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This week we're going to be talking about global health and disease.
And I'm going to be talking to a professor of political science here at Wesleyan
University, Jim McGuire, who works on global health and disease internationally.
And we'll have a chance also to talk with
some other guests about the issues that are plaguing
much of the world, and causing premature death or the
diminishment of capacities, of our
fellow global citizens. I want to start my part of
this week's discussion off with trying to give you some
of the basic facts around global health and disease,
before we move into our conversations. And I'm drawing a lot of my
information form the World Health Organization, from
some demographers and development economics professors, and
from some foundations like the Gates Foundation, that has been so active
in this sphere for many years.
So, some basic facts. Let's start off with morbidity.
I'm afraid this week's discussion is going to be,
focus on the least pleasant aspects of our global challenges.
The top ten causes of death in the world are first, heart and circulatory diseases.
Second, stroke.
Third, lower respiratory infections. Fourth,
lung disease. Fifth, diarrheal diseases.
Sixth, HIV AIDS.
Seven, lung and lung related cancers. Eight, diabetes.
Nine, injuries,
often from road accidents.
And ten, deaths resulting from premature births.
Now this is, you know, we used to talk
about the four horsemen, the great scourges of humanity.
Here are the 10 leading causes of death. And as you go through them you see they,
immediately you'll think they afflict, they affect different
kinds of people, people living in different situations differently.
They affect different parts of the world differently.
Different income groups will be variously affected, and so forth.
In wealthier countries, heart disease and stroke are the leading causes of death,
followed by respiratory diseases, and then Alzheimer related diseases.
You see, in wealthier countries, where life expectancy
is greater, they will be different causes of death.
In poorer countries, the countries we have been focused on in much of the
class so far, in poor countries, HIV AIDS, lower
respiratory infections, and diarrheal diseases are the chief killers.
And they are also the diseases, I think I can say, we know
the most about. We know some of the tools that
would enable us to stop the diseases, or delay them, or to reduce their frequency.
Just again, giving you some facts and, you
know, you'll hear more about this in other videos.
And there's a lot of information
on the web. Here's an important statistic.
In high income countries, in high incomes countries, 7 in every 10
deaths occur among people 70 years of age and older.
This is pretty impressive. Seven out of 10 deaths in high income
countries occur to people over 70 years old.
People predominantly die of chronic diseases.
Cardiovascular, cancers, dementia, chronic
obstructive lung diseases, or diabetes.
Only one in every hundred deaths are among children under 15 years old.
It's a very different story as we move to different parts of the world.
In low income countries then, nearly 4 in every
10 deaths are among children under 15 years old, 40%.
And, only 2 in every 10 deaths are among people age 70 and older.
So, you see the great disparity of experience and life expectancy.
People predominantly die of infectious diseases.
That means a lower
respiratory infection, HIV AIDS, diarrheal diseases, and malaria,
to tuberculosis. These remain scourges and collectively
they account for more than a third of the deaths in low income countries.
Still today, childbirth in low income countries
is a trad-, is a dangerous life event.
Childbirth
and prematurity are very significant causes of death in these areas.
And although we know how to reduce their
frequency, we don't get our knowledge and the
resources behind what we know to the right
places, at the right time, to reduce these frequencies.
But let me just, you know, if I may,
just emphasize this disparity. In the rich countries, 7 in
every 10 deaths occur in people over 70. And
in the poor countries 4
in every 10 under 15, and only 2 out of every 10 for people over 70.
So when we talk about health issues, we're obviously talking about, and
morbidity, we're talking about nature, right.
We're talking about nature.
This is, our lot in life as human beings is
that we are mortal creatures and we're going to die.
What we quickly get into, when we talk about global health challenges, is
how the social construction of our environment, how the political
construction of our societies, how the
human impact on our environment changes the course of life and
death for hundreds of millions of people around
the globe. And we also see that
we can affect nature with extraordinary
results through the use of timely,
tested, and resourceful interventions.
But we don't do so consistently in many parts of the globe.
And so, the life trajectory of people around the planet is so different,
their experience of nature is so
different, their experience of their own bodies,
and of the capacity to
live a full life is so different, depending on geography, on
income, and on politics, as we'll see as we move through our discussions this week.
The World Health Organization estimates that 23%
of the global disease burden Is attributable
to the environment. Almost a quarter of what causes disease
today around the world comes from environmental factors.
The studies suggest that a third of the disease burden among
children is due to environmental factors we can change.
That's the good news, right.
The kind of depressing ,and even frightening, news is
that we have created conditions for more and more disease.
You see me change, shifting in my chair all the time now.
My doctor tells me that this is because the way I live, you know, sitting as a
professor, or sitting reading books, or at my computer
all the time has wreaked havoc on my back.
