International Health, Global Health, and Public Health

As someone who loves the mountains and all related activities, I was frustrated by my first visit to Geneva, Switzerland. Geneva is on a gorgeous lake close to Mont Blanc and the French Alps — a mecca for outdoor enthusiasts — and I was going to miss them all.

I was in Geneva to participate in the development of a new patient safety initiative by the World Health Organization (WHO). I vividly remember the sense of awe and wonder entering the WHO Geneva headquarters — the place where international healthcare initiatives happen.

The WHO is indeed an impressive enterprise, but exceedingly complex and complicated as a bureaucracy. Over the course of a few years, we successfully developed and launched several significant patient safety initiatives (WHO Patient Safety Solutions) designed for use in the international healthcare arena: hand-washing protocols, surgical safety checklists, medication safety protocols, safe use of electrolyte solutions, single-use injection, hand-off communication, etc. Many are now in common usage in the United States, but less so in other countries.

All-in-all, this WHO experience was highly satisfying professionally, but also left me with lingering uncertainties about the efficiencies and adequacies of international healthcare. The WHO is the international body primarily responsible for regulating and governing health-related policies and practices across nations. While the WHO uses these various policies and treaties to address international health issues, many of its policies have no binding power and thus state and country compliance are often limited.

With the ongoing pandemic, my curiosity has been piqued regarding the complexities of international healthcare delivery. The general awareness of this complexity has been gaining international attention.

International health is defined as the branch of public health focusing on developing nations and foreign aid efforts by industrialized countries, usually with a public health emphasis, dealing with health across regional or national boundaries. International health, however, most often refers to health personnel or organizations from one area or nation providing direct healthcare or health sector development in another area or nation.

Much work in international health is also performed by non-governmental organizations (NGOs). Services provided by international health NGOs include direct healthcare, community potable water, vitamin supplementation, and mitigation of endemic and epidemic infectious diseases and malnutrition. One important characteristic of NGOs’ work is that, in the “pure” sense, they provide services based solely upon need, without political, ethnic, religious, or other considerations.

Thus, strictly speaking, religious missionary organizations that perform services as part of a proselytizing or evangelical campaign should be separated from the NGO category and simply be referred to as religious missionary organizations.

In America, the U.S. Agency for International Development, USAID, leads international development and humanitarian efforts to save lives, reduce poverty, strengthen democratic governance, and help people progress beyond assistance. U.S. foreign assistance has always had the two-fold purpose of furthering America’s interests while fostering good will abroad and improving lives in the developing world.

USAID currently works in more than 100 countries to:

• Promote global health;

• Support global stability;

• Provide humanitarian assistance;

• Catalyze innovation and partnership; and

• Empower women and girls.

Global health is the health of the population in the worldwide context. It has been defined as “the area of study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide.”(1) Global health work often emphasizes problems that transcend national borders or have a global political and economic impact. Numerous international universities and related academic centers, including Harvard, McGill, and Johns Hopkins universities, and Karolinksa Institutet, have evolved in the past few decades with a distinct focus on global health.

The predominant international agency associated with global health is the WHO. Other important agencies that focus on global health include UNICEF and the World Food Programme (WFP). The Bill and Melinda Gates Foundation received significant notoriety in recent years for the scope of its projects and the depth of funding available to advance its work in the area of global health.

The United Nations system has also played a part in addressing global health and its underlying socioeconomic determinants with the declaration of the Millennium Development Goals and the more recent Sustainable Development Goals. Both of these initiatives drive significant focus and intellectual research within international and global health circles.

Population health refers to the health status and health outcomes within a group of people rather than the health of one person at a time. The primary components of population health are health outcomes, patterns of health determinants, and policies and interventions.”(2)

Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks. According to the U.S. Department of Health and Human Services, social determinants of health are currently grouped into five domains(2):

1. Economic stability;

2. Education access and quality;

3. Healthcare access and quality;

4. Neighborhood and built environment; and

5. Social and community context.

Public health promotes and protects the health of people and the communities where they live, learn, work, and play. Public health works on a more personal level than population health, promoting wellness to the public by encouraging patients to live healthier lives.

Measuring Impact

So how does one measure impacts in these assorted disciplines? This is the focus of ongoing scientific development and debate. Crude mortality rates are still an important part of data analysis, primarily because of the ease of data collection. However, death certificate reporting can be inaccurate in their diagnoses listed and thus create inconsistencies in the data. Ongoing efforts are in effect to clarify disability and quality of life measures.

Disability-adjusted life years, DALY, is a summary measure that combines the impact of illness, disability, and mortality by measuring the time lived with disability and the time lost due to premature mortality. One DALY can be thought of as one lost year of “healthy” life. The DALY for a disease is the sum of the years of life lost due to premature mortality and the years lost due to disability for incident cases of the health condition.

Quality-adjusted life years, QALY, combine expected survival with expected quality of life into a single number. If an additional year of healthy life is worth a value of one year, then a year of less-healthy life is worth less than one year. QALY calculations are based on measurements of the value that individuals place on expected years of survival.

Measurements can be made in several ways: by techniques that replicate gambles about preferences for alternative states of health, with surveys or analyses that infer willingness to pay for alternative states of health, or through instruments that are based on trading off some or all likely survival time that a medical intervention might provide to gain less survival time of higher quality.

On a related note, AAPL itself has members in 35 to 40 countries at any one time. Even with the pandemic, we still engage in the development of international collaborations and participate with various related initiatives. AAPL is highly regarded in the international community. So, it makes me especially proud to have the collection of international articles in the current PLJ issue and I encourage you to have a read. The influence of AAPL has not been lost on these individual authors, and their ongoing work to better the international delivery of healthcare through physician leadership is to be admired. My many thanks to the authors and contributors.

And as for my frustration of not getting to the French Alps from Geneva, well, there is another story for another time on how the town of Chamonix later more than satisfied my thirst for activities in the mountains…I even named a dog after the town it was so special. It was a wonderful privilege!

Remember, leading and creating significant change in healthcare is our overall intent as physicians. AAPL focuses on maximizing the potential of physician-led, interprofessional leadership to help create personal and organizational transformation that benefits patient outcomes, improves workforce wellness, and refines the delivery of healthcare internationally.

We must all continue to seek deeper levels of professional and personal development, and to recognize ways we can each generate constructive influence for one another at all levels. As physician leaders, let us become more engaged, stay engaged, and help others to become engaged. Exploring and creating the opportunities for broader levels of positive transformation in healthcare is within our reach — individually and collectively.

References

1. Koplan JP, Bond TC, Merson MH, et al. Towards a Common Definition of Global Health.” Lancet. 2009;373(9679):1993–1995.

2. Kindig D, Stoddart G. What Is Population Health? Am J Public Health. 2003;93(3):380–383.