K. S. Mohindra

The Growing Impact of Globalization for Health and Public Health Practice

In recent decades, public health policy and practice have been increasingly challenged by globalization, even as global financing for health has increased dramatically. This article discusses globalization and its health challenges from a vantage of political science, emphasizing increased global flows (of pathogens, information, trade, finance, and people) as driving, and driven by, global market integration. This integration requires a shift in public health thinking from a singular focus on international health (the higher disease burden in poor countries) to a more nuanced analysis of global health (in which health risks in both poor and rich countries are seen as having inherently global causes and consequences). Several globalization-related pathways to health exist, two key ones of which are described: globalized diseases and economic vulnerabilities. The article concludes with a call for national governments, especially those of wealthier nations, to take greater account of global health and its social determinants in all their foreign policies.

Urban food insecurity in the context of high food prices: a community based cross sectional study in Addis Ababa, Ethiopia.

BackgroundHigh food prices have emerged as a major global challenge, especially for poor and urban households in low-income countries such as Ethiopia. However, there is little empirical evidence on urban food security and how people living in urban areas are coping with sustained high food prices. This study aims to address this gap by investigating the food insecurity situation in urban Ethiopia -a country experiencing sustained high food prices, high rates of urban poverty, and a growing urban population.MethodsA community based cross-sectional study was conducted from January 18 to February 14, 2012. A total of 550 households were selected from three sub-cities of Addis Ababa using three-stage sampling technique. Data were collected using questionnaire based interview with household heads. Items in the questionnaire include, among others, basic socioeconomic variables, dietary diversity and coping strategies. Food security status of households was assessed by a Household Food Insecurity Access Score. Data analysis was done using SPSS software and both univariate and bivariate analysis were done.ResultsThe study found that 75% of households were food insecure and 23% were in a state of hunger. Households with higher food insecurity scores tend to have lower dietary diversity and are less likely to consume high quality diets. Reduction in meal size and shifting to poor quality/less expensive/food types were among the common coping strategies to high food price used by households. Household incomes, occupational and educational status of household heads were significant determinants of food security.ConclusionFood insecurity in Ethiopia is not only a rural problem. Urban food insecurity is a growing concern due to the toxic combination of high rates of urban poverty, high dependency of urban households on food supplied by the market, and fluctuating food prices. Household food insecurity was particularly high among low income households and those headed by uneducated, daily wagers and government employed household heads. Therefore, policy makers should work on stabilization of the food market and creating opportunities that could improve the livelihood and purchasing power of urban households.

“Health divide” between indigenous and non-indigenous populations in Kerala, India: Population based study

BackgroundThe objective of this study is to investigate the magnitude and nature of health inequalities between indigenous (Scheduled Tribes) and non-indigenous populations, as well as between different indigenous groups, in a rural district of Kerala State, India.MethodsA health survey was carried out in a rural community (N = 1660 men and women, 18–96 years). Age- and sex-standardised prevalence of underweight (BMI < 18.5 kg/m2), anaemia, goitre, suspected tuberculosis and hypertension was compared across forward castes, other backward classes and tribal populations. Multi-level weighted logistic regression models were used to estimate the predicted prevalence of morbidity for each age and social group. A Blinder-Oaxaca decomposition was used to further explore the health gap between tribes and non-tribes, and between subgroups of tribes.ResultsSocial stratification remains a strong determinant of health in the progressive social policy environment of Kerala. The tribal groups are bearing a higher burden of underweight (46.1 vs. 24.3%), anaemia (9.9 vs. 3.5%) and goitre (8.5 vs. 3.6%) compared to non-tribes, but have similar levels of tuberculosis (21.4 vs. 20.4%) and hypertension (23.5 vs. 20.1%). Significant health inequalities also exist within tribal populations; the Paniya have higher levels of underweight (54.8 vs. 40.7%) and anaemia (17.2 vs. 5.7%) than other Scheduled Tribes. The social gradient in health is evident in each age group, with the exception of hypertension. The predicted prevalence of underweight is 31 and 13 percentage points higher for Paniya and other Scheduled Tribe members, respectively, compared to Forward Caste members 18–30 y (27.1%). Higher hypertension is only evident among Paniya adults 18–30 y (10 percentage points higher than Forward Caste adults of the same age group (5.4%)). The decomposition analysis shows that poverty and other determinants of health only explain 51% and 42% of the health gap between tribes and non-tribes for underweight and goitre, respectively.ConclusionsPolicies and programmes designed to benefit the Scheduled Tribes need to promote their well-being in general but also target the specific needs of the most vulnerable indigenous groups. There is a need to enhance the capacity of the disadvantaged to equally take advantage of health opportunities.

