GEOG 3692: EXAM I

What kinds of health issues were the focus of colonial medicine and why?

"Tropical diseases" that would weaken their labor force: malaria and yellow fever, epidemic diseases.

Give 3 arguments regarding why race still impacts health, even if income and education are factored out.

1.) Accumulated wealth over a lifetime and across generations may be a more important predictor than simply annual income. At each level of income, blacks and Hispanics have far less accumulated wealth than whites. 2.) Neighborhood socioeconomic characteristics at a given level of income: neighborhood characteristics impact people's health over and above the impact of individual socioeconomic characteristics. Blacks and Hispanics generally live in more disadvantaged neighborhoods than their white counterparts. 3.) Socioeconomic conditions in childhood/social advantages. 4.) Chronic stress related to race may impact health (experience of racial bias → birth outcome disparities between US born black women and their white counterparts.)

Give two specific examples of how chronic discrimination harms the body.

1.) Black people in states high in structural discrimination are more likely to have heart attacks than black people in low-discrimination states. 2.) Children who experience discrimination have higher rates of depression. 3.) Teenagers who endure more discrimination are more likely to have elevated blood pressure and higher body mass index later in life.

How was the trans-Atlantic slave trade linked to certain understandings about race and health? Be able to explain the logic.

1.) Exposing indigenous people to new diseases and believing they were inferior/"less healthy". 2.) More resilience to "tropical diseases" led them to think that the black body was better suited for labor in hot climates than the white body.

Know the 3 pathways through which work impacts health.

1.) Exposure to hazards. 2.) Control/demand imbalance. 3.) Stress.

List the 3 dimensions of poverty included in the Global Multidimensional Poverty Index (be prepared to interpret graphs if given on an exam question -example graphs can be found in Lecture 1.3 slides).

1.) Health (indicated by nutrition and child mortality). 2.) Education (indicated by years of schooling and school attendance). 3.) Living standard (indicated by cooking fuel, improved sanitation, safe drinking water, electricity, flooring and assets). If an individual is deprived in 3 or more of the weighted indicators, they are identified as "MPI poor" and the extent of their poverty is measured by the number of deprivations they're experiencing. Considered "destitute" if deprived in at least 1/3 of the "extreme indicators".

Describe the 3 pathways of how education impacts health.

1.) Health knowledge and behaviors: make better informed choices; evidence that people with more education pick up new health information faster and respond faster to public health campaigns (ex. risk of smoking). 2.) Jobs/income: greater education generally means better jobs and higher income. There also tends to be more negative physical exposures on lower level jobs → being able to work without harm to body and health, being able to afford a vacation (not working weekends, weeks off, trips). 3.) Social and psychological factors: personal control (positive beliefs about control result in higher self rated health, lower physical impairments, less chronic conditions → the Marshallese had very little personal control), social standing (how you perceive yourself related to others impacts health) and social networks (higher education → more people you can rely on, possibly because you have more time and resources to maintain relationships. Social support leads to longer life. Higher education → more contacts with similar educational attainment, resulting in more connections for jobs, political power).

Understand the three key themes as described by Marcos Cueto in the Declaration of Alma-Ata and its definition of primary health care. Why wasn't the grand vision of "health care for all" that was promoted in the Declaration of Alma-Ata ever realized?

1.) Introduced the concept of "appropriate technology" to describe medical and public health tools that are readily deployable in resource-poor settings → way to address the concentration of international health resources in urban hospitals. 2.) Critique of medical elitism; top down health initiatives steered by highly trained doctors in urban centers and calls for increased community participation in health care delivery and Western practices. 3.) Frames health as an avenue for social and economic development. "Health care for all" was never realized as it was shelved and in some ways, reversed. The drafters of Alma-Ata failed to design and implement a road map and financing strategy for their vision.

Know the 4 legacies of colonial medicine, apply them to the theory of the origins of HIV in the Congo.

1.) Investing in "vertical" programs → have to choose between immediate services or investment in long-term infrastructure. 2.) Targeting specific infectious diseases (NOT chronic diseases)→ prevent the spread of diseases to colonial residents. 3.) Technical fixes → not addressing social/economic roots of health problems (determinants of health). 4.) Top-down approach → decisions made without local input.

If given some information about a specific disease, be able to explain: 1.) Whether it has higher incidence or prevalence. 2.) Whether it exerts a higher burden of disease through morbidity or mortality.

