ACE

Category: Public Health

  • Maternal Mortality in the United States

    Maternal Mortality in the United States

    The International Classification of Diseases (ICD-10) defines maternal death as “[the] death of a woman while pregnant or within 42 days of the end of pregnancy from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.” Maternal Mortality is a global issue; around the world every minute a woman dies during labor or delivery. According to the World Health Organization, two regions, sub-Saharan Africa and South Asia, account for 86% of maternal deaths worldwide. The United States is an outlier whose maternal mortality rate (MMR) is high compared with other developed countries. 

    Amnesty International released a report in 2010 which explained that global maternal mortality was down 34% (1990-2008) but “the US was among just 23 countries to see an increase in maternal mortality” during that time. In the United States, 18 women die per 100,000 live births—a ratio more than double that of most other high-income countries. In addition, women of color at all income levels are 3 to 4 times more likely to die from childbirth-related complications than white women.

    The literature points to various reasons why the United States has the highest MMR in the developed world. But it focuses specifically on:  

    1. Shortcomings of the US healthcare system.
    2. Implicit racial bias in the medical field which results in a higher maternal mortality rate for BIPOC women in the United States. 

    The American Healthcare System

    American citizens have vastly different experiences with healthcare depending on which state they live in. Some states expanded Medicare through the Affordable Care Act while others opted for a more limited public health program. Abortion policy also varies by state, with states permitting it at different stages in pregnancy and at clinics versus hospitals.

    Low income women who rely on Medicaid face several obstacles in receiving care. In 2019, 20% of obstetricians and gynecologists would not accept new Medicaid patients because of low reimbursement rates and bureaucratic delays. Postpartum care is not covered beyond sixty days of giving birth, and complications can arise up to a year after giving birth. Medicaid provided coverage for 43% of births in the US in 2018, disproportionately covering young women, women of color, and those in rural communities.

    Reducing legal access to family planning services can lead to increased maternal mortality. When abortion is limited, women are more likely to turn to unsafe abortion methods which create a higher risk of maternal death or lifelong health complications. Unsafe abortions are the cause of 13% of maternal deaths globally. 

    Implicit Health Provider Bias

    Louisiana is the state with the highest MMR in the country with 58.1 deaths per 100,000 births. In Louisiana, “59% of black maternal deaths are preventable, compared to 9% of white maternal deaths.” This is the result of both the challenges discussed above, as well as implicit bias in healthcare providers. Healthcare providers frequently hold false beliefs about black people’s pain tolerances, which influence the pain treatment they are prescribed. In addition, black mothers often find that they are not listened to or believed while reporting symptoms, and are pressured into health decisions they don’t feel are in their own or their unborn child’s best interests.

  • Intro to Vaccine Hesitancy

    Intro to Vaccine Hesitancy

    Vaccines are a simple, safe, and effective way to protect people from harmful diseases by using your body’s immune system to build resistance. However, a large portion of people in the United States are hesitant to receive vaccines for various and complex reasons. Vaccine hesitancy is a term used to refer to the reluctance or refusal to vaccinate despite the availability of vaccines. Hesitancy exists on a wide spectrum, as the image below illustrates. 

    Today, the main reasons for vaccine hesitancy can be grouped into 3 C’s: confidence, complacency, and convenience.

    These 3 C’s and data about COVID-19 vaccine hesitancy can be used to explore the complex reasons behind vaccine hesitancy. 

    Black people are the most hesitant, with 41% of poll respondents reporting hesitancy about the COVID-19 vaccine. This is due to both confidence and convenience issues. There is a long history of medical abuse of Black bodies from slavery to the present day, ranging from the Tuskeegee Syphilis Trials to everyday racism as Black peoples’ symptoms are continuously not taken seriously. As a result, confidence in the healthcare industry is understandably lacking. Additionally, convenience is an issue as many Black people work frontline jobs and often can’t take time off to get vaccinated. This is why it’s important for employers to give paid time off to allow employees to receive vaccines. There is also still some confusion about who is eligible to receive the vaccine. According to the KFF COVID-19 Vaccine Monitor, lack of information about the vaccine, including eligibility, is still a determining factor of whether Hispanic adults get vaccinated or not.

    Republicans are the most hesitant, with 44% indicating so when polled. This is seen as a result of vaccinations becoming politicized. Counties with the most vaccine-hesitant people generally also voted for Donald Trump. Concerns are mostly around confidence and a sense of complacency. There’s uncertainty about side effects and whether the vaccine is effective. Some also don’t think COVID-19 will impact them and thus don’t see a need for getting the vaccine. Confusion about mask mandates at the beginning of the pandemic helped spread misinformation about the virus and vaccine mandates are being pushed against with concerns over individual rights.

    The 18-34 age group is the most hesitant. According to KFF COVID-19 Vaccine Monitor, around ¼ of 18-29 year olds want to wait and see how the vaccine is working. Furthermore, a lot of information has been circulated about how harmful COVID-19 is to older adults. Complacency is part of this, as less concern about younger generations leads to thinking that vaccines aren’t necessary for younger age groups. As a result, young adults are more receptive to the vaccine if friends have taken it, so peer networks play a large role. Lastly, a lack of public messaging about the vaccine on social media, where Gen Z and Millennials get most of their information, is a missed opportunity to spread important information about vaccines to younger age groups. 

    According to the poll, people who make less than $50,000 are the most hesitant. This is mainly due to convenience issues. People with lower income brackets often don’t have the time to go to a vaccination site. They often also have poorer access to transportation, which is needed to get to a vaccine center or doctors office. Some people also have health issues, disabilities, and experience language barriers which, combined with jobs and family duties, makes getting vaccinated a daunting ordeal. These lower-income jobs are also not as flexible and typically remained in person throughout the pandemic, limiting the time that could be used to receive the vaccine.

