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[MUSIC]

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This week we're going to be talking about
global health and disease.

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And I'm going to be talking to a professor
of political science here at Wesleyan

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University, Jim McGuire, who works on
global health and disease internationally.

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And we'll have a chance also to talk with

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some other guests about the issues that
are plaguing

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much of the world, and causing premature
death or the

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diminishment of capacities, of our

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fellow global citizens.
I want to start my part of

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this week's discussion off with trying to
give you some

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of the basic facts around global health
and disease,

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before we move into our conversations.
And I'm drawing a lot of my

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information form the World Health
Organization, from

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some demographers and development
economics professors, and

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from some foundations like the Gates
Foundation, that has been so active

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in this sphere for many years.

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So, some basic facts.
Let's start off with morbidity.

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I'm afraid this week's discussion is going
to be,

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focus on the least pleasant aspects of our
global challenges.

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The top ten causes of death in the world
are first, heart and circulatory diseases.

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Second, stroke.

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Third, lower respiratory infections.
Fourth,

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lung disease.
Fifth, diarrheal diseases.

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Sixth, HIV AIDS.

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Seven, lung and lung related cancers.
Eight, diabetes.

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Nine, injuries,

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often from road accidents.

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And ten, deaths resulting from premature
births.

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Now this is, you know, we used to talk

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about the four horsemen, the great
scourges of humanity.

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Here are the 10 leading causes of death.
And as you go through them you see they,

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immediately you'll think they afflict,
they affect different

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kinds of people, people living in
different situations differently.

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They affect different parts of the world
differently.

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Different income groups will be variously
affected, and so forth.

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In wealthier countries, heart disease and
stroke are the leading causes of death,

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followed by respiratory diseases, and then
Alzheimer related diseases.

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You see, in wealthier countries, where
life expectancy

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is greater, they will be different causes
of death.

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In poorer countries, the countries we have
been focused on in much of the

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class so far, in poor countries, HIV AIDS,
lower

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respiratory infections, and diarrheal
diseases are the chief killers.

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And they are also the diseases, I think I
can say, we know

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the most about.
We know some of the tools that

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would enable us to stop the diseases, or
delay them, or to reduce their frequency.

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Just again, giving you some facts and, you

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know, you'll hear more about this in other
videos.

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And there's a lot of information

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on the web.
Here's an important statistic.

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In high income countries, in high incomes
countries, 7 in every 10

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deaths occur among people 70 years of age
and older.

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This is pretty impressive.
Seven out of 10 deaths in high income

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countries occur to people over 70 years
old.

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People predominantly die of chronic
diseases.

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Cardiovascular, cancers, dementia, chronic

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obstructive lung diseases, or diabetes.

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Only one in every hundred deaths are among
children under 15 years old.

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It's a very different story as we move to
different parts of the world.

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In low income countries then, nearly 4 in
every

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10 deaths are among children under 15
years old, 40%.

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And, only 2 in every 10 deaths are among
people age 70 and older.

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So, you see the great disparity of
experience and life expectancy.

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People predominantly die of infectious
diseases.

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That means a lower

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respiratory infection, HIV AIDS, diarrheal
diseases, and malaria,

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to tuberculosis.
These remain scourges and collectively

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they account for more than a third of the
deaths in low income countries.

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Still today, childbirth in low income
countries

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is a trad-, is a dangerous life event.

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Childbirth

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and prematurity are very significant
causes of death in these areas.

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And although we know how to reduce their

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frequency, we don't get our knowledge and
the

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resources behind what we know to the right

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places, at the right time, to reduce these
frequencies.

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But let me just, you know, if I may,

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just emphasize this disparity.
In the rich countries, 7 in

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every 10 deaths occur in people over 70.
And

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in the poor countries 4

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in every 10 under 15, and only 2 out of
every 10 for people over 70.

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So when we talk about health issues, we're
obviously talking about, and

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morbidity, we're talking about nature,
right.

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We're talking about nature.

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This is, our lot in life as human beings
is

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that we are mortal creatures and we're
going to die.

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What we quickly get into, when we talk
about global health challenges, is

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how the social construction of our
environment, how the political

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construction of our societies, how the

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human impact on our environment changes
the course of life and

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death for hundreds of millions of people
around

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the globe.
And we also see that

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we can affect nature with extraordinary

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results through the use of timely,

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tested, and resourceful interventions.

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But we don't do so consistently in many
parts of the globe.

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And so, the life trajectory of people
around the planet is so different,

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their experience of nature is so

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different, their experience of their own
bodies,

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and of the capacity to

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live a full life is so different,
depending on geography, on

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income, and on politics, as we'll see as
we move through our discussions this week.

