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Courtesy of Mark Tuschman.

CHAPTER 2Health Determinants, Measurements,and the Status of Health Globally

LEARNING OBJECTIVES

By the end of this chapter, the reader will be able to do the following:

■ Describe the determinants of health■ Define the most important health indicators and key terms related to measuring health

status and the burden of disease■ Discuss the status of health globally and how it varies by country income group, region,

and age group

Copyright 2020. Jones & Bartlett Learning.

All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

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M Vignettes

aria is a poor woman who lives in the highlands of Peru. She is from an ethnic groupcalled Quechua. In Peru, poor people tend to live in the mountains and be indigenous, be

less educated, and have worse health status than other people. In Eastern Europe, the sameissues occur among ethnic groups that are of lower socioeconomic status, such as the Romapeople. In the United States, there are also enormous health disparities, as seen in the healthstatus of African Americans and Native Americans, compared to white Americans. If we want tounderstand and address differences in health status among different groups, how do wemeasure health status? Do we measure it by age? By gender? By socioeconomic status? Bylevel of education? By ethnicity? By location?

Yevgeny is a 56-year-old Russian male. Life expectancy in Russia in 1985 was about 64 yearsfor males and 74 years for females. It then fell to about 59 years for males and 72 years forfemales in 2001, before rising again to 67 for males and 77 for females in 2016. What doeslife expectancy at birth measure? What are the factors contributing to the earlier decline in lifeexpectancy at birth in Russia? What has happened to trends in life expectancy in othercountries? Which countries have the longest and shortest life expectancies, and why?

Sarah is a 27-year-old woman in northern Nigeria. While women in high-income countries veryrarely die of pregnancy-related causes and have a maternal mortality ratio of about 10 per100,000 live births, the maternal mortality ratio for women in low-income countries like Sarah isabout 500 per 100,000 live births. This is 50 times higher than that in the best-off countryincome group. What does the maternal mortality ratio suggest about a country? What does itsay about the status of women in that country? What does it indicate about the access ofwomen to obstetric and emergency obstetric care of appropriate quality?

Abdul is a 4-year-old in northern India. For every 1,000 children born in South Asia in 2016,about 50 will die before their fifth birthday. The rate of child death is even higher in sub-SaharanAfrica. In the cohort of 1,000 children born there in 2016, almost 80 will die before they are five.These two regions have the worst child mortality rates.

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The Importance of Measuring Health StatusIf we want to understand the most important global health issues and what can be done toaddress them, then we must understand what factors have the most influence on health status,as well as how health status is measured.

This chapter, therefore, covers two distinct but closely related topics. The first section concernswhat are called . That section examines the most important factorsthe determinants of healththat relate to people’s health status. The second section reviews some of the most importantindicators of health status and how they are used.

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The Determinants and Social Determinants of HealthWhy are some people healthy and some people not healthy? When asked this question, manyof us will respond that good health depends on access to health services. Yet, as you will learn,whether or not people are healthy depends on a large number of factors, many of which areinterconnected, and most of which go considerably beyond access to health services.

The World Health Organization (WHO) defines the as the “range ofdeterminants of healthpersonal, social, economic and environmental factors which determine the health status ofindividuals or populations.” WHO defines the social determinants of health as the “conditions inwhich people are born, grow, live, work and age.”

There has been considerable writing about the determinants and social determinants of health,which different organizations depict in a range of ways. The next section builds on the work of anumber of actors and agencies. It briefly discusses the determinants and social determinants ofhealth and how they influence health. It is essential to understand these concepts if one wantsto understand why people are healthy or not and what can be done to address different healthconditions in different settings. shows one way of depicting the determinants ofFIGURE 2-1health.

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FIGURE 2-1 The Determinants of Health

Reproduced from Dahlgren, G., & Whitehead, M. (1991). .Policies and strategies to promote social equity in health

Stockholm, Sweden: Institute for Futures Studies. Retrieved from http://www.iffs.se/media/1326

/20080109110739filmZ8UVQv2wQFShMRF6cuT.pdf

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The first group of factors that helps to determine health relates to the personal and inbornfeatures of individuals. These include genetic makeup, sex, and age. Our genetic makeupcontributes to what diseases we get and how healthy we are. One can inherit, for example, agenetic marker for a particular disease, such as Huntington’s disease, which is a neurologicaldisorder. One can also inherit the genetic component of a disease that has multiple causes,such as breast cancer. Sex also has an important relationship with health. Males and femalesare physically different, for example, and may get different diseases. Females face the risksinvolved in childbearing. They also get cervical and uterine cancers that males do not. Femaleshave higher rates of certain health conditions, such as thyroid and breast cancers. For similarreasons, age is also an important determinant of health. Young children in low- andmiddle-income countries often die of diarrheal disease, whereas older people are much morelikely to die of heart disease, to cite one of many examples of the relationship between healthand age.