1.) See incidence and prevalence definitions. 2.) Diseases that are not leading killers but have significant morbidity (the condition of being diseased) burdens: depression, lower back pain, falls. Diseases that are more likely to case death than disability: maternal mortality, aneurysms. Diseases with both high morbidity and high mortality: ischemic heart disease, COPD, stroke.

If given a list of Merton's 5 reasons for unanticipated consequences, know what each of them mean. If given a scenario, be able to assess which of Merton's reasons would best explain the unanticipated consequence in the scenario.

1.) The existing state of knowledge: there are interplays of forces and circumstances so complex that prediction is beyond reach; don't have all the data; we can't consider everything or we'd never do anything. Example: you plan a health intervention in Longmont for September: community wide, and then a flood hits. Your staff can't make it to work, nobody cares about your priority and your funding gets diverted away from your project to flood control. 2.) Error in appraisal: we assume that if something worked in the past, we'll get the same results if we do it again. Example: if technical fixes worked to eradicate smallpox, technical fixes will eradicate malaria 3.) Imperious immediacy of interest: only thinking about foreseen immediate consequences, neglecting others. Example: Prohibiting people from travelling without determining how to distribute food and medicine amidst a travel ban (travel ban for ebola). 4.) Basic values: our values don't let us see possible outcomes. Example: promoting idea that homosexuality is a sin (American Christians promoting the idea of homosexuality as a sin in Uganda. Failed to see the impact that legislation would have on HIV rates and on crimes against gays.) 5.) Our prediction itself can influence outcomes: if we're evaluating a program and really want a certain outcome, our expectation can impact what we find. Example: CU binge drinking initiative → our results indicate success, but we neglected to think about other possible explanations for the outcomes (like perhaps another group's alcohol initiative or a recent alcohol fueled tragedy that triggered behavior changes).

Know the four primary ways that health data is collected for populations and what each means.

1.) Vital statistics 2.) Census questions 3.) Population surveys 4.) Health systems

What are the "4 persistent dilemmas" in the relationship between development and health? Be able to explain them (HINT: they are defined in the intro on p. 9 and discussed in detail in each of the chapter's sub-sections).

1.) What are the relationships among underdevelopment, development, and ill health and how have these definitions influenced health policy? 2.) How does the distribution of development's benefits and deficits impact the distribution of access to good health? 3.) Which groups own development and how do their interests shape health policies and practices affecting underserved populations? 4.) What institutional form does development take and how does this influence the outcomes of public health? → Opinions on these issues among scientists, economists, medical personnel, and both public health and development specialists have varied dramatically over the last 60 years.

Define a biosocial approach to health problems.

Biosocial interactions: the intertwining reality of biological and social factors in health. Biological processes and social processes affect each other and thereby influence health and disease. A biosocial approach to public health allows for a focus on interactions rather than relying solely on biological or social explanations.

How did modernization approach to development fall apart in the 1970s? What new paradigm replaced modernization and what were it's basic tenets? Explain how this new framework was critiqued, and know the name of that kind of critique.

By the 1970s, after decades of modernization and economic development, much of the Third World was still "in a state of advanced crises characterized by static or worsening life conditions. Critiques: Dependency Theory (a Marxist framework) stated that the problem was not underdevelopment, but development itself. Development could not end poverty and deprivation; development produces deep and persistent inequalities as the rich need the poor to stay poor in order to maintain their own wealth.

If given a list of Merton's reasons for unanticipated consequences, articulate how each might explain the CIA's unintended consequences of decreased vaccination rates in Pakistan following their raid on the Bin Laden compound.

CIA decided to send in a vaccination team to the Bin Laden compound to gather information and DNA → when it came to light, angry villagers chased off legitimate vaccinators, accusing them of being spies → Taliban commanders in 2 districts banned polio vaccination teams → 7 U.N. vaccinators were murdered, possibly in retaliation for this event → decreased immunization rates have been an unintended consequence.

Know some examples of diseases that are referred to as "non-communicable diseases" in "What's in a name? A call to reframe non-communicable diseases".

Cardiovascular diseases, cancers, diabetes, COPD.

Know what GOBI, GOBI-FFF, and ORT stand for, what group spearheaded these ideas, and what approach (PHC or SPHC) they are associated with. Also be able to state the successes and limitations of these campaigns. ORT:

Challenges: not sustainable; short-term benefits. Associated with: UNICEF and SPHC.

Know the meaning of the terms "civil registration" and "vital statistics."

