Key Determinants

Problem definition: As of 2008, 35% of Africa’s population does not have sustainable access to safe¹ drinking water.*

As discussed in my last blog, the magnitude of this problem is vast; not only in its quantification, but also in the detrimental effects it leads to in the human life. A former UN Secretary General, Kofi Annan said that “No single measure would do more to reduce disease and save lives in the developing world than bringing safe water... to all” (Amponsah 1). This statement brings together the magnitude and importance of this problem.

The problem definition seems straightforward, maybe even straightforward enough to conclude simple solutions. However, a detailed amount of determinants contort this problem into being very complex and multifactorial. This blog will analyze several key determinants within six categories (as listed below). Also, a Haddon Phase-Factor Matrix will give a better visual at the pre-event, event, and post-event factors specific to this problem. 

  

Biological Determinants:

Biological determinants include any anatomic, physical, or clinical reasons a problem might exist. When concerning human health, these reasons might be contributed to genetics or micro-organisms (“Promote…”). For this particular problem, the biological determinants are not so clear. As we shall see in later discussion, the problem of not having access to safe drinking water directly affects human health through the onset of water-borne diseases, many of which are fatal. Complications in the human immune system allow these bacterium and viruses to take ahold of the body and become diseases. And, as demonstrated by type 2 diabetes – where African Americans have a higher risk of developing the disease over other ethnic groups – as well as others, ethnicity, gender, and other differences can conclude diverse risk factors among populations (“Non-Modifiable…”). These differences are also biological determinants for contraction of water-borne illnesses. However, in terms of access of safe drinking water, biological determinants are limited to one’s physical ability to obtain the water. This also expands into the environmental determinants.

Environmental Determinants:

Environmental determinants are those that inhabit the area around a person, whether the physical (natural and built) or social environments. Physical environmental determinants for the lack of safe drinking water in sub-Saharan Africa relate to the population’s living conditions and the surrounding conditions. For example, sub-Saharan Africa has the highest prevalence of slums (“Development…”). Poor housing conditions give rise to a poor sewage system and therefore contribute to dirty water in the proximity. The waste and other contaminants that are put into surface water directly affect those living in these environments. Other physical environmental determinants are the geography and climate of the region. Africa has many deserts and open spaces, where drinking water sources are limited. Furthermore, the disparities between the urban and rural population discussed in the “Magnitude” section of this report identify another physical environmental key determinant to this problem. According to the World Health Organization (WHO), a person who lives in an urban area is twice more likely to have piped drinking water than someone in a rural area (United Nations). The difference in the percentage of those suffering from a lack of access to safe drinking water in rural sub-Saharan Africa as compared to those in urbanized areas verifies this statement. However, urbanization in Africa places a strain on physical structures and environmental sustainability (“Development…”). Urbanization in itself is a social environmental determinant; it enables education, jobs, and other social factors to determine a population’s interaction with its natural and built resources. The inverse trend that urbanization has in Africa with sustainability greatly contributes to the lack of clean water access in the region.

Social and Cultural Determinants:

Social and cultural determinants are very diverse, ranging from social class and social norms to religion and ethnicity. Social class and social norms are key determinants for this problem. Africa has 48 countries, each one consisting of different governments and social standards. These differences can elevate or depreciate the practices and social norms that contribute to the lack of access to safe drinking water. For example, certain tribes in sub-Saharan Africa do not have the knowledge or trust of western medicine. They are hesitant to take medicine or practices offered that do not fit the traditions specific to their tribe. In the same way, water purification practices and equipment are not readily recognized as a solution to their problem. In urbanized areas, social class can play a role in whether or not a person has clean water. With limited resources – and clean water being one – those of a lower class are left out of this basic commodity, mostly because they cannot afford it (this key determinant also expands to economic determinants). Ethnicity is a key determinant to the access of clean drinking water as well. In many rural areas of sub-Saharan Africa, disputes arise among ethnicities on ownership of land, particularly that with high value in food and water resources (Bujra 4). Different ethnicities also react to diseases differently, which was explained in the biological determinants section.

