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Article

Aminur Rahman, Amy E. Peden, Lamisa Ashraf, Daniel Ryan, Al-Amin Bhuiyan, and Stephen Beerman

Drowning has been described as a major global public health problem and has recently been acknowledged by a United Nations Declaration on Global Drowning Prevention. While drowning impacts countries of all income levels, the burden is overwhelmingly borne by low- and middle-income countries (LMICs) who account for 90% of the global death toll. In addition, there is scarce data collection on drowning in LMICs, so the magnitude of drowning may be far greater than is represented. A range of factors including sex, age, education, income, access to water, a lack of swimming skills, certain occupations like commercial fishing, geographically isolated and flood-prone locations, preexisting medical conditions, and unsafe water transport systems, influence the risk of drowning. Some behavioral factors, such as alcohol or drug consumption, not wearing life jackets, and engaging in risky behaviors such as swimming or boating alone, increase drowning risk. Geopolitical factors such as migration and armed conflict can also impact drowning risk. There is a growing body of evidence on drowning prevention strategies. These include pre-event interventions such as pool fencing, enhancing community education and awareness, providing swimming lessons, use of lifejackets, close supervision of children by adults, and boating regulations. Interventions to reduce harm from drowning include appropriate training for recognition of a drowning event, rescue, and resuscitation. An active and/or passive surveillance system for drowning, focusing on individual settings and targeting populations at risk, is required. Drowning requires coordinated multisectoral action to provide effective prevention, rescue, and treatment. Therefore, all countries should aim to develop a national water safety plan, as recommended in the WHO Global Report on Drowning. Further research is required on the epidemiology and treatment of drowning in LMICs as well as non-fatal and intentional drowning in both high-income countries (HICs) and LMICs. Effective and context-specific implementation of drowning prevention strategies, including pilot testing, scale up and evaluation, are likely to help reduce the burden of both fatal and non-fatal drowning in all countries.

Article

Deisy Ventura, Jameson Martins da Silva, Leticia Calderón, and Itzel Eguiluz

The World Health Organization has recognized health as a right of migrants and refugees, who are entitled to responsive healthcare policies, due to their particular social determinants of health. Migrants’ and refugees’ health is not only related to transmissible diseases but also to mental health, sexual and reproductive health, and non-communicable diseases, such as diabetes. Historically, however, migration has been linked to the spread of diseases and has often artificially served as a scapegoat to local shortcomings, feeding on the xenophobic rhetoric of extremist groups and political leaders. This approach fosters the criminalization of migrants, which has led to unacceptable violations of human rights, as demonstrated by the massive incarceration and deportation policies in developed countries, for example, the United States under the Trump administration. In Latin America and the Caribbean, in particular, there have been legal developments, such as pioneering national legislation in Argentina in 2004 and Brazil in 2017, which suggest some progress in the direction of human rights, although in practice drawbacks abound in the form of countless barriers for migrants to access and benefit from healthcare services in the context of political turmoil and severe socioeconomic inequality. The COVID-19 pandemic has exposed and enhanced the effects of such inequality in the already frail health conditions of the most disenfranchised, including low-income migrants and refugees; it has both caused governments in Latin America to handle the crisis in a fragmented and unilateral fashion, ignoring opportunities to cooperate and shield the livelihoods of the most vulnerable, and served as a pretext to sharpen the restrictions to cross-border movement and, ultimately, undermine the obligation to protect the dignity of migrants, as the cases of Venezuela and the U.S.-Mexico border illustrate. Still, it could represent an opportunity to integrate the health of migrants to the public health agenda as well as restore cooperation mechanisms building on previous experiences and the existing framework of human rights organizations.

