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Solveig A. Cunningham and Hadewijch Vandenheede
There are over 230 million international migrants worldwide, and this number continues to grow. Migrants tend to have limited access to and knowledge about resources and preventative care in their communities of reception, but nonetheless they are often in better health by many measures compared with native-born people in their communities of reception and with the people they left behind at their place of origin. With time since arrival, however, immigrants’ health advantages often dissipate and they experience increases in health problems, especially obesity and diabetes, which are chronic diseases that are increasingly prevalent in the overall population as well and are associated with multiple co-morbidities and limitations. It may be that immigrants have specific health endowments leading to these health patterns, or that the processes involved in migration, including exposure to new environments, behavioral change, and stress of migration may also affect risks of obesity and other chronic conditions. Understanding the health patterns of migrants can be useful in identifying their specific health needs, as well as contributing to our understanding of how specific environments, changes in environments, and individual health endowments interplay to shape the long-term health of populations.
Emily Q. Ahonen
Occupational health and safety concerns classically encompass conditions and hazards in workplaces which, with sufficient exposure, can lead to injury, distress, illness, or death. The ways in which work is organized and the arrangements under which people are employed have also been linked to worker health. Migrants are people who cross borders away from their usual place of residence, and about one in seven people worldwide is a migrant. Terms like “immigrant” and “emigrant” refer to the direction of that movement relative to the stance of the speaker. Any person who might be classified as a migrant and who works or seeks to work is an immigrant worker and may face challenges to safety, health, and well-being related to the work he or she does. The economic, legal, and social circumstances of migrant workers can place them into employment and working conditions that endanger their safety, health, or well-being. While action in support of migrant worker health must be based on systematic understanding of these individuals’ needs, full understanding the possible dangers to migrant worker health is limited by conceptual and practical challenges to public health surveillance and research about migrant workers. Furthermore, intervention in support of migrant worker health must balance tensions between high-risk and population-based approaches and need to address the broader, structural circumstances that pattern the health-related experiences of migrant workers. Considering the relationships between work and health that include but go beyond workplace hazards and occupational injury, and engaging with the ways in which structural influences act on health through work, are complex endeavors. Without more critically engaging with these issues, however, there is a risk of undermining the effectiveness of efforts to improve the lot of migrant workers by “othering” the workers or by failing to focus on what is causing the occupational safety and health concern in the first place—the characteristics of the work people do. Action in support of migrant workers should therefore aim to ameliorate structural factors that place migrants into disadvantageous conditions while working to improve conditions for all workers.
Maria Cristina Schneider, Claudia Munoz-Zanzi, Kyung-duk Min, and Sylvain Aldighieri
The vision that everything is connected in this world is not new. However, to respond to the current challenges that the world is facing, the integrated vision that humans, animals, and the environment are linked is more important than ever. Collaboration among multiple disciplines is crucial, and this approach is fundamental to understanding the One Health concept.
A transdisciplinary definition of One Health views animals, humans, and their shared settings or environment as linked and affected by the socioeconomic interest of humans and external pressures. A One Health concept calls for various disciplines to work together to provide new methods and tools for research and implementation of effective services to support the formulation of norms, regulations, and policies to the benefit of humanity, animals, and the environment for current and future generations. This will improve the understanding of health and disease processes as well as prediction, detection, prevention, and control of infectious hazards and other issues affecting health and well-being in the human-animal-ecosystem interface, contributing to sustainable development goals, and to improving equity in the world.
Colin Binns and Mi Kyung Lee
Breastfeeding is one of the best public health “buys” available for countries at all levels of development. In the first year of life, appropriate infant nutrition (exclusive breastfeeding to around 6 months) reduces infant mortality and hospital admissions by 50% or more. Early life nutrition has important influences, including on childhood illnesses, obesity, cognitive development, hospitalizations, and later chronic disease. Breastfeeding is consistent with the historical cultural practices of all societies, and its benefits of breastfeeding last a lifetime. While the development of infant formula has been of benefit to some infants, its inappropriate promotion has resulted in a decline of breastfeeding, and, as a result, health gains in many countries have not been as great as they could have been. The health benefits of breastfeeding will provide some protection against the effects of climate change, which will cause a decline in potable water supplies and increases in the incidence of some infections. Infant formula production has very high environmental costs, while breastfeeding as well as being the best infant feeding intervention also has very low environmental impact. An important part of the sustainable development agenda must be to promote breastfeeding and its benefits and to reverse the inappropriate promotion and use of infant formula.
