Lecture 10: non communicable diseases
▪ Non communicable diseases are the leading cause of
Definition: mortality in the world
NCDs are long duration diseases, that ▪ They have health and economic burden and
have slow progression, and are not complications
communicable to others, and normally
can’t be cured completely Four main types:
cardiovascular, chronic respiratory distress, cancer and
Characteristics:
diabetes
complex causes, multiple risk factors, long latency
period, non-contagious origin, prolonged course, others include neurologic diseases, musculoskeletal and
functional impairment injuries
Most NCD deaths occur in low and middle
All NCDs mostly depend on modifiable and preventable risk
income countries
factors, working on these factors is suggested to be
▪ NCDs affect men and women almost equally
promising to decrease NCD
▪ they affect people’s finance (expensive
treatment) and productivity (disabilities)
Definition of risk factors: any element or aspect that
Types of risk factor differ depending on the increases the risk of occurrence of a certain disease, injury
source: or condition.
non modifiable, modifiable (include: behavioural,
Modifiable: can be reduced, controlled (major four:
environmental, physiological) → you can check
physical inactivity, tobacco use, alcohol use and unhealthy
them in the slides, they’re v. easy, page 4
diets)
Today we focus on preventing rather than
NCD are preventable through tackling these 4 shared
treating by targeting risk factors
risk factors ( CVD, cancer and diabetes share these 4,
chronic respiratory diseases only tobacco use)
The major four risk factors lead to 4 key metabolic
changes (biochemical processes in the body):
1) raised BP 2) obesity/Ov-wt 3) raised blood non modifiable: can’t be reduced nor controlled (genetics,
glucose 4) raised cholesterol age)
Cardio-vascular diseases: disorders of heart and BVs
Include: coronary heart disease, cerebrovascular disease, peripheral arterial disease, congenital heart disease
CVDs are the #1 cause of death globally, the number of deaths is estimated to increase
Most of them occur in low and middle income countries
CVD risk factors:
major modifiable: high BP, abnormal blood lipids, tobacco use, physical inactivity, obesity, unhealthy diet
other modifiable: Low socioeconomic status - Mental ill health (depression) - Psychosocial stress - Heavy alcohol
use - Use of certain medication - Lipoprotein(a)
non-modifiable: genetic aspects
novel risk factors (related to biochemistry of the body) e.g. blood excess homocysteine, inflammatory markers
Diabetes: a disorder of metabolism
Has 4 types: 1, 2, gestational and pre-diabetes
▪ Type 2 is caused by modifiable risk factors and is the most common worldwide. (90% of all adult cases)
▪ Most diabetes deaths occur in low- and middle income countries.
Diabetes deaths are estimated to increase
▪ Modifying risk factors can prevent or delay diabetes 2
Major modifiable Risk Factors: Unhealthy diets - Physical Inactivity - Obesity or Overweight
- High Blood Pressure - High Cholesterol
Other Modifiable: Low socioeconomic status - Heavy alcohol use - Psychological stress - High consumption
of sugar-sweetened beverages - Low consumption of fiber
Non-modifiable: Distribution of fat
Other Risk Factors: Low birth weight - Presence of autoantibodies (T1)
Cancer: large group of diseases that can affect any Chronic respiratory disease:
part of the body
A leading cause of death
70% (most) of all cancer deaths occur in low- and
Most deaths occur in Low income countries
middle-income countries.
Risk factors:
About 30% of cancers are attributable to behavior risk
Cigarettes, occupational dust and chemicals,
factors (no certain direct causes, many risk factors)
environmental tobacco smoke, air pollution
Cancer epidemiology:
Genes, infections, socio-economic status, aging
Highest incidence: breast> prostate> lung populations
Highest mortality: lung> breast> stomach Targeting risk factors is key to decrease them, why?
Surveillance for NCD can be difficult because
relationships between exposures and conditions are
complex and appearance of the disease takes time
Lecture 11: the global burden of mental health problems
World Mental health day: 10-10
Read and understand:
Mental health definition: a state where every individual realizes his or her own potential,
can cope with the normal stresses of life, can work productively and fruitfully, can find
fulfilling relationships with other people, have the ability to adapt to change and to cope
with adversity, and show behaviors that are age-appropriate and congruent with local
and cultural norms.
