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Article

Anna Jarkiewicz and Mariusz Granosik

Defining global citizenship (GC) depends on the perspective undertaken. The academic literature on GC is divided into two theoretical approaches: normative and interpretative. The first of these can also be called the attributive approach, because it refers to specific attributes that indicate whether someone is, or is not, a global citizen. This approach emphasizes the importance of education, during the course of which appropriate skills, competencies, and attitudes characterizing a global citizen are shaped. In contrast, representatives of the interpretative approach do not concentrate on creating a list of attributes through the prism of which the concept of GC can be identified but, rather, try to recognize what meaning individuals and language users ascribe to the concept. Understanding what GC is and what meaning actors ascribe to it is crucial in this view. The adopted theoretical perspective also determines who is and who can be a (global) citizen. The education emphasized in the normative approach, and the related course of acquiring specific attributes, means that only adults are recognized as (global) citizens. Young people are only citizens in the making. Consequently, full citizenship is an exclusive social category that is acquired on reaching the age of majority. In the interpretative approach, both adolescents and adults are considered equally as citizens. This approach stands in opposition to the age-determined order and seeks to broaden analysis by breaking from a transitional life-stage paradigm that works to divide childhood from adolescence and adolescence from adulthood. In this approach, we do not become citizens but are citizens from the very beginning of our lives. Within this concept, shifting young people’s understanding of life by applying “citizenship” as an inclusive social category is necessary. Depending on what theoretical perspective is used, a diverse range of educational practices will be employed—global citizenship education (GCE). The normative approach is related to the idea of GCE and practical notions about how GC could be taught in educational institutions or learned in other settings. In the interpretive approach, the emphasis is on cooperation in creation, joint and democratic decision-making, from which no one is excluded, regardless of age, race, religion, gender, and so on. In the same way that globalization became the target of criticism, the idea of GC and GCE is generating increasingly more discussion. Some of its aspects refer to the neoliberal foundation of GC; in that context, GCE can be understood as a system of influencing individuals to adjust them to the economic expectations of contemporary markets. Also, the expansion of the GC idea to other continents forced educators to take into account the achievements of cultural anthropology and academics to conduct international comparative research. What in the normative conceptualization was considered a universal norm in light of intercultural studies began to be perceived as a neocolonial expansion of Euro-American culture. This raises a fundamental question about a better (less colonializing) variant of global education. One of many answers is critical global learning, focused on demystification of dominant global discourses, mapping local discourses to recognize their statuses, tracing individual or institutional narratives to collective “root” meta-narratives, and emancipation of those who are discriminated against or not recognized in their formal civil rights.

Article

Ndola Prata and Karen Weidert

Adolescence, spanning 10 to 19 years of age, begins with biological changes while transitioning from a social status of a child to an adult. For millions of adolescents in low- and middle-income countries (LMICs), this is a period of exposure to vulnerabilities and risks related to sexual and reproductive health (SRH), compounded by challenges in having their SHR needs met. Globally, adolescent sexual and reproductive ill-health disease burden is concentrated in LMICs, with sexually transmitted infections and complications from pregnancy and childbirth accounting for the majority of the burden. Adolescents around the world are using their voices to champion access to high-quality, comprehensive SRH information and services. Thus, it is imperative that adolescents’ SRH and rights be reinforced and that investments in services be prioritized.

Article

Aurea Maria Zöllner Ianni and Patricia Tavares Ribeiro

The second half of the 20th century saw the development of social thought in health in Latin America and the Caribbean in which the social sciences had a central role. Such an innovative development was based on the understanding that health and disease are social processes that require the understanding of different health contexts. The origins of this development dates back to the renewal of medical teaching in Latin America, which had important support from the Pan-American Health Organization. The so-called field of social sciences in health then took shape, especially beginning in the 1970s and 1980s. The social sciences became part of teaching and assistance activities in social medicine and public health in many countries and contributed to consolidating postgraduate programs and networks of professors, researchers, professionals, and government agents who were active in public health actions and policies. Regarding Latin American realities, the issues of inequality in incidences of sickness and death and in the healthcare delivered to populations became relevant during this time. In close dialogue with relevant social groups, these actors have been significant in constructing responses to health problems in the region. Given the profound political, social, economic, environmental, and sanitary changes that took place in the transition from the 20th to the 21st century, social thought has attempted to meet the new empirical as well as theoretical and conceptual challenges to social sciences as applied to health. The analysis of the trajectory of this regional development, its details, advancements, and limits, is an important endeavor that should help to encourage suggestions toward bettering public health as well as fairness in these times of uncertainties and of new risks for humanity, as evidenced in an unprecedented way in the handling of the Covid-19 pandemic.