    Rural residents are the most hesitant. About 60% of rural residents in the poll said they already got the vaccine or were going to as soon as possible, compared to 71% of urban residents. This hesitancy falls into the complacency and convenience categories. For rural residents, getting the vaccine is more of a personal choice.  39% say they aren’t worried about someone in their family getting COVID-19, compared to 23% of urban residents. Additionally, rural communities tend to have a high percentage of people who are older, who lack health insurance, and who have limited access to healthcare facilities, which can all be barriers to vaccination.

    Non-college graduates are more hesitant, with 43% reporting hesitancy in the poll. Adults with a bachelor’s degree or higher see the vaccine as safer and more effective. The Understanding America Study, found that people with less than a college degree believe in a higher risk of a serious side effect from the vaccine. Adults with college degrees are also more likely to know someone who is vaccinated, which helps to encourage their own vaccination.

    How should we continue the conversation about vaccine hesitancy? It’s important to listen to people’s concerns and not shame those who are vaccine hesitant or anti-vaxx. Correcting misinformation about vaccines and possible side-effects is also very important. Personal healthcare providers are who the majority of people turn to for advice about vaccines so they are at the forefront of communicating accurate information. Speaking in a nonbinary dialogue, rather than limiting it to people who get vaccines versus people who don’t is imperative in order to understand the broad continuum of vaccine acceptance. A person doesn’t have to and likely won’t go from skepticism to acceptance right away but any shift along the spectrum towards vaccine acceptance is still valuable. It’s also important to recognize the role that medical institutions have played in historic racism to gain a better understanding of how Black and Brown people have been mistreated and why it results in hesitancy and skepticism today. Lastly, perhaps ‘vaccine hesitancy’ is the wrong phrase to use as accessibility, convenience, and institutional problems in the healthcare field are huge contributors to why people don’t get vaccines. 

  • The Impact of COVID-19 on Other Global Health Initiatives

    The Impact of COVID-19 on Other Global Health Initiatives

    The COVID-19 pandemic has deeply impacted other international and domestic health initiatives. Although COVID was undoubtedly the most imminent threat to global health, there were inevitable setbacks to other initiatives which had been making significant strides to improve the health of people across the globe, specifically in the developing world. International health initiatives previously at the forefront of the international health conversation have been forced to take a backseat to the coronavirus.

    In recent years, significant progress has been made in disseminating measles and polio vaccines. The COVID-19 pandemic has imposed significant obstacles on global vaccination campaigns in places where these diseases have yet to be eradicated. Twenty six countries have suspended their measles vaccinations as resources have been redirected to combat the coronavirus. This has put 94 million people at risk, with the World Health Organization (WHO) projecting that more children will die from measles than from COVID itself. Polio vaccination campaigns have also been halted in twenty eight countries. In previous years, polio was close to being eradicated entirely due to these campaigns.

    The coronavirus has impeded recent progress in the fight against malaria. This can be seen in decreased access to supplies such as mosquito nets and reductions in preventative information dissemination. While Sub-Saharan Africa already experiences 90% of global malaria cases, this region has endured an increase in cases as a result of the pandemic. According to the WHO, efforts to reduce malaria cases and deaths will fall significantly short this year.

    HIV treatment has not faced as many setbacks as public health officials feared. Although testing capacity has declined, access to treatment has not suffered as much. In a study conducted by the UNAIDS organization, of the twenty two countries which provided sufficient treatment data, only five – Sierra Leone, Zimbabwe, Peru, Guyana, and the Dominican Republic – experienced declines in treatment accessibility. Meanwhile, countries such as Kenya, Ethiopia, and Botswana were able to maintain a steady treatment regimen while simultaneously battling the coronavirus.

    COVID has had a noticeable impact on world hunger, which was on the rise before the pandemic, and has only been further exacerbated in 2020 and 2021. World hunger is caused by conflict, socio economic issues, and climate change. Climate change can increase food prices, and decrease access to nutritious food. This decreased access to food leads to malnutrition which serves to weaken people, therefore making them more susceptible to other illnesses. The introduction of COVID-19 to the equation has disrupted global supply chains and contributed to inflation, making food less accessible to lower income families. The World Food Programme (WFP) estimates that the coronavirus has caused over 200 million people to experience food insecurity. The World Bank is cooperating with local governments to bolster programs and provide financial support to countries struggling with enhanced food insecurity.

    In the United States, the coronavirus has drastically increased mental health issues such as depression and anxiety, as well as rates of alcohol and drug abuse. In June 2019, 1 in 10 American adults reported experiencing mental illness, compared to January 2021 during which 4 in 10 adults reported experiencing mental illness. This spike can be attributed to stressors driven by the pandemic such as isolation and unemployment. The rates of mental illness have been even higher for young adults between the ages of 18 and 24. This demographic reports a 56% rate of depression and anxiety due to isolation, the inability to attend school, and job insecurity. While these rates of mental health problems are shockingly high, it is also important to note they will not simply disappear with the end of the pandemic.

    The increase in COVID vaccine availability has provided a possible light at the end of the tunnel. As more people gain access to the vaccine, coronavirus will be better controlled which will allow other world health issues to return to the forefront. The reallocation of supplies and attention to more endemic global health concerns will ensure millions of people are able to improve their standard of living in an effort to promote a healthier world.

