Yudit Namer and Oliver Razum
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.
Luiz Augusto Cassanha Galvao, Volney Câmara, and Daniel Buss
The relationship between environment and health is part of the history of medicine and has always been important to any study of human health and to public-health interventions. In Latin America many health improvements are related to environmental interventions, such as the provision of better water and sanitation services. Latin America’s development, industrialization, and sweeping urbanization have brought many improvements to the well-being of its populations; they have also inaugurated new societies, with new patterns of consumption. The region’s basic environmental-health interventions have needed to be updated and upgraded to include disciplines such as toxicology, environmental epidemiology, environmental engineering, and many others. Multidisciplinary and inter-sector approaches are paramount to understanding new profiles of health and well-being, and to promoting effective public-health interventions.
The new social, economic, labor, and consumption aspects of modern Latin American society have become more and more relevant to understanding the complex interactions in the region’s social, biological, and physical environment, which are essential to explaining some of the emerging and re-emerging public-health problems. Environmental health, as concept and as intervention, is simple and easily understood, but no longer sufficient to achieve the levels of health and well-being expected and required by these new realities. Many global changes such as climate change, biodiversity loss, and mass migrations has been identified as main cause of ill health and are at the center of the sustainable development challenges in general, and many are critical and specific public health. To face this development, other frameworks have emerged, such as planetary health and environmental and social determinants of health. Public health remains central to some, such as the improved environmental-health agenda, while others assign public health a relative position in a variety of overarching frameworks.
Juan Garay, David Chiriboga, Nefer Kelley, and Adam Garay
There is one common health objective among all nations, as stated in the constitution of the World Health Organization in 1947: progress towards the best feasible level of health for all people. This goal captures the concept of health equity: fair distribution of unequal health. However, 70 years later, this common global objective has never been measured. Most of the available literature focuses on measuring health inequalities, not inequities, and compare health indicators (mainly access to health services) among population subgroups.
A method is hereby proposed to identify standards for the best feasible levels of health through criteria of healthy, replicable, and sustainable (HRS) models. Once the HRS model countries were identified, adjusted mortality rates were applied to age- and sex-specific populations from 1950 to 2015, by calculating the net difference between the observed and expected mortality, using the HRS countries as the standard. This difference in mortality represents the net burden of health inequity (NBHiE), measured in avoidable deaths. This burden is due to global health inequity, that is, unfair inequality, due to social injustice. We then calculated the relative burden of health inequity (RBHiE), which is the proportion of NBHiE compared with all deaths. The analysis identified some 17 million avoidable deaths annually, representing around one-third of all deaths during the 2010–2015 period. This avoidable death toll (NBHiE) and proportion (RBHiE) have not changed much since the 1970s. Younger age groups and women are affected the most. When data were analyzed using smaller sample units (such as provinces, states, counties, or municipalities) in some countries, the sensitivity was increased and could detect higher levels of burden of health inequity.
Most of the burden of health inequity takes place in countries with levels of income per capita below the average of the HRS countries, which we call the “dignity threshold.” Based on this threshold, a distribution of the world’s resources compatible with the universal right to health—the “equity curve”—is estimated. The equity curve would hypothetically be between this dignity threshold and a symmetric upper threshold around the world’s average per capita GDP. Such excess income prevents equitable distribution is correlated with a carbon footprint leading to >1.5º global warming (thus undermining the health of coming generations), and does not translate to better health or well-being. This upper threshold is defined as the “excess accumulation threshold.”
The international redistribution required to enable all nations to have at least an average per capita income above the dignity threshold would be around 8% of the global GDP, much higher than the present levels of international cooperation. At subnational levels, the burden of health inequity can be the most sensitive barometer of socioeconomic justice between territories and their populations, informing and directing fiscal and territorial equity schemes and enabling all people within and between nations to enjoy the universal right to health.
HRS models can also inspire lifestyles, and political and economic frameworks of ethical well-being, without undermining the rights of others in present and future generations.