Article

The design of municipal water tariffs requires balancing multiple criteria such as financial self-sufficiency for the service provider, equity among customers, and economic efficiency for society. Globally, various forms of water tariffs are in use (e.g., tariffs based on fixed or volumetric charges, single and two-part tariffs, and increasing or decreasing block tariffs) but increasing block tariffs (IBTs) have become popular worldwide over the last few decades for two main reasons. Apart from the fact that IBTs incentivize households to save water by charging large volumes at a higher price, there is a widespread belief that IBTs are pro-poor. The latter would be the consequence of providing all households with a minimum amount of water at a low (subsidized) price while large water users pay higher prices. However cross-subsidization between wealthy and poor households will occur only if poor households’ consumption falls in the low (subsidized) block and if rich households consume in the higher block and pay a price that is above the average cost of supply. These two conditions are rarely met in reality and IBTs often fail to allocate subsidies to the poor effectively. There are a few examples of water utilities making adjustments to the tariff to take into account that poor households with large families are likely to be adversely affected by IBTs. However, the provision of a minimum amount of water for free (as in South Africa), the design of household-specific low-cost water allowances (as in California), or tariffs being adjusted based on household size do not usually improve the targeting of subsidies to the poorest households. The widespread use of IBTs is difficult to rationalize, in particular while knowing that the use of a (simple) uniform volumetric tariff where water provision is charged at its full cost could improve social welfare by removing price distortions and would be easier for households to understand than IBTs. This simple tariff could be combined with some consumer assistance programs to help the poorest households pay their bills.

Article

Water planners and policy analysts need to pay closer attention to the behavioral aspects of water use, including the use of nonprice measures such as norms, public communications, and intrinsic motivations. Empirical research has shown that people are motivated by normative as well as economic incentives when it comes to water. In fact, this research finds that after exposure to feedback about water use, adding an economic incentive (rebate) for reducing water use holds no additional power. In other cases, nonprice measures can be a way to increase the salience, and subsequently, effectiveness of any adopted pricing mechanisms. We review these empirical findings and locate them within more general literature on normative incentives for behavioral change. Given increasing water scarcity and decreasing water security in cities, policy planners need to make more room for normative incentives when designing rules for proenvironmental behavior.

Article

Lillian Abracinskas and Santiago Puyol

As time goes by, the world experiences advances and setbacks in the field of sexual and reproductive health and rights. But new challenges appear in terms of professional performance and implementation of services created by newer laws and policies. The development of new ethical frames in dialogue with disputed value systems is one of the main obstacles to ensuring universal access and comprehensive services to guarantee the exercise of these rights. Since 2002, Uruguay has been one of the few countries in Latin America and the Caribbean that has achieved significant advances regarding sexual and reproductive rights by recognizing them as human rights. The passage of several laws has resulted in the implementation of programs in SRHS and legal abortion as being considered mandatory for the National Health System. The follow-up and monitoring of this process by the Observatory of Mujer y Salud en Uruguay (MYSU) has demonstrated how changes in the legal framework led to a new stage for health-care providers, politicians, and decision makers and also for the social movement that has historically advocated for this agenda, all now facing new problems and challenges—some of which are completely unexpected. The high prevalence of conscientious objection exercised by physicians and OB/GYNs in refusing the provision of care in SRHS is one of the ethical dilemmas that needs to be discussed to innovate solutions to the problems and promote best practices from a gender equity and human rights paradigm.