Individual lifestyle factors, including people’s own health practices and behaviors, are alsoimportant determinants of health. Being able to identify when you or a family member is ill andneeds health care can be critical to good health. One’s health also depends greatly on how oneeats, or if one smokes tobacco, drinks too much alcohol, or drives safely. We also know thatbeing active physically and getting exercise regularly is better for one’s health than is beingsedentary.

The extent to which people receive social support from family, friends, and community also hasan important link with health. The stronger the social networks and the stronger the supportthat people get from those networks, the healthier people will be. Of course, culture is also anextremely important determinant of health.

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Living and working conditions also exert an enormous influence on health. These include, forexample, housing, access to safe water and sanitation, access to nutritious food, and access tohealth services. Crowded housing, for example, is a risk factor for the transmission oftuberculosis. The lack of safe water and sanitation, coupled with poor hygiene in many settings,is one of the major risk factors for the diarrheal disease that is associated with so much illnessand death in young children. Nutrition is central to health, beginning at conception, and familieshave to be able to access appropriate foods to promote good health. Of course, even if otherfactors are such important determinants of health, one’s health depend on access todoesappropriate healthcare services. Even if one is born and raised healthy and engages in goodhealth behaviors, access to health services of appropriate quality is important to maintaininggood health. To address the risk of dying from a complication of pregnancy, for example, onemust have access to health services that can carry out an emergency cesarean section ifnecessary. Even if the mother has had the suggested level of prenatal care and has preparedwell in all other respects for the pregnancy, in the end, certain complications can only beaddressed in a healthcare setting.

PHOTO 2-1 The circumstances in which people live have a profound impact on their health.

This is a slum in Jakarta, Indonesia. In what ways would living here influence the health of the

slum dwellers?

© Nikada/E+/Getty Images.

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A range of socioeconomic factors, including culture, education, and socioeconomic status, areimportant determinants of health. The broader environment is also a critical health determinant.Socioeconomic status refers to a person’s economic, social, and work status. It is highlycorrelated with educational attainment. People with higher educational attainment have bettereconomic opportunities, higher socioeconomic status, and more control over their lives thanpeople of lower educational status. As one’s socioeconomic status improves, so does his or herhealth.

More specifically, education is a powerful determinant of health for several reasons. First, itbrings with it knowledge of good health practices. Second, it provides opportunities for gainingskills, getting better employment, raising one’s income, and enhancing one’s social status, all ofwhich are also related to health. Studies have shown, for example, that the single best predictorof the birthweight of a baby is the level of educational attainment of the mother. Most of usalready know that throughout the world there is an extremely strong and positive correlationbetween the level of education and all key health indicators. People who are better educatedeat better, smoke less, have less obesity, have fewer children, and take better care of theirchildren’s health than do people with less education. It is not a surprise, therefore, that they andtheir children live longer and healthier lives than do less well-educated people and theirchildren.

Culture also exerts a profound impact on health. Culture shapes how one feels about healthand illness, how one uses health services, and the health practices in which one engages. Inaddition, the gender roles that are ascribed to women in many societies also have an importantimpact on health. In some settings, women may be treated more poorly than men and this, inturn, may mean that women have less income, less education, and fewer opportunities toengage in employment. All of these militate against their good health.

The environment, both indoor and outdoor, is a powerful determinant of health. Related to thisis the safety of the environment in which people work. Although many people know about theconsequences of outdoor air pollution for health, fewer people are aware of the consequencesof indoor air pollution to health. In many low- and middle-income countries, families, and usuallywomen, cook indoors with poor ventilation, thereby creating an indoor environment that may befull of smoke and that increases the risk of respiratory illness and asthma. The lack of safedrinking water and sanitation is a major contributor to ill health in poor countries. In addition,many people in those same countries work in environments that are unhealthy. Because theylack skills, socioeconomic status, and opportunities, they may work without sufficient protectionfrom hazardous chemicals, in polluted air, or in circumstances that expose them to occupationalaccidents.