Mental illness: Is a term used to mean all diagnosable mental disorders. Any malfunction
in the mental health definition.
Mental disorder: a syndrome characterized by clinically significant disturbance in an
individual’s cognitions, emotional regulation, or behavior that reflects a dysfunction in the
psychological, biological, or developmental processes underlying mental functioning
Mental health problems: Is a term used when signs and symptoms of mental illness occur
but do not meet all criteria for a disorder. It’s the best time to catch a mental problem
Mental illness protective factors: read and understand it’ll be easier to remember
Individual: related to one’s nutrition, attachment, temper, faith, spirituality, sense of
purpose & resilience
Family: stability of the family, support, caring of parents and well spacing of siblings
School: Positive environment, feeling safe, Supportive & positive peers, Opportunities to
be responsible/helpful, Success and achievement
Other: economic security, connection to community, faith, access to mental and physical
Health care, no violence or trauma exposure.
The undefined and hidden burden: problem with those is that they’re hard to quantify
The Undefined: economic and social burden on people that are not measured, they take
a toll one the one suffering from them and on the people around them, on emotional
and socio-economic aspects
The hidden: burden associated with stigma and violations of human rights and freedoms
Specific economic and social losses:
- Lost productivity of the mentally ill and people taking care of them and from
premature deaths caused by MIs, and reduced productivity of people working with MI
- Cost of accidents caused by MI people (if they work, like airplane captains for ex.)
- Financial costs of taking care of them MI= mental illness, Mentally
ill
- Unemployment, alienation and crime in people with unaddressed childhood issues
- poor cognitive development in the children of mentally ill parents, and the emotional
burden and diminished quality of life for family members.
Stigma can be defined as a mark of shame, disgrace or disapproval which results in an
individual being shunned or rejected by others. The stigma associated with all forms of mental
illness, increases with severity of MI presentations, and odd behavior of the mentally ill,
-Because of stigma MI people are rejected causing feelings of anger, loneliness, sadness and
they’re denied normal participation in family life, normal social networking and employment.
-Stigma has an effect on the recovery, the treatment and the type of support a mentally ill
person receives, it also affects their families and caretakers and leads them to humiliation
It originates from myths, misconceptions and negative stereotypes
Global burden of mental illness: Mental disorders are among the leading
causes of ill health world wide
Five types of mental illness appear in the top
20 causes of global burden of disease (GBD): Depressvie disorders are the commonest
1. Major depression (second) ranking after ischemic heart disease
2. Anxiety disorders
3. Schizophrenia Health systems aren’t dealing adequately
4. Dysthymia or persistent depressive disorder with mental illness so, more mentally ill
5. Bipolar disorder people and lesser available treatment.
A further compounding problem is the poor
Poor people carry Treatments are
quality of care for those receiving treatment,
the greatest burden available but most
because most of the money put into mental
because they’re people with mental
illness treatment go to stand-alone mental
exposed to the risk disorders, don’t get it
hospitals despite their association with poor
factors and because of stigma,
health outcomes and human rights
deprived from neglect and lack of
violations
treatment understanding
The number of specialized and general
People with mental disorders experience health workers dealing with mental health in
disproportionately higher rates of disability low-income and middle-income countries is
and mortality owing to physical health grossly insufficient
problems that are often left unattended [such
as cancers, cardiovascular diseases, diabetes Responsibility of taking action about MI
and HIV infection) and suicide is majorly on governments
Selected mental disorders and associated issues: Suicidees means suicidal people
Disorder Definition and Burden and epidemiology Notes, prognosis and treatment
characteristics
Major An alteration in ◘One of the main causes of ◘Prevention programs reduce it in
depression mood that is disability worldwide children and adults
expressed by feelings ◘More women are affected ◘first line treatment is talking
of sadness, despair, than men therapy (mild to moderate)
and pessimism. ◘Long lasting or recurrent. ◘Antidepressants are used more
Loss of interest in ◘affects people’s coping with for moderate to severe,
usual activities, and everyday life. Second line for adolescents
somatic symptoms ◘Most severe→ leads to Not used in children
may be evident. suicide Management should include
Changes in appetite psychosocial aspects, identifying
and sleep patterns stress factors (e.g. financial
are common. problems, difficulties at work or
physical or mental abuse) and
sources of support like family and
friends.
