Chapter 21 Review Questions Answer Key

Development and Health
  1. For a long time, population health researchers believed that countries would undergo a relatively standardized epidemiological transition as they grew richer. Infectious or communicable diseases, many of which disproportionately affect children, would decline in importance as causes of death, while deaths from NCDs such as cardiovascular disease and cancer, which normally affect people later in life, would increase. Although reductions in infant and under-five mortality make an important contribution to the improvement in health status that often accompanies increases in income in low-and middle-income countries (LMICs), the full picture is more complicated. Communicable diseases continue to take a toll in the low-income world. Roughly 95 per cent of new HIV infections now occur in LMICs, especially in sub-Saharan Africa where AIDS kills an es­timated 470 million people per year despite increases in access to antiretroviral therapy. Malaria kills an estimated 435,000 people per year and tuberculosis 1.6 million despite considerable progress in recent years and despite the demonstrated effectiveness of relatively low-cost solutions. At the same time, people in LMICs are increasingly exposed to industrial pollution; to risk factors for non-communicable diseases such as cardiovascular disease and diabetes, exemplified by rapid increases in overweight and obesity; and to road traffic accidents, which kill an estimated 1.25 million people per year in LMIC The number of non-fatal injuries, often resulting in permanent disability, is vastly larger and less well documented. The double burden of disease refers to the persistence of com­municable diseases in parallel with the rapidly growing prevalence of non-communicable diseases and injuries—often thought, stereotypically but inaccurately, to be diseases of wealth. [p. 376]
  1. Social or socio-economic gradients of health refer to the differences in health status that can be found within nations attributable to access to healthcare and social determinants of health. Health inequality is not only present in the health status of residents in different countries, but also in residents of different social economic status within any country around the world. Socio-economic gradients exist even in high-income jurisdictions that (in theory) offer universal access to health care independently of ability to pay, like the United Kingdom, which suggests the impor­tance of social determinants of health in explaining health inequalities. Further, such gradients are only partly attributable to the effects of material depriva­tion. Marmot’s studies of British public servants (the Whitehall studies, referring to the street in London where the main offices of the British public service historically were located) are central to the research literature on socio-economic gradients. They showed a gradient in various health outcomes across a popula­tion, none of whom were living in poverty or affected by inadequate nutrition or insalubrious housing; in most cases, they also enjoyed considerable job secu­rity. Marmot has argued powerfully, with reference to well-established physiological effects of psychosocial stress, for an explanation based on the quite different ways in which stress is experienced depending on one’s access to economic resources and position within a social hierarchy. [p. 377]
  1. Perhaps the most conspicuous example is the har­monization of intellectual property (IP) protection under the WTO Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) and its effects on access to essential medicines. TRIPS was driven in the first instance by transnational, mainly US, corpo­rations. A subsequent civil so­ciety campaign organized around lowering the prices of patented antiretroviral drugs to treat HIV/AIDS, in the face of bitter opposition from the pharmaceutical industry, also led to the adoption in 2001 of the Declaration on the TRIPS Agreement and Public Health (Doha Declaration), which established the principle that health concerns could outweigh intellectual property protections under certain conditions. Although initial use of this flexi­bility was slow, a 2018 study identified 144 instances in which countries had made use of TRIPS flexibilities between 2001 and 2016. Meanwhile, the United States government in par­ticular has actively pursued IP protection that goes beyond TRIPS (“TRIPS-plus” provisions) in bilateral and regional trade and investment agreements, such as an agreement with several Central American countries and the Dominican Republic (CAFTA-DR) that has kept off the Guatemalan market even some generic drugs that are available in the US. [p. 378]
  1. National governments disburse funds through channels like the World Bank and an expanding range of hybrid, multi-sectoral, and multi­lateral organizations, notably the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (the Global Fund), established by the G8 countries in 2001 at least partly to avoid the bureaucracy that was seen, by the United States in particular, as compromising WHO and the UN system more generally. The Global Fund operates like an international granting council, mainly funded by high-income-country governments; its board includes representatives of donor and recipient governments, non-governmental organizations, and the private sector. As of 2019, it had disbursed US$42 billion to projects that must first be proposed by recipi­ent country applicants and then approved by a scientific review panel. Like other ventures of its kind, the Global Fund has been criticized for emphasizing “vertical,” disease-specific programs at the expense of efforts to support overall health system strengthening. The limits of vertical programming, which has achieved demon­strated successes, may be less of a concern than the Global Fund’s lack of stable long-term funding: it relies on periodic “voluntary replenishment conferences” where it in effect passes around a hat. [p. 381]