Economic Determinants:

Economic determinants are those related to money, on the individual and community level. In sub-Saharan Africa, the majority of the population is very poor and has scarce resources. As mentioned above, sub-Saharan Africa has the highest prevalence of slums in the world, and 50% of the region is without access to electricity (“Sub-Saharan Africa”). Furthermore, only a small fraction of the regions GDP is used on infrastructure, and in order to meet the economy goals set by the United Nations, this percentage would have to increase substantially. The amount of poor people in Africa and those without access to appropriate infrastructure make having sustainable access to safe drinking water very limited. These limitations exist not only in the rural areas, but also in urbanized communities as well. Additionally, new disparities between the rich and poor in rural areas have concluded arguments and disagreements about land and water resources throughout sub-Saharan Africa (Bujra 11).  

Political Determinants:

Political determinants that lead to this problem mainly exist through executive power. Revolutions, war, and civil unrest are common in sub-Saharan Africa, and these complications are detrimental to the population’s access to water resources. From the time period between the 1960s and 1990s, there have been approximately 80 violent changes in government (Bujra 1). Wartime depletes resources more heavily than in times of peace, and the constant struggles in both urban and rural Africa make having sustainable access to safe drinking water very hard to obtain.

Behavioral Determinants:

Behavioral Determinants are individually based and are often hard to categorize for this particular problem. The most significant key determinants for this problem in sub-Saharan Africa are in the political, economic, and environmental sections, because it is on a larger scale that this problem takes its toll. That being said, one behavioral determinant would be individuals not accepting or acknowledging the problem, and not willing to find solutions when they become available.

Haddon Phase-Factor Matrix for Lack of Safe Drinking Water

	Human Factors	Agent or Vector	Environment         Physical               Socio-Cultural
Pre-Event (access to safe drinking water)	Readiness to accept water sources	Lack of resources Unsustainable water systems No electricity	Rural communities Lack of infrastructure	Poor vs. rich
Event (contracting water-borne diseases)	Drinking dirty, infested water	Disease strands within the water	No sewage system, poor or no piping system	Poor, rural, lack of infrastructure
Post-Event (receiving care for diseases)	Acknowledging sickness and seeking out help	No access to hospitals or medicine	Rural communities No transportation No clinical resources	Poor vs. rich Political situation Western medicine acceptance

*The problem definition has changed slightly due to recent acquisition of sources from 2008, rather than 2006 as previously noted.

¹ “Safe” is analogous with “clean” in this report.

Sources:

Amponsah, Edward Nketiah, Patricia Woedem Aidam, and Bernardin Senadza. Socio-economic Determinants of Sources of Drinking Water: Some Insight from Ghana. Rep. University of Hamburg, 8 Oct. 2009. Web. 26 Apr. 2012. <www.tropentag.de/2009/abstracts/full/185.pdf>.

Bujra, Abdalla. African Conflicts: Their Causes and Their Political and Social Environment. Rep. Development Policy Management Forum, 2002. Web. 28 Apr. 2012. <http://notunprojonmo.com/wp-content/uploads/2012/03/African-Conflicts-Their-Causes-and-their-political-and-social-env.pdf>.

"Development Issues in Sub-Saharan Africa." EAST 4 SOUTH. Web. 28 Apr. 2012. <http://www.east4south.eu/index.php/eu_and_development/4._development_issues_in_sub-saharan_africa>.

"Promote to Prevent." Determinants of Health. Web. 27 Apr. 2012. <http://www.westone.wa.gov.au/k-12lrcd/learning_areas/health_studies/health1D/content/002_promote_prevent/page_02.htm>.

"Non-Modifiable Risk Factors." Professional.diabetes.org. Diabetes Pro. Web. 27 Apr. 2012. <http://professional.diabetes.org/resourcesforprofessionals.aspx?typ=17&cid=60390#Race & Ethnicity>.

"Sub-Saharan Africa." Wikipedia. Wikimedia Foundation, 27 Apr. 2012. Web. 29 Apr. 2012. <http://en.wikipedia.org/wiki/Sub-Saharan_Africa>.

United Nations, comp. The Millennium Development Goals Report. Rep. United Nations, 2009. Web. 28 Apr. 2012. <http://millenniumindicators.un.org/unsd/mdg/Resources/Static/Products/Progress2009/MDG_Report_2009_En.pdf>.

