READINGS

Global Health and Social Medicine

Those who work in low-resource settings in the developing world need to recognize the global nature of many diseases that increase the disease burden for rural populations. In 1997, the Institute of Medicine defined global health as “Health problems, issues and concerns that transcend national boundaries, may be influenced by circumstances or experiences in other countries, and are best addressed by cooperative actions and solutions.”

Throughout prehistory and history, humans have always taken their pathogens along with them on their migrations and expansions. Some typical examples include infectious diseases like Yellow Fever and malaria, water-borne diseases such as cholera (the 7th pandemic began in the early 1980s.), and the HIV-AIDS “pandemic,” which is a global constellation of interconnected regional epidemics. So, global health is about linkages: common problems and common solutions best addressed by cooperative actions such as the Millennium Development Goals. By 2015 all 189 United Nations member states have pledged to:

Eradicate extreme poverty and hunger Achieve universal primary education Promote gender equality/empower women Reduce child mortality Improve maternal health Combat HIV/AIDS, malaria and other diseases Ensure environmental sustainability Develop a global partnership for development

See: Millenium Goals Site

Not everyone who is exposed to an infectious agent or an environmental contaminant will have an adverse health event such as becoming infected or developing a disabling condition. Likewise, among those who do become infected or debilitated, the symptoms and severity may vary greatly due to many factors. Some important variables include:

Social medicine is an interdisciplinary field that seeks to better understand the cultural, economic, and political contexts that impact health, disease and the practice of biomedicine. Social medicine considers many factors, trying to understand the reciprocal influences of biology, environment and behavior. It also aspires to foster grassroots awareness at the community level and health policies at the governmental levels that can lead to healthier societies. Finally, it is important to realize that both global health and social medicine are about linkages. Economic development is always linked to health, for example:

For technology to be a solution to health problems, it must:

Epidemiology is the study of the determinants and distribution of disease. Figure 2 models approaches that recognize multiple factors as an “epidemiological triangle,” showing the epidemiological triangle for an infectious disease, malaria

Figure 1

To the classical "epidemiology triangle" of agent, host, and environment, people who are interested in medical problems should add "Treatment availability" to their analysis of "Environment." "Education level" might also be added to the human "Host" list because a person's level of education may be the key to what preventive actions and other decisions that will affect activity patterns and nutrition.

Community Health

The community is the most important level for implementation of health projects. A community can be defined as “a group of people who have common characteristics” such as location, ethnicity, age, occupation, common-interests, self-identity, etc. Persons living in complex, heterogeneous developed societies often belong to multiple (and sometimes overlapping) communities. In rural areas of developing countries, a person is most often a member of a distinct, delimited, homogeneous group with common residence, typically an extended family- or kin- grouping. For developed countries, community health has been defined as “the health status of a defined group of people and the actions and conditions—both public and private—employed to promote, protect and preserve health.” While this definition is equally valid for the developing world, practitioners in the lesser-developed countries usually call it “primary health care.”

Another important consideration is that the definition of the “self” usually varies between those living in complex, technology-based societies and those in low-resource, subsistence or non-wage economies. While each person is the product of enculturation and many socializing influences during his or oher growth and development, two general orientations are recognized:

Some authorities estimate that as high as 70% of the global population lives in collectivist societies where the self is defined more communally. Other facets of human psychology also impact self-identity as well, such as self-focus and group-identity (ingroup-defined self, publicly-defined self, privately-defined self). Despite the complexities of personal psychology and social anthropology, those working among rural communities should be aware of these differences. The following lists offer some attributes of persons who have grown up in individualist or collectivist societies.

Theories and Models for Community-Based Health Interventions

Obviously, scientific theories and models are conceived within the cultural orientations of advanced societies. There science, since its beginning, has been dominated by individualistic approaches and explanations of human behavior. However, over the past two decades current public-health professionals have relied less on individualistic models and have made more efforts to develop theories and models that account for the social and contextual influences on human behavior. These emerging “community” models have come from the social sciences and have been developed by those interested in social medicine, or what is often called “behavioral health” or “behavioral medicine.” There are several reasons for this fresh look and reorientation, for example,

However, community-based models of behavior are not easy to apply.