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PHOTO 2-2 The lack of access to safe water and sanitation causes people to seek water from

unsafe sources and is a major risk factor for child deaths. Children are shown here washing

their dishes in a river. What can be done to improve access to safe water and sanitary disposal

of human waste in resource-poor environments?

Courtesy of Mark Tuschman.

The approach that governments take to different policies and programs in the health sector andin other sectors also has an important bearing on people’s health. People living in a country thatpromotes high educational attainment, for example, will be healthier than people in a countrythat does not promote widespread education of appropriate quality because better-educatedpeople engage in healthier behaviors. A country that has universal health insurance is likely tohave healthier people than a country that does not insure its entire population because theuninsured may lack needed health services. The same would be true, for example, for a countrythat promoted safe water supply for its entire population, compared to one that did not.

As we think about the determinants of health, we should be aware that increasing attention isbeing paid to the social determinants of health. In 2005, WHO created a Commission on theSocial Determinants of Health. WHO published the commission’s report in 2008. The reporthighlighted some of the following themes :12

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■ Health status is improving in some places in the world but not in others.■ There are enormous differences in the health status of individuals within countries, as well

as across countries.■ The health differences within countries are closely linked with social disadvantage.■ Many of these differences should be considered avoidable, and they relate to the way in

which people live and work and the health systems that should serve them.■ People’s life circumstances, and therefore their health, are profoundly related to political,

social, and economic forces.■ Countries need to ensure that these forces are oriented toward improving the life

circumstances of the poor, thereby enabling them to enjoy a healthier life as well. The globalcommunity should also work toward this end.

We should also note the importance to health of child development, including the ways in whichfamilies nourish and care for infants and young children, beginning at conception. Being bornpremature or of low birthweight can have important negative consequences on health over thelife course. There is a strong correlation between the nutritional status of infants and youngchildren and the extent to which they meet their biological and intellectual potential, enroll inschool, or stay in school. In addition, poor nutritional status in infancy and early childhood maybe linked with a number of noncommunicable diseases later in life, including diabetes and heartdisease. There is also considerable evidence that a range of stressors, including poverty,abuse, and discrimination, have a powerful impact on the health of children that may continuethrough adulthood.

Finally, as we think about the determinants and social determinants of health, it is important toconsider how, directly and indirectly, different factors influence health. One framework for suchconsideration is shown in . This framework places the determinants of health intoFIGURE 2-2three categories based on the directness of their influence on health: root causes at themacro/societal level; underlying causes at the meso/community level; and proximal causes atthe immediate/interpersonal level. Viewing the determinants of health in this manner shouldalso be helpful in assessing why health conditions exist and what can be done to address them.

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FIGURE 2-2 Selected Examples of Root, Underlying, and Immediate Determinants of Health

Modified with permission from Bouwman, L., Wentink, C., & Ormond, M. (2017, April 6). Global Health, W3 Tutorial 3:

Determinants [Powerpoint Slides], Based on Northridge.

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Key Health IndicatorsIt is critical that we use data and evidence to understand and address key global health issues.Some types of health data concern the health status of people and communities, such asmeasures of life expectancy and infant and child mortality, as discussed further hereafter. Someconcern health services, such as the number of nurses and doctors per capita in a country orthe indicators of coverage for certain health services, such as immunization. Other dataconcern the financing of health, such as the amount of public expenditure on health or theshare of national income represented by health expenditure.

There are a number of very important uses of data on health status. We need data, forexample, to know from what health conditions people suffer. We also need to know the extentto which these conditions cause people to be sick, be disabled, or die. We need data to carryout disease surveillance. This helps us understand if particular health problems such as cancer,influenza, polio, or malaria are occurring, where they are infecting people, who is gettinginfected, and what might be done to address these conditions. Other forms of data also help usto understand the burden of different health conditions, the relative importance of them todifferent societies, and the importance that should be given to dealing with them.

If we are to use data in the previously mentioned ways, then it is important that we use aconsistent set of indicators to measure health status. In this way, we can make comparisonsacross people in the same country or across different countries. There are, in fact, a number ofindicators that are used most commonly by those who work in global health and in developmentwork. These are listed and defined in .TABLE 2-1

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TABLE 2-1 Key Health Status Indicators

The section that follows will examine these key indicators of health status in two ways, first byWorld Bank region and second by country income group. The graphics will reflect a number ofpoints quite starkly:

■ There is a very strong correlation between country income group and health status. Thelower the income group, the lower the status; the higher the income group, the higher thestatus.

