GLOBAL HEALTH AND ITS DETERMINANTS

Roberto De Vogli

Department of Epidemiology and Public Health, University

College London
 Theory and Evidence

Ideas
THEORY

Inductive Deductive
Reasoning Reasoning

EVIDENCE
Reality
 Scientific Evidence?

“Data speak by themselves”

vs.

“If you torture the data long enough, they will

eventually confess everything!”
 Lies, Damn Lies and Statistics

“There are three kinds

of lies: lies, damned
lies and statistics ”
 “It is easy to lie with statistics,
but
it is even easier to lie without them”
“The important thing
is not to stop
questioning”

A. Einstein
 UN Food Shortage Worldwide Survey.
The only question asked was:
“Would you please give your honest opinion about solutions to
the food shortage in the rest of the world?”

The survey was a huge failure....

• In Africa they didn't know what 'food' meant.

• In Eastern Europe they didn't know what 'honest' meant.
• In China they didn't know what 'opinion' meant.
• In the Middle East they didn't know what 'solution' meant.
• In South America they didn't know what 'please' meant.
• In Western Europe they didn't know what ’give' meant.
• And in the USA they didn't know what 'the rest of the world' meant.
 Outline

A. What are the major categories of global

health determinants?

B. What are the most important?

C. What are their relative contributions in

determining global health?

D. Exercise
 Outline

A. What are the major categories of global

health determinants?

B. What are the most important?

C. What are their relative contributions in

determining global health?

D. Exercise
“Meta-theories” of Health Determinants
• Nutrition (Mc Keown, 1976)
• Public health technology (Preston, 1976)
• Economic growth - poverty reduction (Preston, 1976)
• Sanitation, hygiene and clean water
• Education, autonomy of women and maternal and child
services (Caldwell, 1986)
• Income Inequality (Wilkinson, 1992)
• Health behaviors (Mc Ginnis, 1993)
• Medical treatment (Bunker, 1994)
• Gene expression (Venter, 2001)
• …
 Frameworks of Health Determinants (I)

Other Health
Disease
Factors Care

Cure, care

Clinical Epidemiology
Healthcare Evaluation
Source: Evans and Stoddart, 1994. Health Services Research, etc.
HEALTH CARE
OECD, 2005. Health at a glance
Source: Ontario Cancer Registry 1999
 Frameworks of Health Determinants (II)
Lifestyle Environment Biology

Other Health
Disease
Factors Care

Cure, care

Clinical Epidemiology
Source: Evans and Stoddart, 1994.
Healthcare Evaluation
Health Services Research, etc.
BEHAVIOURS
Smoking and Lung Cancer: animal studies…
…and human studies…
 ENVIRONMENT
(PHYSICAL AND SOCIAL)
Fig 1 Neighbourhood specific homicide rates (per 100 000 population per year) in relation
to male life expectancy at birth (with effects of homicide mortality removed) for 77 community
areas of Chicago, 1988-93
BIOLOGY
 STRESS AND ITS BIOLOGICAL TRANSLATION

• Stress is posited to “get under the skin”

via different biological pathways
including the hypothalamic-pituitary-
adrenal (HPA) system

• People may differ in terms of

psychological, biological and
behavioural response to stressors
 Frameworks of Health Determinants (III)

Social Physical Genetic

Environment Environment Endowment

Individual
Responses:
• Behavior
• Biology

Health
Health
& Disease
Care
Function

Wellbeing Prosperity
Source: Evans and Stoddart, 1994.
 Outline

A. What are the major categories of global

health determinants?

B. What are the most important?

C. What are their relative contributions in

determining global health?

D. Exercise
Kunst A 1998.
Fig. 1. Probability of men in non-manual and manual classes dying between the ages 45 and 65.
Figure 3. Under-5 mortality rates by socioeconomic quintile of the household for selected
countries based on data taken from the World Bank.
Victora et al. Lancet 2003;362:233-41
Source: Davey-Smith (1996) Age adjusted mortality of 300 685 white American men by median family
income of zip code areas in the United States. AJPH 1996;86:497-504.
Socioeconomic status and sport of choice

1. The sport of choice for the urban poor is

BASKETBALL.
2. The sport of choice for maintenance level employees
is BOWLING.
3.The sport of choice for front-line workers is
FOOTBALL.
4. The sport of choice for supervisors is BASEBALL.
5. The sport of choice for middle management is TENNIS.
6. The sport of choice for corporate officers is GOLF.
Figure Life expectancy among males and females in India compared with United States, mid-1990s
from Sen (2002)
 Inequality and health worlwide

Babones (2007) Social Sciences

Income inequality and life expectancy among wealthy nations

Source: De Vogli R, Mistry R, Gnesotto R and Cornia GA (2005) Has the relation between income
inequality and life expectancy disappeared? J Epidemiology and Community Health
Fig. 1. Mortality in working age men by proportion of income belonging to the less well off half of households, US states
(1990) and Canadian provinces (1991). Mortality standardised to Canadian population in 1991.
State abbreviations: LA-Louisiana; MS-Mississippi; AL-Alabama; SC-South Carolina; FL-Florida; TX-Texas; CA-California; AR-Arkansas;
NH-New Hampshire; MN-Minnesota. Province abbreviations: QC-Quebec; NS-Nova Scotia; NB-New Brunswick; ND-Newfoundland;
PE-Prince Edward Island; ON-Ontario; AB-Alberta; BC-British Columbia; MB-Manitoba; SK-Saskatchewan
 Outline

A. What are the major categories of global

health determinants?

B. What are the most important?

C. What are their relative contributions in

determining global health?

D. Exercise
WHO (2002). GLOBAL RISK FACTORS. High-mortality, developing REGIONS=subregions in D and E mortality strata. Lower-mortality, developing
REGIONS=AMR-B, EMR-B, SEAR-B, and WPR-B subregions. Developed REGIONS=AMR-A, EUR, and WPR-A. The figure shows the estimate d
mortality and disease burden for each risk factor considered individually. These risks act in part through other risks and act jointly with other risks.
Consequently, the burden due to groups of risk factors will usually be less than the sum of individual risks.
WHO (2002).
 Relative Influence of Health Determinants

Genes & Biology

Societal/social
characteristics
Health Behaviors

Total Ecology Health Care

Now I can see the real picture…