Maintenance of social networks
and social activities is important.
Adolescent Depression, but in 20% of teenagers have at Adolescent depression shows with
depression teenagers least one episode of atypical presentations
depression before 18
20% of those seek help
And 40% of those get the
support needed (don’t mind
percentages)
Suicide “the act of choosing to For every suicide, many many Knowledge of the most commonly
end it all, because all attempts take place used suicide methods is important
is unbearable” “A prior suicide attempt is the to devise prevention strategies.
single most important risk Suicide facts: (the opposite is not
factor for suicide” real) READ AND UNDERSTAND
-Suicide is the second leading ◘Most suicidees give signs about it
cause of death among 15–29- ◘Most suicidees don’t want to die
year-olds. for sure, they just cry for help
Most suicides occur in low ◘People who are suicidal, only
and middle income countries want to die for a transient period
Most common methods are of time
Firearms, hanging and ◘Most suicidal deaths occur after
pesticides -L&M income C. months of depression
Gun shot wounds are the improvement because they have
leading cause of death more energy to do it
among suicide victims ◘Suicidal tendency is not inherited,
-The link between suicide and it’s an individual matter, but we’re
mental disorders (in affected by close ones’ acts
particular, depression and ◘Suicidees are very unhappy, but
alcohol use disorders) is they aren’t all mentally ill
strong, but ◘All suicidal thoughts should be
many suicides happen attended to with the possibility of
impulsively in moments of the actual act taking place.
crisis with a breakdown in the
ability to deal with life Suicide is preventable, by taking
stresses. certain measures at different levels:
Factors: conflict, disaster, -reducing access to self-harm
violence, abuse, or loss and a means
sense of isolation are strongly -reporting by media responsibly
associated with suicidal -reducing the harmful effect of
behavior. alcohol
High risk groups: -early identification, treatment and
People who experience care of people disorders, chronic
discrimination, such as pain and acute emotional distress;
refugees and migrants; -training of non-specialized health
indigenous peoples; (LGBTI) workers in the assessment and
persons; and prisoners. management of suicidal behavior;
-follow-up care for people who
attempted suicide and provision of
community support.
Bipolar Disregulation of Manic episodes involve elevated
disorder mood mood, over-activity, pressure of
That consists of both speech, inflated self-esteem and a
manic and decreased need for sleep.
depressive episodes Effective treatments (mode
separated by periods stabilizers) for the acute phase of
of normal mood. bipolar disorder and the
Some classified prevention of relapse.
bipolar people only Psychosocial support is important
have manic episodes
Schizophrenia A bad, sad mental The disorder can make it -begins in late adolescence or
spectrum disorder-psychosis difficult for people affected to early adulthood
characterized by work or study normally. - Treatment with medicines and
distortions in psychosocial support is effective
thinking, - Facilitation of assisted living,
perception, supported housing and supported
emotions, language, employment can help people with
sense of self and it lead a relatively normal life.
behavior. include
hallucinations and
delusions (fixed
false beliefs or
suspicions).