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The World Health Organization estimates
that 23%

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of the global disease burden Is
attributable

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to the environment.
Almost a quarter of what causes disease

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today around the world comes from
environmental factors.

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The studies suggest that a third of the
disease burden among

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children is due to environmental factors
we can change.

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That's the good news, right.

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The kind of depressing ,and even
frightening, news is

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that we have created conditions for more
and more disease.

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You see me change, shifting in my chair
all the time now.

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My doctor tells me that this is because
the way I live, you know, sitting as a

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professor, or sitting reading books, or at
my computer

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all the time has wreaked havoc on my back.

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So this is a minor disease

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compared to what we're talking about.

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But I have constructed a way of life, as

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my doctor says, your back ain't made to do
that.

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Right?

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Your back ain't made to do that.
That's the sad part for me.

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I go there.
You know?

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And I, I'm getting old and I have to

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figure out how to live with with an achy
back.

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But the good news is, there are actually
things you can do to make an

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enormous difference, and this is what this
class

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is all about right, from the very
beginning.

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And although we know that a quarter of the

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disease burden comes from environmental
factors, we also know the

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things we need to do in order to reduce
what

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to many of seems like the most dramatic or
tragic

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consequence of disease, which is really
early death,

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death among children that could have been
prevented.

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And we can change the things that are
causing those high rates of morbidity.

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Children are, of course, vulnerable to
disease.

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They're, they can seem quite resilient in,
in many respects.

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But they are really vulnerable to
infection and

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to the consequences of living in extreme
poverty.

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Children bear the highest death toll, with
more

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than 4 million environmentally caused
deaths every year.

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These numbers become abstracted.

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Please think that through.

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Four million environmentally caused deaths
yearly.

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And mostly in developing countries, 4
million children each year.

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The infant death rate from environmental
causes is 12 times higher

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in developing than in developed countries.
12 times higher.

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So that childbirth,never an easy thing,
even in

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a wealthy country [LAUGH], is an
extraordinarily fraught

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and dangerous procedure for mother and
child in

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developing countries still today, despite
what we know.

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So, we're here today with Professor Jim
McGuire, who is in

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the government department at Wesleyan
University,

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and chair of the department now.

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Thanks for making time to talk to me and
to our students

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here in this Coursera Wesleyan class
called How to Change the World.

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>> My pleasure.

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>> And our theme this week, as you
know, is disease and global health.

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And, you know, I think for some people,

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political scientist is not the first kind
of person they

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think of as being the person working on
health issues.

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So how did you first get involved with the
issues of global health?

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>> Well it was actually through my
teaching here at Wesleyan.

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I was teaching a class in the early 1990s
called Political Economy of Developing

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Countries, and in the course of preparing
the class, I encountered the work

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of Amartya Sen.
>> yes.

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>> The philosopher and economist at
Harvard.

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And he has the idea that, you know, the
goal of human development

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is the expansion of human capability.
>> Yes.

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For Sen, you know, a very important
capability is the

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capability to survive physically from one
day to the next.

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So, I got quite interested in his work.

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And, at the same time in the course, I was
teaching a unit on why the East Asian

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countries have developed more successfully
in terms of economic

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growth and income inequality than the
Latin American countries.

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And it occurred for, to me, that like,
whenever people

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compare East Asian countries and Latin
American countries, the East Asian

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countries always win.
>> Uh-huh.

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>> But the criteria are always income
related criteria.

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And why hasn't anybody ever tried to
compare the

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two regions on things like infant
mortality and life expectancy?

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So I got quite interested in capabilities,
capability expansion, physical survival.

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Of course, health issues are very closely
related to that.

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So it was

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actually through my teaching right here at

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Wesleyan that I changed my whole research
program.

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>> That's interesting.

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>> Before that, I was trying to study
why some

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countries did better than others at
establishing and consolidating democracy.

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>> Mm hm.

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>> And the country on which focused was
Argentina.

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So this was a radical turn in my research
program.

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And it was all related to the teaching.
And, I think

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actually my teaching has influenced my
research as

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much as my research has influenced my
teaching.

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>> That's really interesting.

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And I know that many of the people, even
in these online classes, where

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we don't have the same kind of contact
with students as you would in a

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physical classroom, you wind up developing
ideas and approaches

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that change the nature of the scholarship
you do.

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We are reading some of Amartya Sen in the
class.

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At least we've assigned that for this
week.