Article

Marie Thoma, Jasmine Fledderjohann, Carie Cox, and Rudolph Kantum Adageba

Infertility remains a neglected area in sexual and reproductive health, yet its consequences are staggering. Infertility is estimated to impact about 10–25% (estimates range from 48 to 180 million) of couples of reproductive age worldwide. It is associated with adverse physical and mental health outcomes, financial distress, severe social stigma, increased risk of domestic abuse, and marital instability. Although men and women are equally likely to be infertile, women often bear the societal burden of infertility, particularly in societies where a woman’s identity and social value are closely tied to her ability to bear children. Despite these consequences, disparities in access to infertility treatment between low- and high-income populations persist given the high cost and limited geographic availability of diagnostic services and assisted reproductive technologies. In addition, a considerable proportion of infertility is a result of preventable factors, such as smoking, sexually transmitted infections, pregnancy-related infection or unsafe abortion, and environmental contaminants. Accordingly, programs that address the equitable prevention and treatment of infertility are not only in keeping with a reproductive rights perspective but can also improve public health. However, progress on infertility as a global concern in the field of sexual and reproductive health and rights is stymied by challenges in understanding the global epidemiology of infertility, including its causes and determinants, barriers to accessing quality fertility care, and a lack of political will and attention to this issue. The tracking and measurement of infertility are highly complex, resulting in considerable ambiguity about its prevalence and stratification in reproduction globally. A renewed global focus on infertility epidemiology, risk factors, and access to and receipt of quality of care will support individuals in trying to reach their desired number and spacing of children and improve overall health and well-being.

Article

Ashley van Niekerk

A burn occurs when cells in the skin or other tissues are destroyed by hot liquids (scalds), hot solids (contact burns), or flames (flame burns). Injuries to the skin or other organic tissue due to radiation, radioactivity, electricity, friction or contact with chemicals are also identified as burns. Globally, burns have been in decline, but are still a major cause of injury, disability, death and disruption in some regions, with about 120,000 deaths and 9 million injuries estimated in 2017. Low-to-middle-income countries carry the bulk of this burden with the majority of all burn injuries occurring in the African and Southeast Asia regions. Thermal injuries are physically painful and may leave disabling scars not only to the skin or the body, but also impair psychological wellbeing. Severe injuries often impose significant psychological, but also educational consequences and social stigmatization, with the consequent adjustments exacerbated by a range of factors, including the circumstances of the burn incident, the severity and site of the injury, the qualities of the affected individual’s personality, and the access to supportive interpersonal and social relationships. The contributions of: economic progress, enhanced environmental and home structures, energy technology, and safety education interventions have been reported as significant for burn prevention. Similarly, legislative and policy frameworks that support access to modern energies such as electricity, govern domestic appliances and heating technology, and control storage and decanting of fossil fuels are important in energy impoverished settings. The recovery of burn survivors is affected by the availability of specialized treatment, physical rehabilitation and psychosocial support to burn victims and families, but which is still limited especially in resource constrained settings.

Article

The COVID-19 pandemic has upended nearly all the safeguarding systems in the lives of children and youth, such as family life, school, extracurricular activities, sports, unstructured social opportunities, health care, and church. With many of the typical promotive and protective factors disrupted all at once, and for so long, the mental health of children and youth has deteriorated in many areas, but not all, and for many children and youth, but not all. It is important to acknowledge, however, that the mental health of children and youth was in crisis before the pandemic, with 1 in 7 children and youth worldwide having a mental disorder. Given the continued decline in this area of health, children and youth may well be on the cusp of a “generational catastrophe” that could involve lasting harms if immediate action is not taken. Of particular concern are marginalized and vulnerable children and youth—they are the ones unduly enduring the brunt of this global crisis. Accordingly, child and youth mental health recovery must be prioritized, along with the reduction of inequity within and across countries. A commitment to public health strategies that never include harming children and youth as a tolerated side effect must also be made.