Asa Cristina Laurell and Ligia Giovanella
Since the early 1990s, health policy in Latin America has focused on reform in most countries with the explicit purpose to increase access, decrease inequity, and provide financial protection. Basically, two different and opposed models of reform have been implemented: the Universal Health Coverage (UHC) model and the Single Universal Health System model. The essential characteristics of Latin American UHC are that health care is commodified by the introduction of competition that depends, in turn, on the payer/provider split, free choice, and pre-priced health service plans. In this framework, insurance, be it public or private, is crucial to assuring market solvency, because health needs not backed by purchasing power do not constitute a market that is particularly important in the Latin American region, the most unequal in the world. The Single Universal Health System (in Spanish, Sistema Universal de Salud, SUS) model is a model inspired by the principles of social justice and egalitarian, universal social rights. Characteristically funded by tax revenues, it makes provision of health services to the whole population a responsibility of the State and a universal citizens’ entitlement, independent of individual ability to pay or prior contributions. It considers health to be a public good that, for reasons of efficiency and equity, the market cannot provide. Everyone is entitled, as a right, to free care financed by the State.
Given that health system reform occurs in specific historical contexts, these models have had different results in each country. In order to highlight the concrete reform outcomes, the following issues need be addressed: the political scenario and the stakeholders involved; the previous health system and the relative strength of the public and private sectors; coverage achieved by public institutions or insurance, public or private; the different health packages existing within each country; the institutional (re)organization; and the relative importance of public health actions. An analysis is needed of the UHC reforms in Chile, Colombia, and Mexico, on the one hand; and the Single Universal Health System in Brazil, Venezuela, and Cuba on the other.
The UHC model in practice tends to increase inequity in access, create new bureaucratic barriers to timely care, fail to provide financial protection, and leads to deteriorated public health measures. It has also created new powerful private sector stakeholders, particularly in Chile and Colombia, while in Mexico the predominance of a strong public sector has “crowed-out” the private one. The Single Universal Health System has significantly increased access for millions that before reform had almost no access and has also strengthened public health actions. However, the strong preexisting private sector providers have profited from the public-sector purchases of complex medical services. Private health insurance has also increased among the upper middle class and workers belonging to strong labor unions.
Catarina Roseta-Palma, Miguel Carvalho, and Ricardo Correia
Many utilities, including water, electricity, and gas, use nonlinear pricing schedules which replace a single uniform unit price, with multiple elements such as access charges and consumption blocks with different prices. Whereas consumers are typically assumed to be utility maximizers with nonlinear budget constraints, it is more likely that consumer behavior shows limited-rationality features such as reference dependence. Recent studies of water demand have explored consumer reactions to social comparison nudges, which can moderate consumption and might be a useful tool given low demand-price elasticities. Other authors have noted the difficulties of correct price perception when tariff schedules are complex, and attributed those low elasticities to a lack of information. Nonetheless, it is also possible that consumers form reference prices, relative to which the actual price paid is compared, in a way that affects consumption choices. Faced with a nonlinear price schedule, such as increasing block tariffs, consumers could evaluate their actual marginal price as a loss or a gain relative to a particular reference price that is derived from the schedule. Introducing gain/loss terms into the utility function, in the discrete/continuous model of consumer choice that has been widely used for water demand analysis, leads to consumption decisions that vary when a higher-than-reference price is seen as a loss and a lower-than-reference price as a gain. Utilities might wish to explore these reference-price effects according to their strategic goals. For example, if there are capacity constraints or water scarcity problems, potential water savings can be achieved from highlighting the first-block price as a reference and framing higher-block prices as losses, inducing conservation even without raising overall prices. Furthermore, if higher-block prices are subsequently raised the demand response could be stronger.
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.
Street science is the processes used by community residents to understand, document, and take action to address the environmental health issues they are experiencing. Street science is an increasingly essential process in global urban health, as more and more people live in complex environments where physical and social inequalities create cumulative disease burdens. Street science builds on a long tradition of critical public health that values local knowledge, participatory action research, and community-driven science, sometimes referred to as “citizen science.” Street scientists often partner with professional scientists, but science from the street does not necessarily fit into professional models, variables or other standards of positivist data. Street science is not one method, but rather an approach where residents are equally expert as professional scientists, and together they co-produce evidence for action. In this way, street science challenges conventional notions in global health and urban planning, which tend to divorce technical issues from their social setting and discourage a plurality of participants from engaging in everything from problem setting to decision-making. Street science does not romanticize local or community knowledge as always more accurate or superior to other ways of knowing and doing, but it also recognizes that local knowledge acts as an oppositional discourse that gives voice to the often silent suffering of disadvantaged people. At its best, street science can offer a framework for a new urban health science that incorporates community knowledge and expertise to ensure our cities and communities promote what is already working, confront the inequities experienced by the poor and vulnerable, and use this evidence to transform the physical and social conditions where people live, learn, work, and play.