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And in your book, Wealth, Health and
Democracy

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in East Asia, you used this capabilities
approach.

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>> Right, yeah.

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>> And so maybe I should just

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go on right with the naive questions.

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So, wealth and health, how are they
connected?

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Well there's one hypothesis out there,
which

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is known as the Wealthier is Healthier
Hypothesis.

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>> Mm-hm.

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>> Which says that both wealthier
individuals and wealthy countries

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and wealthy subnational units within
countries, like provinces or states.

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>> Right.

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>> Are going to be healthier, with
health

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measured in terms of, okay, measured in a
variety

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of ways, but one way of course is through
mortality.

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>> Mm-hm.

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>> Indicators like life expectancy and
infant mortality.

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And it's quite true that when you look at
levels, wealthier is definitely healthier.

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>> Right.

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>> If you look cross nationally, which
is basically the area

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that I work in, countries that have higher
levels of economic affluence

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have lower levels of infant mortality and
longer life expectancy.

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So, that's absolutely true for level.

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But when you look at progress, the
relationship is much weaker.

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For example, if you look in the year 2010,
compare all the counties in the world,

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you'll find a very strong relation between
level of GDP per capita, gross domestic

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product per capita, which is a measure of

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overall affluence, and, say the infant
mortality rate.

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>> Great.

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>> But if you look at progress, at
achieving economic

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growth over, say, a 50 year period, 1960
to 2010,

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and you look at progress at reducing
infant mortality over

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that same 50 year period, the relation is
much weaker.

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So the wealthier is healthier conjecture
holds much

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better for level than it does for
progress.

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And this is important because, actually,
how

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countries do at progress is more
important,

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from both theoretical and practical
standpoints, than

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what level they had achieved in 2010.

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>> Yeah.
>> Because, say, the level of

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economic affluence that a country has
achieved in 2010 or the level of infant

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mortality that is achieved in 2010
reflects factors going back millennia.

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>> That's right.

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Right.

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>> Whereas if you just look at progress
during a particular

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span of time, that's a lot better for
extracting policy lessons.

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>> Yeah.

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>> And other things that are, you know,
amenable to human intervention.

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>> Yeah.
>> So,

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you know, if you look at, only at levels
and neglect progress, which is what a lot

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of people in the wealthier is healthier
tradition do, I think that biases

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policy solutions toward, you know,
thinking that

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the role of a government or even of

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00:17:16,810 --> 00:17:19,730
a private entry or organization, is simply
to

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increase the overall economic affluence of
the population.

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>> Right.

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>> And if you do that, people's health
will take care of itself.

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>> I see.

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>> But if you look at progress, that's
definitely not true.

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>> That's not the case.

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>> There are some countries that have
done really well

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at economic growth, but not very well at
reducing premature mortality.

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And other countries have done very poorly
at

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economic growth but extremely well at
reducing premature mortality.

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>> And is that due to the fact that you
can have significant

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economic growth without a great

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redistribution of that wealth across
sectors?

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In other words, if, does the wealthy is

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healthier hypothesis work if you
dis-aggregate the population?

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Like the people who are wealthy in the
population are in fact healthier?

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Or does, you see what I mean?

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If a region gets much wealthier, but
infant

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mortality stays high, is that because the
poor are

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still poor and those are the ones who are
dying?

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Or is it because that wealth doesn't
matter as

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much as we thought it did about infant
mortality?

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>> I'd say it's a little of both.

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That you know, you can have rapid economic
growth and a bad income distribution.

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Well that's worse for reducing premature
mortality.

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>> Right.

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>> Than having rapid economic growth
and a very low level of income inequality.

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00:18:39,240 --> 00:18:40,450
>> Mm-hm
>> But it's not all

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00:18:40,450 --> 00:18:42,885
about income inequality.
>> It's not all about the money.

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00:18:42,885 --> 00:18:44,650
>> [LAUGH] No it's not all about the
money.

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Because [LAUGH] let's face it.

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Like what needs to be done to reduce

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00:18:49,890 --> 00:18:54,510
premature mortality is mostly very cheap
types of interventions.

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>> Right.

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And you can have a country, a good example
is Chile.

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00:18:57,910 --> 00:18:58,560
>> Right.

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>> Say Chile, during the first ten
years of Pinochet's.

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>> Right.
>> Dictatorial military

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government, from 1974 to 1983.

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There, they were poorer in 1983 than they
were in 1974.

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GDP per capita went down.
>> Mm-hm.

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>> Income inequality skyrocketed and
income poverty

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went from 20% to 30% of the population.

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>> Hm.