  • Nursing and Residential Care in the United States One Pager

    Nursing and Residential Care in the United States One Pager

      

    Nursing and residential care consists of services that are utilized by people who require medical and/or custodial assistance and who will potentially move to a care facility that provides more support than caregivers can give. There are two types of care facilities: assisted living facilities and nursing homes. Assisted living facilities are for individuals who need some daily care, and can range in population from 25 to 120 residents. Individuals pay for higher levels of care depending on their needs and reside in single rooms or apartments, while sharing common rooms. In contrast, nursing homes are skilled nursing facilities that provide a greater range of health and personal care in comparison to assisted living facilities. They focus on medical care and rehabilitation services for individuals who can no longer care for themselves. Some residents live there permanently because they have ongoing physical or mental conditions that require more supervision.

    There are approximately 15,600 nursing homes in the United States. On average a patient receives around 4 hours of nursing care per day. The Centers for Medicare and Medicaid Services (CMS) created a quality rating for nursing homes to help families evaluate facility performance based on three areas:

    1. Health Inspections: based on the number, scope, and severity of deficiencies identified during the two most recent annual inspection surveys, as well as substantiated findings from complaint investigations
    2. Staffing: defined by the number of hours of care provided on average to each resident each day by nursing staff, subject to the needs to residents in the nursing homes
    3. Quality Measures (QMs): 15 different physical and clinical measures for nursing home residents to identify how well nursing homes are caring for their residents’ physical and clinical needs

    There are many ways to pay for nursing and residential home care depending on the services required. Care is divided into two sectors: custodial care and high-level inpatient medical care. Custodial care is for people who can no longer care for themselves entirely and need long-term residence and non-medical assistance with the activities of daily living such as bathing, eating, walking, and dressing. This care and the services required are often not covered by Medicare. High-Level inpatient medical care consists of skilled nursing or rehabilitation care and covered by Medicare Part A for a limited time. Skilled Nursing Facility Care is covered by Medicare but for only limited periods of inpatient care and can pay for short, costly rehabilitation. A benefit period begins on the day that an individual is admitted as an inpatient in a hospital or a skilled nursing facility and it ends when no care has been administered for sixty days in a row. Medicare Part A covers days 1-20 for $0 for each benefit period, day 21-100 covers $185.50 coinsurance per day of each benefit period, and for days 101 and beyond: all costs are covered by the individual. 

    There are four conditions for nursing home coverage to be covered by Medicare:

    1. Prior Hospital Stay – nursing home stay must begin within 30 days of an inpatient hospital stay of at least three days in length 
    2. Necessity for skilled nursing or rehabilitation – need for services every day
    3. Medicare-approved facility
    4. Improving condition – coverage only as long as the patient is improving, once stabilized, coverage is no longer available

    Medicare Part C/Medicare Advantage Plans include Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). Medicaid has different eligibility requirements by states for various levels of income but residents are able to receive services from any level nursing home that is certified by Medicaid and accepts Medicaid payments. For eligible beneficiaries, Medicaid pays the full cost of room and board in a nursing facility plus any regular therapies and custodial care. There are no copayments and no time limit on Medicaid nursing home coverage. 

    Program of All-Inclusive Care for the Elderly (PACE) is a program for individuals eligible for Medicare and Medicaid benefits at the same time. This enables individuals to remain in their homes and communities, rather than receive care in a nursing or residential home. When individuals enroll in the program, it becomes the sole source of Medicaid and Medicare for PACE participants. Individuals can join PACE if they meet four criteria: 

    1. Age 55 or older
    2. Live in the service area of a PACE organization
    3. Eligible for nursing home care
    4. Be able to live safely in the community

    Health Savings Accounts (HSA) are options available for individuals who have or previously had high-deductible health plans. With an HSA, deductibles can be paid with pre-tax dollars. Individuals can add pre-tax dollars to the account and money in HSAs carries over each year to accumulate in total. However, once an individual is enrolled in Medicare, they can no longer add to a HSA. These accounts can be used to pay for qualified medical expenses such as long-term care services and premiums up to the maximum annual tax-free amount based on age.

    Through long-term care insurance, premium rates are much lower for people who are in good health when they purchase their policy. Some life insurance policies that cover long-term benefits are pricier than standard life insurance. 

  • The COVAX Initiative

    The COVAX Initiative

    Introduction

    COVID-19 is a rapidly transmissible virus which has shut down the global economy for the past 15 months. In the past six months, vaccine production and distribution has ramped up, but vaccine nationalism—the hoarding of vaccines by countries for their own populations—is threatening to prolong the pandemic for several years. The COVAX Initiative seeks to close this vaccination gap by distributing vaccines to low and middle income countries who otherwise wouldn’t have access to them—an essential step to end the acute stage of the pandemic.

    Wealth inequality is the root of the current global vaccine access disparity. As of March 2020, “High-income countries, representing just a fifth of the global adult population (~20%), have purchased more than half (~54%) of all vaccine doses.” 

    As shown by this figure from the Kaiser Family Foundation, high income countries have enough doses to fully vaccinate their adult populations twice over, while lower income countries can only vaccinate around a quarter of their population. This poses risks for the spread of global variants, as well as a slower global economic recovery. 

    Countries hoard vaccines because they are prioritizing domestic economic recovery and aim to reach herd immunity (with 70% of their citizens vaccinated) within their borders. However, this ideology could end up hurting them more than helping them as variants mutate among the unvaccinated and spread as countries ease lockdowns. This would hinder public health progress and slow economic recovery. Therefore, the COVAX initiative is essential to combat vaccine nationalism by distributing vaccines to low and middle income countries which do not have the same ability to purchase vaccines in bulk.  