Civil registration: continuous, permanent, compulsory and universal recording of the occurrence and characteristics of vital events (live births, deaths, fetal deaths, marriages and divorces) and other civil status events pertaining to the population as provided by decree, law or regulation, in accordance with the legal requirements in each country. It establishes and provides legal documentation of such events. These records are also the best source of vital statistics. Vital statistics: summary measures of vital events drawn from all sources of vital events data.

What are some of the barriers mentioned in "What's in a name? A call to reframe non-communicable diseases" to affect policy and social change to decrease NDCs?

Disproportionately low levels of national and international attention paid to NCDs in terms of action plans, funding and global institutions. Ongoing and largely unhelpful emphasis on individual health choices hamper a shift towards more effective and equitable population-level policies like tighter tobacco control and measures addressing obesogenic environments. Regulatory changes (ex. tobacco, alcohol and food policies) can face stiff opposition from powerful economic interests.

Apply a biosocial approach to the Bad Sugar film by describing the determinants of health which impacted the rates of diabetes.

Diversion of river water to upstream white settlements disrupted the Pima's agricultural economy and customary ways → local tribes were plunged into poverty and became dependent on the U.S. government → healthy traditional foods like tepary beans, cholla buds, and wild game were replaced by surplus commodities like white flour, lard, processed cheese and canned foods.

Know the term double burden.

Double burden of high rates of Group 1 diseases (communicable/infectious, perinatal, maternal and nutritional) and Group 2 diseases (non-communicable). Sometimes these different groups of diseases are occurring in different populations within the same country → affluent are more likely to have a high burden of non-communicable, the poor are more likely to have a high burden of diseases of extreme poverty. Having high rates of both is extremely taxing on the health system.

Know how the epidemiologic and demographic transitions are related and how they differ.

Epidemiologic transition: focuses on the causes of death within the demographic transition, and how those have changed over time. Begins with high and fluctuating mortality related to Group 1 diseases (diseases of extreme poverty) → decline in mortality as epidemics become less frequent → further declines in mortality, increases in life expectancy and the predominance of Group 2 (noncommunicable diseases). Demographic transition: when economic development rises, we see a transition from high birth and death rates to low birth and death rates. The death rate tends to decline first, followed by a decline in fertility or birth rate. Some countries are now in a new stage in which birth rates are below replacement levels and populations are declining.

Describe the critiques of the epidemiologic and demographic transition models.

Epidemiologic transition: holds for high-income countries, but in low and middle-income countries that transition is "protracted" → high communicable and noncommunicable diseases at the same time. Demographic transition: based mainly on European societies that went through the Industrial Revolution → model assumes that the fall in the death rate was due to industrialization. Timescale and curve may not apply to all countries.

Know what GOBI, GOBI-FFF, and ORT stand for, what group spearheaded these ideas, and what approach (PHC or SPHC) they are associated with. Also be able to state the successes and limitations of these campaigns. GOBI-FFF:

Growth monitoring, oral rehydration therapy, breastfeeding, immunizations (GOBI) + Family Planning/Birth Spacing, Female literacy campaign, and Food Supplementation (FFF). Successes: cost effective; not dependent on profound changes in values or priorities; universal in relevance and synergistic in their relationships; required minimal health infrastructure and capitalized on existing cost-effective advancements in medical technology; expanded ORT. Challenges: getting support for the target of universal child immunization; minimal impact on health systems; did not bolster infrastructure, workforce, supply chains, or provision of primary care services; did not improve health indicators besides infant mortality; not sustainable; prioritized ORT so the other interventions were not as widely deployed; progress of maternal mortality stagnated; quick fixes rather than building a foundation. Associated with: UNICEF and SPHC.

Know what GOBI, GOBI-FFF, and ORT stand for, what group spearheaded these ideas, and what approach (PHC or SPHC) they are associated with. Also be able to state the successes and limitations of these campaigns. GOBI:

Growth monitoring, oral rehydration therapy, breastfeeding, immunizations (GOBI). Low cost, high impact platform for international health. Easy to monitor and measure. Critiques: Excluded leading causes of death in poor countries, such as acute respiratory infections. Merely a band-aid covering the real problem of deficient health systems. Associated with: UNICEF and SPHC.

Understand how neoliberal policies and the "Washington Consensus" changed the way the World Bank and other international actors view health and health care.