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>> Nevertheless, General Pinochet
managed to reduce

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the infant mortality rate in one decade

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00:19:31,540 --> 00:19:34,520
faster than anyone else in human history.

302
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In 1974, the infant mortality rate was 65
infant deaths per 1,000 live births.

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By 1983 it was 19 per 1,000.
>> Wow.

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>> This was a plunge.
So income distribution got

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00:19:51,240 --> 00:19:56,650
worse, and GDP per capita declined.
What happened

306
00:19:56,650 --> 00:19:59,680
is that the government, for reasons that

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00:19:59,680 --> 00:20:03,259
still remain to be revealed because, as
Dreze

308
00:20:03,259 --> 00:20:06,450
and Sen pointed out, General Pinochet does
not

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00:20:06,450 --> 00:20:09,010
have a reputation as a soft-hearted do
gooder.

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00:20:09,010 --> 00:20:09,792
>> Right, right.

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00:20:09,792 --> 00:20:13,090
>> He actually introduced these
extremely

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00:20:13,090 --> 00:20:16,270
inexpensive maternal and infant health
care

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00:20:16,270 --> 00:20:19,900
policies, particularly in very
impoverished areas

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00:20:19,900 --> 00:20:22,300
of the country, urban shanty towns,

315
00:20:22,300 --> 00:20:23,880
remote rural areas.

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00:20:23,880 --> 00:20:27,780
And these extremely cheap interventions
more than made up for the

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00:20:27,780 --> 00:20:30,540
lousy economic growth and terrible
worsening

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00:20:30,540 --> 00:20:32,640
of income inequality and income poverty.

319
00:20:32,640 --> 00:20:33,860
>> Yeah, that's fascinating.

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00:20:33,860 --> 00:20:36,550
>> So, not only is it not just a matter
of economic

321
00:20:36,550 --> 00:20:42,068
growth, it's not even a matter of economic
growth plus income distribution.

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The public provision of basic social
services on its own can be

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00:20:47,910 --> 00:20:48,830
really effective.

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00:20:48,830 --> 00:20:52,610
>> So the public, I want to hold onto
that, the public, say that again.

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00:20:52,610 --> 00:20:55,170
>> [LAUGH] Once the public provision.

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00:20:55,170 --> 00:20:58,700
Public provision of basic services.
>> Basic services, yeah.

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00:20:58,700 --> 00:21:01,310
>> And also, you can't look only at the
supply side.

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00:21:01,310 --> 00:21:04,010
You have to look at the demand side as
well.

329
00:21:04,010 --> 00:21:07,780
Services not only have to be provided,
they have to be utilized.

330
00:21:07,780 --> 00:21:08,016
>> Yeah.

331
00:21:08,016 --> 00:21:09,695
>> So you've got to look at the

332
00:21:09,695 --> 00:21:12,940
conditions under which people are willing
and able

333
00:21:12,940 --> 00:21:17,234
to use even putatively free social
services.

334
00:21:17,234 --> 00:21:17,760
>> Right.

335
00:21:17,760 --> 00:21:19,880
>> So, they might have to take time off
work,

336
00:21:19,880 --> 00:21:22,678
or take a bus to the health clinic or
whatever.

337
00:21:22,678 --> 00:21:26,280
So you've got to look at the utilization
side as well as the provision side.

338
00:21:26,280 --> 00:21:27,680
>> Right, right, mm-hm.

339
00:21:27,680 --> 00:21:29,660
So how does, how does this kind

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00:21:29,660 --> 00:21:34,640
of background plug into the capabilities
framework?

341
00:21:34,640 --> 00:21:35,050
>> Okay.

342
00:21:35,050 --> 00:21:38,043
>> Because, because, you know, I can
imagine why

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00:21:38,043 --> 00:21:40,598
some social scientists are interested in

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00:21:40,598 --> 00:21:43,792
measuring income, or even income
distribution.

345
00:21:43,792 --> 00:21:45,246
And you can measure GDP.

346
00:21:45,246 --> 00:21:48,412
You can measure mortality.

347
00:21:48,412 --> 00:21:51,316
But, how do you get at the capabilities

348
00:21:51,316 --> 00:21:55,498
as something you can understand, and track
over time?

349
00:21:55,498 --> 00:22:03,182
>> Well, I guess, you know, I view the
capabilities approach, and capabilities

350
00:22:03,182 --> 00:22:10,301
themselves, basically, the expansion of
human capabilities equals the

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00:22:10,301 --> 00:22:17,086
expansion of a person's ability to lead a
thoughtfully chosen life.

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