health
state of complete physical, mental, and social well-being
not merely absence of disease or infirmity
public health
-disease prevention
-promoting physical health and efficiency
-prolonging life via organized community efforts
- developing social machinery to ensure standard of living adequate for maintenance of health
key aspects of public health
- disease prevention
- respect individual rights
- carry out community-based work (communities are actively participating)
- specific attention given to the disenfranchised
- perform data and evidence-based work
- wide range of disciplinary perspectives
- respect values, culture, and beliefs of others
- enhance physical and social environments
public health (in terms of differentiating it from clinical medicine)
- disease prevention, health promotion
- concerned with large populations (ie. public health system of the US)
- not narrow and directed; training of professionals is variable
clinical medicine
- focus is on individual people (obligated to the individual rather than a population) & their diagnosis, treatment, and care
- training is standardized
global health
- health problems, issues, concerns that transcend national boundaries
best addressed by cooperative action
- prevention and (ongoing) clinical care to solve these concerns
- focus on health needs of the impoverished
population-level screening for an infection or chronic disease is an example of a public health initiative
true
focus in field of public health
population-level health
focus in field of clinical medicine
individual health
focus for global health
health-related challenges that require international cooperation
- emphasis on needs of people experiencing poverty
clinical care is mainly outside the realm of global health
false
global health challenges
- lack of POC in leadership positions
- lack of women / gender diversity in leadership positions
- people in LMICs have insufficient control over global health agenda
why does textbook author prefer "impoverished countries" terminology?
demonstrates how these countries are poor as a product of their colonial legacy / exploitation rather than as a result of lack of hard work / merit
limitation of "impoverished countries" terminology
provides a single story
- what defines these areas is that they live in poverty and are victims
LMIC terminology
low and middle income countries
- general term that indicates the socioeconomic status of the countries that global health is interested in uplifting
(*not comprehensive*)
treaties versus declarations
treaties require countries to put the substance of the treaty into law within the country
declarations do not
The Universal Declaration of Human Rights was set forth in 1948 and is extremely well known, in part because it is legally-binding on all countries that have signed
false
The United States ratified the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) after international pressure to do so
false
Around the world, the Convention on the Rights of the Child was ratified very quickly; currently, every nation except the United States has ratified this treaty
true
Declaration of Alma Ata
- recognized the need to address factors such as food, water, and trained attendants for childbirth
- emphasis on access to primary care
- advocated for international financing
*health as a human right*
Primary healthcare
essential healthcare that is evidence-based, accepted by the people it serves, and universally available to individuals and families in a given community
Right after the Declaration of Alma Ata, the concept of “sustainability” essentially forced the ideals of Alma Ata to be put on hold, and many LMICs were constrained to spending only about $5 per person per year on healthcare
true
Bamako Initiative
promoted the idea of user fees to generate the money needed to restock drugs in pharmacies and to pay healthcare workers
- drugs sold were marked up, profits used to restock drugs and pay health workers
The Bamako Initiative was relatively successful in many LMICs and has helped governments improve their healthcare financing and coverage
false
transatlantic slave trade
- took place for more than 400 years
- spanned three continents
- continues to have a major negative impact today on the health and well-being of many people in LMICs
resource extraction from formerly colonized countries continues to this day and plays a substantial causal role in the inability of many countries to fully offer universal healthcare
true
neoliberal economic theory
economies should be controlled exclusively by capitalist forces and the laws of supply and demand
ethical challenges in global health
- lack of POC/women/gender diversity in leadership
- LMICs have lack of control over global health agenda
- need for reparations / rectification of past injustices
- brain drain
- one-sided collaborations / current academic publishing system
focuses of our global health textbook
- activism around health as a human right
- infectious disease prevention= insufficient (ongoing care)
- prevention, treatment, and care
- actions in solidarity with people in impoverished countries
- understanding of the roots of inequities
public health versus global health (Mukherjee)
90% vaccination rate = huge PH success
global health -- who are those 10% who are not vaccinated and why?
how did AIDS epidemic reshape global health
focus was initially on prevention of disease
- now, has shifted toward combination of prevention, treatment, and care
International Bill of Human Rights (documents)
1) The Universal Declaration of Human Rights
2) The International Covenant on Economic, Social, and Cultural Rights (ICESCR)
UDHR, Universal Declaration of Human Rights
- government has obligation to guarantee rights of their citizens; respect, protect, and fulfill them along with educating society to demand them
coincided with Nuremberg trials
not legally binding, has moral weight
basis for developing several other national legal documents
World Bank
- international organization
- provides technical and financial assistance to developing countries to foster economic development and reduce poverty
Health-Related Clause of UDHR
1) everyone has right to standard of living adequate for health and well-being of himself and of his family
- food, clothing, housing, necessary social services, security in unemployment, etc.
2) motherhood / childhood are entitled to special care and assistance; all children, whether born in or out of wedlock, shall enjoy the same social protection
International Covenant on Civil and Political Rights (ICCPR)
- backed by US
- promoted rights associated with democratic society (free speech, assembly, voting, judiciary system)
1966
*focused on government repression of civil / political rights rather than lack of available healthcare/education as a violation of rights
International Covenant on Economic, Social, and Cultural Rights (ICESCR)
- backed by Soviet Union
- promoted socialist principles (right to employment, health, shelter, and education)
- includes right to health unlike ICCPR
1966
have the US or Russia ratified each other's covenants? (ICESCR & ICCPR)
no
Affordable Care Act (ACA)
freedom from health-related bankruptcy & impoverishment
Structural Adjustment Programs (SAPs)
loans in exchange for severe reductions to public expenditures, tax-breaks to businesses
- led to fewer civil servants on govt. payroll, little money for public infrastructure
- couldn't spend government money that would lead to a deficit, but that was the only way they could build middle class / protect citizens from destitution
- impoverished countries couldn't deliver on rights
Selective Primary Healthcare (SPHC)
- more realistic approach to healthcare for all
- simple interventions; using existing budgets for volunteer healthcare workers (rather than rebuilding infrastructure)
- low-cost tech to prevent disease
GOBI
- growth monitoring of children (nutritional education for mothers if children are underweight)
- ORS (oral rehydration solution) - preventing death from dehydration associated with diarrheal disease
- breastfeeding until age 6 months continuation until age 2 years
- immunization of children
Bamako Initiative drawbacks
- "user fees" as barrier to health for poor people, unequal access to care
- money collected through user fees -- not enough to adequately pay staff or stock pharmacies
Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW)
- international bill of rights for women
Convention on the Rights of the Child
- most rapidly and broadly ratified human rights treaty in history
- rights to be free of discrimination, to health, and to education... states that children must have a say in decisions affecting their lives"
- only US hasn't ratified
ORS
oral rehydration solution
- given to individuals to prevent death from dehydration usually in case of diarrheal disease
immune deficiency
a state in which the body's normal defenses against infection or cancer are weakened
4-H club
- disparaging reference to homosexuals, Haitians, heroin users, and hemophiliacs
term emerged as AIDS claimed lives of more and more people -> led to widespread panic and stigma
synonymous with carrying the disease
members of all 4-H group were...
