“Health spending is not a cost, it’s an investment in poverty reduction, jobs, productivity, inclusive economic growth, and healthier, safer, fairer societies.”1 This was said by Dr Tedros Adhanom Ghebreyesus, World Health Organisation (WHO) Director-General. The health of each individual affects not just themselves but also society. It is no wonder that healthcare expenditure accounts for 10% of the world’s gross domestic product (GDP).1 In fact, based on an analysis by Our World in Data, there is an upward trajectory relationship between health expenditure and life expectancy for several rich countries, although the USA is an outlier.2 This shows that health expenditure is not the single factor behind life expectancy. However, with that said, expenditure can still be a good indicator. Between year 2000 to 2016, global healthcare spending rose at a rate of 6% each year.3 This is supported by the increase in global life expectancy at birth by 5.5 years to 72.0 years between 2000 and 2016. Zooming into Africa, the life expectancy increased by 10.3 years in the same period. This can be attributed to improvements in healthcare services, such as access to antiretrovirals for HIV treatment, and improvements in child survival.4
In a paper written by David Cutler, Angus Deaton, and Adriana Lleras-Muney5 about global mortality, they stated that:
Mortality in England began to decline in the wake of the Enlightenment, directly through the application to health new ideas about personal health and public administration, and indirectly through increased productivity that permitted (albeit with some terrible reversals) better levels of living […] Most recently, the major life-saving scientific innovations in medical procedures and new pharmaceuticals have had a major effect […] important health innovations whose effect has been mainly in poor countries.
From this quote, it can be seen that the factors which led to the reduction in mortality rates are many. Before we delve into these factors that have improved the health of people, let us first understand what health is.
According to the WHO, health is defined as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.6 In other words, the mind and emotions of a person, in addition to the physical body, all affects the health of the person. However, if we think deeper about the definition presented by WHO, we can include a greater population into the definition. This idea was shared by Dr. David Misselbrook on the British Journal of General Practice.7 He raised the example of an amputee. With a missing limb, does that mean that person can never be in good health since it does not fulfil the definition by WHO? It would be absurd to think so. This is because the amputee can still live a fulfilling life and be free from illnesses. A person who lives up to the latter definition is Nick Vujicic, who was born with tetra-amelia but did not let his condition of not having limbs deter him from living life. Hence, good health should also include the ability to overcome illnesses and disabilities.
Bearing the definition of health in mind, we can look at the following determinants of health identified by WHO:8
The Physical Environment
As defined in a paper by National Research Council (NRC) and the Institute of Medicine (IOM) in the USA, “the factors in the physical environment that are important to health include harmful substances, such as air pollution or proximity to toxic sites (the focus of classic environmental epidemiology); access to various health-related resources (e.g., healthy or unhealthy foods, recreational resources, medical care); and community design and the “built environment” (e.g., land use mix, street connectivity, transportation systems).”9
The Social Environment
This consists of two aspects: the conditions and the systems. The conditions involve those “in which people are born in, grow, live, work and age”. The systems refer to those that “affect a wide range of health, functioning, and quality of life outcomes and risks”.10
The person’s individual characteristics and behaviours
This encompasses genetics (the innate biological characteristics), which includes age and gender, as well as the way of living and behaving, which includes diet, alcohol consumption and sexual practices. 11
We shall explore these determinants in this essay and a question to ask as we go through each determinant is: How can technology play a role in ensuring good health?
Some elements of the physical environment are:11
- Natural environment (e.g. plants, weather, or air quality)
- Built environment (e.g. buildings, or transport)
In the Global Shapers Survey done by the World Economic Forum, climate change and the environment were the most critical concern for years 2015 to 2017, with 48.8% of the approximately 25,000 survey responses by millennials selecting that as the top concern in 2017.12 Their concern is valid because global emissions have indeed been rising each year. Emissions have always been rising, yet the rate of increase has been fluctuating.13 This inevitably leads to the rise in global temperatures due to the trapping of greenhouse gases in the atmosphere, with 18 out of the 19 warmest years occurring since 2001.14 As a result of air pollution which causes heart disease and stroke, approximately 7 million people died in 2012 according to WHO.15 Based on a paper written by Professor Drew Shindell from Duke University, if the emissions in the USA were cut to 40% by 2030, 295,000 premature deaths could be prevented.16 It is with no doubt that the health of the planet is directly associated to the health of people.