■ In all cases, sub-Saharan Africa has the worst health indicators of all World Bank regions,and South Asia has the second worst health indicators.

You will understand better as you progress in your study of global health that part of therelatively low health status of sub-Saharan Africa and South Asia related to the fact that theseisare the two regions with the lowest per capita income. However, as you will read about hereand elsewhere, their relatively low health status also has to do with government policies andprograms, the lack of safe water and sanitation, low levels of education, and a number of otherfactors.

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It is also important to understand that country income level does not have to determine acountry’s health status. Rather, as you will also read about throughout this text and elsewhere,resource-poor countries that make wise policy choices in fair ways enable better health forcantheir people than their income level might suggest. This has certainly been the case for anumber of countries whose development history is well known, such as Cuba, Sri Lanka, andChina. Thus, it will be essential as you think about key issues in global health to always keep inmind questions about which policies can help to achieve the best health for any population atthe least cost and in fair, doable, and sustainable ways. In light of all this, let us now turn toexploring the specific health indicators.

Among the most commonly used indicators of health status is . Lifelife expectancy at birthexpectancy at birth is “the average number of additional years a newborn baby can beexpected to live if current mortality trends were to continue for the rest of that person’s life.”

In other words, it measures how long a person born today can expect to live, if there wereno change in their lifetime in the present rate of death for people of different ages. The higherthe life expectancy at birth, the better the health status of a country. In the United States, ahigh-income country, life expectancy at birth in 2016 was about 79 years; in Jordan, amiddle-income country, life expectancy was 74 years; in Sierra Leone, a very low-incomecountry, life expectancy was 52 years.

FIGURE 2-3 shows life expectancy at birth by country income level. This figure shows anexceptional correlation between country income group and life expectancy. It also shows therange of life expectancy across country income groups, from 63 years in low-income countriesto 29 percent higher, or 81 years, in high-income countries.

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FIGURE 2-3 Life Expectancy at Birth by World Bank Country Income Group, 2016

Data from The World Bank. (n.d.). Data: Life expectancy at birth, total (years). Retrieved from https://data.worldbank

.org/indicator/SP.DYN.LE00.IN?end=2016&locations=XD-XT-XN-XM&start=2016&view=bar

FIGURE 2-4 shows life expectancy by World Bank region. It reflects the points notedpreviously, with sub-Saharan Africa and South Asia having the lowest life expectancy. It is alsoimportant to note that the region with the highest life expectancy has a life expectancy that is 19years, or about 30 percent, greater than the region with the lowest life expectancy.

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FIGURE 2-4 Life Expectancy at Birth by World Bank Region, 2016

Data from The World Bank. (n.d.). Data: Life expectancy at birth, total (years). Retrieved from https://data.worldbank

.org/indicator/SP.DYN.LE00.IN?end=2016&locations=Z4-ZG-8S-ZJ-Z7-ZQ&start=2016&view=bar

The is a measure of the risk of death that is associated with childbirth.maternal mortality ratioBecause these deaths are more rare than infant and child deaths, the maternal mortality ratio ismeasured as “the number of women who die as a result of pregnancy and childbirthcomplications per 100,000 live births in a given year.” The rarity of maternal deaths andthe fact that they largely occur in low-income settings also contribute to maternal mortality beingquite difficult to measure. Very few women die in childbirth in rich countries; for example, thematernal mortality ratio in Sweden in 2016 was 4 per 100,000 live births. On the other hand, invery poor countries, in which women have low status and where there are few facilities fordealing with obstetric emergencies, the ratios can be over 700 per 100,000 live births, as theywere in 2016, for example, in the Central African Republic, Liberia, Nigeria, Somalia, and SouthSudan. In the worst-off country for maternal health, Sierra Leone, the maternal mortality ratio isestimated to be 1,360 per 100,000 live births.

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FIGURE 2-5 gives the maternal mortality ratio by country income group, and FIGURE 2-6shows the same data by World Bank region.