Challenges for newly emerging, community models

Complexity—When one works at the broad social and contextual level, the issues are complex, therefore the constructs will be complex, addressing multiple determinants

Design & analysis—This results in a critical challenge: to better craft research design and analysis methods that are capable of determining program efficacy

Theory selection—Choosing a theoretical orientation for an intervention is complicated

Multilateral nature—Since sociocontextual approaches are multidisciplinary and multi-layered, probably no single theory will explain all the variables and contexts

Metrics & measurement—One must develop reliable and valid assessment techniques

Cultural differences—Each cultural context requires fitting the application to the setting. It is important to be flexible and adaptive; the cultural equivalence and relevance of constructs must be considered

Social Ecology and Community Capacity

While we do not have time to cover in detail specific models or theories and discuss their strengths and weaknesses, is it important to discuss briefly “social ecology” and “community capacity.” As we have emphasized, (1) recently public-health authorities have urged reorientation to emphasize and prioritize the community as the best setting for change (Institute of Medicine’s 1988 report, The Future of Public Health); and (2) health professionals working in rural, low-resource settings in the developing world must understand human adaptations (cultural and biological) within an “ecological framework.” Such an understanding emphasizes a systemic approach to the interactions and interdependence of people, their values and norms, their institutions, etc. all operating within the broader ecologic, social, and political environment (from local to global). As such the local community has been viewed as:

Some attributes of communities include:

When one works with many communities, it becomes very apparent that the capabilities, leadership, community spirit and initiative, and so on vary considerably due to the personal dynamics and the group’s social history. The term used today to summarize these attributes is community capacity. McLeroy defines the concept this way: “Characteristics of communities that affect their ability to identify, mobilize and address social and public health problems.”

Community capacity, then, is based on the idea that the nature of social relationships within a community affects the ability of that community to redress health problems. While creating community capacity is often seen an important outcome (of an intervention) in and of itself, at the very least capacity building is essential for sustaining programs and health improvements:

Infrastructure is created (facilities, tools, equipment) People are empowered (skills, confidence) Community commitment is created All of which can be applied to future health and social problems

Understanding community capacity requires a cross-disciplinary approach. Researchers have yet to develop a consensus “metric,” i.e., some way to measure community capacity/competence. However, it is obvious that (a) community capacity consists of the human and material resources that are the building blocks for assets, (b) community assets can be recognized and mobilized to bring about change, and (c) community capacity is linked to quality-of-life. Students working in rural communities should be aware that community capacity integrates many facets:

Building Community Capacity and Community Coalitions

If community capacity is critical to health improvement, projects and interventions must address and assess it. Based largely on decades of United Nations work to develop tools for rural community development, collective “development wisdom” can be useful.

For our purposes, “sustainability” can be defined as:he capacity to maintain service coverage at a level that will provide continuing control of a health problem (Claquin 1989 in Norton et al. 2002); and [Optimal] Improved community capacity/competence to conduct effective health promotion programs (Jackson et al 1994 in Norton et al. 2002).

Summary

Projects and interventions implemented in low-resource settings like those found in rural communities in the Developing World must be based on social-medicine and multifactorial approaches. To be effective at the community level, health interventions must assess and address community capacity. These ingredients are essential for ethical project implementations: (1) commitment to genuine grassroots development using participatory methods; (2) stakeholder ownership; (3) community empowerment; and (4) a reasonable plan for access and sustainability. Intercultural communication and health care-related engineering projects are not formulaic. They must be carefully designed with the input of the community.

Example of How to Start a Health Project in Liberia, West Africa

The purpose of this last section is to very briefly list the steps, and use the terminology introduced above, showing how the concepts are used in an actual field implementation designed to build community capacity. Set in a rural West African community, the project entailed conducting health assessments and implementing a community health program. Participatory methods are covered in a separate module (Module 6) and you should refer to that module for details on the methods, approaches and techniques. Essentially, PRA (participatory rural appraisals) and PAR (participatory action research) use a process in which outsiders and insiders work systematically together to explore, define, identify, and redress health concerns for the community. In this case study, five major steps were employed to undertake a community-health assessment and implement a sustainable, community health worker program.

SUMMARY: When beginning health-related projects, remember to take a community-based approach. Health problems and are often based upon many factors and rooted deeply within a community. Health solutions are rarely formulaic and a cross disciplinary approach is often required. The keys to success lie in improving community capacity by building infrastructure, empowering the community, and focusing on sustainability.

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