There are an estimated 300 million indigenous peoples worldwide. Although there is ample evidence of worse health and social outcomes for the majority of indigenous peoples, compared to their non-indigenous counterparts, there has yet to be a review of racism as a determinant of indigenous health using global literature. Racism constitutes unfair and avoidable disparities in power, resources, capacities, or opportunities centered on ethnic, racial, religious, or cultural differences that can occur at three levels: internalized, interpersonal, or systemic. For indigenous peoples this is closely related to ongoing processes of colonization. Available research suggests that at least a third of indigenous adults experience racism at least once during their lives and that about a fifth of indigenous children experience racism. For indigenous peoples, racism has been associated with a considerable range of health outcomes, including psychological distress, anxiety, depression, suicide, posttraumatic stress disorder, asthma, physical illness, obesity, cardiovascular disease, increased blood pressure, excess body fat, poor sleep, reduced general physical and mental health, and poor oral health, as well as increased alcohol, tobacco, and marijuana use and underutilization of medical and mental healthcare services. Disparities in medical care experienced by indigenous patients compared to non-indigenous patients have also been found. Existing studies indicate that avoidant and passive coping tends to exacerbate the detrimental health impacts of racism for indigenous peoples, whereas active coping ameliorates the ill-health effects of racism. Reducing individual and interpersonal racism can be achieved by (a) providing accurate information and improving awareness of the nature of racism and racial bias; (b) activating values of fairness, reconciling incompatible beliefs, and developing antiracist motivation; (c) fostering empathy and perspective-taking and confidence in regulating emotional responses; (d) improving comfort with other groups and reducing anxiety; and (e) reinforcing antiracist social norms and highlighting personal accountability. There are five key areas for combating systemic racism in organizations and institutions: (a) institutional accountability; (b) diversity in human resources; (c) community partnership; (d) antiracism and cultural competence training; and (e) research and evaluation.
The indigenous peoples of Europe and Russia comprise the Inuit in Greenland, the Sami in northern Norway, Sweden, Finland and Russia and forty officially recognized ethnic minority groups in northern Russia plus a few larger-population indigenous peoples in Russia. While the health of the Inuit and Sami has been well studied, information about the health of the indigenous peoples of Russia is considerably scarcer. The overall health of the Sami is in many aspects not very different from that of their non-indigenous neighbors in northern Scandinavia; the health of the Inuit is similar across Greenland and North America and far less favorable than that of Denmark, southern Canada and the lower 48 American states, respectively; the health of the indigenous peoples of the Russian north is poor, partly due to poverty and alcohol.
This is an advance summary of a forthcoming article in the Oxford Research Encyclopedia of Global Public Health. Please check back later for the full article.
The People’s Health Movement (PHM) is a vibrant, global network bringing together grassroots health activists; civil society organizations; issue-based networks; academic institutions; and individuals from around the world, particularly the Global South. Since its inception in 2000, PHM has played a significant role in revitalizing Health for All (HFA) initiatives; and addressing underlying health determinants with a social justice perspective at global, national, and local levels. Members engage critically and constructively in health initiatives, health policy advocacy, and action. They undertake capacity building of community activists to participate in monitoring health-related policies and in governance of health systems. They play a crucial role in keeping Comprehensive Primary Health Care (CPHC) as a strategy to strengthen public health systems; in developing mechanisms to address the societal or social determinants of health; and in ensuring that people’s voices are part of decision making processes. PHM has an evolving presence in over 80 countries worldwide, consisting of groups of individuals and/or well-established circles with their own governance and information-sharing mechanisms. Additionally, there are issue-based circles across different countries.
David Sanders and Louis Reynolds
The global project to achieve Health for All through Primary Health Care (PHC) is a profoundly political one. In seeking to address both universal access to health care and the social determinants of health (SDH) it challenges power blocs which have material vested interests in technical approaches to health and development.