    The COVAX Initiative

    The COVID-19 Vaccines Global Access (COVAX) Initiative is an international partnership led by the Coalition for Epidemic Preparedness Innovations (CEPI), Gavi, the Vaccine Alliance, and the World Health Organization (WHO) to close the vaccination gap between high income countries (HICs) and lower-middle income countries (LMICS). It fulfills the vaccine pillar of the Access to COVID-19 Tools (ACT) Accelerator, which was created in April 2020 to ensure that all countries, regardless of GDP, would have access to needed COVID-19 response resources.

    COVAX seeks to achieve: 

    1. Doses for at least 20% of countries’ populations
    2. Diverse and actively managed portfolio of vaccines
    3. Vaccines delivered as soon as they are available
    4. End the acute phase of the pandemic
    5. Rebuild economies

    COVAX uses international infrastructure to coordinate equitable vaccine distribution and relies on multiple actors in multiple sectors in order to reduce gaps in vaccination coverage. COVAX aims to provide 2 billion COVID-19 vaccines to the most vulnerable citizens in all participating countries through the COVAX Facility, which is a “global risk-sharing mechanism for pooled procurement and equitable distribution of COVID-19 vaccines.” This initiative seeks to combat vaccine nationalism by recognizing that no country or single population will be protected from the virus if populations in low and middle income countries remain unvaccinated. 

    COVAX and US Policy

    Changes in U.S. administrative policies on COVAX reflect different ideologies about the United States’ role on the world stage. The Trump Administration did not join or support the COVAX initiative while in office. However, the Biden Administration is now a vocal supporter of the program and has pledged $4 billion dollars to COVAX. They have also supported waiving intellectual property patents on COVID-19 vaccines. This is consistent with the Administration’s foreign policy strategy of rebuilding alliances and repositioning the U.S. on the world stage as a global leader. 

    Criticisms and Critiques 

    While COVAX is certainly an essential step in the right direction, many organizations feel it is not effectively meeting the needs of the moment. The People’s Vaccine Alliance argues that the COVID-19 vaccines must be seen as a public good and readily available to all those in need, and that COVAX is not the right tool to enable this paradigm shift. These concerns reflect a disconnect between the profit motive of vaccine manufacturers and the imperative to vaccinate as many high risk individuals as possible. In addition, some feel that vaccine hoarding is justified because governments must put the lives of their own citizens before those in other countries. While this does not explain hoarding enough vaccines to vaccinate citizens twice over, it is a main reason why not all countries are ready to give away a portion of their domestic vaccine supply.

  • Operation Warp Speed: Accelerated Covid-19 Vaccine Development

    Operation Warp Speed: Accelerated Covid-19 Vaccine Development

    The Covid-19 pandemic is one of the most challenging public health crises the United States has contended with in over a century. During a state of emergency, the benefits of creating effective vaccines and the risks of delaying their release are extremely high. Vaccinating the population as soon as possible decreases loss of life and allows economic activity to resume, but the vaccine approval process must be completed diligently with particular attention paid to the statistical rigor of the clinical trials. If a vaccine is released that lacks adequate efficacy, the relaxed behavior that occurs in people who are vaccinated could lead to the paradoxical result of more infections. If a vaccine is released that has a high occurrence of unpleasant and/or deadly side effects, vaccine hesitancy may negatively impact the number of people who choose to get vaccinated. These realities caused a dilemma for public health authorities—every month the Covid-19 vaccines delayed cost tens of thousands of lives, but prematurely releasing the vaccine could have caused just as much, if not more, damage. In response to this historic pandemic, the federal government and biomedical research companies cooperated to develop effective vaccines in just under a year, a speed that is historically unprecedented. 

    Coordinated efforts by the United States to develop a Covid-19 vaccine began with the announcement of Operation Warp Speed (OWS) on May 15th 2020. OWS was a private-public partnership between the United States Federal Government and pharmaceutical companies with the goal to “produce and deliver 300 million doses of safe and effective vaccines with the initial doses available by January 2021, as part of a broader strategy to accelerate the development, manufacturing, and distribution of COVID-19 vaccines, therapeutics, and diagnostics”. OWS was an interagency program which consisted of several components of the Department of Health and Human Services (HHS) including the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the National Institutes of Health (NIH), the Biomedical Advanced Research and Development Authority (BARDA), and the Department of Defense (DoD). BARDA functioned as the leadership and financial interface between the federal government and the biomedical industry, providing funding for research and manufacturing to the companies that produced the most promising vaccine candidates. OWS received nearly 10 billion dollars of initial funding, 6.5 billion of which went towards medical countermeasure development and the other 3.5 billion towards NIH research. As clinical trials progressed, OWS funding was expanded to over 18 billion dollars. Six vaccine candidates (out of over one hundred) received substantial funding from OWS. 

    Rather than pursuing a Biologics License Application (BLA), the standard licensure requirement for distributing vaccines to the general public, pharmaceutical companies were able to acquire Emergency Use Authorizations (EUA). The federal government established the use of EUAs as a means to quickly produce and distribute unproven but potentially life saving drugs to the general public following the declaration of a public health emergency by the Secretary of Health and Human Services. Once a state of emergency was declared, the FDA published several guidelines for issuing EUAs. By pursuing an EUA as opposed to a BLA, pharmaceutical companies were able to expedite vaccine research, clinical trials, and mass production. The Covid-19 EUA also standardized the clinical trial protocols that pharmaceutical companies had to follow. Standardizing the clinical trial protocols ensured that all of the vaccines met the same efficacy and safety standards. Due to the dangers of releasing ineffective vaccines, the FDA required certain efficacy standards.

    While the Covid-19 vaccines had to comply with the same safety criteria as every other preventative vaccine for an infectious disease, certain parts of the process were shortened. Normally the periods between phase 1 and 2, and phase 2 and 3 of the clinical trial have six month observation periods to observe if any side effects develop. This six month observation period was reduced to two months in the EUA, with the rational being that 95% of adverse reactions occur within 6 weeks. 

