[MUSIC] This week we're going to be talking about global health and disease. And I'm going to be talking to a professor of political science here at Wesleyan University, Jim McGuire, who works on global health and disease internationally. And we'll have a chance also to talk with some other guests about the issues that are plaguing much of the world, and causing premature death or the diminishment of capacities, of our fellow global citizens. I want to start my part of this week's discussion off with trying to give you some of the basic facts around global health and disease, before we move into our conversations. And I'm drawing a lot of my information form the World Health Organization, from some demographers and development economics professors, and from some foundations like the Gates Foundation, that has been so active in this sphere for many years. So, some basic facts. Let's start off with morbidity. I'm afraid this week's discussion is going to be, focus on the least pleasant aspects of our global challenges. The top ten causes of death in the world are first, heart and circulatory diseases. Second, stroke. Third, lower respiratory infections. Fourth, lung disease. Fifth, diarrheal diseases. Sixth, HIV AIDS. Seven, lung and lung related cancers. Eight, diabetes. Nine, injuries, often from road accidents. And ten, deaths resulting from premature births. Now this is, you know, we used to talk about the four horsemen, the great scourges of humanity. Here are the 10 leading causes of death. And as you go through them you see they, immediately you'll think they afflict, they affect different kinds of people, people living in different situations differently. They affect different parts of the world differently. Different income groups will be variously affected, and so forth. In wealthier countries, heart disease and stroke are the leading causes of death, followed by respiratory diseases, and then Alzheimer related diseases. You see, in wealthier countries, where life expectancy is greater, they will be different causes of death. In poorer countries, the countries we have been focused on in much of the class so far, in poor countries, HIV AIDS, lower respiratory infections, and diarrheal diseases are the chief killers. And they are also the diseases, I think I can say, we know the most about. We know some of the tools that would enable us to stop the diseases, or delay them, or to reduce their frequency. Just again, giving you some facts and, you know, you'll hear more about this in other videos. And there's a lot of information on the web. Here's an important statistic. In high income countries, in high incomes countries, 7 in every 10 deaths occur among people 70 years of age and older. This is pretty impressive. Seven out of 10 deaths in high income countries occur to people over 70 years old. People predominantly die of chronic diseases. Cardiovascular, cancers, dementia, chronic obstructive lung diseases, or diabetes. Only one in every hundred deaths are among children under 15 years old. It's a very different story as we move to different parts of the world. In low income countries then, nearly 4 in every 10 deaths are among children under 15 years old, 40%. And, only 2 in every 10 deaths are among people age 70 and older. So, you see the great disparity of experience and life expectancy. People predominantly die of infectious diseases. That means a lower respiratory infection, HIV AIDS, diarrheal diseases, and malaria, to tuberculosis. These remain scourges and collectively they account for more than a third of the deaths in low income countries. Still today, childbirth in low income countries is a trad-, is a dangerous life event. Childbirth and prematurity are very significant causes of death in these areas. And although we know how to reduce their frequency, we don't get our knowledge and the resources behind what we know to the right places, at the right time, to reduce these frequencies. But let me just, you know, if I may, just emphasize this disparity. In the rich countries, 7 in every 10 deaths occur in people over 70. And in the poor countries 4 in every 10 under 15, and only 2 out of every 10 for people over 70. So when we talk about health issues, we're obviously talking about, and morbidity, we're talking about nature, right. We're talking about nature. This is, our lot in life as human beings is that we are mortal creatures and we're going to die. What we quickly get into, when we talk about global health challenges, is how the social construction of our environment, how the political construction of our societies, how the human impact on our environment changes the course of life and death for hundreds of millions of people around the globe. And we also see that we can affect nature with extraordinary results through the use of timely, tested, and resourceful interventions. But we don't do so consistently in many parts of the globe. And so, the life trajectory of people around the planet is so different, their experience of nature is so different, their experience of their own bodies, and of the capacity to live a full life is so different, depending on geography, on income, and on politics, as we'll see as we move through our discussions this week. The World Health Organization estimates that 23% of the global disease burden Is attributable to the environment. Almost a quarter of what causes disease today around the world comes from environmental factors. The studies suggest that a third of the disease burden among children is due to environmental factors we can change. That's the good news, right. The kind of depressing ,and even frightening, news is that we have created conditions for more and more disease. You see me change, shifting in my chair