In Teaching Global Health, Is the Glass Half Empty or Half Full?
Glass half full: These three boys live in Nepal, which reduced under-five child mortality from 325 for every 1,000 children born in 1960 to 27 in 2021. (Photo from Global Health 101, Fourth Edition)
As Professor Gavin Yamey of Duke University mentioned in a recent Tweet, there is a “pessimism bias” in global health that needs to be overcome. Nicholas Kristoff, a New York Times columnist, wrote at the same time about the progress that Sierra Leone has achieved in health, despite its low-income status and the fact that, when polled, many people believe that fighting global poverty is “hopeless.”
Indeed, many of us who study, teach, or work in global health may focus too much on what is wrong in global health. In doing so, we may lose sight of the enormous progress that has been achieved in many countries in reducing avertable illness, disability, and deaths over the last 50 years or so. In addition, if we are too pessimistic we might pay insufficient attention to the lessons learned from such progress in a number of areas in global health.
Even if we focus on what remains to be done, we should all be familiar with key areas of progress in global health. Here are a handful of examples:
- Global life expectancy increased from 51 in 1960 to 71 in 2020.
- Smallpox was eradicated and Guinea worm and polio have been nearly eradicated.
- The number of children dying every year in the world has declined from about 12.6 million in 1990 to about 5 million in 2020.
- Maternal deaths decreased by 38% from 2000 to 2020.
- 53 million tuberculosis deaths were averted through treatment from 2000 to 2020.
- In 2020, there were 820,000 fewer deaths related to HIV than in 2000.
In addition, an enormous amount of illness and disability has been averted, for example, through childhood vaccination, supplementation with vitamin A, and the use of oral rehydration therapy. It is critical that we be aware of these success stories and what can be learned from them. They can also inspire us to continue working to address the unfinished agenda in global health.
Despite the progress noted above, the unfinished agenda is a very large one. About 5 million children die every year before their fifth birthday. About 10.6 million people became sick with tuberculosis in 2021 and 1.6 million people died of it. About 1.5 million people were newly infected with HIV in 2021 and 650,000 died of AIDS-related causes. There were also about 300,000 maternal deaths in 2020 and more than 600,000 deaths from malaria. Disability from some of the parasitic infections and diseases remains almost incalculable–with about 1 billion people, for example, infected with roundworm.
When it comes to noncommunicable diseases, the prevalence of diabetes has quadrupled globally since 1980. In addition, there remain large gaps and unacceptable disparities in access to universal health coverage and some of the key determinants of health, such as water and sanitation. We must also learn the lessons reflected in these gaps, while ensuring they are addressed as quickly as possible, in the fairest possible ways.
As we think about the study and teaching of global health, the above data can be confusing. The unfinished agenda is large, our time is limited, and we could jump right into what needs to be done. Or, we could spend considerable time setting the agenda for our teaching and learning, on the areas of progress.
Considering these points, I have decided to focus on enabling my readers and students to get a good understanding of:
- Key progress in global health— This is: “the good news in global health;”
- Critical gaps in global health—This is the “unfinished agenda” that remains or "the bad news” and;
- Key lessons from efforts to address some of the most important global health issues of the day.
I seek to accomplish this by introducing summary data on progress and gaps early in Global Health 101, Fourth Edition and in my teaching. I then seek to reinforce and expand on these notions as we cover the range of key topics. One important way to do this is through discussion of the more than 30 cases in Global Health 101, Fourth Edition. What broad lessons emerge, for example, from the efforts to eradicate smallpox, control onchocerciasis, or reduce TB infections and deaths in China? What should we learn from Poland’s efforts to reduce tobacco consumption, the Nepali program to provide vitamin A to all children, or Morocco’s efforts to eliminate trachoma?
In addition, as time has gone on, I have become more and more interested in exposing students early to some of the most important lessons from addressing the major burdens of disease globally. Thus, today I would encourage students to read House on Fire by Dr. William H. Foege before the first classroom session. The book is short, easy to read, remarkably insightful, and a wonderful summary of key lessons for working in public health by a giant in the field. Toward the end of the course, I would reiterate some of the key lessons of that book by asking students to watch Dr. Foege’s interview for the Yale Institute for Global Health.
Although the interview focuses considerable attention on COVID, the lessons Dr. Foege presents in this interview go far beyond those learned from COVID alone.
Today, I would also ask students to learn from the experience of BRAC, a Bangladesh-based NGO of great importance in efforts to address poverty and improve health. I have always appreciated BRAC’s self-critical approach, the extent to which it so carefully has its work evaluated, and the manner in which BRAC draws lessons from its experience.
About the Author:
Richard Skolnik, MPA, has spent more than 40 years working on international development and global health and was formerly a lecturer in the Yale School of Public Health, the Yale School of Management, and the George Washington University School of Public Health. He is also author of the best selling text, Global Health 101 and Global Population Health: A Primer.
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