Public Health Term Paper: Magnitude

Problem Definition: As of 2006, 36% of Africa’s population does not have sustainable access to safe drinking water.

The magnitude of this problem is great and has taken notice by the world. However, the people in Africa who still do not have access to safe drinking water falls short of the Millennium Development Goals (MDG). In order to meet the goal set by the United Nations, 78% of Africa would need to have access to safe drinking water. As mentioned, 36% of the African does not have access, and in order to cut that to 22%, the African continent would need vast improvements in government, socioeconomic, and foreign interventions that improve water quality and access. Only 26 countries in Africa are on track to reach this percentage, and about 33 million Africans will need to gain access to safe drinking water to reach the MDG by 2015.¹ The growth rate of the amount of people gaining sustainable access to safe drinking water provides evidence that these goals cannot be met. The drinking water coverage for Africans was at 56% in 1990, and has only increased by 8% to 64% in 2006. In order for the MDG to be met, this percentage would have to increase an additional 14% by 2015, nearly twice the growth rate in nearly half the time.² The magnitude of these statistics is more alarming because the population of Africa is growing, projected to increase from 943 million in 2006 to 1,149 million in 2015.³ As the population increases, the percentage of people gaining access to safe drinking water will be much more difficult to increase. Below are some staggering ratios that demonstrate the magnitude of this problem in Africa:⁴

Ratio	Magnitude	Meaning	Useful for	Type of Indicator
Population using improved drinking water sources in 2006 / Total Population in 2006	602 mil / 943 mil = 64%	Total African population with access to safe drinking water	Government, United Nations, Public Health Officials	Direct
Population using piped water on premises in 2006 / population using improved drinking water sources in 2006	244 mil / 602 mil = 41%	African population with proximate, sustainable access to safe drinking water	Government, United Nations, Non-profit organizations	Direct
(Population using improved drinking water sources in 2006 – population using improved drinking water in 1990) / difference in years from 1990-2006	(602 mil – 375 mil) / 16 ~ 142 mil	Average population increase each year who receive access to safe drinking water in Africa	Government, United Nations, Public Health Officials	Direct
Average yearly population who gain access to safe drinking water / average population growth of Africa	142 mil / 191 mil = 74 %	Average growth rate of population with access to safe drinking water compared to average growth rate of overall population	Government, United Nations, Public Health Officials	Direct
Mortality rate of children under 5 in sub-Saharan Africa / Mortality rate of children under 5 in industrialized nations	.125 / .005995 = 21	The magnitude of child mortality in sub-Saharan Africa compared to that of industrialized nations	Government, United Nations, WHO, Public Health Officials	Indirect

The data collected to develop these indicators are taken from health records, surveys, and other surveillance techniques. The accuracy of the population statistics should be verified by the United Nations, and they are viable to the magnitude of this problem. The first four indicators are direct because they fully demonstrate the magnitude of the lack of Africa’s access to safe drinking water. The last ratio is indirect because childhood mortality is not the only result of a lack of access to safe drinking water. One of the leading causes of childhood mortality is diarrhea, which occurs from water-borne illnesses. However, there are also other leading causes of death for children under five which does not directly associate with drinking water. Some other indicators of the magnitude of this public health problem can be seen by disparities between the urban and rural areas of Africa. The population of the urban areas was larger in 2006, but the percentage of African people without access to safe drinking water in rural areas was larger in 2006.⁶

1.        Unicef, and WHO. "A Snapshot of Drinking Water and Sanitation in Africa." Wssinfo.org. Web. 20 Apr. 2012. 8. <http://www.wssinfo.org/fileadmin/user_upload/resources/1251454622-A_Snapshot_of_Drinking_Water_in_Africa_Eng.pdf>.

2.        Unicef, and WHO. "A Snapshot of Drinking Water and Sanitation in Africa." Wssinfo.org. Web. 20 Apr. 2012. 4. <http://www.wssinfo.org/fileadmin/user_upload/resources/1251454622-A_Snapshot_of_Drinking_Water_in_Africa_Eng.pdf>.