A systematic review of population health interventions and Scheduled Tribes in India

BackgroundDespite Indias recent economic growth, health and human development indicators of Scheduled Tribes (ST) or Adivasi (Indias indigenous populations) lag behind national averages. The aim of this review was to identify the public health interventions or components of these interventions that are effective in reducing morbidity or mortality rates and reducing risks of ill health among ST populations in India, in order to inform policy and to identify important research gaps.MethodsWe systematically searched and assessed peer-reviewed literature on evaluations or intervention studies of a population health intervention undertaken with an ST population or in a tribal area, with a population health outcome(s), and involving primary data collection.ResultsThe evidence compiled in this review revealed three issues that promote effective public health interventions with STs: (1) to develop and implement interventions that are low-cost, give rapid results and can be easily administered, (2): a multi-pronged approach, and (3): involve ST populations in the intervention.ConclusionWhile there is a growing body of knowledge on the health needs of STs, there is a paucity of data on how we can address these needs. We provide suggestions on how to undertake future population health intervention research with ST populations and offer priority research avenues that will help to address our knowledge gap in this area.

The global financial crisis: whither women's health?

The global integration of trade and financial markets that has been the hallmark of the past 30 years of neoliberal globalization means that local economies can be shaped by economic events seemingly unrelated to the scale or geography where womens empowerment projects unfold. These global–local interactions raise questions so far largely absent in public discussions of the 2008 crisis precipitated by the US sub-prime loan scandal: what are the gendered effects of global financial crises; specifically, how do these crises affect women? And how do these market crises intersect with the non-market activities that are key to understanding gendered health issues in developing countries. This article addresses these questions by reviewing the literature on gendered health impacts of financial crises over the past two decades. We find that the manner in which national governments and the broader international community react to crises can either magnify (as illustrated through the impacts of structural adjustment programmes on womens health) or mitigate (as illustrated through the policies pursued following the loss of support from the collapsed Soviet Union on Cuban womens health) gendered health-negative effects. Lack of attention to gender-specific consequences of past crises or health-positive interventions into such crises has weakened the ability to advance policy advice on protecting womens health during the present crisis. The article concludes with a gender-focused critique of the dominant policy responses to the 2008 financial crisis and a call to undertake real-time investigation of gendered health risks and opportunities arising from the present crisis.

Reducing inequalities in health and access to health care in a rural Indian community: an India-Canada collaborative action research project.

BackgroundInadequate public action in vulnerable communities is a major constraint for the health of poor and marginalized groups in low and middle-income countries (LMICs). The south Indian state of Kerala, known for relatively equitable provision of public resources, is no exception to the marginalization of vulnerable communities. In Kerala, women’s lives are constrained by gender-based inequalities and certain indigenous groups are marginalized such that their health and welfare lag behind other social groups.The researchThe goal of this socially-engaged, action-research initiative was to reduce social inequalities in access to health care in a rural community. Specific objectives were: 1) design and implement a community-based health insurance scheme to reduce financial barriers to health care, 2) strengthen local governance in monitoring and evidence-based decision-making, and 3) develop an evidence base for appropriate health interventions.Results and outcomesHealth and social inequities have been masked by Kerala’s overall progress. Key findings illustrated large inequalities between different social groups. Particularly disadvantaged are lower-caste women and Paniyas (a marginalized indigenous group), for whom inequalities exist across education, employment status, landholdings, and health. The most vulnerable populations are the least likely to receive state support, which has broader implications for the entire country. A community based health solidarity scheme (SNEHA), under the leadership of local women, was developed and implemented yielding some benefits to health equity in the community—although inclusion of the Paniyas has been a challenge.The partnershipThe Canadian-Indian action research team has worked collaboratively for over a decade. An initial focus on surveys and data analysis has transformed into a focus on socially engaged, participatory action research.Challenges and successesAdapting to unanticipated external forces, maintaining a strong team in the rural village, retaining human resources capable of analyzing the data, and encouraging Paniya participation in the health insurance scheme were challenges. Successes were at least partially enabled by the length of the funding (this was a two-phase project over an eight year period).