Health care is a commodity, not a right; can be efficiently allocated by the market; relying on private sector to deliver clinical services; privatizing public health services; charging patients.

Explain how biological and social processes can together influence heart disease and depression or anxiety.

Heart disease: unhealthy foods are often targeted towards impoverished communities. These fast/convenient, unhealthy foods are high in saturated and trans fats, leading to high cholesterol, blood clots, resulting in heart attack or stroke. Anxiety: stressful circumstances (poverty, job insecurity, discrimination, etc.) increase cortisol levels and the activation of the HPA axis.

Know what the "Hispanic paradox" is and what researchers hypothesize as the explanation for it.

Hispanic paradox: first-generation Latinos in the US are generally poorer, have lower levels of education and are less likely to have health insurance. However, they maintain lower adult and infant mortality rates than that of non-Hispanic whites. Hypothesis: recent immigrants may be inherently healthier (able to face the challenge of immigrating), have healthier behaviors, have other sources of psychological resilience than US born, come from places with specific healthier practices (breastfeeding, no smoking).

Compare and contrast primary health care (PHC) and selective primary health care (SPHC) with regard to 1.) their philosophical approaches to health care (i.e., "for all" versus cost-effectiveness) and 2.) in practical terms, e.g what health services should be provided under each approach?

In response to the vagueness of primary health care (PHC) and the conference of Alma Ata, an alternative movement began to gain momentum. This movement, termed Selective Primary Health Care (SPHC), emphasized the cost-effectiveness of vertical programs with measurable results. In addition, an important part of selective primary health care was the creation of political will for funding opportunities. → "interim" strategy to begin the process of primary health care implementation. → best way to improve health was to fight disease based on cost-effective medical interventions.

If you wanted to gather data in the years 2010 and 2017 to determine whether the number of new transmissions of HIV was rising or falling, which would you measure?

Incidence.

Be able to explain the benefits (to individuals, society, and the international community) and the risks associated with universal civil registration efforts.

Individual benefits: establish and protect identities, citizenship and property rights. Societal benefits: essential for planning of services for populations (resource allocation); enables annual estimates of population size. International community benefits: at least 6 of the Millennium Development Goals rely on accurate data of vital events relating to fertility, mortality and causes of death. Risks associated: misuse of registration information (individuals and vulnerable minorities → identity cards in the Rwanda genocide); abuse of individual information.

Know the categories of disorders that Rosling refers to as diseases of extreme poverty.

Infectious diseases, nutritional diseases, pregnancy and childbirth related (maternal), newborn diseases (neonatal).

Know the difference between interpersonal discrimination and structural discrimination as described in the article (How Prejudice Can Harm Your Health, Khullar) and an example of each.

Interpersonal discrimination: harassment, "micro-aggressions" or the anticipation of prejudice. Structural discrimination: the social and economic policies that systematically put certain groups at a disadvantage.

Does treating people for HIV increase or decrease prevalence of HIV?

It increases prevalence because people who would have died prematurely are now living longer.

Know what Community Based Participatory Research is and why it's important.

Local people gather data on their own communities. The point of CBPR is for individuals to gain skill and in analyzing and problem solving in their own communities → empowerment at a local level. People should NEED it (gather data about important things in their community so they can solve a problem), DO it (they are the ones physically going door to door/gathering water samples/etc.), UNDERSTAND it (needs to be presented in a way that makes sense to local people → graphs that show issue), USE it (do not let the data "sit around", create an action plan) and OWN it (it's THEIRS, it belongs to the local people → not just for a researcher to come in, gather it and publish it far away.

Apply a biosocial approach to malaria and to anxiety/depression.

Malaria: changing irrigation practices (what are the irrigation/agricultural patterns that allow for sitting water?) while providing insecticides and anti-malarial medications. Anxiety/depression: counseling, medication, behavior change and policies/interventions addressing social factors influencing anxiety/depression (unemployment rates, discrimination, etc.)

If given a scenario with a subgroup of the population, determine whether it meets the criteria to be considered a marginalized group.

Marginalized: being excluded from full access to resources, rights and opportunities.

Articulate why GNP and GDP are not sufficient for examining health and income inequalities. What is obscured by these measures?

Measures like GNP and GDP often obscure local inequalities, such as those seen within a nation, state, district, city, etc.

What are the pathways the article, "What's in a name? A call to reframe non-communicable diseases", mentions by which some NCDs are "partly or wholly communicable"?