The forces that have shaped PHC include Community Oriented Primary Care and the Health Centre Movement, the “basic health services approach,” and nongovernmental and national initiatives that exemplified comprehensive and participatory approaches to health development. The 1978 Alma-Ata Declaration codified these experiences and advocated Health for All by the year 2000 through PHC. It emphasized equitable and appropriate community and primary-level health care as well as intersectoral actions and community participation to address the social and environmental determinants of health. This would need the support of a new international economic order.
The concept of “Selective Primary Health Care” emerged soon after Alma-Ata, privileging a limited set of technical interventions directed at selected groups, notably young children. This was soon operationalized as UNICEF’s Child Survival Revolution. The visionary and comprehensive policy of PHC was further eroded by the 1970s debt crisis and subsequent economic policies including structural adjustment and accelerated neoliberal globalization that deregulated markets and financial flows and reduced state expenditure on public services. This translated, in many countries, as “health sector reform” with a dominant focus on cost efficiency to the detriment of broad developmental approaches to health. More recently this selective approach has been aggravated by the financing of global health through public-private partnerships that fund specific interventions for selected diseases. They have also spawned many “service delivery” NGOs whose activities have often reinforced a biomedical emphasis, supported by large philanthropic funding such as that of the Gates Foundation.
Educational institutions have largely failed to transform their curricula to incorporate the philosophy and application of PHC to inform the practice of students and graduates, perpetuating weakness in its implementation.
Revitalizing PHC requires at least three key steps: improved equity in access to services, a strong focus on intersectoral action (ISA) to address SDH and prioritization of community-based approaches. The third sustainable development goal (SDGs) focuses on health, with universal health coverage (UHC) at its center. While UHC has the potential to enhance equitable access to comprehensive health care with financial protection, realizing this will require public financing based on social solidarity. Groups with vested interests such as private insurance schemes and corporate service providers have already organized against this approach in some countries. The SDGs also provide an opportunity to enhance ISA, since they include social and environmental goals that could also support the scaling up of Community Health Worker programs and enhanced community participation.
However, SDG-8, which proposes high economic growth based substantially on an extractivist model, contradicts the goals for environmental sustainability. Human-induced environmental degradation, climate change, and global warming have emerged as a major threat to health. As presciently observed at Alma-Ata, the success of PHC, and Health for All requires the establishment of a new, ecologically sustainable, economic order.
Eve Dubé and Noni E. MacDonald
Vaccination is one of the greatest public health successes. With sanitation and clean water, vaccines are estimated to have saved more lives over the past 100 years than any other health intervention. Vaccination not only protects the individual, but also, in many instances, provides community protection against vaccine-preventable diseases through herd immunity. To reduce the risk of vaccine-preventable diseases, vaccination programs rely upon reaching and sustaining high coverage rates, but paradoxically, because of the success of vaccination, new generations are often unaware of the risks of these serious diseases and their concerns now concentrate on the perceived risk of individual vaccines. Over the past decades, several vaccine controversies have occurred worldwide, generating concerns about vaccine adverse effects and eroding trust in health authorities, experts, and science. Gaps in vaccination coverage can, in part, be attributed to vaccine hesitancy and not just to “supply side issues” such as access to vaccination services and affordability.
The concept of vaccine hesitancy is now commonly used in the discourse around vaccine acceptance. The World Health Organization defines vaccine hesitancy as “lack of acceptance of vaccines despite availability of vaccination services. Vaccine hesitancy is complex and context specific, varying across time, place and vaccines.” A vaccine-hesitant person can delay, be reluctant but still accept, or refuse one, some, or all vaccines. Technical, psychological, sociocultural, political, and economic factors can contribute to vaccine hesitancy. At the individual level, recent reviews have focused on factors associated with vaccination acceptance or refusal, identifying determinants such as fear of side effects, perceptions around health and prevention of disease and a preference for “natural” health, low perception of the efficacy and usefulness of vaccines, negative past experiences with vaccination services, and lack of awareness or knowledge about vaccination.