banned from giving blood, denied housing, employment
victims of violence and discrimination
cases suggested that AIDS pandemic likely began in
Africa, appeared a decade before it appeared in the US
idea of "Black African" disease origin led to further stigma along racial lines, promoted racist narratives of sexuality
HIV
human immunodeficiency virus
virus or infection that leads to AIDS, ie. weakens the immune system
AIDS
chronic immune system disease caused by immunodeficiency virus
UNAIDS (United Nation AIDS Program)
raise awareness and money for prevention efforts
help countries develop national plans to combat disease
three important factors in controlling AIDS
concept and infrastructure of primary healthcare -- people can access needed services
modern behavioral science -- public health information to craft prevention messages
emergence of a global conscience -- inspire international community to work together, finance response in coordination with WHO
transmission of AIDS
blood products, needles, and other instruments containing fluids
from mother to child through exchange of body fluids in utero, during birthing process & through breastfeeding
Special Programme on AIDS
tracked the spread of AIDS
PLWA
people living with AIDS
opportunistic infections
attack those with weakened immune systems
(AIDS leaves people susceptible to other infections)
_________ is the number-one cause of death for PLWA
tuberculosis (TB)
TASO
Ugandan-based AIDS fighting organization
Dr. Kaleeba and AIDS Support Organization
ACT UP
AIDS Coalition to Unleash Power
more militant group, direct action to call attention to AIDS and silence of policy makers
TAG
treatment action group
nonprofit that pushed for increased funding for pharmaceutical research for AIDS, particularly drug trials
About how many cases of dracunculiasis were recorded for the calendar year 2024?
15
Most high-income countries are predicted to accomplish the SDGs by the year originally set out for their accomplishment
false
In a TED talk about progress towards the SDGs, the speaker, Michael Green, made the very concerning point that progress has actually gone backwards for the goals related to water and sanitation
false
One feature of a communicable disease is that it is caused by an infectious agent
true
A chronic disease is one that lasts for a long time
true
An acute disease might have either infectious or non-infectious origins
true
A parasite is an organism that benefits from a host, that returns no benefit to the host, and that harms the host in some way
true
The Millennium Development Goals were in place from around 2000 to 2015, prior to the implementation of the SDGs
true
The following are likely to help control dracunculiasis...
ensure that all people can access safe drinking water
ensure that all people can access healthcare for about a month to remove the worm
All protozoa are parasitic
false
There is a medication that can be given to people with dracunculiasis to kill the worm; however, this medication is not available in most areas where dracunculiasis is present
false
During the MDG era, MDG 6 (infectious disease) experienced the best outcomes compared with the other MDGs; this is probably because of dedicated funding for that goal
true
vertical program
initiatives that are disease-specific and focus on the prevention of certain conditions rather than on bettering healthcare systems themselves (and health infrastructure).
diagonal program
leveraging of vertical funding to support her;thcare systems overall
more comprehensive than vertical programs
priority is to better healthcare infrastructure rather than target specific diseases
communicable diseases
(infectious diseases, transmissible diseases)
illnesses that result from infection, presence, and growth of pathogenic biologic agents
- in human or other animal host
pathogenic
capable of causing disease
infection is not interchangeable with...
communicable disease
infection
infection with biological agent has occurred, but may not be pathogenic or result in any type of disease
non-communicable diseases (NCDs)
diseases that are not spread through an infectious agent
chronic disease
disease that lasts a long time
acute disease
disease that develops rapidly, lasts for a short time, and has clear symptoms
may be caused by infectious agents
may also have non-infectious causes
injuries
includes a variety of ways that the human body can be harmed
total disease burden '90-'19 observations
communicable diseases have been decreasing overtime
communicable diseases still represent a large burden of the overall GBD
microbe
microscopic organism, not a technical term
- synthesize vitamins, prevent pathogenic organisms from invading, aid digestion, improve immune function
- objective: propagate
parasite
organism that benefits from a host
returns no benefit to the host
harms the host in some way
pathogen
any agent that can cause disease
zoonosis
disease of vertebrate animals that is transferred to humans
vector
organism that transmits a pathogen
host
the free food for a parasite
definitive host
host in which a parasite sexually reproduces / completes its lifecycle
intermediate host
the host in which a parasite develops but does not sexually reproduce (may asexually reproduce)
reservoir
any animal, person, plant, soil, substance, or combination of any of these in which the infectious agent normally lives
infectious agent...