Article

Suzanne O. Bell, Mridula Shankar, and Caroline Moreau

Induced abortion is a common reproductive experience, with more than 73 million abortions occurring each year globally. Worldwide, the annual abortion incidence decreased in the 1990s and the early decades of the 21st century, but this decline has been driven by high-resource settings, whereas abortion rates in low- and middle-resource countries have remained stable. Induced abortion is a very safe procedure when performed according to World Health Organization guidelines; however, legal restrictions, stigma, cost, lack of resources, and poor health system accountability limit the availability, accessibility, and use of quality abortion care services. Even as women’s use of safer self-managed medication abortion options becomes more common in some parts of the world, 45% of all abortions annually are unsafe, nearly all of which occur in low- and middle-resource settings, where unsafe abortion remains a primary cause of maternal death. Beyond country-level legal and health care system factors, significant disparities exist in women’s reliance on unsafe abortion. Even among women who receive a safe abortion, quality of care is often poor. Yet abortion’s precarious status as a health care service and its clandestine practice have precluded a systematic focus on quality monitoring and evaluation of service inputs. Improving abortion and postabortion care quality is essential to meeting this reproductive health need, as are efforts to prevent abortion-related mortality and morbidity more broadly. This requires a three-tier approach: primary prevention to reduce unintended pregnancy, secondary prevention to make abortion procedures safer, and tertiary prevention to reduce the negative sequelae of unsafe abortion procedures. Strategies include two complementary approaches: vulnerability reduction and harm reduction, the first focusing on the root causes of unsafe abortion by addressing the determinants of unwanted pregnancy and clandestine abortion, while the latter addresses the harmful consequences of clandestine abortion. Political commitments to extend service coverage of abortion and postabortion care need to be implemented through actions that build the public health system’s capacity. Beyond the model of receiving care exclusively in clinical settings, models of guided self-managed abortion are expanding the capacity of individuals to take evidence-based actions to terminate their pregnancies safely and without the threat of judgment. Research has strived to keep up with the changes in the abortion care landscape, but there remains a continuing need to improve methodologies to generate robust evidence to identify and address inequities in abortion care and its health consequences in a diversified landscape. Doing so will provide information for stakeholders to take actions toward a new era of health care reforms that repositions abortion as an integral component of sexual and reproductive health care.

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

Charley E. Willison and Amanda I. Mauri

Homelessness is a public health challenge for modern governments. Homelessness emerged as a formal policy problem for rich nations in the mid- to late 20th century as nations developed stable economies and democracies, including housing and job markets, and social welfare mechanisms to protect citizens from disenfranchisement. In early 21st-century Organisation for Economic Co-operation and Development (OECD) nations, homelessness arises most often among at-risk or vulnerable populations, such as historically marginalized groups and/or persons with constrained access to welfare state mechanisms, such as immigrants or refugees. Thus, homelessness in OECD nations is very different from informal housing or mass poverty in poor nations and/or non-democratic regimes. Homelessness affects individual and population health, requiring complex policy solutions across multiple domains of health, as well as intergovernmental coordination. Policy responses to homelessness vary across OECD nations in their approach and efficacy. There are four key factors influencing how OECD nations respond to homelessness: (a) the strength and inclusivity of the welfare state; (b) degrees of decentralization in homeless policy governance; (c) the strength, capacity, and inclusivity of the health and behavioral healthcare systems; and (d) the role of federated structures in health and welfare state policy. Overall, nations with weaker welfare states and health/behavioral healthcare systems face greater risks of homelessness. The inclusivity of these systems also shapes who may be eligible for protection or experience homelessness. Local governments, especially those in large metropolitan areas, are the frontline providers of homelessness services. Yet local governments are constrained at both ends: Policies designed, delivered, and funded at larger units of government—such as welfare state provisions—influence many of the determinants of homelessness, such as housing, and the resources available to subnational actors to combat homelessness. Local actors are also constrained by the degree of decentralization. Devolution of homelessness policy to smaller units of government or even solely to nongovernmental actors, through federated mechanisms or decentralization, may create barriers to locally tailored solutions by perpetuating disparities across jurisdictions and/or constraining authority and resources necessary to design or deliver homeless policy.