So this is a minor disease
compared to what we're talking about.
But I have constructed a way of life, as
my doctor says, your back ain't made to do that.
Right?
Your back ain't made to do that. That's the sad part for me.
I go there. You know?
And I, I'm getting old and I have to
figure out how to live with with an achy back.
But the good news is, there are actually things you can do to make an
enormous difference, and this is what this class
is all about right, from the very beginning.
And although we know that a quarter of the
disease burden comes from environmental factors, we also know the
things we need to do in order to reduce what
to many of seems like the most dramatic or tragic
consequence of disease, which is really early death,
death among children that could have been prevented.
And we can change the things that are causing those high rates of morbidity.
Children are, of course, vulnerable to disease.
They're, they can seem quite resilient in, in many respects.
But they are really vulnerable to infection and
to the consequences of living in extreme poverty.
Children bear the highest death toll, with more
than 4 million environmentally caused deaths every year.
These numbers become abstracted.
Please think that through.
Four million environmentally caused deaths yearly.
And mostly in developing countries, 4 million children each year.
The infant death rate from environmental causes is 12 times higher
in developing than in developed countries. 12 times higher.
So that childbirth,never an easy thing, even in
a wealthy country [LAUGH], is an extraordinarily fraught
and dangerous procedure for mother and child in
developing countries still today, despite what we know.
So, we're here today with Professor Jim McGuire, who is in
the government department at Wesleyan University,
and chair of the department now.
Thanks for making time to talk to me and to our students
here in this Coursera Wesleyan class called How to Change the World.
>> My pleasure.
>> And our theme this week, as you know, is disease and global health.
And, you know, I think for some people,
political scientist is not the first kind of person they
think of as being the person working on health issues.
So how did you first get involved with the issues of global health?
>> Well it was actually through my teaching here at Wesleyan.
I was teaching a class in the early 1990s called Political Economy of Developing
Countries, and in the course of preparing the class, I encountered the work
of Amartya Sen. >> yes.
>> The philosopher and economist at Harvard.
And he has the idea that, you know, the goal of human development
is the expansion of human capability. >> Yes.
For Sen, you know, a very important capability is the
capability to survive physically from one day to the next.
So, I got quite interested in his work.
And, at the same time in the course, I was teaching a unit on why the East Asian
countries have developed more successfully in terms of economic
growth and income inequality than the Latin American countries.
And it occurred for, to me, that like, whenever people
compare East Asian countries and Latin American countries, the East Asian
countries always win. >> Uh-huh.
>> But the criteria are always income related criteria.
And why hasn't anybody ever tried to compare the
two regions on things like infant mortality and life expectancy?
So I got quite interested in capabilities, capability expansion, physical survival.
Of course, health issues are very closely related to that.
So it was
actually through my teaching right here at
Wesleyan that I changed my whole research program.
>> That's interesting.
>> Before that, I was trying to study why some
countries did better than others at establishing and consolidating democracy.
>> Mm hm.
>> And the country on which focused was Argentina.
So this was a radical turn in my research program.
And it was all related to the teaching. And, I think
actually my teaching has influenced my research as
much as my research has influenced my teaching.
>> That's really interesting.
And I know that many of the people, even in these online classes, where
we don't have the same kind of contact with students as you would in a
physical classroom, you wind up developing ideas and approaches
that change the nature of the scholarship you do.
We are reading some of Amartya Sen in the class.
At least we've assigned that for this week.
And in your book, Wealth, Health and Democracy
in East Asia, you used this capabilities approach.
>> Right, yeah.
>> And so maybe I should just
go on right with the naive questions.
So, wealth and health, how are they connected?
Well there's one hypothesis out there, which
is known as the Wealthier is Healthier Hypothesis.
>> Mm-hm.
>> Which says that both wealthier individuals and wealthy countries
and wealthy subnational units within countries, like provinces or states.
>> Right.
>> Are going to be healthier, with health
measured in terms of, okay, measured in a variety
of ways, but one way of course is through mortality.
>> Mm-hm.
>> Indicators like life expectancy and infant mortality.
And it's quite true that when you look at levels, wealthier is definitely healthier.
>> Right.
>> If you look cross nationally, which is basically the area
that I work in, countries that have higher levels of economic affluence
have lower levels of infant mortality and longer life expectancy.
So, that's absolutely true for level.
But when you look at progress, the relationship is much weaker.
For example, if you look in the year 2010, compare all the counties in the world,
you'll find a very strong relation between level of GDP per capita, gross domestic
product per capita, which is a measure of
overall affluence, and, say the infant mortality rate.
>> Great.