all the time now. My doctor tells me that this is because the way I live, you know, sitting as a professor, or sitting reading books, or at my computer all the time has wreaked havoc on my back. So this is a minor disease compared to what we're talking about. But I have constructed a way of life, as my doctor says, your back ain't made to do that. Right? Your back ain't made to do that. That's the sad part for me. I go there. You know? And I, I'm getting old and I have to figure out how to live with with an achy back. But the good news is, there are actually things you can do to make an enormous difference, and this is what this class is all about right, from the very beginning. And although we know that a quarter of the disease burden comes from environmental factors, we also know the things we need to do in order to reduce what to many of seems like the most dramatic or tragic consequence of disease, which is really early death, death among children that could have been prevented. And we can change the things that are causing those high rates of morbidity. Children are, of course, vulnerable to disease. They're, they can seem quite resilient in, in many respects. But they are really vulnerable to infection and to the consequences of living in extreme poverty. Children bear the highest death toll, with more than 4 million environmentally caused deaths every year. These numbers become abstracted. Please think that through. Four million environmentally caused deaths yearly. And mostly in developing countries, 4 million children each year. The infant death rate from environmental causes is 12 times higher in developing than in developed countries. 12 times higher. So that childbirth,never an easy thing, even in a wealthy country [LAUGH], is an extraordinarily fraught and dangerous procedure for mother and child in developing countries still today, despite what we know. So, we're here today with Professor Jim McGuire, who is in the government department at Wesleyan University, and chair of the department now. Thanks for making time to talk to me and to our students here in this Coursera Wesleyan class called How to Change the World. >> My pleasure. >> And our theme this week, as you know, is disease and global health. And, you know, I think for some people, political scientist is not the first kind of person they think of as being the person working on health issues. So how did you first get involved with the issues of global health? >> Well it was actually through my teaching here at Wesleyan. I was teaching a class in the early 1990s called Political Economy of Developing Countries, and in the course of preparing the class, I encountered the work of Amartya Sen. >> yes. >> The philosopher and economist at Harvard. And he has the idea that, you know, the goal of human development is the expansion of human capability. >> Yes. For Sen, you know, a very important capability is the capability to survive physically from one day to the next. So, I got quite interested in his work. And, at the same time in the course, I was teaching a unit on why the East Asian countries have developed more successfully in terms of economic growth and income inequality than the Latin American countries. And it occurred for, to me, that like, whenever people compare East Asian countries and Latin American countries, the East Asian countries always win. >> Uh-huh. >> But the criteria are always income related criteria. And why hasn't anybody ever tried to compare the two regions on things like infant mortality and life expectancy? So I got quite interested in capabilities, capability expansion, physical survival. Of course, health issues are very closely related to that. So it was actually through my teaching right here at Wesleyan that I changed my whole research program. >> That's interesting. >> Before that, I was trying to study why some countries did better than others at establishing and consolidating democracy. >> Mm hm. >> And the country on which focused was Argentina. So this was a radical turn in my research program. And it was all related to the teaching. And, I think actually my teaching has influenced my research as much as my research has influenced my teaching. >> That's really interesting. And I know that many of the people, even in these online classes, where we don't have the same kind of contact with students as you would in a physical classroom, you wind up developing ideas and approaches that change the nature of the scholarship you do. We are reading some of Amartya Sen in the class. At least we've assigned that for this week. And in your book, Wealth, Health and Democracy in East Asia, you used this capabilities approach. >> Right, yeah. >> And so maybe I should just go on right with the naive questions. So, wealth and health, how are they connected? Well there's one hypothesis out there, which is known as the Wealthier is Healthier Hypothesis. >> Mm-hm. >> Which says that both wealthier individuals and wealthy countries and wealthy subnational units within countries, like provinces or states. >> Right. >> Are going to be healthier, with health measured in terms of, okay, measured in a variety of ways, but one way of course is through mortality. >> Mm-hm. >> Indicators like life expectancy and infant mortality. And it's quite true that when you look at levels, wealthier is definitely healthier. >> Right. >> If you look cross nationally, which is basically the area that I work in, countries that have higher levels of economic affluence have lower levels of infant mortality and longer life expectancy. So, that's absolutely true for level. But when you look at progress, the relationship is much weaker. For example, if you look in the year 2010, compare all the counties in the