    Another way that the Covid-19 EUA expedited the process was by encouraging pharmaceutical companies to engage in financially high-risk vaccine development. In normal situations, vaccine development is not a highly profitable endeavor. Pharmaceutical companies spread out the financial risk over a longer period of time by completing each step sequentially in the development process. In the standard paradigm, the process usually occurs as follows; 

    1. In vitro laboratory research, 
    2. In vivo animal studies, 
    3. Phase 1 clinical trial, 
    4. 6-month observation, 
    5. Phase 2 clinical trial, 
    6. 6-month observation, 
    7. Phase 3 clinical trial and manufacturing scale up, 
    8. Manufacturing process and product validation, 
    9. Biologics License Application (BLA) approval (standard licensure requirement for distributing vaccines to the general public),
    10. Production at a commercial level

    This entire process can take anywhere between 5-15 years, and given that less than 10% of vaccine prototypes end up acquiring a BLA, spreading out the steps is a financially smart decision. If a vaccine were to fail in the early clinical trial stages, the financial losses would be minimized since little investment was made towards manufacturing. In financially high-risk vaccine development, however, many of the steps occur simultaneously. In vivo animal studies and phase 1 of the clinical trial are often merged, as well as phase 2 and 3 of the clinical trial. This reduces the clinical trial time substantially without undertaking significant safety and efficacy risks since all of the steps that would have occured in a normal biologics license application trial have still occurred, albeit in a merged or overlapped manner. Most importantly, manufacturing scale up and commercial manufacturing of the vaccines occur simultaneously to the clinical trial. This is a financially high-risk strategy since significant investments are made into manufacturing before knowing if the vaccine is safe and effective. In this case, the federal government provided funding for the large manufacturing scale up, removing the financial-risk from the pharmaceutical companies. 

    Although this was an expensive and financially high-risk strategy, it led to vaccines being created, tested, and distributed in an unprecedented timeframe. Covid 19 vaccines were available to the first qualified members of the general public in just under a year, significantly faster than the normal 10-15 year timeframe. Of the six vaccines that received research funding from OWS, just two vaccines (Moderna and Janssen Pharmaceuticals) received an EUA from the FDA. The total funding for the other four vaccines that did not receive EUAs amounts to nearly five billion dollars. Two of the vaccines (Astrazeneca and Merck) have been either paused or terminated, and the other two vaccines (Norovax and GlaxoSmithKline) are still in development. Although OWS did not fund research for the Pfizer-BioNTech Covid-19 vaccine, an EUA was granted following submission of data from their phase 3 clinical trial and two billion dollars worth of vaccines were pre ordered.

  • Healthcare in America

    Healthcare in America

  • The World Health Organization

    The World Health Organization

    The World Health Organization (WHO) was founded in 1948 as a UN specialized agency to direct and coordinate international health policy within the UN System with the goal of improving global health outcomes. The WHO would be created with the backing of 61 countries, including the United States, giving it legitimacy to steer the global health conversation as a major international actor. The WHO Constitution defines health as, “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” This definition expanded the concept of health to include not just medical interventions, but also the social determinants of health and healthcare access. Despite this robust definition of health, the WHO initially prioritized communicable disease, women and children’s health, nutrition, and sanitation as opposed to healthcare access or addressing the social structures impacting health. Over time, these facets of health would be more directly addressed by the agency.

    The WHO is headquartered in Geneva, Switzerland and has six regional and 149 country offices throughout the world. Delegates from the 194 member states compose the World Health Assembly, which sets WHO policy, approves and monitors budgets, and elects a director-general as a leader of the WHO for 5-year terms. Tedros Adhanom Ghebreyesus is the current director-general of the WHO after being elected to his first 5-year term in 2017. He is the first African in the organization’s history to occupy the post. The WHO is governed by the member states and must respect their sovereignty. Therefore, it cannot enter a country without their permission and a country does not have to follow the agency’s recommendations. The WHO also maintains an Executive Board that is comprised of 34 members who have technical qualifications in the field of health. They provide proposals, make recommendations to the director-general, and implement the agency’s work plan.

    The WHO rarely provides direct medical interventions or direct funding to implementors, but rather focuses on administrative, logistical, and advisory support for countries and other organizations. Core functions of the organization include partnership development, conducting research, setting global health morns, providing technical support, disease monitoring, and advocacy for global health initiatives. For example, guidelines regarding essential medicines, diagnostics, and medical practices are published by the WHO for countries to follow although they are not obliged to follow them. In addition, the WHO supports initiatives to control epidemic and endemic disease by promoting vaccination programs, the use of antibiotics and insecticides, the improvement of clinical facilities for early diagnosis and prevention, access to clean water and sanitation systems, and health education for rural communities. The final major function the agency has, is the ability to declare a Public Emergency of International Concern or a Pandemic. This function allows the WHO to draw attention to, and rally global resources against, emerging health threats or trends in an effort to address them.

    The WHO can direct the global health discussion through its World Health Report and other tools to influence global actions as well. This can be seen in its 2019 General Programme of Work, where the WHO identified three priorities it seeks to address in the coming years:

    1. Providing health coverage to one billion more people
    2. Protecting one billion more people from health emergencies such as epidemics; and
    3. Ensuring another one billion people enjoy better health and well-being, including protection from non-infectious diseases such as cancer.

    Since at least half of the world’s population does not currently have full coverage of essential health services, publishing this document allows the WHO to highlight a global health challenge and set a goal for the countries of the world to strive for.