3.        Unicef, and WHO. "A Snapshot of Drinking Water and Sanitation in Africa." Wssinfo.org. Web. 20 Apr. 2012. 4. <http://www.wssinfo.org/fileadmin/user_upload/resources/1251454622-A_Snapshot_of_Drinking_Water_in_Africa_Eng.pdf>.

4.        Unicef, and WHO. "A Snapshot of Drinking Water and Sanitation in Africa." Wssinfo.org. Web. 20 Apr. 2012. 4. <http://www.wssinfo.org/fileadmin/user_upload/resources/1251454622-A_Snapshot_of_Drinking_Water_in_Africa_Eng.pdf>.

5.        "Childinfo.org: Statistics by Area - Child Mortality - Overview." Childinfo.org:. Web. 22 Apr. 2012. <http://www.childinfo.org/mortality.html>.

6.        Unicef, and WHO. "A Snapshot of Drinking Water and Sanitation in Africa." Wssinfo.org. Web. 20 Apr. 2012. 4. <http://www.wssinfo.org/fileadmin/user_upload/resources/1251454622-A_Snapshot_of_Drinking_Water_in_Africa_Eng.pdf>.

Public Health Problem: Access to Clean Drinking Water

Access to safe drinking water has been a public health problem for many years, and it is still an overwhelming issue to this day. Public health officials began to mobilize towards constraining the severity of this situation worldwide in 1981, when the United Nations set out to provide “safe water and sanitation for all by 1990”. Although they were able to provide 1.2 billion people with better access to clean water, there is still approximately one-sixth of the world’s population, particularly in developing countries, that do not have this luxury. This commodity is overlooked as a problem in America; we have laws and standards that ensure safe drinking water for Americans. However, we also know the benefits that safe drinking water has on a population as well: the 30 year life expectancy increase from 1900 to 1940 largely had to do with improved water sanitation. Yet it is in the developing part of the world that struggles to obtain this basic human right. Population growth and rapid urbanization magnify this struggle, and war-time periods and natural disasters also pay their toll on access to clean water.

Water is a very powerful vector in distributing the world’s diseases. Water-borne diseases can be in the form of protozoal infections, such as cryptosporidiosis, parasitic infections, such as schistosomiasis, or viral infections, such as cholera or typhoid fever. Children are especially susceptible to these diseases because their immune systems are weaker than adults in battling infections. The WHO estimates that children under five who die from diarrhea each year to be between 2 and 3 million! That does not include respiratory infections and gastroenteritis that are linked to certain water-borne diseases as well. These are frightening numbers and need to be reduced substantially in the next decade. Public health aims to cut the number of people who do not have access to clean drinking water by half as part of the Millennium Development Goals, but I believe that it should be a goal to cut it by three-quarters.

This public health problem is particularly important to me because I have seen its effects on the physical, psychological, and emotional being. I went on a mission trip to Haiti last summer, and the poverty and lack of resources of the Haitian people forbid them to have safe drinking water in their country. Also, as I am studying environmental engineering here at Hopkins, I see the problem broken down to its scientific function, and am exposed to the methodology in fixing the issue. Water-borne diseases are easy to fix if they are controlled at their source, cleaned and filtrated before they can enter the body. The resources and procedures to do so are standard in the United States; they just need to be made available for developing countries. I find it interesting that by combining engineering tactics to fix problems, and then by utilizing public health means to deliver the solutions, the world can truly be changed. I believe that this problem has that potential.*

*Statistics from “Safe Water” by Rhonda Mullen, <http://www.whsc.emory.edu/_pubs/ph/phwin05/safer_water.html>

      

Human Rights

The Webster dictionary defines human rights “regarded as belonging fundamentally to all persons”. This definition can be expanded to say that all people – no matter their age, gender, race, ethnicity, religion – are regarded to have certain rights and freedoms that cannot be withheld from them. This idea of human rights started with John Locke, and foresaw the drafting of the American constitution. I think human rights are important to public health because of the implications that public health has on the population. Public health should not and does not apply only to a certain type of person, but to all people. Its sole purpose is to improve humanity, and if it is to achieve this purpose, the inalienable rights that each person possesses must be taken into account when any public health decisions or decrees are made or passed.