must depend mainly on the reservoir for its existence
must be able to multiply in the reservoir
types of microbes
viruses, bacteria, protozoa, helminths
viruses
packaged DNA or RNA
protein coat
attack and invade host cells (think trojan horse)
do not propagate without a host cell
(examples: cold, HIV, measles, COVID)
bacteria
single-celled organisms visible with a microscope
one ring of DNA, sometimes plasmids
acquire genetic material from other organisms
(examples: strep throat, tuberculosis, leprosy)
protozoa
single-celled organisms
free-living or parasitic
generally are able to multiply in a human host
typically transmitted fecal-oral route
helminths
multicellular organisms
macroscopic
free-living or parasitic
helminths, three main groups
flatworms: flukes and tapeworms
thorny-headed worms: acanthocephalans
roundworms: nematodes
dracunculiasis
guinea worm disease
caused by the nematode dracunculus medinensis
one of the largest nematodes
infection is caused by drinking water contaminated with copepods that carry this type of larvae
life cycle
dracunculiasis
1) human drinks unfiltered water containing copepods
2) larvae released when copepods die
3) larvae penetrate host's stomach and intestinal wall; they grow and reproduce
4) fertilized female worm migrates to surface of the skin, causes blister, discharges larvae
5) larvae released into water from emerging female form
6) female worm begins to emerge from skin one year after infection
7) larvae consumed by copepod and grow into mature larvae in copepod
dracunculiasis epidemiology
only found in Chad and South Sudan
non-human reservoirs for infection do exist
no acquired immunity
only helminth transmitted ONLY via drinking water
dracunculiasis pathology
pain from emergence of adult worms
secondary bacterial infection
trapped adult worms
dracunculiasis diagnosis
characteristic blister
adult worm emerging from skin
dracunculiasis treatment
remove adult worm (5 ish cm a day)
control secondary bacterial infection
dracunculiasis infection risk factors
little or no access to safe drinking water
living in a community where other people have dracunculiasis
lack of access to healthcare facilities
lack of opportunity to filter unsafe water
lack of access to chemicals to kill copepods
living in a place where there is insufficient political will or ability to address dracunculiasis
dracunculiasis eradication efforts
began in 1980 at CDC in US
WHA called for full effort in '86
currently: concerns about dogs and other animals serving as reservoirs -- hope remains for eradication
eradication of disease
absence of X disease for 3 consecutive years in all countries
three categories Green (TEDTalk) grouped the 17 SDGs into?
- Nutrition and Basic Medical Care
- Personal Rights / Inclusiveness
- Water and Sanitation
need to measure progress / where we've seen progress so far (TEDTalk with Green)
not only focus on areas where we've been successful (nutrition and basic medical care), but can identify our challenge areas (personal rights and inclusiveness)
- seeing where there are opportunities to accelerate progress, negative trends to reverse
worrying trend (noticed by Green in TEDTalk)
declines in personal rights and inclusiveness in many wealthy countries (US and Brazil, countries moving backward in the past few years)
are most countries on track to meet the SDGs, as of 2018
no
- Denmark is the closest, most fall lower on the scale
not going to achieve this goal until 2094 overall
what we need is for the larger, wealthier countries to make more significant progress (have the resources to create change, need to be held accountable)
health system responsiveness
(ie. what does a health system need to be responsive?)
1) data
2) descriptive statistics
3) measurement tools and surveillance systems
descriptive statistics
mean, median, range, standard deviation of data set, etc.
- prevalence of conditions / risk factors
- incidence of new cases
- outcomes
The neonatal mortality rate is defined as the number of deaths of infants under 12 months per 1,000 live births in a given year.
false
The under-5 mortality rate is defined as the number of deaths of children under 5 per 1,000 live births, measured annually
true
One thing (among others) that DALYs can help measure is the disease burden associated with conditions that have low mortality but high morbidity
true
In our textbook, Dr. Mukherjee emphasizes that prevention of disease alone is insufficient without a commitment to treatment and ongoing care.
true
A neonate is a person under 28 days of age.
true
A cost-effectiveness approach in the context of global health states that interventions should cost no more than three times the per capita health costs, in order to be considered acceptable.
true
The following are important key criticisms of the “epidemiological transition model”...
- The disease burden is diverse in all countries, and the model fails to capture that reality
- Health systems in all countries are needed that can address a variety of health issues
Which of the following are common criticisms of the cost-effectiveness approach in global health...
- It doesn’t address other factors that negatively impact health
- The fixed costs in these models are planned for 5 to 10 years ahead of time, but this approach fails to account for changes in cost over time
- Out-of-pocket costs and other costs the patient experiences can still be high and aren’t captured by this approach
- It fails to address the actual burden of disease
Maternal mortality is measured as the deaths associated with pregnancy, labor, delivery, or within 42 days of childbirth
true
infant mortality rate
number of deaths of infants (<12 months) per 1,000 live births, measured annually
life expectancy at birth
average number of years a new baby can expect to live if current mortality trends continue
neonatal mortality rate
number of deaths of neonates (<28 days) per 1,000 live births, measured annually
under-5 mortality rate (child mortality rate)
number of deaths of children under 5 per 1,000 live births, measured annually
maternal mortality ratio
measure of the risk of death associated with childbirth
number of women who die each year as a result of pregnancy, labor, delivery, or within 42 days after delivery, per 100,000 women who deliver a live child
why is MMR measured per 100,000 but neonatal morality and under-5 mortality are measured per 1,000?
