Welcome. In this session we're going to speak about the health status of people in different parts of the world. When you finish this session you should be able to describe some of the progress made in improving human health in the last several decades. Describe some of the key gaps that remain to improving human health. Indicate some of the key indicators from measuring progress in global health. Articulate how those indicators vary across countries and income groups. And finally indicate the importance of highlighting differences in health status not only across countries but within countries as well. Let's begin by talking about some of the good news in global health. Some of the important progress that's been made over the last several decades in improving human health globally. First there's been an increase of 42% in life expectancy globally, from 1960 to 2013. Never before have so many people lived for so long. Second, there's been a substantial reduction in under five deaths. 50% few under five deaths occurred in 2013, in fact, than in 1990. There are 1.2 million fewer new cases of HIV than there were in the mid to late 1990s as well. There are 500,000 fewer TB deaths per year in HIV-negative individuals than there were in 1990. There are almost maternal deaths have been cut since 1990 by almost half. There has been a greater than 50% decrease in malaria mortality rates among under five children since the year 2000. More than 2.5 billion children have been immunized against polio since 1988. And polio is now down to only about 100 cases globally. And finally, there's been a 99.9% reduction in the guinea worm since 1986. And there are now just a handful of guinea worm cases left in the world before the world can say that it's eradicated guinea worm disease. Now despite this very good progress there are also some really important areas where there's been much less progress and there remains an important unfinished agenda in global health. There's still 6.3 million under five children who die every year in the world. And if you divide that by 365 days, that's about 17,000 under five children who die every single day in the world. In about 45% of these deaths are related to the fact that these children are undernourished. They don't get enough food or they don't get a diverse enough diet or they're lacking for example in certain micronutrients. These deaths would not occur if these children were better nourished. Despite the progress against the HIV, there's still 1.5 millions AIDS deaths in 2013. Despite the progress against the HIV, there's still more than two million new HIV infections every year. There's been substantial progress in reducing the burden of tuberculosis. And yet there were still 1.5 million TB deaths in the world in 2013, almost 600,000 malaria deaths. Almost 300,000 women who die of pregnancy related causes. And about two billion people worldwide who are infected with soil transmitted helminths. So let's probe some of the good and some of the bad news, by looking at some health status, by first defining some of the health status indicators that we're going to use in measuring health. And then what we'll do is we'll probe them and look at how those health status indicators play out for different regions of the world. Before I show you the definitions. Let's asked the students about some of the important definitions of key global health indicators. Emily, if I might, what is the maternal mortality ratio? >> The maternal mortality ratio is the number of woman who die from pregnancy related causes for every 100,000 live births. >> And Elizabeth, what's the neonatal mortality rate? >> The neonatal mortality rate is the number of neonates or children under the age of 28 days who are dying per 1,000 live births. >> Again, what's a neonate? >> An infant who's under 28 days old. >> And why would be pay particular attention to neonates, to infants who are under 28 days of age? >> Because a person is at the most dangerous stages of their lives, at the very beginning of it and at the end of it. So looking at neonates indicates the risk of death at a person's start of life. >> It's a really risky period. And what's an infant? >> An infant is a child under one year. >> And what's the infant mortality rate? >> So that is the number of under one year old infants who have died per 100,000 lifers. Or per 1,000. >> Right, I now got Emily confused. It's 100,000 for what by the way. Why do we measure maternal deaths over 100,000 and neonatal deaths and infant deaths and under five deaths, which I'm not going to define because we don't have to over 1,000 live births? >> Because maternal deaths are more rare and so we use 100,000 rather than 1,000 for the others. >> Right. If we used 1,000 from maternal deaths, we have this figure that's a fraction that's really hard to follow. So we measure maternal deaths over 100,000 live births and we measure neonatal infant and under five child deaths. And I think I forgot life expectancy. Shalen, life expectancy. I should have started with that. >> Life expectancy is the age an infant is expected to live in a certain location given the trends that are in place when they are born, continue in the same way. >> Right, so these were all well articulated definitions but let's just reiterate them. Life expectancy at birth is the average number of years a newborn baby could expect to live if current mortality trends were to continue for the rest of the newborn's life. The maternal mortality ratio is the number of women who die as a result of pregnancy related causes per 100,000 live births in a given year. Neonatal mortality rate is the number of deaths to infants under 28 days of age in a given year per 1,000 live births in that year. Infant mortality rate parallels neonates and under five child mortality rate is the probability that a new born baby will die before reaching age five expressed as a number per 1,000 live births. So now that we have a better sense of these health indicators, let's look at how these health indicators play out as I mentioned for the different world bank regions of the world. And for each of these, what we're going to do is look at them by world bank region. And we're going to look at them as well for some of the high-income countries. So here we see changes in life expectancy at birth for world bank regions in high-income countries over the period of 1960 to 2013. Rachel what messages should we take away from this graphic? >> That from 1960 to 2013 there has been a significant increase in life expectancy globally. But that there's still a huge gap between life expectancy in high income countries than in lower lower income regions, especially in Africa. >> Life expectancy has been increasing, it's been increasing in all regions of the world. And yet despite these