NCDs are considered partly or wholly communicable through social networks, cultural and economic conditions, food deserts and intergenerational transmissions (ie, diabetes and obesity). NCDs have largely sociogenetic antecedents and to focus efforts on individual behavior will have little overall effect if the social and policy environments do not change in parallel.

Do the authors of "A scandal of invisibility: Making everyone count by counting everyone" believe that collecting vital statistics is too costly for some of the world's poorest countries? Why or why not?

No, when costs divided by the number of people benefiting, the price becomes negligible. Vital statistics become expensive if they are obtained but never used.

Apply a biosocial approach to the Marshall Island video: describe the wider political decisions and the subsequent cascade of events that resulted in increased rates of tuberculosis and other diseases.

Nuclear fallout → evacuation of the Marshallese people → no indigenous people allowed to live on main island/military base → jobs only on the main island → costly to get healthcare and safe drinking water (poor sanitation) + discrimination → lack of economic opportunity, access to healthy food → increase in tuberculosis and other infectious diseases due to poverty and squalid conditions + increase in chronic illnesses like diabetes, heart disease and obesity.

Explain what William Easterly means by the terms "planners" and "searchers."

Planners: TOP DOWN. The problem lies in "Big Western Plans" that seek to create a "Big Push," one that will for once and for all end underdevelopment. Easterly insists that such plans are neocolonial; they are imbued with colonial ideas of trusteeship, of a "white man's burden." Such plans are doomed for failure; as instances of utopian social engineering, they cannot address the complex and variable realities of poverty and disease on the ground. Searchers: BOTTOM UP. In the place of planners and their big plans, Easterly calls for searchers and their incremental ideas and practices, piecemeal efforts initiated at the grassroots, often by the poor themselves.

Know what the cultural dimension Power Distance means and how it relates to the need to collaborate with the Ministry of Health in Nicaragua.

Power Distance: how far apart people are who have more and less power → the extent to which the less powerful members of institutions and organizations within a country expect and accept that power is distributed unequally. In Central America, power distance is one of the highest in the world. If you don't honor the power of the Ministry of Health or other authority figures, you will not be successful.

Which would be higher: prevalence or incidence of HIV in 2015?

Prevalence, because it includes all those who are currently HIV positive (those diagnosed in 2015 and those previously diagnosed)

Define: prevalence, incidence, morbidity and mortality.

Prevalence: the number of people suffering from a certain health condition at a certain time → "how many people have this disease this year?" Incidence: the number of people diagnosed with a health condition over a specific period of time → "how many people acquired this disease this year?" Morality: the number of deaths.

Articulate the "resocializing disciplines" and what they offer to the study of global public health. What disciplines are not included among that list? (HINT: "resocializing discipline" is referred to several times throughout the preface and introduction).

Resocializing disciplines: anthropology, sociology, history, and political economy. Resocializing disciplines, when combined with fields like epidemiology, clinical practice, molecular biology and economics build a new, coherent field better termed "global health equity". Resocializing disciplines can illuminate and improve global health practice as a multidisciplinary, biosocial approach to what are biosocial problems.

Compare and contrast the smallpox, malaria, and polio eradication efforts.

SMALLPOX: surveillance and containment in Brazil; direct human-to-human contact/transmission (i.e. no non-human reservoir that could re-infect humans); permanent immunity from a single infection or vaccination; short and known latency period (7-14 days); infection is obvious - distinctive rash. Vaccine is (was) extremely effective and didn't require a cold chain MALARIA: Transmission via Anopheles mosquitoes (have to get the parasite out of both humans and mosquitoes); Malaria can recur many times throughout lifetime, no immunity (so vaccine would likely not work). Latency: can remain in the body for many months without symptoms Case-identification: symptoms can resemble other diseases Prevention: either kill the mosquito with DDT or deal with the parasite with chemoprophylaxis. No vaccine yet. POLIO: labor intensive erradication campaign; door to door, requires cold chain. Cold chain means that the vaccine must stay cold until it is administered....more difficult than smallpox. Requires significant documentation of vaccines and ongoing surveillance. Obstacles of people's fears about vaccines. Transmission: Virus transmitted through fecal/oral route, and respiratory droplets. Recurrence: 25-40% have "post-polio syndrome" - onset is decades after polio onset. Latency: average 7-10 days (range 4-35 days). Case-identification: 1% are easily identifiable, others not Prevention: Oral vaccine (no need for syringes), but requires cold chain. Surveillance: 1. Nationwide Acute Flaccid Paralysis (AFP) surveillance reporting children with acute flaccid paralysis (AFP); sending stool samples and IDing in lab. Mapping the virus to determine the origin of the virus strain. 2. Environmental surveillance: testing sewage for the presence of polio virus. 100% immunization - had to vaccinate EVERYONE (different from smallpox). National Immunization Day; "mop-up campaigns". How Polio eradication campaign improved overall health systems: Created diagnostic laboratories in many areas that had few or none of these previously, for analysis of stool and water samples. Establishment of cold chains for the vaccine. Could be used for other vaccines or other treatments. Training of health workers in surveillance, disease control, cold chain management, and operational research.