Article

Célia Landmann Szwarcwald, Maria do Carmo Leal, Wanessa da Silva de Almeida, Mauricio Lima Barreto, Paulo Germano de Frias, Mariza Miranda Theme Filha, Rosa Maria Soares Madeira Domingues, Elisabeth Barboza Franca, Silvana Granado Nogueira da Gama, Cristiano Sigueira Boccolini, and Cesar Victora

Child health has been placed at the forefront of international initiatives for development. The adoption of the Millennium Development Goals has propelled worldwide actions to improve maternal and child health. In the course of the year 2000, the Latin American (LA) countries made marked progress in implementing effective newborn and infant life-saving interventions. Under-five mortality in LA fell by a third between 1990 and 2015, with a sharp decline in diarrheal diseases and respiratory infections. Due to the successful immunization programs in the region, some vaccine-preventable diseases have been eliminated. Many of the LA countries have reached nearly universal coverage of childbirths attended by skilled personnel and >80% coverage for antenatal care. In 2015, 18 countries in the region reported the elimination of mother-to-child transmission for both HIV and syphilis. Although the advances in the public agenda aimed at promoting child health and development in Latin American countries are undeniable, unresolved issues remain. While many stillbirths and neonatal deaths could be averted by improving access to antenatal, intra-partum, and postnatal interventions, Latin America has the highest cesarean rate among all regions of the world with an excessive number of such operations without medical indications. The simultaneous lack and excess of cesarean deliveries in LA countries reflects a model of care that excludes a considerable portion of the population and reveals the persistent gaps and inequalities in the region. One of the main challenges to be faced is the lack of sustainable financing mechanisms to provide integrated and high-quality health care to all children, equal education opportunities, and social services to support disadvantaged families. When planning interventions, equity should be restored as the guiding principle of actions to ensure inclusion and social justice. Children represent the future of society in Latin America and elsewhere. For this reason, social commitment to provide universal child health is the genesis of sustainable development and must be an absolute priority.

Article

Marco Akerman, Gabriela Murillo Sancho, and Samuel Jorge Moysés

Cities have been considered in many places and times a cornerstone of innovation and wealth creation in society, fostering the privilege of more comfortable lives, with existential dignity and producing healthier generations, as well as an important source of pathogenic determinants. The concept of health in cities and its intersectoral relationships unfolds in a new era of urban sociability, mediated by technologies that connect citizens in social networks and in many services provided by digital platforms. All changes have their respective economic and cost-effective impacts. Healthy cities, or smart and sustainable cities, intend to express well-being and the fulfillment of good health among people who enjoy social inclusion, effectively using policies and services concentrated in the most developed cities. However, the extent of the challenges that permeate the current urban civilization cycle is also related to the social inequities manifested in health problems and public mismanagement in cities around the world. It is necessary to think about the integration of the intersectoral habitus of conceptualizing health promotion, considering all its inclusive scope of diversity, without leaving any social and identity group out, with a view to the full realization of healthy cities. There is an ethical, political, and cultural imperative to urgently adopt an ecosocial approach to promoting the health of populations in cities around the world, recognizing the interactions between ecological determinants (all planetary systems and living species) and the very internal dispositions of what constitutes human health.

Article

Climate change has resulted in rising global average temperatures and an increase in the frequency and intensity of extreme weather events, which already has and will yield serious public health consequences, including the risk of diarrheal diseases. Sufficient evidence in the literature has highlighted the association between different meteorological variables and diarrhea incidence. Both low and high temperatures can increase the incidence of diarrheal disease, and heavy rainfall has also been associated with increased diarrhea cases. Extreme precipitation events and floods are often followed by diarrhea outbreaks. Research has also concluded that drought can concentrate pathogens in water sources, which makes it possible for diarrhea pathogens to distribute broadly when the first heavy rain happens. Substantial evidence underscores the important role social, behavioral, and environmental factors may have for the climate-diarrhea relationship. Meteorological factors may further influence the social vulnerability of populations to diarrhea through a variety of social and behavioral factors. Future research should focus on social factors, population vulnerability, and further understanding of how climate change affects diarrhea to contribute to the development of targeted adaptation strategies.