world, you'll find a very strong relation between level of GDP per capita, gross domestic product per capita, which is a measure of overall affluence, and, say the infant mortality rate. >> Great. >> But if you look at progress, at achieving economic growth over, say, a 50 year period, 1960 to 2010, and you look at progress at reducing infant mortality over that same 50 year period, the relation is much weaker. So the wealthier is healthier conjecture holds much better for level than it does for progress. And this is important because, actually, how countries do at progress is more important, from both theoretical and practical standpoints, than what level they had achieved in 2010. >> Yeah. >> Because, say, the level of economic affluence that a country has achieved in 2010 or the level of infant mortality that is achieved in 2010 reflects factors going back millennia. >> That's right. Right. >> Whereas if you just look at progress during a particular span of time, that's a lot better for extracting policy lessons. >> Yeah. >> And other things that are, you know, amenable to human intervention. >> Yeah. >> So, you know, if you look at, only at levels and neglect progress, which is what a lot of people in the wealthier is healthier tradition do, I think that biases policy solutions toward, you know, thinking that the role of a government or even of a private entry or organization, is simply to increase the overall economic affluence of the population. >> Right. >> And if you do that, people's health will take care of itself. >> I see. >> But if you look at progress, that's definitely not true. >> That's not the case. >> There are some countries that have done really well at economic growth, but not very well at reducing premature mortality. And other countries have done very poorly at economic growth but extremely well at reducing premature mortality. >> And is that due to the fact that you can have significant economic growth without a great redistribution of that wealth across sectors? In other words, if, does the wealthy is healthier hypothesis work if you dis-aggregate the population? Like the people who are wealthy in the population are in fact healthier? Or does, you see what I mean? If a region gets much wealthier, but infant mortality stays high, is that because the poor are still poor and those are the ones who are dying? Or is it because that wealth doesn't matter as much as we thought it did about infant mortality? >> I'd say it's a little of both. That you know, you can have rapid economic growth and a bad income distribution. Well that's worse for reducing premature mortality. >> Right. >> Than having rapid economic growth and a very low level of income inequality. >> Mm-hm >> But it's not all about income inequality. >> It's not all about the money. >> [LAUGH] No it's not all about the money. Because [LAUGH] let's face it. Like what needs to be done to reduce premature mortality is mostly very cheap types of interventions. >> Right. And you can have a country, a good example is Chile. >> Right. >> Say Chile, during the first ten years of Pinochet's. >> Right. >> Dictatorial military government, from 1974 to 1983. There, they were poorer in 1983 than they were in 1974. GDP per capita went down. >> Mm-hm. >> Income inequality skyrocketed and income poverty went from 20% to 30% of the population. >> Hm. >> Nevertheless, General Pinochet managed to reduce the infant mortality rate in one decade faster than anyone else in human history. In 1974, the infant mortality rate was 65 infant deaths per 1,000 live births. By 1983 it was 19 per 1,000. >> Wow. >> This was a plunge. So income distribution got worse, and GDP per capita declined. What happened is that the government, for reasons that still remain to be revealed because, as Dreze and Sen pointed out, General Pinochet does not have a reputation as a soft-hearted do gooder. >> Right, right. >> He actually introduced these extremely inexpensive maternal and infant health care policies, particularly in very impoverished areas of the country, urban shanty towns, remote rural areas. And these extremely cheap interventions more than made up for the lousy economic growth and terrible worsening of income inequality and income poverty. >> Yeah, that's fascinating. >> So, not only is it not just a matter of economic growth, it's not even a matter of economic growth plus income distribution. The public provision of basic social services on its own can be really effective. >> So the public, I want to hold onto that, the public, say that again. >> [LAUGH] Once the public provision. Public provision of basic services. >> Basic services, yeah. >> And also, you can't look only at the supply side. You have to look at the demand side as well. Services not only have to be provided, they have to be utilized. >> Yeah. >> So you've got to look at the conditions under which people are willing and able to use even putatively free social services. >> Right. >> So, they might have to take time off work, or take a bus to the health clinic or whatever. So you've got to look at the utilization side as well as the provision side. >> Right, right, mm-hm. So how does, how does this kind of background plug into the capabilities framework? >> Okay. >> Because, because, you know, I can imagine why some social scientists are interested in measuring income, or even income distribution. And you can measure GDP. You can measure mortality. But, how do you get at the capabilities as something you can understand, and track over time? >> Well, I guess, you know, I view the capabilities approach, and capabilities themselves, basically, the expansion of human capabilities equals the expansion of a person's ability to lead a thoughtfully chosen life. [BLANK_AUDIO]