>> But if you look at progress, at achieving economic
growth over, say, a 50 year period, 1960 to 2010,
and you look at progress at reducing infant mortality over
that same 50 year period, the relation is much weaker.
So the wealthier is healthier conjecture holds much
better for level than it does for progress.
And this is important because, actually, how
countries do at progress is more important,
from both theoretical and practical standpoints, than
what level they had achieved in 2010.
>> Yeah. >> Because, say, the level of
economic affluence that a country has achieved in 2010 or the level of infant
mortality that is achieved in 2010 reflects factors going back millennia.
>> That's right.
Right.
>> Whereas if you just look at progress during a particular
span of time, that's a lot better for extracting policy lessons.
>> Yeah.
>> And other things that are, you know, amenable to human intervention.
>> Yeah. >> So,
you know, if you look at, only at levels and neglect progress, which is what a lot
of people in the wealthier is healthier tradition do, I think that biases
policy solutions toward, you know, thinking that
the role of a government or even of
a private entry or organization, is simply to
increase the overall economic affluence of the population.
>> Right.
>> And if you do that, people's health will take care of itself.
>> I see.
>> But if you look at progress, that's definitely not true.
>> That's not the case.
>> There are some countries that have done really well
at economic growth, but not very well at reducing premature mortality.
And other countries have done very poorly at
economic growth but extremely well at reducing premature mortality.
>> And is that due to the fact that you can have significant
economic growth without a great
redistribution of that wealth across sectors?
In other words, if, does the wealthy is
healthier hypothesis work if you dis-aggregate the population?
Like the people who are wealthy in the population are in fact healthier?
Or does, you see what I mean?
If a region gets much wealthier, but infant
mortality stays high, is that because the poor are
still poor and those are the ones who are dying?
Or is it because that wealth doesn't matter as
much as we thought it did about infant mortality?
>> I'd say it's a little of both.
That you know, you can have rapid economic growth and a bad income distribution.
Well that's worse for reducing premature mortality.
>> Right.
>> Than having rapid economic growth and a very low level of income inequality.
>> Mm-hm >> But it's not all
about income inequality. >> It's not all about the money.
>> [LAUGH] No it's not all about the money.
Because [LAUGH] let's face it.
Like what needs to be done to reduce
premature mortality is mostly very cheap types of interventions.
>> Right.
And you can have a country, a good example is Chile.
>> Right.
>> Say Chile, during the first ten years of Pinochet's.
>> Right. >> Dictatorial military
government, from 1974 to 1983.
There, they were poorer in 1983 than they were in 1974.
GDP per capita went down. >> Mm-hm.
>> Income inequality skyrocketed and income poverty
went from 20% to 30% of the population.
>> Hm.
>> Nevertheless, General Pinochet managed to reduce
the infant mortality rate in one decade
faster than anyone else in human history.
In 1974, the infant mortality rate was 65 infant deaths per 1,000 live births.
By 1983 it was 19 per 1,000. >> Wow.
>> This was a plunge. So income distribution got
worse, and GDP per capita declined. What happened
is that the government, for reasons that
still remain to be revealed because, as Dreze
and Sen pointed out, General Pinochet does not
have a reputation as a soft-hearted do gooder.
>> Right, right.
>> He actually introduced these extremely
inexpensive maternal and infant health care
policies, particularly in very impoverished areas
of the country, urban shanty towns,
remote rural areas.
And these extremely cheap interventions more than made up for the
lousy economic growth and terrible worsening
of income inequality and income poverty.
>> Yeah, that's fascinating.
>> So, not only is it not just a matter of economic
growth, it's not even a matter of economic growth plus income distribution.
The public provision of basic social services on its own can be
really effective.
>> So the public, I want to hold onto that, the public, say that again.
>> [LAUGH] Once the public provision.
Public provision of basic services. >> Basic services, yeah.
>> And also, you can't look only at the supply side.
You have to look at the demand side as well.
Services not only have to be provided, they have to be utilized.
>> Yeah.
>> So you've got to look at the
conditions under which people are willing and able
to use even putatively free social services.
>> Right.
>> So, they might have to take time off work,
or take a bus to the health clinic or whatever.
So you've got to look at the utilization side as well as the provision side.
>> Right, right, mm-hm.
So how does, how does this kind
of background plug into the capabilities framework?
>> Okay.
>> Because, because, you know, I can imagine why
some social scientists are interested in
measuring income, or even income distribution.
And you can measure GDP.
You can measure mortality.
But, how do you get at the capabilities
as something you can understand, and track over time?
>> Well, I guess, you know, I view the capabilities approach, and capabilities
themselves, basically, the expansion of human capabilities equals the
expansion of a person's ability to lead a thoughtfully chosen life.
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