    The WHO is funded through a combination of assessed contributions, which are calculated based on each member countries’ wealth and population, and voluntary contributions which are provided at the discretion of governments and private donors. Approximately 17 percent of the WHO’s budget comes from assessed contributions, with the rest coming from voluntary contributions. This has increasingly made the WHO dependent on voluntary contributions and placed pressure on the organization to align with the goals of their donors. This was seen in 2020 with President Trump’s plans to withdraw completely from the WHO and take U.S. funding with it due to his belief that the WHO was too deferential to China. Non-government donors also impact the WHO’s direction as seen when private donors make voluntary contributions with the understanding that the donors’ preferred projects will be addressed. One example includes the donations given to the WHO by the Bill & Melinda Gates Foundation. The Bill & Melinda Gates Foundation has prioritized the eradication of polio and the increased resources allocated to this cause by the WHO reflect the foundation’s priority. This has presented a growing challenge to the WHO as monetary contributions are increasingly becoming inflexible through donor restrictions. 93 percent of funds given to the WHO for its health programs is now earmarked and cannot be distributed to other projects that may have a greater need.

    The WHO has accomplished remarkable feats through its global leadership and coordination during multiple outbreaks, vaccination campaigns, and other global health initiatives. What many point to as the agency’s greatest achievement began in 1967 when the WHO started a smallpox vaccination campaign. By 1980, smallpox was eradicated due to the coordination and determination of the WHO’s staff and leadership. Similarly, the WHO’s role in the polio vaccination campaign has been highly lauded, with polio currently on the verge of eradication. The WHO’s handling of the SARS (severe acute respiratory syndrome) outbreak in 2003 was widely praised for the agency’s quick medical and travel guidance. The WHO’s decisive action and travel recommendations were crucial to the successful containment of what many feared could be a global health disaster. The impact of the outbreak was contained mostly to Asia and the death toll was quite low.

    Conversely, the most common criticism of the WHO comes in the form of mismanaged and slow responses due to poor coordination or political considerations. Political friction between WHO headquarters and the regional offices has been a hindrance to the agency’s efficiency, as many believe the regional offices have too much autonomy which leads to a lack of internal cooperation. During the 2014 Ebola outbreak, the WHO was criticized for waiting 5 months to declare a public health emergency despite the pleas of many organization such as Doctors Without Borders. More recently, many criticized the WHO’s response to COVID-19 as being too deferential to China. In particular, the Trump Administration believed the WHO accepted misinformation from China at face value due to the country’s political power within the agency. In general, critics believe the WHO should have been more forceful in its requests for accurate information at the start of the pandemic.

    The United States has played an outsized role in the WHO from its inception due to its monetary contributions and international political clout. The United States’ support for the creation of the United Nations (UN) following World War II was integral to the creation of the WHO as a UN specialized agency. Ever since the agency’s establishment, the United States has traditionally been the largest donor to the WHO. In 2019, the U.S. provided a of total $419 million through assessed and voluntary contributions of the WHO’s $5.624 billion budget. Additionally, The U.S. has been an active participant in WHO governance and provided technical support for health initiatives. This is seen in the country’s representation on the Executive Board along with U.S. government experts and resources being provided for research, laboratory work, and international outbreak response teams.

    As it relates to the current COVID-19 pandemic, the WHO responded with its coordination, technical support, and advisory expertise. On December 31st, 2019, China reported a cluster of unknown pneumonia cases to the WHO. One month later, before any deaths were reported outside of China but a sharp increase in cases was seen outside of the country, the WHO declared a Public Emergency of International Concern. By March of 2020, the agency declared it a Pandemic as cases spread around the world. Additionally, the WHO provided critical supplies such as diagnostic tests and personal protective equipment to member states and created online courses to train health care workers in diagnosis and treatment methods for COVID-19. Furthermore, the WHO is providing medical and technical guidance to countries as they continue to investigate the virus and its new variants. The agency has sent more than 70 teams of technical advisors to assist countries with their COVID-19 responses. 

  • Understanding the Social Determinants of Health

    Understanding the Social Determinants of Health

    The social determinants of health are the conditions where people live, work, grow, and age that impact their health outcomes. Other factors, including social structures and economic conditions, are also considered to be social determinants of health. These social, economic, and physical conditions can be essential to health outcomes, and in part explain existing health disparities in the United States. Many of the challenges which lead to lower health outcomes are intertwined; for example, low-income families are more likely to live in unsafe housing conditions as well as be further from healthcare resources, and racial and ethnic minorities are overrepresented in the low-income population. Disparities in health also exist across sexualtiy, gender, age, and socioeconomic status. Community ties, neighborhood quality, and education are all impact health outcomes and can affect children starting at a young age. This brief discusses social determinants in 3 categories: marginalized populations, socioeconomic status, and community/location. 

    Inequalities based on gender, sexuality, race, and ethnicity are replicated through health outcomes in the United States. These fall into two main categories: discrimination and structural challenges:

    Experiencing discrimination has a physical toll on the body. Discriminatory experiences induce chronic stress, which over time produces high blood pressure, anxiety, and mental health issues like depression and substance abuse. Ethnic and racial minorities who experience racism are more likely to have children born with a low birth rate, high blood pressure, and overall poorer quality of health. Women who experience discrimination are more likely to be depressed or experience other mental health issues. In addition, women, racial and ethnic minorities, and LGBTQ individuals can experience discrimination within the healthcare system, making them less likely to seek out discretionary care like preventative care. For example, minorities report less trust in the medical system and are less likely to believe that their physician will act in their best interest. Distrust in the medical system can worsen health outcomes by leading to lower rates and delayed utilization of beneficial health care services, like primary care. For LGBTQ individuals, discrimination is associated with higher rates of mental health related issues and a higher prevalence of suicide. 