Very few interventions have been shown to be effective in reducing vaccine hesitancy. Most of the studies have only focused on metrics of vaccine uptake and refusal to evaluate interventions aimed at enhancing vaccine acceptance, which makes it difficult to assess their potential effectiveness to address vaccine hesitancy. In addition, despite the complex nature of vaccination decision-making, the majority of public health interventions to promote vaccination are designed with the assumption that vaccine hesitancy is due to lack or inadequate knowledge about vaccines (the “knowledge-deficit” or “knowledge gap” approach). A key predictor of acceptance of a vaccine by a vaccine-hesitant person remains the recommendation for vaccination by a trusted healthcare provider. When providers communicate effectively about the value and need for vaccinations and vaccine safety, people are more confident in their decisions. However, to do this well, healthcare providers must be confident themselves about the safety, effectiveness, and importance of vaccination, and recent research has shown that a proportion of healthcare providers are vaccine-hesitant in their professional and personal lives. Effective strategies to address vaccine hesitancy among these hesitant providers have yet to be identified. A better understanding of the dynamics of the underlying determinants of vaccine hesitancy is critical for effective tailored interventions to be designed for both the public and healthcare providers.
Maria Cecília de Souza Minayo and Saul Franco
Violence is a problem that accompanies the trajectory of humanity, but it presents itself in different ways in each society and throughout its historical development. Despite having different meanings according to the field of knowledge from which it is addressed and the institutions that tackle it, there are some common elements in the definition of this phenomenon. It is acknowledged as the intentional use of force and power by individuals, groups, classes, or countries to impose themselves on others, causing harm and limiting or denying rights. Its most frequent and visible forms include homicides, suicides, war, and terrorism, but violence is also articulated and manifested in less visible forms, such as gender violence, domestic violence, and enforced disappearances.
Although attention to the consequences of different forms of violence has always been part of health services, its formal and global inclusion in health sector policies and guidelines is very recent. It was only in 1996 that the World Health Organization acknowledged it as a priority in the health programs of all countries. Violence affects individual and collective health; causes deaths, injuries, and physical and mental trauma; decreases the quality of life; and impairs the well-being of people, communities, and nations. At the same time, violence poses problems for health researchers trying to understand the complexity of its causes, its dynamics, and the different ways of dealing with it. It also poses serious challenges to health systems and services for the care of victims and perpetrators and the formulation of interdisciplinary, multi-professional, inter-sectoral, and socially articulated confrontation and prevention policies and programs.
In different countries and regions of the world—particularly in Latin America and the Caribbean—the term “workers’ health” may have different meanings. From a more traditional perspective, defined on economic and demographic bases, this term introduces a delimitation characterized by economically active people, usually over 10 years of age, of both sexes, and who are working, have worked at some point in their life, or are in search of work. This condition usually ceases in case of retirement or disability. Such a criterion, as can be imagined, is extremely imprecise, particularly in regions such as the ones analyzed here, since it includes great variability of situations, including work considered informal; the work of children and adolescents (prohibited or restricted in accordance with international labor standards); clandestine and illegal work; domestic work (sometimes not formally recognized); and slave and forced labor. It is not clear, either, when work activity actually ceases, especially when there are no social protection systems for elderly and disabled people. But even if this definition is adopted, it is already possible to foresee the complexity of the theme, both in the conceptual perspective and in the scope of health programs, as well as in the health and illness problems of this population.
However, in some countries, the term “workers’ health” (or “worker’s health”) goes beyond the economic or demographic delimitation, and includes a paradigm shift about the role of workers in the struggle for their health. This perspective, political and ideological, originates in the concepts and experience of the “Italian Labor Model”; brings in elements of the Marxist discourses and Liberation Theology; takes advantage of and improves the perspective of “Social Epidemiology” or “Social Medicine”; and, in our continent, can be considered as an unfolding of “Latin American Social Epidemiology.” This understanding of workers’ health also depends on social movements—such as unions and other forms of organizing workers—as well as on political leaders committed to the struggle of workers against precarious work, unemployment and the destruction of already established social rights, especially in the context of neoliberalism.
Therefore, workers’ health is a polysemic and complex concept, and its discussion is a living, dynamic, and extremely rich agenda.