it's relatively rare compared to child mortality / neonatal mortality rates
produces a more meaningful, less fractional number
fertility rate
number of births per woman
morbidity
sickness
mortality
death
mortality rate
annual number of deaths per 100,000 population
disability
long-term or short-term reduction in functional capacity
prevalence
number of people with condition X at any given time
cross-sectional in nature
incidence rate
number of new cases over time per a given population that's at risk
disability-adjusted life year (DALY)
a measure of losses due to illness, disabilities, and premature death
- accounts for loss due to death and disability
- requires data about prevalence and incidence
Mortality + Morbidity
goal of health policy
avert DALYs in the most cost-effective way
risk factor
an entity (characteristic, environment, behavior, etc.) that is known to be associated with a health issue
health professionals seek to ______ risk factors
minimize
_______ is the lead risk factor for death and disability in high-income countries
smoking
malnutrition
a leading risk factor worldwide (too much, not enough, not the right kind of nutrition)
categories covered in global burden of disease study (GBD project)
- infections and perinatal and maternal conditions
- NCDs
- injuries and accidents
(grouped into 8 global regions - established market economies)
findings: global burden of disease study
- high premature mortality in impoverished regions
- lack of good data
- NCDs and injuries play a major role (infectious diseases also critical component)
- inequities among regions are enormous
- findings can be very different for mortality versus for DALYs
epidemiologic transition "ages"
1) age of pestilence and famine
2) age of receding pandemics
3) age of degenerative and manmade diseases
4) age of delayed chronic diseases
limitations of the epidemiologic transition model
1) diseases do not occur in a stepwise fashion (in contrast to what the model states)
2) disease burden is diverse in all countries
3) health systems in all countries are needed that can address a variety of health issues
4) treatment often is prevention, so healthcare systems need to be able to provide treatment
cost-effectiveness
1) formula proposed in '77 by Weinstein and Stason
2) for intervention to be cost-effective, its cost should be no more than 3x the per capita health costs
3) limited impoverished countries to interventions $5-15 per patient per year
limitations of cost-effectiveness
1) cheap interventions fail to address the actual burden of disease, out-of-pocket costs, & other costs the patient experiences (also - doesn't address other factors that negatively impact health)
2) fixed costs in cost-effectiveness models that are planned for 5-10 years out fail to account for cost changes
3) too little money allocated for health in impoverished countries; failing to provide healthcare is a moral issue
the epidemiologists's bathtub
prevalence = water in bathtub
water leaking out = death
recovery = water evaporating from tub
incidence = faucet putting water into the tub
burden of disease
quantity of diseases and conditions and their impact on a population
- assessing this = attempting to build systems of care to achieve targets in SDGs
Global Burden of Disease project ('90)
quantifies the impact of diseases worldwide on a regular basis
epidemiological transition
observed shift in the types of diseases that affect populations as economic conditions improve
- used disease burden to help countries of differing economic strata to assign health priorities
Disease Control Priorities (DCP) project
burden of disease in impoverished countries impede economic development -- need to address this
prioritize interventions with greatest impact on burden of disease impoverished communities
(uses cost-effectiveness analyses to help policymakers set priorities in national health systems)
health system responsiveness x burden of disease
the health of a population must be measured and understood if the health system is to appropriately respond
reasons to quantify the burden of disease
planning, policymaking, design of delivery systems, and program evaluation
disease
refers to conditions, illnesses, and injuries
burden
refers to the impact of disease on a population
disease surveillance
measurement of conditions
why insufficient data to estimate burden of disease early on?
1) never reach medical care (get sick and die at home)
2) facilities don't have adequate diagnostic capabilities (causes of illnesses remain unknown)
3) record keepers in short supply (insufficient data to estimate BOD)
sequelae
consequences of diseases
- GBD sought to characterize this
age of pestilence and famine
- high mortality rate in population
- caused by infectious diseases and starvation
low life expectancies
age of receding pandemics
reductions in mortality (esp. young children and infants)
life expectancy increase w/ improved access to food, clean water, and infrastructure
age of degenerative and manmade diseases
total fertility rate declines as infant mortality continues to fall
major causes of death = NCDs (cancer, diabetes)
age of delayed chronic diseases
reductions in mortality, old age, and primary prevention of chronic diseases (promotion of exercise and healthy diets)
three dependent inputs for prioritization (GBD project)
1) understanding types of diseases and overall burden within a country
2) design of health system to respond to need of population
3) ability of govt to set priorities, ability to use instruments at their disposal
*choosing interventions that could be supported within the confines of their health budgets*
There were around _______________ forced sterilizations of people in the US as part of a eugenics movement.
60,000
The Tuskegee Study focused on untreated syphilis among African American men; the study is considered highly unethical, in part because penicillin, a known treatment, was denied to participants for decades.
true
The US Government finally discovered the existence of the Tuskegee Study in 1972 and put an end to it
false
The Nuremberg Code was a result of the Nuremberg Doctors’ Trial, in which Nazi physicians were tried for war crimes and crimes against humanity.
true
The Nuremberg Code states that physicians doing research with human participants must ensure voluntary informed consent from participants (among other things).
true
The Nuremberg Code states that physicians doing research with human participants must ensure that the research is necessary in the sense of being a social good (among other things).
true
The Nuremberg Code states that physicians doing research with human participants must ensure that there are safeguards in place with respect to risk to human participants (among other things).
true
The Declaration of Helsinki came after the Nuremberg Code and supersedes it
true
The Declaration of Helsinki is a highly influential and extremely widely cited set of international research ethics guidelines.
true
Clinical research protocols must have social value and be scientifically valid when they involve human participants.
true
Clinical research protocols must fairly select study participants and researchers cannot enroll members of vulnerable populations when those same populations are unlikely to reap any benefits from the study.
true
For clinical trials, participants must always receive financial compensation (money).
false
The eugenics movement in the United States involved coercive policies (e.g., forced sterilizations, institutionalization) that targeted specific groups of people and forced them to have fewer children or no children at all.
true
How long did the Tuskegee study on untreated syphilis in African American men last?