    Structural challenges also impact health by limiting access to health services. This is often the case for racial and ethnic minorities, who often have less access to physical and mental healthcare resources. They are more likely to face disparities in regards to physical health, mental health, and healthcare quality. Minorities are less likely to receive preventative services, including yearly checkups and screenings, which can lead to worse health outcomes. When receiving medical care, that care tends to be lower quality care when compared to non-minority counterparts and they are more likely to suffer from morbidity and mortality from chronic diseases. Structural barriers in healthcare usage also differ by gender, since women tend to have higher rates of morbidity yet have a longer life expectancy than men. Men are more likely to die at younger ages, despite having overall better health than women during their lifespan. This could be attributed to men being less likely to seek out medical care than women and being more likely to engage in high risk behaviors. LBGTQ individuals are less likely to receive care and are less likely to have insurance, fill prescriptions, and use emergency services. They are also more likely to report poorer health and suffer from chronic conditions. 

    Both structural barriers and discrmination impact the access and utilization of health services  which can greatly affect health outcomes. It is important that people both have access to health services and an understanding as to how health services can impact their own health, or health literacy. The first involves having access to comprehensive, high-quality health care services which includes health insurance and primary care services. Health literacy is also important, because it allows individuals to make appropriate health decisions for themselves. When discrimation and structural barriers get in the way of access to comprehensive care, worse health outcomes can occur. For example, in the United States there are prevalent disparities in health outcomes when it comes to race. Black and Native Americans have the lowest life expectancy in the United States. Disparities even exist with infant mortality rates, with black infants having mortality rates 2.3 times higher than white infants. LBGTQ individuals are also impacted by discrimination and structural barriers, and are at higher risk for substance abuse disorders, STDs, cancers, cardiovascular disease, obesity, bullying, isolation, rejection, anxiety, depression, and sucide compared to the general population. 

    Socioeconomic status is a fundamental cause of disease which disproportionately impacts many groups. The relationship between socioeconomic status, race and ethnicity is intertwined, with racial and ethnic stratification leading to higher rates of poverty for these individuals. In the United States, 39% of Black children and 33% of Latino children live in poverty, while only 14% of non-hispanic white and Asian children live in poverty. Native Americans, Native Alaskans, Hispanics, and Pacific Islander families are more likely to live in poverty compared to white families. Individuals who identify as LBGTQ are also more likely to be of low socioeconomic status. This, in part, might be due to access employment opportunities, with around 42% of LBGTQ individuals reporting employment discrimination. The elderly also disproportionately experience low socioeconomic status, with 14.6% of older adults (65 years or older) living below the poverty line. Factors, including the death of a spouse, decline in health, relying on social security for a primary source of income, and the inability to work, can greatly impact financial stability. 

    Those with low socioeconomic status are more likely to have poorer health outcomes and have higher morbidity and mortality rates. Individuals with low socioeconomic status are disproportionately impacted by not having access to healthcare, poorer working conditions, and less safe housing. There is a positive relationship between people’s financial circumstances and their health. Financial circumstances include income, cost of living, and socioeconomic status, which all can affect key issues like food security, housing security, and employment. Individuals without steady employment are more likely to live in poverty and are more likely to be unhealthy. Those with disabilities may be limited in their ability to work, contributing to a low socioeconomic status. Those without steady employment might also struggle to afford supplies and services that support health, like medications, copays at the doctor’s office, or high quality healthy foods.

    An individual’s social relationships and community ties can affect health outcomes as well. The social and community context of health includes social relationships with friends, family, co-workers, and community members. Having healthy relationships at home, at work, and within the community can reduce the negative impacts of stress and  discrimination. Social support works as a protective factor for both physical and mental health by enhancing resilience to stress. Stress can contribute to many health problems, such as high blood pressure, obesity, heart disease, and diabetes, so managing stress leads to better health outcomes. When an individual experiences discrimination, their health can be impacted by both psychological and physiological repsonces to stress. Family connectedness, social support, religious involvement, and diversity of friendships can improve health outcomes by reducing stress and promoting healthy coping mechanisms. 

    Location and housing also impact health and wellbeing. Both the physical infrastructure and the social impact of a neighborhood can directly affect health outcomes. Due to the exposure to hazardous conditions, low quality housing is associated with chronic disease, injury, and poor mental health. Some neighborhoods also have worse air quality and water quality. Healthy food and access to resources such as transportation are less available in certain neighborhoods. Neighborhoods with high rates of crime and violence can cause both short and long-term health effects by exposing individuals to violence in their community. Where you live also impacts access to care. This is especially true for individuals who live in rural communities, where less health services are available. Worse health outcomes are seen in rural areas as compared to urban areas. Rural areas tend to lack access to care and individuals in rural areas are more likely to live in geographic isolation, engage in higher health risk behaviors, and be of lower socioeconomic status. 

    From a young age, children’s health can be impacted through access to education. Primary and secondary educational access and quality can have an impact on health outcomes. Education is important for the development of social ties, which can impact stress management and coping mechanisms. Education is essential to children’s social and cognitive development and can impact both emotional and social wellbeing. Education can help develop skills including internal control, multitasking, planning, self-awareness, and social cognitive skills like perceptive talking and the understanding of social emotions. Children who are living in poverty are less likely to receive a high quality education. The stress of living in poverty can affect children’s ability to do well in school and affect children’s brain development. Schools in low income areas are more likely to be lower quality, and growing up in a poorer neighborhood is associated with reduced educational attainment. Those with low educational attainment are more likely to work in less safe and low paying jobs. They are also more likely to have health problems such as heart disease, diabetes, and depression.