FIGURE 2-5 Maternal Mortality Ratio by World Bank Country Income Group, 2015

Data from The World Bank. (n.d.). Data: Maternal mortality ratio (modeled estimate, per 100,000 live births). Retrieved

from https://data.worldbank.org/indicator/SH.STA.MMRT?end=2014&locations=XM-XD-XT-XN&start=2014&view

=bar

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FIGURE 2-6 Maternal Mortality Ratio by World Bank Region, 2015

Data from World Bank. (n.d.). Data: Maternal mortality ratio (modeled estimate, per 1,000 live births). Retrieved from

https://data.worldbank.org/indicator/SH.STA.MMRT?end=2015&locations=Z4-8S-ZG-Z7-XU-ZJ-ZQ&start=2015

&view=bar

As suggested earlier, the pattern of the maternal mortality ratio, by both country income group and region, is similar to that for life expectancy. However, the differences among regions andcountry income groups are even greater. The low-income group, with the worst maternalmortality ratio, has a 50 times greater ratio than the high-income group. Sub-Saharan Africa hasa ratio that is 42 times greater than in North America. Many people believe that the maternalmortality ratio is the indicator that is most sensitive to a country’s overall development statusand best reflects the place of women in different societies.

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Another important and widely used indicator is the . The infant mortalityinfant mortality raterate is “the number of deaths of infants under age 1 per 1,000 live births in a given year.”This rate is expressed in deaths per 1,000 live births. In other words, it measures how manychildren younger than 1 year of age will die for every 1,000 who were born alive that year. Eachcountry seeks as low a rate of infant mortality as possible, but we will see that the rate varieslargely with the income status of a country. Afghanistan, for example, had an infant mortalityrate in 2016 of 53 infant deaths for every 1,000 live births, whereas in Sweden only about 2infants die for every 1,000 live births. shows the infant mortality rate by countryFIGURE 2-7income group. shows the infant mortality rate by World Bank region.FIGURE 2-8

FIGURE 2-7 Infant Mortality Rate by World Bank Country Income Group, 2016

Data from The World Bank. (n.d.). Data: Mortality rate, infant (per 1,000 live births). Retrieved from https://data

.worldbank.org/indicator/SP.DYN.IMRT.IN?locations=XD-XT-XN-XM

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FIGURE 2-8 Infant Mortality Rate by World Bank Region, 2016

Data from The World Bank. (n.d.). Data: Mortality rate, infant (per 1,000 live births). Retrieved from https://data

.worldbank.org/indicator/SP.DYN.IMRT.IN?end=2016&locations=Z4-ZG-8S-ZJ-Z7-ZQ-XU&start=2016&view=bar

There are no surprises for these data either, which vary in the same directions as lifeexpectancy and the maternal mortality ratio. In this case, however, the highest rates of infantmortality are both about 10 times greater than the lowest rates.

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Although the infant mortality rate is a powerful indicator of the health status of a country, mostchildren younger than 1 year of age who die actually die in the first month of life. Thus, the

is also an important health status indicator. This rate measures “theneonatal mortality ratenumber of deaths to infants younger than 28 days of age in a given year, per 1,000 live births inthat year.” Like the infant mortality rate, this rate will generally vary directly with the levelof income of different countries. Poorer countries will usually have a much higher neonatalmortality rate than richer countries. Sierra Leone, among the poorest countries in the world, hada neonatal mortality rate of 33 per 1,000 live births in 2016. In Norway, one of thehighest-income countries in the world, the rate that year was 2 per 1,000 live births. Theneonatal mortality rate by country income group is given in , and the data by WorldFIGURE 2-9Bank region are portrayed in .FIGURE 2-10

FIGURE 2-9 Neonatal Mortality Rate by World Bank Country Income Group, 2016

Data from The World Bank. (n.d.). Data: Mortality rate, neonatal (per 1,000 live births). Retrieved from https://data

.worldbank.org/indicator/SH.DYN.NMRT?end=2016&locations=XD-XT-XN-XM&start=2016&view=bar

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FIGURE 2-10 Neonatal Mortality Rate by World Bank Region, 2016

Data from The World Bank. (n.d.). Data: Mortality rate, neonatal (per 1,000 live births). Retrieved from https://data

.worldbank.org/indicator/SH.DYN.NMRT?end=2016&locations=Z4-Z7-XU-ZG-8S-ZQ-ZJ&start=2016&view=bar

The poorest countries have a neonatal mortality rate that is 9 times that of the best-offcountries. The two regions with the worst rates have neonatal mortality rates that are 7 timeshigher than the region with the best rate.

