkey and former Jugoslavian countries.

The most serious problem is an education gap between genders because it has negative influence on the whole society. This kind of gap is normally resulting from attitudes and the values of culture. Either the limited resources of the family are spent on boys´education or then the norms of the country don´t prefer women to be independent and sophisticated. The first is the case in many poor countries where men have been seen traditionally as an investment who can bring income and feed his parents when they are old. Almost in every countries at some point boys have been more valuated than girls regarding social and financial benefit.

In addition, religion can have a big impact as in those many islamic countries where Islam has been misinterpreted and used as an excuse to exclude women from decisionmaking and financial power. Women´s place have been seen at home taking care of children and just being a wife to whom high education isn´t necessity and can be even dangerous to their future marriage(like in the past also in christian and jewish cultures). The countries where religious views are influencing a lot are Yemen, Turkey, Saudi-Arabia, Somalia, Egypt, Pakistan and Afghanistan.

School environment can also be girl-unfriendly. In Afghanistan, for example, fundamental movements are attacking on girls´ schools and this way making their studying too unsafe there. In many poor countries poor facilities to girls can make it impossible to spend whole day at school like in India where one reason for the gender gap is lack of proper sanitation to girls at school.

Still the combination of different cultural factors are contributing to the final value of education and gender gap in each country. There are also countries where intepretation of religion, poverty and values have been indicating women´s inferior position in a society but still the culture´s tradition has been supporting sophistication and investment on it. It´s especially the case in countries who have long history with education and civilization, like Iran, China and Russia.

Women´s education(and all education) is normally related to the stage of development process and wealth in a country. Obviously harsh times and fighting for survival prefer boys to girls. The more modern and developed the society is the more there are need for both genders as the factors of production and the faster society is then developing. Industrialised societies also reduce gender-related work(hard physical work for example) and emphasize brain work to which both gender have equal features.

Poverty and Health

2009-10-18T11:15:00.000-07:00

Lancet et al. article "Structural Violence and Clinical Medicine" was handling the issue about how medical staff should consider social determinants in the planning process of curing and preventing diseases. There was claimed medicine often focuses solely on molecular level treatment excluding biosocial contributors of ill health.

Two major concepts of the article were as first structural violence and as second holistic interventions in which are included both distal(treatment of people with sickness) and proximal( preventing diseases beforehand) approaches at the both individual and society levels.

Structural violence is term created first by Johan Galtung and it means "social structures- economical, political, legal, religious, and cultural -that stops individuals, groups, and societies from reaching their full potential". According to Galtung, the word violence in this term means "avoidable impairment of fundamental human needs or the impairment of human life, which lowers the actual dgeree to which someone is able to meet their needs below that which would otherwise be possible". Structural violence is close to terms social injustice and social machinery of oppression. Often the forms of social violence are something that people have become blind with because they have considered them as a part of normal society that can´t be changed.

There are multiple ways how structural violence can influence on poverty and health. Due to unfair income distribution of society, power tends to be concentrated on those who are wealthier and they tend to care more about their own benefit. Legislation can favor the most powerful ones to make it possible to supress those weaker(women, poor, disabled) ones and prevent them from becoming getting heard and participating in decision making. The structural violence related to values and atmosphere of society are exclusion, discrimination, stigma, racism and gender inequities. These all in turn influence how different people have access to health services, where they live, in which conditions they live, what kind of work they can get and what kind of food they can eat and water to drink. Education in many countries is not available to poor people which makes it impossible to reach better position to themselves or to future generation. All those factors have significant impact on people´s health status and possibilities to care about their health.

Holistic view on interventions and treatments basically means that in addition to clinical care, medical staff or public health professionals should also try to influence on social factors determining who is getting ill and who is getting treated. In many societies there are poor or excluded people who do not have access to any medical care due to several reasons - they can´t afford it, infrastructure of the area is insufficient, people are scared of social stigma or health care is mainly men´s privilege. Also people can be treated differently(For example the amount of medicine etc.) due to their socioeconomic status, race or gender. It´s the reason why taking care of the social level treatment is equally important to molecular level treatment. Examples of social level considerations are making community to support itself and people to support each other, paying people´s travelling expences in order to get them to a clinic, making broader decisions in order to reduce poverty and support employment and giving people access to sufficient food, sanitation and safe living conditions. The most important is that health care should be provided to everyone regardless the wealth of the person.

Remarkable fact related to poverty and ill health is the vicious circle those two create together. On the one hand, poverty causes ill health and on the other hand ill health and malnutrition create poverty when sick and weak people don´t have energy to work and contribute to the economy of the area. Due to this vicious circle, it seems crucial to invest in the health of poor to improve their productivity and to enable them to support their own survival in the future.

References:

Dying for change. Poor people's experience of health and ill-health. (pdf) WHO & The World Bank.
Farmer, P., Nizeye, B., Stulac, S. & Keshavjee, S. 2006. Structural Violence and Clinical Medicine. (pdf) PLoS Medicine, Vol. 3(10).
Poverty in Focus 2006. What is poverty? Concepts and measures. (pdf)
Sanchez, P. & Swaminathan, M.S. 2005. Hunger in Africa: the link between unhealthy people and unhealthy soils. (pdf) The Lancet, Vol. 365, 442-444.

Public Health

2009-10-11T08:43:00.000-07:00

Why is it important to consider health at the global level?

Globalisation is a phenomenon that is very difficult to stop anymore or to control by one person, country or even many countries. Nobody can be immune for the influences of globalisation whether one wants it or not. In today´s society one can hardly survive without knowing about rest of the world, using internet or relying on the services of international companies.

Globalisation process has its advantages and disadvantages regarding health. On the one hand it has tools to increase welfare and equity among people and countries and on the other hand it can increase adverse effects on both. Whether the outcome is positive or negative depends a lot on the good will and responsibility of different actors involved on the scene and the success of cooperation among them. While the power of national institutions to decide is becoming less the meaning of the decisions of international institutions are becoming greater. Single actor can´t do so much on health of the population of the world but combining efforts can result in hope for more equal and safe tomorrow to everyone.

Many different aspects of globalisation can have influence on health in complex interaction of different health determinants. Normally those causes have been divided in three levels, contextual, distal and proximal. On each level determinants have been classified into four groups, institutional, economic, social-cultural and environmental. In addition these causes have impact on eachother in interlevel or intralevel interaction.

Typical features of globalisation are rapid share of goods, capital, people, culture and knowledge. Also diseases and bad habits are spreading with the same efficiency. Environmental issues have impact on the whole world´s ecosystem and possibilities to produce food and water as an example. The core challenges of globalisation include the questions such as how to guarantee the same level of health to all people and the nations around the world and how the limited resources and economic growth should be distributed? Who is managing the process of supporting common health, funding it and responsible for gaining results?

References:

Huynen, M., Martens, P. & Hilderink, H. 2005. The health impacts of globalisation: a conceptual framework. Globalization and Health
Kickbusch, I. 2002. Global Health - A definition.