  • Introduction to Global Health

    Introduction to Global Health

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    Global health is defined as the study, research, and practices related to improving health and achieving health equity on a global scale. Global health focuses on health issues that are cross-cultural, cross-regional, or global in scope and local health issues that have transnational significance. It includes both population-based preventative measures along with individual-based clinical interventions. The major components of global health include disease monitoring, data gathering, direct medical interventions, addressing social and economic factors that impact health outcomes, and the coordination between international actors and implementors to fund and execute health solutions.

    Global Health can be broken down into three functions.

    1. The generation of knowledge regarding global health issues to develop global solutions.
    2. The distribution of knowledge through education, training, and publication of research.
    3. The application of global health knowledge and interventions to solve global health problems.

    The historical roots of global health can be traced back to the European colonial era. During the 16th and 17th centuries, as European powers started to explore and colonize new regions, they encountered new infectious diseases. As settlers and native populations suffered from contact with new diseases, colonial powers sought to study and negate the impact of infectious disease upon their settler population and military personnel. These international health measures taken by colonial nations and their colonies were referred to as tropical medicine.

    As the world became more interconnected over the course of the 18th century and international trade expanded, nations began to take greater notice of disease and its relationship with their global trade interests. This led to The International Sanitary Conference which was held between 11 European powers and Turkey in 1851 with the goal of standardizing quarantine regulations and preventing the importation of cholera, plague, and yellow fever through foreign trade. A total of 10 conferences would be held between 1851 and 1897 with little in the form of international agreements to show for them until the 1890’s, but a norm of international dialogue concerning international health was born. These conferences led to the International Sanitary Regulations (ISR) of 1903 which established a requirement for international disease reporting, initially only for cholera and plague outbreaks, to mitigate the impact of disease outbreaks on the commercial interests of industrialized countries while preventing the importation of diseases from developing countries. In 1907, the Office International d’Hygiene Publique was formed in Paris and began to monitor disease outbreaks throughout the world.

    Following the First World War, the League of Nations established a Health Committee with the aim of cooperating with new regional organizations, international organizations, and foundations. However, developments in global health were stalled by World War II and global health would not return to the forefront until the late 1940’s with the rise of the new liberal world order. In 1948, the World Health Organization (WHO) was created as a UN specialized agency and institutionalized the concept of global health. U.S. support for the UN was crucial, and the U.S. has historically provided more funds to the WHO than any other country.

    The WHO sought to bring disease outbreak monitoring and technical assistance to developing countries to mitigate infectious disease outbreaks. In addition, WHO guidelines and statistics are used by countries from across the income spectrum to make informed decisions on health policy. The WHO Constitution defined health as, “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”, thus providing a robust definition for the global health agenda that did not limit health to clinical parameters but expanded it to include social determinants and healthcare access too.

    Following the end of the Cold War, leading nations in global health, like the United States and United Kingdom, grew concerned that direct aid to developing countries contributed to corruption by local governments. Additionally, many believed the WHO was focusing too much on preventing infectious diseases to the detriment of basic healthcare. This presented an opportunity for NGOs and other philanthropic organizations to play a role in global health as implementers who specialized in addressing specific regions, diseases, or health challenges in partnership with donors (Governments, Development Banks, etc.). NGOs filled the gaps which the WHO was not addressing while reducing corruption as they were more accountable to donors than sovereign states. NGOs now play a significant role in implementing global health initiatives for the U.S. In 2014, USAID disbursed 41% of its global health activities budget to NGOs.

    During the 1990’s, the HIV/AIDS crisis spurred an increased interest in international cooperation on global health between governments, inter-governmental organizations (IGOs), and NGOs. In addition, a growing recognition formed that the vast growth in human contact facilitated by increased trade and travel could lead to the increased transmission of infectious diseases between countries. In short, diseases do not respect national borders. 

    In 2000, the WHO released eight Millennium Development Goals (MDGs) to establish a global health agenda for the 21st century.

    1. Eradicate extreme poverty and hunger
    2. Provide universal primary education
    3. Improve gender equity and empowerment of women
    4. Reduce childhood mortality
    5. Improve maternal health
    6. Combat HIV/ AIDS, malaria, and other diseases
    7. Promote environmental sustainability
    8. Develop global partnerships for development

    These goals highlight the evolution of global health from its initial focus on infectious disease intervention to also address socio-economic factors that limit healthcare delivery. This modern vision of global health has corresponded to increased investments in global health development. Spending on development assistance for health (DAH) increased from $7.1 billion USD in 1990 to $37.6 billion USD in 2016.

    Traditionally, the U.S. has been a leader in global health efforts as the largest funder in the world. The U.S. motivations for funding global health initiatives coincide with its larger international development goals. These goals include the promotion of democratic stability, fostering diplomatic relations, promoting economic development, and preventing disease outbreaks that could threaten U.S. citizens. Under the Trump administration, this leadership role was called into question as plans were made to withdraw from the WHO and reduce global health funding for FY 2020. However, the U.S. seems poised to rebound in its leadership role as Dr. Anthony Fauci, Chief Medical Advisor to President Biden, advised the WHO in January 2021. The meeting pledged a recommitment to U.S. leadership on global health security, HIV/AIDS, malaria, women’s health, and epidemic preparedness initiatives.

    Global health faces enormous challenges due to the COVID-19 pandemic. Not only does the COVID-19 pandemic constitute a serious global health crisis in its own right, but it also threatens to set back decades of progress as COVID-19 takes precedence over other global health initiatives such as measles and polio vaccine campaigns. In addition, experts are worried about increased malnutrition in children and increased infectious disease rates due to resource diversion to COVID-19 activities. Global health faces one of its greatest challenges yet and rebuilding the capacity of global health systems in a post-pandemic world will be just the beginning.