  1. The simplest answer involves concern about spread of communicable diseases like influenza and SARS. Document-based research on health and foreign policy has found that security-oriented rationales, specifically the fear of international epidemics, predominate by the characterization of HIV/AIDS “as a threat to both human and national security” at the time of the UN General Assembly special session on HIV in 2001. Australians, Britons, Canadians, or Germans have little to fear from (for example) maternal and child mortality or rising traffic fatality counts in low-income countries. Failure to translate the political salience of health security into meaningful domestic policies was revealed by the COVID-19 pandemic of 2020, suggest­ing at the very least a disjuncture between what gov­ernments say about global health, internationally and for domestic consumption, and what they are actually competent or willing to do about mobilizing in re­sponse to threats about which they have been warned for a quarter-century. [p. 381]
  1. What if three or four airliners crashed every day, killing more than 800 people? Such a situation would quickly be regarded as an emergency: the stuff of headlines, especially if ways of preventing the events were well known and widely practised in some parts of the world. This is the casualty count from complications of pregnancy and childbirth, which kill an estimated 303,000 women per year—poor women, in poor countries. In Canada, a woman’s lifetime risk of dying from complications of pregnancy or childbirth is estimated at 1 in 8800; for a woman in sub-Saharan Africa, the world’s poorest region, it is 1 in 36. The most basic explanation for this disparity has to do with the unequal global distribution of income and wealth, which are necessary although not sufficient for the financing of health systems. One recent estimate is that providing “essential” health services for 80 per cent of the people in a low-income country would cost an average of US$76 per person, per year. This sum would not buy anything like the care most readers of this chapter take for granted yet is several times what many low-income countries spend on health care. For example, in 2012 the public budget for health care, adjusted for purchasing power, was US$27 per person in Bangladesh, US$37 in Ethiopia, and US$23 in Madagascar. Meanwhile, high-income countries spend thousands of dollars per person per year on their health care systems, which operate in facilities like the US cancer centre. In many poor countries, resources for cancer care are almost non-existent despite rapid increases in prevalence. Low-income countries, in particular, cannot realistically provide even a bare minimum standard of care without external resources, which is why development assistance for health (DAH)—discussed later in the chapter—is so important. That said, the health of the poor and marginalized may simply not be high on domestic policy agendas, given internal distributions of political resources. On the other hand, a number of low-income countries (such as Cuba, Sri Lanka, and Costa Rica) and regions within countries (India’s Kerala state is the example most often cited) have achieved (relatively) Good Health at Low Cost—the title of a 1985 study of such jurisdictions. More recent research identifies Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu as jurisdictions that have achieved substantial improvements in health despite low public expenditure levels, although their health systems are in no respect comparable to those in the high-income world. [p. 374]
  1. Health care is only one of the influences on health and in many contexts is less important than social determinants of health: conditions under which people live and work that affect their opportunities to lead healthy lives. A World Health Organization (WHO) commission on this topic organized its work around eliminating health inequities: unjust and unavoidable health inequalities. Some of the more extreme illustrations: despite progress over the past decades, and with some uncertainties about data quality (as is often the case), more than 800 million people in the world suffer from chronically insufficient caloric intake, the most extreme form of malnutrition, and one out of five children in the world is affected by stunting. Paradoxically, roughly twice as many people in the world are overweight—another form of malnutrition, with comparably serious consequences for health because of links with cardiovascular disease, diabetes, and other non-communicable diseases, or NCDs. This is an important aspect of, and contributor to, the double burden of disease. Again, despite recent progress, more than 800 million people lack access to basic drinking water service, and 2.3 billion lack access to basic sanitation. Thus, economic deprivation means that daily routines of living are hazardous. Charcoal or dung smoke from heating and indoor cooking is a major contributor to respiratory disease among the world’s poor. It is estimated that more than 800 million people now live in slums, including 62 per cent of the urban population of sub-Saharan Africa; there is room for disagreement about definitions, but on almost any definition slums do not provide a healthy environment. [p. 374]