Globalization and the rise of precarious employment: the new frontier for workplace health promotion:

Global market integration over the past three decades has led to labour market restructuring in most countries around the world. Employment flexibility has been emphasized as a way for employers to restructure their organizations to remain globally competitive. This flexibility has resulted in the growth of precarious employment, which has been exacerbated by the global financial crisis and resulting recession in 2007/2008, and the ongoing economic uncertainty throughout much of the world. Precarious employment may result in short and long-term health consequences for many workers. This presents a deeper and more structural determinant of health than what health promoters have traditionally considered. It calls for a different understanding of workplace health promotion research and intervention that goes beyond enabling healthier lifestyle choices or advocating safer workplace conditions to ensuring adequate social protection floors that provide people with sufficient resources to lead healthy lives, and for advocacy for taxation justice to finance such protection.

Debt, shame, and survival: becoming and living as widows in rural Kerala, India

BackgroundThe health and well-being of widows in India is an important but neglected issue of public health and women’s rights. We investigate the lives of Indian women as they become widows, focussing on the causes of their husband’s mortality and the ensuing consequences of these causes on their own lives and identify the opportunities and challenges that widows face in living healthy and fulfilling lives.MethodsData were collected in a Gram Panchayat (lowest level territorial decentralised unit) in the south Indian state of Kerala. Interviews were undertaken with key informants in order to gain an understanding of local constructions of ‘widowhood’ and the welfare and social opportunities for widows. Then we conducted semi-structured interviews with widows in the community on issues related to health and vulnerability, enabling us to hear perspectives from widows. Data were analysed for thematic content and emerging patterns. We synthesized our findings with theoretical understandings of vulnerability and Amartya Sen’s entitlements theory to develop a conceptual framework.ResultsTwo salient findings of the study are: first, becoming a widow can be viewed as a type of ‘shock’ that operates similarly to other ‘economic shocks’ or ‘health shocks’ in poor countries except that the burden falls disproportionately on women. Second, widowhood is not a static phenomenon, but rather can be viewed as a multi-phased process with different public health implications at each stage.ConclusionMore research on widows in India and other countries will help to both elucidate the challenges faced by widows and encourage potential solutions. The framework developed in this paper could be used to guide future research on widows.

A snapshot of global health education at North American universities

Global health education is becoming increasingly prominent in North America. It is widely agreed upon that global health is an important aspect of an education in the health sciences and increasingly in other disciplines such as law, economics and political science. There is currently a paucity of studies examining the content of global health courses at the post-secondary level. The purpose of our research is to identify the content areas being covered in global health curricula in North American universities, as a first step in mapping global health curricula across North America. We collected 67 course syllabi from 31 universities and analyzed the topics covered in the course. This snapshot of global health education will aid students searching for global health content, as well as educators and university administrators who are developing or expanding global health programs in Canada and the United States.

From bulldozing to housing rights: reducing vulnerability and improving health in African slums.

Forced evictions heighten vulnerability among slum dwellers who already face multiple risks of ill health. They constitute a well-documented violation of economic and social rights and are reaching epidemic proportions in sub-Saharan Africa as economic globalization creates and strengthens incentives for forced evictions. We describe evictions in the slums of four African metropolitan areas: Accra (Ghana), Lagos (Nigeria), Luanda (Angola) and Nairobi (Kenya). We survey diverse strategies used in responding to forced evictions and outline the challenges and barriers encountered. We conclude that the international human rights framework offers an important approach for protecting the health of vulnerable populations.