What does PhotoVoice allow communities to do?

Simple disposable cameras → take a picture of a strength or problem in your community. Print them out, post them around the room in categories. People see the strengths ad problems and are effectively thinking critically and assessing their community.

If given one of the determinants (social gradient, stress, early life, social exclusion, work, unemployment and social support), give an example of a policy implication for each.

Social gradient: welfare policies need to provide not only safety nets but also springboards to offset earlier disadvantage. Stress: governments should recognize that welfare programs need to address both psychosocial and material needs: both are sources of anxiety and insecurity. Ex. combat social isolation AND reduce material and financial insecurity. Early life: equal opportunity of access to education, provide good nutrition and health education to pregnant women. Social exclusion: minimum income guarantees, minimum wage legislation. Work: improved conditions of work will lead to a healthier work force and increased productivity, creating a healthier AND more productive workspace; ex. appropriate invovlement in decision-making and good management. Unemployment: prevent unemployment and job security, reduce the hardship suffered by the unemployed and restore people to secure jobs. Social support: improving the social environment in schools, workplace or community; designing facilities to encourage meeting and social interaction in communities.

What do the authors argue are the strengths and limitations of the DALY? (Make sure you understand what each one means).

Strengths: drawing attention to neglected diseases like mental disorders, rationalizing the allocation of health resources. Limitations: researchers often lack adequate data, especially from rural, resource-poor settings. In these cases, DALYs are modeled using data from comparable locations, leaving some suspicious of validity.

Know what a structural adjustment loan is and how they affected health services in developing countries.

Structural adjustment loan: a loan to developing countries; a mechanism by which international financial institutions such as the World Bank and International Monetary Fund impose structural adjustment. → Countries were cutting funding to their health sectors to meet loan criteria.

If given an example of a health issue in the larger social context, assess whether it would or would not be considered an example of structural violence.

Structural violence: social arrangements that put individuals and populations in harm's way. The arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to individuals.

Understand the characteristics of a disease that may help make an eradication campaign successful (or unsuccessful).

Successful: human-to-human contact transmission, no vector. Permanent immunity from a single infection or vaccination (smallpox); short latency. Infection obvious such as a rash (smallpox); effective vaccine and no cold chain (smallpox). Unsuccessful: vector transmission (malaria); no immunity, can reoccur (so vaccine would not work); long latency. Symptoms can resemble other diseases, making case-identification difficult. Prevention requires cold chain or not effective prevention.

Understand the demand/control imbalance that is common in poverty and how it can impact health.

The chronic stress of poverty: too much demand (work, family, deadlines, customers, supervisors); too little control (flexible schedules, pace, task decisions). Chronic stress results in lasting changes in immune system and increased risk of heart disease or diabetes.

From the Rosling video: the importance of investigating global burden data at the level of a country as a whole but also dividing it into segments of the population.

The importance of collecting and analyzing at global level, but also the importance of looking at specific subgroups (by age, by gender, by geography).

Articulate what is included in each of the 7 categories of determinants (social gradient, stress, early life, social exclusion, work, unemployment and social support).

The social gradient: most diseases are more common further down the "social ladder"; life expectancy is shorter. Disadvantages tend to concentrate around the same people and their effects on health accumulate throughout life. Stress: social and psychological conditions (stressful circumstances) can cause long-term stress and may lead to premature death. Early life: a good start in early life means supporting mothers and young children. The health impact of early development and education lasts a lifetime; the foundations of adult health begin in early childhood. Social exclusion: life is short where the quality of life is poor. By causing hardship and resentment, poverty, social exclusion and discrimination cost lives. Work: stress in the workplace increases the risk of disease. People who have more control over their work lives have better health. Unemployment: job security increases health, well-being and job satisfaction. Higher rates of unemployment cause more illness and premature death. Social support: friendship, good social relations and strong supportive networks improve health at home, at work and in the community.