The under-5 child mortality rate is also called the . This is “the probabilitychild mortality ratethat a newborn will die before reaching age five, expressed as a number per 1,000 live births.”

Like the infant mortality rate, this rate is expressed per 1,000 live births. This rate also varieslargely with the wealth of a country. In the highest-income countries, the rate is generally about3 to 5 per 1,000 live births. However, in some of the poorest countries, such as Chad, the ratecan be over 125 per 1,000 live births. The under-5 child mortality rate is depicted in FIGURE

by country income group and in by World Bank region.2-11 FIGURE 2-12

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FIGURE 2-11 Under-5 Mortality Rate by World Bank Country Income Group, 2016

Data from The World Bank. (n.d.). Data: Mortality rate, under-5 (per 1,000 live births). Retrieved from https://data

.worldbank.org/indicator/SH.DYN.MORT?end=2016&locations=Z4-Z7-ZJ-ZG-8S-XU-ZQ&start=2016&view=bar

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FIGURE 2-12 Under-5 Mortality Rate by World Bank Region, 2016

Data from The World Bank. (n.d.). Data: Mortality rate, under-5 (per 1,000 live births). Retrieved from https://data

.worldbank.org/indicator/SH.DYN.MORT?end=2016&locations=Z4-Z7-ZJ-ZG-8S-XU-ZQ&start=2016&view=bar

As expected, the relative standing of different regions in under-5 child mortality, as shown in thefigures, looks very similar to that for neonatal mortality and for infant mortality. In both cases forunder-5 child mortality, however, the highest rates are about 15 times the lowest rates. To alarge extent, this reflects the fact that in high-income countries the risks for young child deathpost-infancy are relatively few, but in the least well-off regions, especially in sub-Saharan Africa,there are substantial risks to child health not only for neonates and infants but also between achild’s first and fifth years. This is illustrated in .FIGURE 2-13

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FIGURE 2-13 Under-5, Infant, and Neonatal Mortality Rate, by World Bank Region, 2016

Data from the World Bank. Data. Mortality rate, infant (per 1,000 live births), Mortality rate, under-5 (per 1,000 live

. Retrieved from births), Mortality rate, neonatal (per 1,000 live births) https://data.worldbank.org/

A few other concepts and definitions are important to understand as we think about measuringhealth status. The first is . Essentially, this means sickness or any departure,morbiditysubjective or objective, from a psychological or physiological state of well-being. Second is

, which refers to death. A is the number of deaths per 1,000 population in amortality death rategiven year. The third is . Although some conditions cause people to get sick ordisabilitydie, they might also cause people to suffer the “temporary or long-term reduction in a person’scapacity to function.” (p51)

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There will also be considerable discussion in most readings on global health of the prevalenceof health conditions. This refers to the number of people suffering from a certain healthcondition over a specific time period. It measures the chances of having a disease. For globalhealth work, one usually refers to of a condition, which is “the proportion ofpoint prevalencethe population that is diseased at a single point in time.” Let’s say, for example, that thepoint prevalence of HIV/AIDS among adults in South Africa was estimated to be 18.9 on the lastday of 2016. This means that 18.9 percent of all adults between the ages of 15 and 49 in SouthAfrica were estimated that day to be HIV-positive.

The is also a very commonly used term. This measures how many people get aincidence ratedisease, for a specified number of people at risk, for a given period of time. The denominatorfor the rate usually depends on how commonly the disease occurs in a year and is often per1,000 or per 100,000 people. In India, for example, the incidence rate for tuberculosis (TB) in2016 was 211 per 100,000 people. This means that for every 100,000 people in India, 211got active TB disease in 2016.

Many people confuse incidence rate and prevalence rate. It may be convenient to think ofprevalence as the pool of people with a disease at a particular time and incidence as the flow ofnew cases of people with that disease into that pool. You should note, of course, that the size ofthe pool will vary as new cases flow into the pool and old cases flow out, as they die or arecured.

We will also speak about , , and primary prevention secondary prevention tertiary. These are defined as follows:prevention

Primary prevention: Intervening before health effects occur, through measuressuch as vaccinations, altering risky behaviors (poor eating habits, tobacco use,etc.), and banning substances known to be associated with a disease or healthcondition.