Article

Throughout history, knowledge and practices on the health of populations have had different names: medical police, public health, social medicine, community health, and preventive medicine. To what extent is the Brazilian collective health, established in the 1970s, identified with and differentiated from these diverse movements that preceded it? The analysis of the socio-genesis of a social field allows us to identify the historical conditions that made possible both theoretical formulations and the achievement of technical and social practices. Collective health, a product of transformations within the medical field, constituted a rupture in relation to preventive medicine and public health and hygiene, being part of a social medicine movement in Latin America that, in turn, had identification with European social medicine in the 19th century. Focused on the development of a social theory of health that would support the process of sanitary reform, collective health has been built as a space involving several fields: scientific, bureaucratic, and political. Thus, it brought together health professionals and social scientists from universities, health care services, and social movements. Its scientific subfield has developed, and the sanitary reform project has had several successes related to the organization of a unified health system, which has ensured universal coverage for the population in Brazil. It has incorporated into and dialogued with several reformist movements in international public health, such as health promotion and the pursuit of health equity. Its small relative autonomy stems from subordination to other dominant fields and its dependence on the state and governments. However, its consolidation corresponded to the strengthening of a pole focused on the collective and universal interest, where health is not understood as a commodity, but as a right of citizenship.

Article

Empowerment features prominently in public health and health promotion policy and practice aimed at improving the social determinants of health that impact communities and groups that are experiencing disadvantage and discrimination. This raises two important questions. How should empowerment be understood from the perspective of health and health equity and how can public health practitioners support empowerment for greater health equity? Many contemporary definitions link empowerment to improvements in individual self-care and/or the adoption of “healthier” lifestyles. In contrast, from a health equity perspective community empowerment is understood as sociopolitical processes that engage with power dynamics and result in people bearing the brunt of social injustice exercising greater collective control over decisions and actions that impact their lives and health. There is growing evidence that increased collective control at the population level is associated with improved social determinants of health and population health outcomes. But alongside this, there is also evidence that many contemporary community interventions are not “empowering” for the people targeted and may actually be having negative impacts. To achieve more positive outcomes, existing frameworks need to be used to recenter power in the design, implementation, and evaluation of local community initiatives in the health field. In addition, health professionals and agencies must act to remove barriers to the empowerment of disadvantaged communities and groups. They can do this by taking experiential knowledge more seriously, by challenging processes that stigmatize disadvantaged groups, and by developing sustainable spaces for the authentic participation of lay communities of interest and place in decisions that have an impact on their lives.

Article

Amira M. Khan, Zohra S. Lassi, and Zulfiqar A. Bhutta

Nearly 80% of the world’s population lives in low- and middle-income countries (LMICs) and these regions bear the greatest burden of maternal, neonatal, and child mortality, with most of the deaths occurring at home. Much of global maternal and child mortality is attributable to easily preventable and treatable conditions. However, the challenge lies in reaching the most vulnerable communities, especially the rural populations, making it imperative that maternal, newborn, and child health (MNCH) interventions focus on communities in tandem with facility-based strategies. There is widespread consensus that delivering effective primary health care (PHC) interventions through the continuum of care, starting from pregnancy to delivery and then to the newborn, infant, and the young child, is an integral component of health strategies in high-, middle- and low-income settings. Despite gaps in research, several effective community-based PHC approaches have been proven to impact MNCH positively. Implementation of these strategies is needed at scale in LMICs and in partnership with all stakeholders including the public and private sector. Community-based PHC, operating on the principles of community engagement and community mobilization, is now more critical than ever. Further robust studies are needed to evaluate certain strategies of community-based PHC and their impact on maternal and child health outcomes, such as the use of mobile technology and social franchises. Recognition of community health workers (CHWs) as a formal cadre and the integration of community-based health services within PHC are vital in strengthening efforts to impact maternal, neonatal, and child health outcomes positively. However, despite the importance of community-based PHC for MNCH in LMICs, the existence of a strong health system and skilled workforce is central to achieving positive health outcomes in these regions.