40 years
The Belmont Report emphasizes the need for “justice” in research contexts, meaning that the benefits and burdens of research must be fairly distributed among populations.
true
The Belmont Report emphasizes the need for “beneficence” in research contexts, meaning that study participants must be financially compensated for study participation when studies contain at least a moderate level of risk.
false
The Belmont Report calls for respect for persons; this means that researchers must treat people as autonomous agents and protect people with diminished capacity to act as autonomous agents.
true
The Belmont Report strongly emphasizes the concept of “due process”.
false
In clinical research involving human study participants, benefits and risks need to be balanced at the level of the individual and at the level of society.
true
Key Principles of Belmont Report
1) respect for persons
people have autonomy, can make their own decisions
people w/ diminished capacity are also protected
2) beneficence
minimizing harms, maximizing possible benefits
3) justice
fairly distributing the benefits and burdens of research
how long did the Tuskegee syphilis study last? how long was it supposed to last?
supposed to last for: 6 months
lasted for: 40 years
two major ethical violations of Tuskegee
Lack of transparency in the study, human rights violations
individuals in the study given only placebos (mineral supplements and aspirin) and despite the fact that penicillin was recommended cure 15 years into the study
Provided participants with no effective care or treatment
PHS researchers convincing local physicians to not treat the patients even when treatment became available (men died, went blind, insane, etc)
Nuremberg Code
Following human rights abuses during WWII
Nazi doctors tried for war crimes and crimes against humanity
key concepts: Nuremberg Code
Voluntary, informed consent from participants (using that terminology rather than subjects) Necessary - research must be a social good (not just out of general curiosity)
Limits on risks to participants (higher risk levels for more fatal conditions, lower risks allowed for something like common cold)
Safeguards for patients with respect to risk (check ins, reporting adverse events)
Declaration of Helsinki
followed Nuremberg Code, superseded it (took the place of)
more specific, elaborates on points made in Nuremberg Code
Although not legally binding, was enshrined into local law
(has substantial moral power, revised frequently)
key focuses in D.O.H.
scientific validity
fairness
risks and benefits
placebos
consent
oversight and accountability
eugenics movement in the US
concluded that things like intelligence and ability are genetic
Humanity could be improved if more “fit” humans had more children
goals of eugenics movement
improving qualities of the family (natural, physical, mental, etc.)
targeted “unfit” individuals - people who would be inhibiting this goal
- Forced them to have fewer children (ERO office), forced sterilizations
- Genetics base for things like criminality, feeblemindedness
(social determinants of health not considered, biased data to support his theory)
how widespread was the eugenics movement in the US?
around 60,000 people in US were sterilized
30 states adopted laws allowing these forced sterilizations
simple explanation, Nuremberg Code
Nuremberg code was created as a result of the Nuremberg Trials that happened post WWII, where Nazi doctors were put on trial for their blatant human rights violations and crimes against humanity
The Nuremberg code was not legally binding but held moral value, and was made up of 10 ideas that established ethical principles for human experimentation
main topics covered: consent (voluntary), limiting risks, putting in place safeguards, and also necessity of the research
According to our textbook, the following are true about medical students in Uganda
They want more mentoring in their positions as clinical personnel, especially when they’re sent to rural areas.
They’re suing the Ugandan government to get access to better supervision/mentoring.
According to our textbook, the following are effective strategies to address brain drain
Provide acceptable mentorship and training opportunities
Ensure acceptable and attractive working conditions
Pay healthcare workers fairly
Programs by NGOs to train clinicians in LMICs are criticized for the following reasons
Providing short-term training that doesn't improve clinical outcomes
Pulling workers away from their posts
In many LMICs, there are generally a sufficient number of healthcare workers for the populations served, but they lack the training quality that’s needed to deliver good health outcomes.
false
The Sustainable Development Goals (SDGs) call for universal health coverage (i.e., everyone has access to healthcare in clinics/hospitals, etc.) by the year 2030.
true
In high-disease-burden settings, there are often enough community health workers, but there may not be a sufficient number of clinical specialists, such as surgeons.
false
The following are true of the healthcare workforce in many LMICs
The health workforce is generally structured and supervised hierarchically
Nurses and midwives are generally supervised by highly skilled specialists at district hospitals and tertiary care hospitals
Community health workers make up most of the health workforce and are supervised by nurses and midwives who work in health centers and district hospitals
Primary healthcare facilities are generally staffed by healthcare workers with professional skills and who have formal training, but who may not be doctors
true
District hospitals may play a role in population-level data analysis and also quality-improvement initiatives
true
District hospitals perform mostly routine tasks such as vaccinations and prenatal visits, but they might also play a role in surgery or emergency obstetric care
false
A skilled professional health worker is defined as any type of healthcare worker who is formally educated
true
A Public-Sector Spending Cap is the amount of available resources for public expenditures, set by local governments.
false
In impoverished countries, the cost of educating the healthcare workforce is mainly covered by private expenditure: individuals who wish to pursue training as doctors, nurses, etc. pay for their education through loans and out-of-pocket payment
false
The United States has noticeably higher healthcare expenditures per person than any other country in the world, according to figures from ourworldindata.org
true
One *general* trend seen in most countries is that with more money spent on health, health indicators such as life expectancy, child mortality, etc. tend to improve.
true
The price of various essential healthcare products such as soap and water disinfectant does not have a huge effect on whether people purchase them, mainly because people recognize their value and prioritize these essential items
false
Task shifting, although commonly practiced, often results in poorer health outcomes for the population served
false
public-sector spending cap
maximum amount of money that can be spent on public services and goods
set by world bank and IMF for countries that have SAPs
how is cost of education covered for healthcare workers in many impoverished countries?
governments provide education funding, free of charge and supported
SAPs restrict amount of money government can put toward services
cannot properly compensate their workers, don't have tools for proper training, cannot hire the graduates
why do some public-sector clinicians in impoverished countries work only half of a day in public clinics?
have private practices to help support their families, do private sector work
(not making enough money doing general work in the public sector)
using public resources to recruit affluent patients, looking for paid training progress
underpaid government health personnel
problems associated with NGO programs to train clinicians in impoverished countries
NGOs provide clinical training workshops
- short-term, not something that is long-lasting
- pull healthcare workers away from their posts, workers looking for more compensation
- training doesn't improve their performance because no one is overseeing them
what is brain drain?
draining of human capital, ie. trained health professionals, from impoverished countries to more affluent settings
why does brain drain occur?
job security, better working conditions, want to be compensated properly for their work
effective strategies to stop brain drain
wealthier countries providing financial support, help LMICs properly compensate their workers
decreasing active recruitment of health professionals from impoverished countries
improving working conditions, make them want to stay
why is brain drain a problem for impoverished countries?