Mental health action plan 2013-2020 objectives:
1- to strengthen effective leadership and governance of mental health
2- to provide comprehensive, integrated and responsive mental health and
social care service in community based settings
3- to implement strategies for promotion and prevention in mental health
4- to strengthen information systems, evidence and research for mental health
Lecture 12: Environmental Health
Environmental Health: Studies how 1- Air pollution: almost everybody now
environmental factors (physical, chemical, and breathes polluted air. The highest to lowest air
biological factors external from human) affect pollution levels are in Eastern Mediterranean >
health. Its goal is to prevent diseases and create South-East Asia > Low and middle-income
safe environments. Social and cultural factors, as countries in Africa and western pacific > High-
well as genetics, are not included here. We will income countries in Europe, Americas, and West
focus on five topics pacific. African and western pacific countries are
not reporting much data, while Europe is doing
2-Chemical safety: is achieved by controlling well in this field. Air pollution lowers average life
the presence, natural extraction, synthesis, expectancy and causes 1 in 9 deaths worldwide
transport, use, and disposal of chemicals in a through NCDs. One third of stroke, lung cancer,
way that does not harm humans and chronic respiratory disease cases and one fourth
environment. These chemicals include: Air of Ischemic heart disease cases are caused by air
pollution, Pesticides, Mercury, Lead, Flouride, pollution. Mechanism: tiny particles enter with
Cadmium, Benzene, Arsenic, Dioxin and air, infiltrate into your lungs and cause
Aspestos. Poisoning by chemicals (intentionally inflammation. They can even enter the
and unintentionally) causes many deaths and bloodstream and induce vasoconstriction,
DALYs. This can be prevented by limiting the causing hypertension, stroke, and ischemia
availability of pesticides (developed countries
are already doing that), also by putting safety 3-Water Sanitation: By 2025,
standards of using chemicals in food. half of the world’s population will
be living in water-stressed areas.
4-Environmental health in Emergencies: Emergencies Clean water is important for
happen frequently, causing damage to environment and public health, whether it is used
humans and they include: for drinking or other purposes.
*Natural disasters: Catastrophic natural events where people Poor water supply and sanitation
normal lives are disrupted and they need shelters, food, etc. leads to poor economy, poverty,
bad education and lives for
*Chemical and Radiological incidents children, and the transmission of
*Complex emergency: which combines internal conflict with certain diseases such as cholera,
mass displacement of people, famine, or failing politics and diarrhea (the most common one),
economy. They can become worse by adding natural disasters. dysentery, hepatitis A, typhoid,
and polio. This is particularly
*Deliberate (intentional) events: they can be as small as important in hospitals where
‘‘contaminating food in a restaurant to get money from them’’ or people are at higher risk,
as big as releasing chemicals and radiations for terrorism. especially in low-income
-Vulnerability is being unable to cope with disasters. Children, countries. Other dangers include
pregnant women, elders, poor and malnourished people, and schistosomiasis, and dengue fever
people who are ill or immunocompromised, are all examples of of which covering water
vulnerable people. Political problems the number of people containers might be enough to
displaced internally (in the same country) as well as refugees. solve the problem
These people usually live in bad environmental conditions.
5-Climate change: the change in the normal environmental state (like the occurrence of extreme weather
states), recently caused by human activities (like fossil fuel burning), which emits gases that trap heat in the
atmosphere.
▪ Climate change can induce some localized benefit, but the overall effect is very negative. For example: In
the next 30 yrs, climate change will cost much directly & indirectly (through malnutrition, malaria, diarrhea,
heat stress), mostly in low income countries
*Extreme heat: extremely high temperatures contribute directly to deaths from, CVDs and respiratory disease
directly and indirectly through increasing ozone and other pollutants like pollen which causes asthma
*Natural disasters and variable rainfall patterns:
Weather related disasters tripled since 1960, most related deaths occurring in developing countries
Rising sea levels and increasingly extreme weather events will destroy homes and facilities, forcing people to
move and risking them by physical and mental health issues.
Increasingly variable rainfall patterns are likely to affect the supply of fresh water. A lack of safe water can
compromise hygiene and increase the risk of diarrheal disease, in extreme cases cause draught and famine.
Floods and extreme precipitation are also increasing in frequency and intensity and expected to increase more
*Outcome: Rising temperatures and variable precipitation are likely to decrease the production of staple foods
in many of the poorest regions → malnutrition and undernutrition
*Patterns of infection: climate change affects water and vector-borne diseases
It can lengthen their transmission season and widen their geographic range. like malaria, dengue and snail
borne schistosomiasis.