According to the UDHR, a good standard of living relates to health in the areas of food, clothing, housing, medical care, and social services. Specifically, this human right is referenced for each person and their family. These five areas are considered to be the necessities in life, not luxuries, therefore they are included in what each person has the right to obtain. Of course, being a right, it is also dependent on that person to reach out to obtain them, not to stray away from them. I believe that the UDHR included this as a major right because these are the living standards associated to a positive well-being. However, these things are not all guaranteed in our society. They must be worked for, because they cost money. Therefore, it is important to distinguish this human right as a right to obtain these criteria upon individual discretion, not on handouts by the government.

The court case of Alyne da Silva Pimentel v. Brazil established the ruling that “States have a human rights obligation to guarantee women of all racial and economic backgrounds timely and non-discriminatory access to appropriate maternal health services”. They also ruled that governments that outsource to private health-care institutions must be responsible for these institutions to follow the same guidelines. I find this decision interesting because it is very subjective in its nature. I think that if there are not specific timelines to these obligations by the States, there could be problems in the future. The words “timely” and “appropriate” can mean different things to different people, and their passive nature might prove to falter in future cases.

Motherhood is specifically mentioned because maternity deaths are a real problem in the world, and the number of deaths can be reduced if proper actions take place. The technology and medicine are advanced enough to reduce the deaths, but they have not been appropriately utilized to do so. Also, motherhood is highlighted instead of say “fatherhood” because of this connection at birth. Although fatherhood is very important, the rights of mothers and women in general were not always to the standard they should have been, equal with men. Therefore, the expression of motherhood in each of these documents supports their roles as women and mothers, and that they have a largely different relationship with childbearing than men. Women are the ones who have to go through child birth, so therefore they have human rights that men do not have and/or need in this area. 

Contagion

The movie Contagion follows a number of different characters in public health, political, medical, and social positions as they try and fight a novel meningoencephalitis virus as it spreads throughout the world. After a businesswoman from Minneapolis travels to Hong Kong and contracts the virus, she returns home and dies from severe seizures. Her son also gets the virus, and dies shortly after. Her husband, played by Matt Damon, is immune to the disease, and he spends the rest of the time trying to protect his daughter from contracting the disease. Meanwhile, the Department of Homeland Security and Centers for Disease Control (CDC) are alarmed by the number of fatalities the virus has piled up, exponentially increasing throughout the world. A vaccine is attempted to be made, with many failures. Finally, the Meningoencephalitis Virus One (MEV-1) is made by a scientist who is able to find a line of bats that support the attempted research of the virus. The virus is then made is mass quantities, and given out to people at random, because there is not enough for everyone. The reactions from the public include panic, fear, and violence as more and more people die, and public health officials struggle to keep it contained and in order.

There are certain terms that can be defined and applied to this movie, in relation to public health. (1) Outbreak is defined in epidemiology as an occurrence of disease greater than otherwise expected in a certain time and place. The outbreak of the meningoencephalitis virus in Contagion raised alarm to the CDC with only a few cases, and they did not know if the virus was contained within a small population or not. (2) Outbreak investigation involves a number of different factors. Some of these seen in Contagion were to verify the diagnosis related to the outbreak, develop a hypothesis about who is included and how the virus can be stopped, and after there is a prevention and control system made from this hypothesis, the information is released to the public. (3) Isolation and quarantine refer to separating a group of people from the general population. In Contagion, the military quarantined Minneapolis, because the disease started there in the United States, and they did not want other people outside Minneapolis to contract the disease.

One area in the movie Contagion where public health officials could have been more prepared was in hospital facilities and staffing. After many people contracted the disease, the number of nurses and doctors available was low, as well as places to contain the people. They had to use stadiums and other large scale buildings to house the infected people. Poor communication and execution by public health officials led to a strike by the nurses, and scarce resources and timeliness at treating the patients. Public health officials could have been more prepared by having a surplus center somewhere just in case an outbreak should occur, and better transportation/communication methods at connecting medical equipment with the infected people would help contain and treat the virus. 