drains them of human capital
worsening healthcare worker shortage
inhibiting development of healthcare infrastructure
mentoring for healthcare workers in high income countries
years of monitoring before they can see patients on their own
key element of clinical training
heavily supervised before allowed to practice independently
mentoring for healthcare workers in low-income countries
not enough specialists or ability to have junior clinicians work under supervision
training occurs through lectures rather than mentoring
limited amount of government funding - lack of oversight and mentoring for trainees
medical students in Uganda
Uganda minister of health changed internship policy
Mandatory two year service at government health facility
intention: using new grads to cover rural/underserved areas as payback for government funded education they received
Interns isolated in crumbling facilities, no mentors, meager stipends
Government needs to properly support trainees, provide work environment necessary to deliver care
1,000 suing government on grounds - entitled to postings with mentoring, payment, adequate training facilities
3 specific benefits expected if CHWs performed ivermectin distribution for onchocerciasis rather than community-selected volunteers
- CHWs could ensure that people receive long-term care and could provide support throughout the process (ie. check-ups, answering questions)
- CHWs are often connected with a health system, so in more serious cases they could provide referral for specialized treatment if ivermectin is insufficient (ie. surgery)
- CHWs have intimate knowledge of the communities that they work within -- ie. they could individualize treatment (also - have community TRUST
One task that CHWs often accomplish is the delivery of preventive health services
true
One role of CHWs is to find people in the community who are sick and vulnerable and who are in need of connection to medical care
true
CHWs are able to deliver curative services and also to provide long-term care for chronic conditions.
true
CHWs are defined in our textbook as non-professionally educated workers who are trained to address health issues at the community level
true
CHWs are members of the communities they serve; they live and work near the patients, families, and communities they serve
true
Historically, CHWs were asked to be unpaid volunteers, but this is now changing to some extent
true
Around the 1960s, with many countries in Africa achieving liberation, CHWs were asked to volunteer and to perform key duties related to selective primary healthcare, such as GOBI initiatives.
true
Data show that most CHWs want to be paid fairly for their work rather than acting as volunteers
true
With proper training, CHWs are able to offer prenatal care and they can recognize obstetric emergencies.
true
CHWs can play many health-related roles, but the integrated community case management (iCCM) of childhood illnesses is reserved for physicians and nurse practitioners.
false
In many countries around the world, Vitamin A deficiency contributes to both maternal and child mortality.
true
Vitamin A supplementation can effectively address some aspects of child morbidity and mortality when given twice a year.
true
Blindness can occur if onchocerciasis remains untreated for a number of years.
true
With onchocerciasis, some individuals have itching and other skin-related symptoms, but these are relatively minor in comparison to symptoms in the eye
false
The adult worms that cause onchocerciasis may live for more than 10 years in a person in the absence of treatment.
true
CDTI (community-directed treatment with ivermectin) is the main strategy for onchocerciasis control in African settings right now
true
The regular distribution of a dewormer (called ivermectin) is widely considered essential for onchocerciasis control at this time
true
Multiple countries in the Americas have made great progress towards onchocerciasis elimination, but none have fully achieved elimination as of 2025.
false
Onchocerciasis transmission control can be partially achieved by controlling copepods in water sources
false
(this is guinea worm)
Mosquitoes are the main vectors that spread onchocerciasis.
false
black flies
filaria
tissue-dwelling worms that require an arthropod vector as an intermediate host
arthropod
invertebrate with jointed appendages that molts
what organism causes onchocerciasis?
Onchocerca volvulus
two key symptoms of onchocerciasis?
dead microfilariae cause severe skin inflammation due to release of wolbachia bacteria
- severe itching, abnormal skin pigmentation, lichenification (thickening, cracking of skin)
blindness if untreated
vector associated with onchocerciasis
black fly
current strategies to control onchocerciasis in endemic countries in Africa
African Program for Onchocerciasis Control (APOC)
established CDTI, community-directed treatment with ivermectin
promoted environmentally-sensitive vector control where possible
where are most cases of onchocerciasis?
Africa
99% of cases currently in 30 African countries
control strategies for onchocerciasis
vector control - dropping insecticide on water bodies to kill black fly larvae
ivermectin and doxycycline
addressing Vitamin A deficiency
supplements, need to find new mode of delivering this to people since polio vaccination scaled down
traditionally given during NIDs for polio
given 2x year
Prof. Dorothy Roberts and need to end race-based medicine
recently has been a push for 'evidence-based medicine' but makes it clear that racial biases still define modern healthcare, lead to misdiagnosis / improper medical treatment
- Black / Latino individuals given less pain medication than whites due to the misconception that they have been predisposed to drugs, have higher pain tolerance, etc.
- pay lip service to racial bias in medicine -- still pervasive, needs active acknowledgment to be fully addressed
The Essential Medicines List (EML) was developed by the WHO and serves as a guide for impoverished countries around drug procurement.
true
Pharmaceutical companies pay little attention to the Essential Medicines List (EML), which means that the EML has mostly failed to impact drug production
false
Generic drugs are needed worldwide; however, production of generic medicines that are off-patent remains low.
false
Generic drugs are almost universally good quality; there are very stringent regulations in place through multiple agencies to ensure this high quality.
false
Beginning with a conference in Bamako, Mali in the 1980s, there has been a push by key international organizations and decision-makers to have patients cover some or all of the cost of drugs.
true
Evidence shows that having consumers pay some or all of the cost of drugs reduces waste and allows healthcare systems to recoup essential costs
false
ART is not yet on the EML due to cost, but progress is being made in the fight to add it.
false
Currently, there are generic versions of ART, which has reduced the price of the drugs substantially
true
A high-level UN panel recommends that research and development (R&D) funding not be linked with drug prices for consumers and that instead, alternative methods of R&D funding be identified.
true
Public money, such as taxes, is often used to fund the preclinical drug discovery phase
true
There are some novel methods already in place to incentivize drug development for diseases that mainly affect people in LMICs; an example is the FDA Amendments Act of 2007.