Lecture 13: global health ethics
Difference between ethical, social and
Definitions:
personal values in health:
*Health ethics: Health ethics is the
Values describe what is important to an
interdisciplinary field of study and practice that individual, a group, or a society. Values that are
seeks to understand the values undergirding commonly invoked include autonomy, fairness,
decisions and actions in health care, health equity, compassion, honesty, freedom, solidarity,
research and health policy, and to provide trust and respect
guidance for action when these values conflict. Sometimes a situation may give rise to a conflict
Health ethics has a broad focus, taking in ethical between different values on different levels, or on
issues faced by anyone involved in the medical the same levels but in groups with different
values, mutual respect is crucial.
area including patients and their families,
concerning any issue related to the term health
The relationship between health ethics and
It’s broader than “medical ethics” and is part of the Law:
“bioethics: ethics concerning all living things” “Normative frameworks”; they define how people
should act
They’re now included and studied in many
health-related fields They’re normally complementary but can conflict;
something that isn’t against the low can be
unethical and vice versa.
Major concepts in health research: (understand)
Ethics is concerned with a broader set of
*Human rights: Fundamental freedoms and
relationships and behaviors than most forms of
rights enshrined in a set of universal legal legal regulation
statements.
Ethical analysis of the law can stimulate important
Important characteristics of human rights: they are reform efforts or acts of civil disobedience.
acknowledged in international declarations; states and
In sum, while ethics and law are different in certain
state actors are obliged to respect them; they cannot be
ways, ethics remains a foundation for law, and
waived or taken away (violated sometimes); they are
often provides a justificatory basis for legal norms.
interdependent and inter-related; and they are universal.
*Autonomy: the ability of someone to be their
key ethical issues in health research:
own self and be independent
▪ Does the research have value for the study
*Beneficence: principle requiring responsible
population?
people to do what benefits people. ▪ Who benefits from it?
*Non-maleficence: principle requiring that health ▪ Are subgroups of the population treated
fairly?
care providers and researchers do not inflict
▪ Are the rights and well-being of individual
undue harm, intentionally or unintentionally. research participants protected?
*Confidentiality: The obligation to keep
information secret unless its disclosure has been
appropriately authorized
Major concepts in health research: (understand) Health issues regarding groups:
*Equity: unequal distribution of some goods to 1- because of socio-economic differences
bring about an equal outcome, responding to at multiple levels, some people might
unjust and unfair health differences. benefit from studies at the expense of less
*Egalitarianism: A belief in equality. However, fortunate others, Unfairness can be
egalitarians disagree about what it is that should reduced or eliminated by ensuring that
be equal. study populations enjoy the benefits of the
research.
*Justice:” giving people what they deserve.”
*Informed consent: Agreement to a certain 2- Research tends to find a drug, to sell it
course of action on the basis of complete and and benefit; because of less commercial
relevant information by a competent individual success in poor communities, they receive
without coercion (persuasion) less care from investigators.
*Privacy: seeks to protect a person from scrutiny 3-when businesses patent new drugs or
by others. a person sharing information only devices and want to ensure that product
when they choose to. sales recoup investments and generate
profits. laws increase the price of new
*Health maximization: as large as possible
drugs and devices and can thereby
beneficial impact on health obtained by
severely restrict or prevent access to life-
resources allocation
saving therapies for resource-limited
The Importance of Ethical and Human Rights populations. (problem in HIV-AIDS
Issues in Global Health: community)
Ethics and human rights stop the violation of peoples 4- related to cultural relativity. It is
health, whether intentionally or unintentionally, show the sometimes asked whether ethical
way for researches to be humane and ethical, stop the standards are universal, given that
violation of one group for the sake of the other and laws different people in different countries may
bind governments to respect the people’s health, all this
hold different values or place different
contributes to better global health
weights on common values.
Future Challenges in Global Health Work 5-concerning international research,
Students of global health get insufficient exposure to especially where investigators from wealthy
ethical issues, No mechanisms of enforcement of countries conduct research in
humans rights, Shortage of trained personnel for impoverished settings where participants
reviewing research for ethical issues, Lack of reviews of
are especially vulnerable or where
how investments are made, There is no clear definition
regarding the human rights in global research in
language and cultural barriers make
particular in low and middle income countries. informed consent difficult. (heated
example → standards of care: how much
So basically, unethical violations of human rights are
prone to happen, especially in misfortunate people. care should study participants receive?)