Global Climate Change

From table 1 in this article, two weather events and health effects that would affect my family and friends are heat waves (causing heat stress) and sea-level rise (causing injuries, drowning, water and soil salinization, ecosystem and economic disruption). Being from Florida, heat waves are a serious issue. It is nicknamed the “Sunshine State” for a reason, and it can get up into the 100s during the summer months. Being outside during this time can be very dangerous if my family and friends are not hydrated. It is especially dangerous for my grandparents to be outside. If the temperature continues to rise, more and more precaution must be taken by them if they want to continue to live in such a hot state. Sea-level rise is also a major issue, especially for my grandmother. She lives right on the beach in Cocoa Beach, and if the sea-level were to rise too rapidly, she would be forced to move farther inland.

One weather event on this list that I did not consider as a global warming effect was winter weather anomalies. I only assumed that global warming meant as it sounds, warming effects across the globe. It is interesting to see that global climate change can also have cooling effects.

Mitigation is the action to decrease the intensity of radiative forcing in order to decrease global warming effects. Adaption is the response to reduce the vulnerability of natural and human systems to effects of climate change. Mitigation involves reducing such agents as greenhouse gases’ production to ultimately reverse global warming, whereas adaptation focuses on the human impact that global warming implies. These two aspects of climate change are analogous to primary prevention and secondary prevention. Mitigation is analogous to primary prevention because it involves attacking the source of health issues in order to stop them from happening. Adaptation is analogous to secondary prevention because it focuses on humans and nature where there health issue has already occurred.

One way public health professionals can help people adapt to climate change is by evaluating effectiveness, accessibility, and quality of personal and population-based health services. In relation to climate change, this service can be used to assess the preparedness effort of heat-wave plans. When a heat-wave occurs, it is up to public health officials to effectively prepare the public with health concerns and precautionary actions. They then need to evaluate this process to figure out how successful it was.

One thing that my hometown is doing to prepare for climate change is made more retention ponds and other infrastructure to prevent flooding. As global warming continues to rise, the amount of precipitation in tropical areas such as Florida will also rise. Therefore, flooding is a serious issue. My hometown is working to make flooding less likely in the case of heavy precipitation. One way I would help people mitigate to climate change would be through education about what global warming is and how it has become an issue. I would give them tips and knowledge on how to reduce their own carbon footprint, thereby taking small steps at improving the climate overall.  

Ten Great Public Health Achievements

“Ten Great Public Health Achievements” discusses the ten top public health achievements of the last decade, ranging from vaccine-preventable diseases to tobacco control to cancer prevention. Death rates decreased and life expectancy increased over the last decade by a significant amount, mostly contributed by advancements in public health. In particular, 7 of the 10 achievements targeted 15 leading causes of death. This article not only describes specific health concerns, but also political and economic advances, where public health regulations have been less construed and contradicted.

I found the most significant achievements discussed in this article to be vaccine-preventable diseases and cancer prevention. The idea behind vaccination in my generation is not often discussed to the gravity that it deserves, where “normal” diseases of the past are now unheard of. Vaccines are now destroying rarer diseases at an alarming rate, and the data behind the lives saved demonstrates this advancement. This achievement is the most important to me because I have gone to many undeveloped countries, and vaccines protect me from exposure to any disease while I am not in America. Cancer prevention is the other most significant achievement in my eyes. Not only screening techniques, but chemotherapy as well, has saved many lives and cured many cancers. Although there is still a lot more work to be done to solve cancers, public health has shown giant leaps in the past decade to aid in its prevention.

One problem I would like to see solved or improved on in the next 10 years is clean drinking water. Although this issue seems tiny on a local level, globally it is a big problem. It is estimated that a child under five dies every 20 seconds from water-related diseases! For the technologies and advancements that developed countries have made over the past half-century, this number is unacceptable. This problem is important to me because I have seen it first hand, in Haiti. The first way to solve this problem is through charity, and by people willing to give service to the problem. However, the ultimate way to fix this problem is to assist undeveloped countries with their needs by improving foreign relations. This should be a goal made by nonprofit organizations and the government; they should improve fund raising and advertising so that others may benefit from the necessities of life that everyone deserves.