true
Aid, novel purchasing plans, and philanthropy currently all play a role in bringing drugs to consumers in LMICs
true
_________________ is the most important producer of generic drugs worldwide
India
Expanded drug access worldwide relies heavily on the current and future availability of good quality generic drugs.
true
In the US, generic drugs are tested by the FDA for their chemical composition, so quality control is excellent.
false
Internationally, the WHO is generally responsible for checking the manufacturing quality and standards used by drug manufacturers; this is mainly done through a process called “prequalification”.
true
The “consumption method” of determining how much drug to stock involves using statistical methods to predict the number of cases of illness that will likely occur in the future and purchasing drugs according to those estimates.
false
this is the morbidity method
The “morbidity method” of stocking drugs relies heavily on data showing the number of drugs consumed in a previous period of time.
false
this is the consumption method
For all countries, about $13-25 per person per year needs to be spent to ensure that everyone can access essential medicines.
true
Priti Krishtel gave a TED talk about why drug prices are so high. One thing she talked about was the “patent wall”, which keeps drugs protected for 40+ years from competition by generics.
true
In her TED talk, Priti Krishtel gave multiple, very specific suggestions, including the following
Only give patents for products that substantially improve health prospects
Stop having the patent office in the US be funded by how many patents they grant
Ensure that the public in the US has the right to go to court over drug prices
AIDS activism and drug access / patents
led the way for the evolution of EML, fought for equal access to medication
getting ART on EML to increase production of generics
what is TRIPS? how does it relate to drug access?
governs the treaties patented and protected by the WTO (Trade-Related Aspects of Intellectual Property Rights)
countries claiming national emergencies to invoke TRIP flexibilities in dealing with AIDS (supporting generic version compulsory license to manufacture drug locally)
Updating and Disseminating the WHO's List of Essential Drugs: The Way Forward
2001 paper
argued for inclusions of newly-developed drugs even under patent when there were no generic options available
powerful pharmaceutical companies lobbied US government against it
- thought that this would cut their profits, that countries would use EML as a justification to invoke TRIP flexibilities, demand generic drug access
eventually allowed
in _______, ART was added to the EML
2002
5 key recommendations from the UN in 2016 that relate to access to drugs
- International agreements should improve innovation, not hinder
- delinking research and development from consumer prices
- Transparency – ie. marketing, distribution, pricing of health technologies = clear to public
- increased investment
- held accountable for ethical access to health technologies
5 key points for international collaboration to achieve the SDGs (2014, The Lancet)
- Basket of essential medicines
- Essential medicines = affordable
- Quality and safety of said medicines
- Correct use of medicines
- Developing missing essential medicines
basket of essential medicines
a list of drugs selected to meet the priority health needs of a population
(need to be affordable, available, etc.)
what happens after governments procure drugs? where do they go and how?
- stored in a national drug store
- district-level pharmacies and hospitals request the medicines from the national drug store based on utilization over the prior month or quarter
- drugs distributed from district depots to health centers, also based on consumption over the prior month or quarter
problems with current drug procurement process
- LMIC budget insufficient to purchase needed drugs to meet disease burden
- lack of management -> leakage via theft / mismanagement of drugs
- poorly paid staff sell drugs and supplies to supplement salaries
- system and inputs needed for distribution are inadequate
consumption method
drug forecasting based on previous year consumption -> perpetual stock outs
demand signal
quantity or prior utilization of drugs
morbidity method
anticipated disease burden rather than forecasting based on previous year’s usage
- impoverished countries can't always use b/c their meager budgets cannot support what forecasted disease burden would be OR cannot determine full burden
(also - excess drugs that would go to waste?)
Soyapi Mumba spoke about innovations related to EMRs; which of the following are true, based on his talk
They needed to build their own cell towers to create a wireless network
They used old touchscreens from a failed US company
They used barcodes and scanners so that clinicians wouldn’t need to re-enter patient data at every visit
Paper booklets for health records can be lost by the patient if the patient is responsible for them. This is a substantial limitation to their use
true
Paper booklets for health records make it slow and difficult to accomplish meaningful data analysis at the population level. This is a substantial limitation to their use
true
Standardized health indicators are useful for program evaluation and to assess changes in health over time; however, a key limitation is that they are difficult to compare across different countries
false
To illustrate some of the key definitions in this chapter, Dr. Mukherjee provided an extensive example of malaria
false
One common problem with aggregated data is that it can be used to identify individuals, which violates some key ethical principles that relate to research with human study participants
false
What is the purpose of OpenMRS? (choose all that apply)
To give countries the ability to design electronic medical records and customize how those records are used
To offer software for electronic medical records at no cost to LMICs
Indicators are..
measurable, specific, observable, and useful for tracking progress / outcomes in healthcare systems
In the context of indicators used to evaluate healthcare systems, an "output" refers to tasks that have been undertaken or completed processes, provided these tasks and processes have resulted in positive outcomes.
false
Which of the following would be expected to have a positive impact in addressing tuberculosis? (choose all that apply)
An uninterrupted supply of good drugs
Data collection and data analysis
Political commitment
Access to diagnostic tools, like sputum-smear microscopy
Standardized DOTS
With respect to TB, a patient who has taken drug treatment for TB and who no longer shows TB bacteria in their sputum after the treatment course would generally be considered a "treatment success"
true
It’s very helpful to select health indicators that have existing data streams, rather than needing to create a new data stream.
true
What does DOTS stand for?