However, Rob Jackson, a senior fellow at Stanford University, says that in nations like India and China where hundreds of millions live without electricity, “the need for electricity surpasses concern for climate.”17 This results in the continual burning of fossil fuels for transport, electricity and industry, which makes people vulnerable to respiratory and circulatory diseases, both in rural and urban areas.18 Climate change is also causing an increase in disease incidence, such as Malaria and West Nile virus.19 This is due to the extended lifespan of the vectors in the warmth, enabling them to carry the disease further and for longer periods of time. The warmer temperatures also allow harmful bacteria to thrive, such as Vibriosis, a flesh-eating bacterium that infects open wounds and contaminates seafood.19
Besides climate change, the built environment influences the health of people as well. Many studies have shown that having green spaces in urban areas that are close to residential and work places is beneficial for health. A study revealed that wards that have a view of trees sped up the recovery of patients and that these patients required less painkillers.20 In another study that compared exercising in a green space and in an urban environment revealed that stress level is reduced in the former setting.21 In a separate study, results showed that living in greener areas improved mental health substantially.22 Hence, an area filled with nature is beneficial to not only people who are recuperating, but also people who are healthy. It is also beneficial for both our physical and mental health.
Poor sanitation facilities can also affect the health of people. Faecal waste is dangerous to health, in which millions of harmful bacteria can be found in just one gram of faeces.23 InAGlobe is working with Engineering Change, a student-led society at Imperial College London, and SNV Mozambique, to develop a septic tank to allow for safe disposal of the waste. Furthermore, hospitals in low-resource environments may find difficulty in disposing waste that is hazardous and possibly contaminated, such as syringes and used gauze. These objects can lead to an increase in blood-transmitted and water-borne diseases. Helvetas has brought this challenge to InAGlobe and we hope to tackle it in the following year.
Besides proper disposal methods, access to clean drinking water is paramount. Contaminated water can infect people with diseases such as cholera, diarrhoea and typhoid. It is estimated that 829,000 people die each year from diarrhoea caused by unsafe drinking water and improper sanitation.24 A country that managed to secure clean potable water despite being water-scarce is Singapore. They developed NEWater in which recycled water is purified through reverse osmosis. NEWater had comparable or better microbiological parameters when compared with regular drinking water and have no toxic or carcinogenic effects when tested on mice and fishes.25 However, this reverse osmosis technology is costly and may not be feasible for all. Hence, InAGlobe partnered with the Department of Civil Engineering of Imperial College and uDrops to develop an affordable clean-water system for an orphanage on Mfangano island in Lake Victoria.
The work environment also matters as this concerns what people do on a regular basis. For example, in India, in rural areas people are often involved in primary industry occupations, such as agriculture and forestry.26 Their exposure to chemicals (such as pesticides) and to air pollution (such as vehicles and machinery) make them prone to, for example, cardiovascular and respiratory diseases.26,27 In urban areas, both blue-collar and white-collar workers are vulnerable to illnesses. Common illnesses between both groups include lower back pain, upper respiratory problems and fatigue, although the rates are higher in blue-collar workers, possibly due to the higher physical demands.28 Due to the sedentary work nature, white-collar workers are prone to diabetes, burnout-linked depression and occupational overuse syndrome.28,29
In the area of agriculture, to reduce emissions and maintain the fertility of the land, there is a growing field called Agroecology, which are “farming practices that mimic nature by adding organic material to soil, planting trees on cropped fields and using natural enemies to attack insect pests.”31 This not only helps farmers to save the costs on fertilisers and pesticides, it also reduces their exposure to chemicals. With respect to office work, companies can adopt ergonomic workstations. This means reducing the strain and stress on workers, such as their posture or their movements.32 One way to do so is to have chairs that promotes good posture and reduces awkward positions, such as having necessary supports.33 Tables can also be designed such that there is enough leg space for the worker. If a job requires constant usage of the telephone, headphones can be used in place of traditional phones to reduce strain on the hands and the neck.
The social environment “encompass[es] the immediate physical surroundings, social relationships, and cultural milieus within which defined groups of people function and interact”34. Essentially, it concerns how people live in the environment they are in, which includes their own individual lives (such as home, work and school) and also the society they are in (such as the city, labour market and culture).
Resource mismanagement has led to the loss of about $455 billion out of the $7.35 trillion spent on healthcare each year.35 One such form is the absenteeism of healthcare workers, in which these workers have jobs in both the private and public sector. Since the private sector usually gives higher wages, the public sector would suffer if these workers are dually scheduled. Another form of corruption is informal payment such as bribery. People do this to perhaps move up the waiting list or to receive more attention. This means that people who are better-to-do would receive treatment sooner and of better quality than those who cannot spare extra money to get the service. Sometimes, resources are mismanaged, resulting in improper equipment acquired or insufficient medications. The former situation happens because hospital administrators might make an agreement with a company to only use their products or to accept their money to use in projects that are not of priority. This can result in acquiring incompatible equipment in which the community does not have the manpower to repair or maintain it. The latter situation happens healthcare resources are diverted during the process of delivery so that such that they can be resold to the private market. These will in one way or another restrict the accessibility of healthcare to the public. However, security and audit tech, as well as technologies for traceability such as IoT systems can have a potential in preventing and controlling corruption.