Article

Accounting for about 15% of the world’s population, persons with disabilities constitute a critical population. Despite a substantial knowledge base in disability and public health, persons with disabilities have been remarkably invisible within general global public health. Public health’s view of disability is shifting from regarding disability only as an outcome to prevent, to using disability as a demographic characteristic that identifies a population experiencing a range of inequities. Alternative models of disability reflect how disability has been viewed over time. These models vary in their underlying values and assumptions, whether the locus of disability is the individual or the environment or their interaction, who designates “disability,” and the focus of intervention outcomes. The United Nations flagship report on Disability and Sustainable Development Goals, 2018 documents that, as a group, the lives of persons with disabilities are marked by large disparities in Sustainable Development Goal indicators. These include increased likelihood of experiencing poverty, hunger, poor health, and unemployment, and greater likelihood of encountering barriers to education and literacy, clean water and sanitation, energy, and information technology. Overall, persons with disabilities experience greater inequalities, and this is particularly experienced by women and girls with disabilities. The COVID-19 pandemic and other disasters have highlighted the gaps in equality and consequent vulnerability of this population. Global disability data have improved dramatically during the decade from 2010 to 2020 with the advent of standardized disability question sets (Washington Group) and model surveys (Model Disability Survey). New studies from the Global South and North identify areas and strategies for interventions that can effectively advance the Sustainable Development Goals. This call-to-action outlines strategies for increasing visibility and improving wellbeing of persons with disabilities, particularly in the Global South. Increased visibility of the disability population within the global public health community can be achieved through active engagement of persons with disabilities. Improved collection of disability data and routine analysis by disability status can provide information vital to planning and policies. A twin-track approach can provide direction for interventions—inclusion in mainstream programs where possible, use of disability-specific and rehabilitation approaches where necessary. The article ends by outlining ways that multiple roles can increase the inclusion of persons with disabilities in global public health.

Article

Jeff Levin and Ellen Idler

Religion, in both its personal and institutional forms, is a significant force influencing the health of populations across the life course. Decades of research have documented that expressions of faith and the practice of spiritual pursuits exhibit significantly protective effects for physical and mental health, psychological well-being, and population rates of morbidity, mortality, and disability. This finding has been observed across sociodemographic categories, across nations and cultures, across specific disease outcomes, and regardless of one’s religious affiliation. A salutary religious effect on health and well-being is especially apparent among older adults, but is also observed across generations and age cohorts. Moreover, this association has been persistently found for various religious indicators, including attendance at worship services, prayer and other private practices, subjective feelings of religiosity, and numerous measures of religious behaviors, attitudes, beliefs, and experiences. Finally, a protective or primary preventive effect of religion has been observed in clinical, epidemiologic, social, and behavioral studies, regardless of research design or methodology. Faith-based organizations also have contributed to the health of populations, in partnerships or alliances with medical institutions and public health agencies, many of these dating back many decades. Examples include congregational health promotion and disease prevention programs and community-wide interventions, especially targeting the health and well-being of older congregants and those in less well-resourced communities, as well as faith–health partnerships in healthcare delivery, public health policymaking, and legislative advocacy for healthcare reform. Religious denominations and institutions also play a substantial role in global health development throughout the world, individually and in partnership with national health ministries, transnational medical mission organizations, and established nongovernmental agencies. These efforts focus on a wide range of goals and objectives, including building public health infrastructure, addressing ongoing environmental health needs, and responding to acute public health challenges and crises, such as infectious disease outbreaks. Constituencies include at-risk populations and cohorts throughout the life course, and programming ranges from perinatal care to maternal and child healthcare to geriatric medicine.