Directly, Observed, Treatment, and Short-Course
OpenMRS
(Open Medical Records System)
software platform that allows countries the ability to design and customize EMR
decreasing cost of EMR
training programers, offering free software
necessary b/c electronic data systems are integral to having strong healthcare system
Some vertical programs in global health have standard monitoring and evaluation frameworks, but others don’t.
true
Health “indicators” need to have clear definitions in order to be useful.
true
Health programs should develop specific targets to be achieved.
true
For monitoring plans, it’s useful to determine at the outset who will
collect the data and
how frequently, but it’s not necessary to
determine until later how the data will be
reported and analyzed.
false
A “logic model” is a way to show the connections between various steps in a program or intervention; it also serves as a framework that can be useful for analyzing the effectiveness of a program/intervention.
true
PDSA
Plan-Do-Study-Act
used to generate plans for improvement beginning with hypothesis for specific practices
(there would be more handwashing by healthcare professionals if ______ we took said action)
focuses on problems within a system / way it operates rather than blaming individuals for their mistakes
key principles of DOTS (scaling up TB treatment in LMICs)
- political commitment (long-term)
- sputum - smear microscopy access
- DOTS treatment
- Uninterrupted drug supply
- Data collection for program evaluation
case detection rate
New cases of TB / expected cases in location
DOTS coverage rate
PH facilities that can correctly offer DOTS / total # of PH
treatment success
patient who has taken drug treatment for TB
no longer shows TB bacteria in sputum
treatment success rate
# of patients who were successfully treated / # of patients diagnosed / started treatment (within set timeframe)
health equity, disaggregated data
aggregated data averaging and masking inequities
groups of people impacted very differently by policies and programs
genus and species: tuberculosis
mycobacterium tuberculosis
A _______ causes TB
bacterium
Approximately ______ of the world’s population is infected with the organism that causes TB.
24%
There is a vaccine currently in use for tuberculosis, but it doesn’t provide complete protection and there are some reasons that it would not be good to use in some settings.
true
The following are considered risk factors for active TB: (choose all that apply)
experiencing homelessness, having HIV, being undernourished, living in a household with others who have active TB, smoking, having alcohol use disorder
The following will probably help reduce the global tuberculosis burden
Poverty reduction strategies and socioeconomic development
Improved nutrition
Universal health insurance
The agent that causes TB need to be in the lungs for a person to be at risk of transmitting TB to others.
true
There can be a long lag between infection with M. tuberculosis and symptoms of disease.
true
People with M. tuberculosis have about a ______________ lifetime risk of developing TB from a latent infection.
5-10%
TB is preventable, according to the WHO.
true
Most cases of TB are treatable
true
The following can be symptoms of TB:
coughing up blood, night sweats, fever, otherwise unexplained weight loss
Men are more often affected by TB than women
true
Of the following options, which WHO region has the heaviest burden of TB?
WHO South-East Asia Region
We currently have a very promising vaccine candidate for tuberculosis, which is a major advancement with respect to TB control.
true
Indoor Residual Spraying with insecticide was a major malaria control strategy in the past but is not in widespread use as of the year 2025
false
Seasonal chemoprophylaxis for kids in the Sahel region can be an effective strategy to help control malaria.
true
Pregnant women should not take most types of antimalarial drugs due to potential for harm to the fetus. This is the major reason that pregnant women represent one of the high-risk groups for malaria mortality.
false
high mortality is due to how pregnancy alters the immune response
The two main factors determining malaria pathology in humans are anemia and the person’s immune response
true
What is an ITN (or IBN)?
A barrier that’s treated with chemicals to reduce the likelihood of insect bites
Which of the following are true of Anopheles gambiae (choose all that apply)
they breed easily
they have relatively long life spans
they prefer biting people more than animals
they are the main vector of concern for malaria
Malaria is considered the single most important parasitic disease of humans
true
By far, most cases of malaria are in countries in Africa; a smaller number of cases are in some countries in Southeast Asia, and there are still some cases in other locations, such as in Latin America.
true
Pregnant people and children younger than 5 years old in sub-Saharan Africa represent the major risk groups for malaria
true
Drug resistance by Plasmodium is concerned a pretty serious problem today.
true
Malaria episodes can include non-specific symptoms, so in places where malaria is endemic, it is important to get a diagnosis correct to perform the right course of treatment.
true
It’s common for children in malaria-endemic locations to be diagnosed incorrectly with malaria when in fact they have another condition, such as a serious bacterial infection.
true
The following are some of the characteristic features of the NTDs:
The tendency for people to have chronic symptoms
High possibility of disability and disfigurement
The tendency to cause stigmatized conditions
The tendency for them to be ancient conditions
Ascaris lumbricoides eggs can remain alive and infectious for years; they are resistant to chemicals like formalin and sulfuric acid.
true
Ascaris lumbricoides eggs can be killed by heat and sunlight.
true
Many NTDs are highly stigmatized; this represents a disproportionate burden for young men, compared with other demographic groups.
false
In the context of ascariasis and trichuriasis, MDA typically involves giving treatment to entire populations, regardless of an individual's infection status.
true
The word “neglected” in “NTDs” refers to the fact that many NTDs are neglected at the community level, country level, and global level.
true
People can contract whipworm or roundworm by ingesting eggs that were passed in the feces of other humans, especially when people who are infected practice open defecation
true
Adults of _______________________________________ live in the human gastrointestinal tract.
both Ascaris lumbricoides and Trichuris trichiura
Whipworm is diagnosed via stool sampling, while roundworm is mainly diagnosed through a rapid diagnostic test.
false
The following are risk factors for the STHs
poverty, poor housing structures, lack of access to sanitation facilities, lack of access to treatment within the community, being young
Ascaris worms have a long and complicated migration route through the body that includes the stomach, small intestine, heart, and lungs
true
Ascaris eggs are viable (able to infect people) for up to 1 year, but after about 1 year, they die and are no longer infectious.
false
Although people with Ascaris can be treated with deworming drugs, the drugs aren’t very effective, which contributes to the difficulty in controlling this NTD.
false
Nearly half of a billion people are infected with Trichuris.
true
Approximately how long do adult Trichuris live if a person doesn’t receive treatment?
a few years
Trichuris and Ascaris are often coendemic because they share similar risk factors.
true
People who have had Trichuris trichiura and Ascaris lumbricoides are very unlikely to be re-infected after treatment due to acquired immunity.
false
Both hand-washing and sanitation facilities are needed to help control Trichuris and Ascaris, among other strategies.
true