Article

It is well recognized that preexisting social connections and networks help people adapt and provide for more positive outcomes in the aftermath of a disaster. The role of place, of local neighborhood, in helping people to adapt and manage through the difficult times is developing. Neighborhood, the place where people live, can help facilitate the important informal response to disasters—where residents come together and provide mutual support. Features such as well-defined geography, intimate streets, walkable access to social infrastructure and natural spaces, and central meeting places all help to build the social connections that foster community resilience. Another important element is the community-focused groups that are already in place, especially ones with people who know their areas and who to support. Community resilience is a consequence of having good social connections, with social infrastructure helping to facilitate those connections; these are the same social and physical characteristics of neighborhoods that influence local health and well-being. The main message is that it is possible to develop urban environments in a way that provides multiple benefits. Social connections make people happier and healthier; they can learn from village life that can improve their future living environments, ones that are healthy and resilient. A vibrant well-connected neighborhood community with walkable access to natural spaces, to local shops and schools, and to places for locals to gather is healthy, self-reliant, and more resilient.

Article

Ine Vanwesenbeeck

Comprehensive sexuality education (CSE) is increasingly accepted as the most preferred way of structurally enhancing young peoples’ sexual and reproductive well-being. A historical development can be seen from “conventional,” health-based programs to empowerment-directed, rights-based approaches. Notably the latter have an enormous potential to enable young people to develop accurate and age-appropriate sexual knowledge, attitudes, skills, intentions, and behaviors that contribute to safe, healthy, positive, and gender-equitable relationships. There is ample evidence of program effectiveness, provided basic principles are adhered to in terms of content (e.g., adoption of a broad curriculum, including gender and rights as core elements) and delivery (e.g., learner centeredness). Additional and crucial levers of success are appropriate teacher training, the availability of sexual health services and supplies, and an altogether enabling (school, cultural, and political) context. CSE’s potential extends far beyond individual sexual health outcomes toward, for instance, school social climates and countries’ socioeconomic development. CSE is gaining worldwide political commitment, but a huge gap remains between political frameworks and actual implementation. For CSE to reach scale and its full potential, multicomponent approaches are called for that also address social, ideological, and infrastructural barriers on international, national, and local levels. CSE is a work never done. Current unfinished business comprises, among others, fighting persevering opposition, advancing equitable international cooperation, and realizing ongoing innovation in specific content, delivery, and research-methodological areas.

Article

Organizations regulating the water sector have major impacts on public health and the sustainability of supply to households, industry, power generation, agriculture, and the environment. Access to affordable water is a human right, but it is costly to produce, as is wastewater treatment. Capital investments required for water supply and sanitation are substantial, and operating costs are significant as well. That means that there are trade-offs among access, affordability, and cost recovery. Political leaders prioritize goals and implement policy through a number of organizations: government ministries, municipalities, sector regulators, health agencies, and environmental regulators. The economic regulators of the water sector set targets and quality standards for water operators and determine prices that promote the financial sustainability of those operators. Their decisions affect drinking water safety and sanitation. In developing countries with large rural populations, centralized water networks may not be feasible. Sector regulators often oversee how local organizations ensure water supply to citizens and address wastewater transport, treatment, and disposal, including non-networked sanitation systems. Both rural and urban situations present challenges for sector regulators. The theoretical rationale for water-sector regulation address operator monopoly power (restricting output) and transparency, so customers have information regarding service quality and operator efficiency. Externalities (like pollution) are especially problematic in the water sector. In addition, water and sanitation enhance community health and personal dignity: they promote cohesion within a community. Regulatory systems attempt to address those issues. Of course, government intervention can actually be problematic if short-term political objectives dominate public policy or rules are established to benefit politically powerful groups. In such situations, the fair and efficient provision of water and sanitation services is not given priority. Note that the governance of economic regulators (their organizational design, values or principles, functions, and processes) creates incentives (and disincentives) for operators to improve performance. Related ministries that provide oversight of the environment, health and safety, urban and housing issues, and water resource management also influence the long-term sustainability of the water sector and associated health impacts. Ministries formulate public policy for those areas under their jurisdiction and monitor its implementation by designated authorities. Ideally, water-sector regulators are somewhat insulated from day-to-day political pressures and have the expertise (and authority) to implement public policy and address emerging sector issues. Many health issues related to water are caused or aggravated by lack of clean water supply or lack of effective sanitation. These problems can be attributed to lack of access or to lack of quality supplied if there is access. The economic regulation of utilities has an effect on public health through the setting of quality standards for water supply and sanitation, the incentives provided for productive efficiency (encouraging least-cost provision of quality services), setting tariffs to provide cash flows to fund supply and network expansion, and providing incentives and monitoring so that investments translate into system expansion and better quality service. Thus, although water-sector regulators tend not to focus directly on health outcomes, their regulatory decisions determine access to safe water and sanitation.