Article

Karen Setty and Giuliana Ferrero

Water safety plans (WSPs) represent a holistic risk assessment and management approach covering all steps in the water supply process from the catchment to the consumer. Since 2004, the World Health Organization (WHO) has formally recommended WSPs as a public health intervention to consistently ensure the safety of drinking water. These risk management programs apply to all water supplies in all countries, including small community supplies and large urban systems in both developed and developing settings. As of 2017, more than 90 countries had adopted various permutations of WSPs at different scales, ranging from limited-scale voluntary pilot programs to nationwide implementation mandated by legislative requirements. Tools to support WSP implementation include primary and supplemental manuals in multiple languages, training resources, assessment tools, and some country-specific guidelines and case studies. Systems employing the WSP approach seek to incrementally improve water quality and security by reducing risks and increasing resilience over time. To maintain WSP effectiveness, water supply managers periodically update WSPs to integrate knowledge about prior, existing, and potential future risks. Effectively implemented WSPs may translate to positive health and other impacts. Impact evaluation has centered on a logic model developed by the Centers for Disease Control and Prevention (CDC) as well as WHO-refined indicators that compare water system performance to pre-WSP baseline conditions. Potential benefits of WSPs include improved cost efficiency, water quality, water conservation, regulatory compliance, operational performance, and disease reduction. Available research shows outcomes vary depending on site-specific context, and challenges remain in using WSPs to achieve lasting improvements in water safety. Future directions for WSP development include strengthening and sustaining capacity-building to achieve consistent application and quality, refining evaluation indicators to better reveal linked outcomes (including economic impacts), and incorporating social equity and climate change readiness.

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

Globally, countries have followed demographic transition theory and transitioned from high levels of fertility and mortality to lower levels. These changes have resulted in the improved health and well-being of people in the form of extended longevity and considerable improvements in survival at all ages, specifically among children and through lower fertility, which empowers women. India, the second most populous country after China, covers 2.4% of the global surface area and holds 18% of the world’s population. The United Nations 2019 medium variant population estimates revealed that India would surpass China in the year 2030 and would maintain the first rank after 2030. The population of India would peak at 1.65 billion in 2061 and would begin to decline thereafter and reach 1.44 billion in the year 2100. Thus, India’s experience will pose significant challenges for the global community, which has expressed its concern about India’s rising population size and persistent higher fertility and mortality levels. India is a country of wide socioeconomic and demographic diversity across its states. The four large states of Uttar Pradesh, Bihar, Madhya Pradesh, and Rajasthan accounted for 37% of the country’s total population in 2011 and continue to exhibit above replacement fertility (that is, the total fertility rate, TFR, of greater than 2.1 children per woman) and higher mortality levels and thus have great potential for future population growth. For example, nationally, the life expectancy at birth in India is below 70 years (lagging by more than 3 years when compared to the world average), but the states of Uttar Pradesh and Rajasthan have an average life expectancy of around 65–66 years. The spatial distribution of India’s population would have a more significant influence on its future political and economic scenario. The population growth rate in Kerala may turn negative around 2036, in Andhra Pradesh (including the newly created state of Telangana) around 2041, and in Karnataka and Tamil Nadu around 2046. Conversely, Uttar Pradesh, Bihar, Madhya Pradesh, and Rajasthan would have 764 million people in 2061 (45% of the national total) by the time India’s population reaches around 1.65 billion. Nationally, the total fertility rate declined from about 6.5 in early 1960 to 2.3 children per woman in 2016, a result of the massive efforts to improve comprehensive maternal and child health programs and nationwide implementation of the national health mission with a greater focus on social determinants of health. However, childhood mortality rates continue to be unacceptably high in Uttar Pradesh, Bihar, Rajasthan, and Madhya Pradesh (for every 1,000 live births, 43 to 55 children die in these states before celebrating their 5th birthday). Intertwined programmatic interventions that focus on female education and child survival are essential to yield desired fertility and mortality in several states that have experienced higher levels. These changes would be crucial for India to stabilize its population before reaching 1.65 billion. India’s demographic journey through the path of the classical demographic transition suggests that India is very close to achieving replacement fertility.