To aid in the undersupply of healthcare workers, Fundación Mozambique Sur proposed for a pillbox that can inform children at a Mozambican orphanage, Casa de Gaiato, when they need to take their medication. This will relieve the work and stress of the healthcare workers and ensure that the children are taking their medications. In turn, this liberates healthcare workers to focus on other aspects of the children’s health.
Governments can play a role in ensuring the good health of its citizens. To encourage the people to walk more, the Health Promotion Board in Singapore developed the “Healthy 365” mobile application which allows users to track their steps.36 As an incentive, the more steps the user walks, the more points he earns, and these points can be used to redeem prizes. Other features in the app includes a diet tracking journal that has a database of the calorie and nutritional information of various foods and drinks, and map views of the nearest exercise facilities and healthier eateries. Another similar application that is applicable to people globally is Sweatcoin37, which uses a cryptocurrency to create the incentive for people to walk. This shows that both governing authorities and private firms can have a substantial role in promoting healthy lifestyles.
Income is also a crucial factor in accessing healthcare. And income comes from employment and entrepreneurship. It is important that people have jobs because it provides the financial ability to spend on goods and services they may require.38 This includes access to health services and education. It also gives people security and fulfilment, a crucial factor in keeping good psychological health.39 It should be noted that the permanence of the job also matters. With employment there is an increase in the revenue through taxes that can then be redirected towards healthcare systems, thus improving access. 40
To help protect the occupations of Mozambicans, a project proposed by Helvetas is to have a mobile phone application that informs Mozambicans of the fair local market price for their goods. 80% of the population depends on agriculture. To prevent them from getting misguided by middle-men, this application informs farmers of the fair price of the grains which takes into consideration the region’s supply and demand. It is interesting to consider that those that experience the most malnourishment and hunger are those that produce food; thereby an application that allows them to distribute their sales will improve the management of their income.
Education is also very much linked to health of people. For example, mothers who have some degree of health and nutritional education will provide their children with a healthier and more balanced diet, avoiding unhealthy food and food from unsafe sources. This can reduce the rates of parasitic worm infections, as well as obesity and diabetes. These two examples promote the prevention of malnutrition and avoidance of diseases, leading to a healthier population. Also, adults who have higher levels of education tend to avoid risky behaviours such as smoking and drinking, and would adopt healthy behaviours such as exercise and a balanced diet.41
Individual Characteristics and Behaviours
Besides the environment, the genetics of a person will have an influence on the person’s health in one way or another. Some genetic conditions include Sickle-cell Anaemia and Down Syndrome. The family history of an individual can also play a role, such as the predisposition of heart disease.11 Compared to children, the elderly are biologically more prone to poor health, an effect of aging. 42 The level of hormones and chemicals in the body changes through the years, and this affects the rate of recovery. For example, the level of collagen decreases as we age, making us more prone to cuts and flesh wounds.42 Another example would be the breaking down and regeneration of our bones. As we age, the rate of bone breaking down is faster than the rate of bone regenerating. Hence, for a fracture, while it takes children a few weeks for them to heal, it can take months for adults to heal.43 Despite this observation, children are also at risk given their yet unprepared immune system, which is why one of the greatest achievements of the last century is the immense reduction in Child Mortality. The incidence of various diseases also differs between gender. For example, females are more prone to autoimmune diseases compared to males, such as Multiple Sclerosis and Sjogren’s Syndrome.44 A person’s ethnic group also influences the state of health of the person. As a result of cardiovascular disease, African communities tend to have strokes whereas South Asian communities tend to have heart attacks.45
Although we cannot control genetics yet, we can control our behaviour, such as washing hands and consumption of a balanced diet. Exercise is very important for both our physical health and mental health. Physically, it reduces the likelihood of diseases such as heart and lung diseases, dementia and diabetes. Mentally, it helps to reduce stress, recover from mental health issues and improves sleep.46 By controlling our behaviour, we can reduce the likelihood of getting ill. For example, although Type II diabetes can be partly attributed to genes, it can also be attributed to lifestyle. Exercise is beneficial in preventing diabetes as it helps to regulate blood sugar level and it helps to increase the body’s sensitivity to insulin.47 Similarly with heart diseases, diet and exercise are factors that affect the health of the heart.48
We all value health because we want to be able to do the things that we want to do. Poor health prevents us from having the energy and ability to achieve a meaningful life. From the above analysis, we can see how complex health is as it is influenced by various factors that are multifaceted. Health is not just influenced by an individual’s genes and behaviour, it is also influenced by the environment and people around them. Despite the complexity of the issue, we can always think of solutions to alleviate health issues through innovative technologies. We need to acknowledge that investing in health will be an investment that we will not regret. Only with a healthy population can society keep improving and pushing itself beyond its limits.
Written By: Jaynell Ng (31/08/2019) - Outreach Volunteer for InAGlobe Education.
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