Be able to describe how "development" was defined in the 1940s and what that meant for global health initiatives.

Theorists and practitioners equated "development" with "modernization". Under the banner of "health and development," international agencies initiated the wide scale transfer of western preventive and clinical practices to the global south. The mid-twentieth century can be described as a "golden age" of medicine, in which discoveries about infection control, epidemiology, vaccines, and pest control transformed medical practice.

If given the graph from the McKeown Hypothesis, explain how it supports the idea that other factors were more important than medications in reducing deaths due to pulmonary infections.

There was a significant decline in deaths before biomedical interventions were readily available → attributed to better nutrition and hygiene.

Describe how European colonists interpreted the high mortality rates among indigenous populations due to infectious diseases. How was that connected to "scientific" understandings of biology and race? Has the idea of darker bodies and distant lands as "diseased" gone away completely? In what ways do these associations persist today?

Thought believed the indigenous population to be biologically inferior and that is why they were dying; used mortality rates to justify racial hierarchies → undermined their health. "Dark bodies" were vectors of diseases. The idea of darker bdies and distant lands as diseased has not gone away, health issues are blown out of proportion to fit an agenda.

Explain how Plan de Parto and Essential Care for Every Baby are examples of top down initiatives which were combined with a community based program to create an integrated initiative.

Top down: from the general to the particular. Plan de Parto: A plan for a rural woman to live in a Casa materna before delivery. The plan is: when will they go, who will take them, who will take care of their other kids while they are gone, who will be at the birth and how will they know when to come? Who will collect firewood for the home? Do laundry? The NGO has community health workers doing monthly home visits for pregnant women in the most remote parts of Nicaragua → part of what they do is help develop a Plan Parto with each woman. Otherwise they wouldn't reach the women who don't go to the clinic. They know what the woman's obstacles are to agreeing to it—maybe someone from the community needs to watch her other kids or maybe someone needs to collect firewood for them. This is an example of how a top down initiative (the MINSA's Plan de Parto) is facilitated by local community members. Essential Care of Every Baby: Vertical initiative which came from the American Association of Pediatrics and the WHO and was proven to be effective, could now be promoted → through horizontal approaches (community health committee and community health worker). BECAUSE the community now knew through THEIR OWN data collection, knowledge that neonatal mortality was an issue locally.

Articulate the reasons why the term "non-communicable diseases" is inaccurate.

Using the term "non-communicable diseases" propagates confusion, undermines efforts to spur a sense of urgency and deflects attention from effective system-wide interventions. Anything that begins with "non" may be considered a "non-issue" or a "non-starter".

Critique how a vaccine campaign (including surveillance and vaccination) may or may not strengthen a health system.

Vaccination campaigns are 'vertical' and technical fixes. Not all vaccines are campaigns to eradicate a disease, e.g. MMR. Individual level: Trigger an immune response to a disabled version of a bacteria or virus, so that if you are exposed, your body will already have the resources to fight it. This doesn't work for everyone - vaccines confer immunity to most people but not to everyone. At the community level, vaccines work through herd immunity - virus is unlikely to encounter a susceptible person. Different diseases have different infection rates, so for each disease a different % of the population is required to have immunity before the disease is contained. E.g. measles (95% vaccination rate needed to achieve herd immunity), whooping cough, mumps outbreaks. To be sure: Vertical campaigns can be very important. Advantage: you can measure whether you met the targets. Disadvantage: isn't sustainable if you don't improve the health system.

Given a scenario of a health impact, discuss how the physical environment interacts with issues of vulnerability to impact health outcomes (need to know definition of vulnerability).

Vulnerability: the characteristics of a person or group and their situation that influence their capacity to anticipate, cope with, resist and recover from the impact of a natural hazard. "There is No Such Thing as a Natural Disaster: Race, Class and Hurricane Katrina": "natural" disasters like Maria impacted Puerto Rico more than Harvey did on the US due to factors like different housing standards, electrical grid, government response and other infrastructure. Differential health outcomes from disasters are NOT natural, they reveal preexisting inequalities.

Know how a DALY is calculated.

YLL = Years of Life Lost YLL = N x L N = incident deaths for a cause L = life expectancy MINUS age at death for a cause YLD = Years Lived with Disability P = prevalence of a cause DW = disability weight