Article

For decades, researchers have been puzzled by the finding that despite low socioeconomic status, fewer social mobility opportunities, and access barriers to health care, some migrant groups appear to experience lower mortality than the majority population of the respective host country (and possibly also of the country of origin). This phenomenon has been acknowledged as a paradox, and in turn, researchers attempted to explain this paradox through theoretical interpretations, innovative research designs, and methodological speculations. Specific focus on the salmon effect/bias and the convergence theory may help characterize the past and current tendencies in migrant health research to explain the paradox of healthy migrants: the first examines whether the paradox reveals a real effect or is a reflection of methodological error, and the second suggests that even if migrants indeed have a mortality advantage, it may soon disappear due to acculturation. These discussions should encompass mental health in addition to physical health. It is impossible to forecast the future trajectories of migration patterns and equally impossible to always accurately predict the physical and mental health outcomes migrants/refugees who cannot return to the country of origin in times of war, political conflict, and severe climate change. However, following individuals on their path to becoming acculturated to new societies will not only enrich our understanding of the relationship between migration and health but also contribute to the acculturation process by generating advocacy for inclusive health care.

Article

Concerns about water affordability have centered on access to networked services in low-income countries, but have grown in high-income countries as water, sewer, and stormwater tariffs, which fund replacement of aging infrastructure and management of demand, have risen. The political context includes a UN-recognized human right to water and a set of Sustainable Development Goals that explicitly reference affordable services in water, sanitation, and other sectors. Affordability has traditionally been measured as the ratio of combined water and sewer bills divided by total income or expenditures. Subjective decisions are then made about what constitutes an “affordable” ratio, and the fraction paying more than this is calculated. This measurement approach typically omits the coping costs associated with poor supply, notably the time costs of carrying water home. Three less commonly used approaches include calculating (a) the expenditure related to procuring a “lifeline” quantity of water as a percent of income or expenditures, (b) the amount of income left for other needs after water and sewer expenditures are subtracted, and (c) the number of hours of minimum wage work needed to purchase an essential quantity of water. Lowering water rates for all customers does not necessarily help those in need in low- and middle-income countries. This includes tariff structures that subsidize the price of water in the lowest block or tier (i.e., lifeline blocks) for all customers, not just the poor. Affordability programs that do not operate through tariffs can be characterized by (a) how they are administered and funded, (b) how they target the poor, and (c) how they deliver subsidies to the poor. Common types of delivery mechanisms include subsidizing public taps for unconnected households, subsidizing or financing the fees associated with obtaining a connection to the piped network, and subsidizing monthly bills for poor households. Means-tested consumption subsidies are most common in industrialized countries, whereas subsidizing public taps and connection fees are more common in low- and middle-income countries. A final challenge is directing subsidies to renters who are more likely to be poor and who do not have a direct relationship with a water utility because they pay for water through their landlord, either included as part of their rent or as a separate water payment. Based on data from the 2013 American Housing Survey, approximately 21% of all housing units in the United States are occupied by this type of “hard to reach” customer, although not all of them would be considered poor or eligible for an assistance program. This ratio is as high as 74% of all housing units in metropolitan areas like New York City. Because of data limitations, there are no similar estimates in low-income countries. Instead of sector-by-sector affordability policies, governments might do better to think about the entire package of services a poor person has a perceived right to consume. Direct income support, calculated to cover a package of basic services, could then be delivered to the poor, preserving their autonomy to make spending decisions and preserving the appropriate signals about resource scarcity.