Secondary prevention: Screening to identify diseases in the earliest stages,before the onset of signs and symptoms, through measures such asmammography and regular blood pressure testing.

Tertiary prevention: Managing disease post diagnosis to slow or stop diseaseprogression through measures such as chemotherapy, rehabilitation, andscreening for complications.

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Finally, one needs to be familiar with how diseases get classified. When you read about health,there will be discussions of , , and communicable diseases noncommunicable diseases

. Communicable diseases are also called infectious diseases. These are illnesses thatinjuriesare caused by a particular infectious agent and that spread directly or indirectly from people topeople, animals to people, or people to animals. Examples of communicable diseases includeinfluenza, measles, and HIV. Noncommunicable diseases are illnesses that are not spread byany infectious agent, such as hypertension, coronary heart disease, and diabetes, even thoughthey might have an infectious cause, such as cervical cancer. Injuries include, among otherthings, road traffic injuries, falls, drownings, poisonings, and violence.

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Vital RegistrationThe quality of data on population and health depends in many ways on the extent to whichcountries maintain a system of vital registration that can accurately record births, deaths, andthe causes of death. Unfortunately, this is not the case in many low- and lower middle-incomecountries. They generally have only rudimentary systems for vital registration, which cannotfulfill either their statistical or their legal purposes. In addition, access to vital registrationsystems is highly inequitable, with higher-income groups enjoying much better access than lesswell-off people ( ). UNICEF estimates that about 25 percent of all of the births inFIGURE 2-14the world are never registered.

FIGURE 2-14 Percentage of Children Under 5 Whose Births Have Been Registered, by Income

Quintile for Selected UNICEF Regions, 2005–2012

Data from UNICEF. (2013). . Retrieved from Every child’s birth right: Inequities and trends in birth registration http:/

/www.unicef.org/media/files/Embargoed_11_Dec_Birth_Registration_report_low_res.pdf

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There are also cultural barriers to timely vital registration because people in many countrieswait until a child is a certain age before registering the birth. Coupled with the lack of access tovital registration, this means the existence of some children is never officially known becausethey die before their births are registered. There are also enormous difficulties with accurateindications of causes of death in countries that have weak health systems and a limited numberof well-trained physicians. This is especially so for causes of death of adults.

The former director-general of WHO, Lee Jong-Wook, noted in a speech to his colleagues: “Tomake people count, we first need to be able to count people.” To overcome the lack ofeffective vital registration systems in many low- and middle-income countries, a number oftools, such as surveys and projection models, have been developed. Some, like theDemographic and Health Surveys, have become an important source of information abouthealth, population, nutrition, and HIV in low-income countries.

In the longer term, however, the world would be better served by helping countries furtherdevelop their own vital registration systems. This would allow countries and their developmentpartners to more accurately gauge the nature of key demographic and health issues and theprogress made toward resolving them. Moving in this direction will require assessments of vitalregistration systems. It will also require programs to improve the organization and functioning ofvital registration departments. This will have to include, among other things, strengthening theirmethods to improve the quality of vital statistics, including for the causes of death, andenhancing their approach to publishing data.

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Main MessagesTo understand the most important global health issues, we must understand the determinantsof health, how health status is measured, and how health status varies by country incomegroup, region, age, and sex. There are a number of factors that influence health status,including genetic makeup, sex, and age. Social and cultural issues and health behaviors arealso closely linked to health status. The determinants of health also include education,nutritional status, and socioeconomic status. The environment is also a powerful determinant ofhealth, as is access to health services, and the policy approaches that countries take to theirhealth sectors and to investments that could influence the health of their people. Increasingattention is being paid to the social determinants of health. Some determinants have a moredirect influence than others, whose influence is more indirect.

There are a number of uses of health data, including measuring health status, carrying outdisease surveillance, making decisions about investments in health, and assessing theperformance of health programs. Those working in health use a common set of indicators tomeasure health status, including life expectancy, infant and neonatal mortality, under-5 childmortality, and the maternal mortality ratio. Vital registration systems are weak in low-incomecountries and need to be strengthened to improve the quality of health data.

There has been progress in all regions of the world in increasing life expectancy over the lastseveral decades. In addition, the pace of those increases has been exceptionally rapid in EastAsia and the Pacific. However, it is clear that the basic health indicators are much worse insub-Saharan Africa than in any other region and that these indicators also lag substantially inSouth Asia.

Study Questions

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