  1. Against the background of casualty figures, one of the “great divides” in health and development is whether the glass should be considered half empty or half full. Those in the latter camp emphasize progress in such areas as measles control whereby estimated deaths dropped from 545,000 in 2000 to 110,000 in 2017 as a result of large-scale immunization campaigns or the roughly 60-fold increase between 2003 and 2018 in the number of people living with HIV whose lives are being prolonged by access to antiretrovirals. Even the optimists concede the importance of intensive efforts to ensure that progress continues. Another such divide involves the relative priority that should be accorded to promoting advances in medical care (biomedical approaches) and to social determinants of health. [p. 375]
  1. The Lancet, one of the world’s leading medical journals, often commissions long, multi-authored review articles on topics of special interest. In 2013 and 2014, two such articles articulated dramatically different visions for global health. The lead authors of one article were former World Bank economists; one (Lawrence Summers) was also a former US secretary of the treasury. The second team (Ottersen et al. 2014) was led by a neuroscientist, the president of the University of Oslo, and included Sir Michael Marmot, the distinguished epidemiologist who chaired WHO’s Commission on Social Determinants of Health. This second team focused on “power asymmetries” and the “political determinants of health” in a globalized world; its treatment of biomedical interventions was limited to considering the role of trade agreements in restricting access to essential medicines. The first team dismissed policies to address the social determinants of health in a paragraph and concentrated on how best to develop and diffuse biomedical interventions, although it did concede the importance of such health promotion measures as high alcohol and tobacco taxes, along with taxes or regulations addressing highly processed foods. They also argued that improved health could accelerate economic growth, although their own assessment of evidence for this point falls back in part on “the inherent plausibility of the finding” (Jamison et al. 2013b). The tension between these approaches is partly illusory. No amount of poverty reduction will produce an effective measles vaccine or treatment for HIV infection. Conversely, vaccines and therapeutics cannot address the problems of deprivation-related indoor air pollution or the rapid dietary transitions that lead to increases in overweight and obesity. A critical point for development policy is that neither perspective provides support for policy nostrums that prioritize economic growth in the expectation that health improvements will follow, sooner or later. This is not a caricature. A 2001 article in the British Medical Journal claimed that “globalization is good for your health, mostly” because countries that integrate into the global economy more rapidly, specifically through trade liberalization, experience more rapid growth and are therefore better able to reduce poverty. Few responsible researchers would now support this claim without numerous qualifications. [pp. 375-7]
  1. Responses in the high-income world to the 2014 outbreak of Ebola virus disease in West Africa, the worst ever recorded, represented an extreme example of the fear factor at work. The New York Times reported on 10 March that “[t]he world [had] spent more than $4 billion fighting Ebola.” The effects of the disease are fearsome, but it cannot be transmitted by asymptomatic individuals and it was pointed out at the time that: “The numbers of children dying every day from preventable causes are far greater than from this Ebola outbreak. One key difference, of course, is that these health prob­lems do not board planes to Europe or North America” (Wright, Hanna, and Mailfert 2015). In the af­termath of the outbreak, WHO was criticized by its own internal review panel for its limited emergency response capability; the panel attributed this failure both to budget constraints and to management shortcomings. Less widely recognized was the fact that “the conspicuous unpre­paredness of countries like Guinea, Liberia, and Sierra Leone [was] a direct consequence of years of insufficient public investment in the underlying public health infrastructure,” attributable at least in part to the IMF’s obsession with fiscal restraint (Rowden 2014; see also Kentikelenis et al. 2015). A second major outbreak starting in 2018 was partly controlled because of the availability of ef­fective vaccines and WHO had been quicker off the mark to declare a public health emergency, but control efforts were compromised by the fact that the outbreak occurred in a civil war zone in the Democratic Republic of Congo. [p. 383]
  1. COVID-19 was not an egalitarian plague. In the densely populated, hyper-unequal cities of parts of Asia, sub-Saharan Africa, and Latin America, much employ­ment is informal and day-to-day, and as the chief global strategist at Morgan Stanley Investment Management put it: “The pandemic [made] it nearly impossible in some places to social distance and to get food at the same time” (Sharma 2020). Further, many deaths from COVID-19 appear to have involved people with pre-existing or underlying health conditions, such as obe­sity and diabetes in Mexico. Nowhere in the world are such conditions distributed evenly within populations; as noted earlier, socioeconomic gradi­ents are nearly ubiquitous. [p. 385]
  1. An abundance of rhetoric about building back better—a phrase adopted by the Organisation for Economic Co-operation and Development—was accompanied by little concrete policy attention. In a hard-hitting analysis of the nec­essary national and international policy changes, the United Nations Conference on Trade and Development (UNCTAD 2020) warned of the danger of a “lost decade” of development, and even this time frame may understate the longer-term effects of the combination of stressed if not collapsing health systems, growing poverty, and relentless ratcheting-up of inequality. [p. 385]
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