increases there remains a substantial gap between the life expectancy in some regions of the world and some others, with the largest gap concerning Sub-Saharan Africa and South Asia. Let's look now at the maternal mortality ratio. And Emily let me come back to you on this one. What are the most important take away messages from this graphic that shows maternal mortality ratios for world bank regions and high-income countries and globally as well, for the year 2013? >> Well, we can see that there's a huge disparity between high income countries and Sub-Saharan Africa really is suffering the most and South Asia is also not doing very well. >> Right. So, as we see here as Emily has pointed out is the maternal mortality ratio in Sub-Saharan Africa in fact is about 30 times the rate in the high income countries. And this Maternal Mortality Ratios in South Asia is more that 10 times the rate in the high income countries. In just in the side. Remember, in principle women die, in principle, anything above this rate is preventable. In the high income countries, women rarely die of complications of pregnancy and maternal related causes. In principle, I repeat, anything above this is preventable and of course, these are things we're going to talk about a lot as we make our way through the course. Let's look now at the neonatal mortality rate. Again, for World Bank regions High-income countries and globally. What should we take from this slide? >> I see a similar trend here where South Asia and Sub Saharan Africa have significantly higher rates of neonatal mortality than a high-income country. In Sub Saharan Africa, it's more than seven times, and in South Asia it's about eight times the rate of a high-income country. Right. So exactly as said what we see is a pattern not so different from the pattern that we saw for the maternal mortality ratio. We see eight times the rate of neonatal mortality in neonates in South Asia as in high-income countries. Seven and a half times here. And again, let me remind you that in principle, that's over this level that occurs in the high-income countries. Ought to be preventable. Let's move on now and look at the infant mortality rate for world bank regions, high-income countries, and globally again. And let's ask Yafet what you would take away from this slide. Yes it was, it has been mentioned previously in a very similar trend in which high-income country have significantly lower infant mortality rates than both South Africa and South Asia, Yeah. >> Well right these countries somewhere in between the rates of the Middle East, North Africa, almost four times >> Rates in Europe and Central Asia more than three times, and these also more than three times the rate of infant mortality in the high-income countries. Let's look at under five rates. And here it's not a surprise what we're going to see is a pattern that's quite similar to the pattern that we saw in almost all of the other slides, but certainly the slides for neonatal mortality and infant mortality as well. What I'd like to do before we move away from these slides on health indicators is look at, actually one of my favorite slides. And this is a slide that combines neonatal mortality, infant mortality and under five child mortality. Elizabeth, what do you make of this slide? If you could pick only one or two messages from this slide, what should we take away from it? >> Well we see that in most regions you have a higher risk of dying if you're under 28 days old, but that risk gradually decreases as you reach one year of age and then five years of age. However, in places like South Asia and Sub-Saharan African, unfortunately the risk appears to be about equal between each one of those ages. >> So what we see here is in the high income countries young children rarely die. For every 1,000 who are born only six will die before their fifth birthday. But of the six who die, four will actually die in their first 28 days. The better off the country is, the larger the share of total under five deaths will occur in the neonatal period, because those children aren't exposed to very many other risks. They're not so likely to die of diarrhea, malaria, HIV. And as we know, if they die, sadly, they'll die of still, maybe, of congenital anomalies that play out later of accidents and injuries or perhaps, sadly, of cancer. By contrast, and let's look at the most extreme difference. When we look at Sub-Saharan Africa, as Elizabeth has said, what we see is really different pattern. Here we see high rates of neonatal mortality, high rates of infant mortality, and high rates of under five child mortality. But we also see an almost equal risk of dying in each of those three periods. Between the birth and the first 28 days, about a third of all the under fives who die, will die. Between their first month and their first year is another third of the under fives who die, who will succumb. And then between the end of their first year and their fifth year, there's another third still. In Sub-Saharan Africa, somewhat uniquely but a little bit mirrored as Elizabeth said for South Asia. There's this pattern in which children who survive to be 28 days old still face substantial risk of dying between their first month and their first year. And those who survive to live till the end of their first year still might face additional, substantial risks of dying between their first birthday and their fifth birthday as well. Now, before ending this session there's one other point that I really want to make and it's been highlighted by a number of these graphics. I want to suggest that as we think about global health issues, we should be very careful about using averages. So let's think for example about Pakistan, and let's think about maternal mortality in Pakistan. The maternal mortality ratio in Pakistan is about 185. But I want to ask Bevick, what do you think is the risk that a well off, well educated woman in Karachi, who is pretty good proximity to an outstanding hospital like the Hospital, university hospital for example. What do you think is the risk or the likelihood that this woman will die of a pregnancy-related cause compared to the risk that a woman in a relatively well off country will die of a pregnancy-related cause? >> It's probably quite similar. She is probably at a much lower risk of dying than some of her counterparts in other poor areas of Pakistan. >> So, this is a woman who is very unlikely to die a maternal death just like most women in high income countries because she's well educated. She cares for herself well. She has good family circumstances. She's well fed. She's gotten good anti natal care. She's got access to good obstetric care and good emergency obstetric care as well. So if her likelihood is very small, and yet the risk in Pakistan of a maternal death overall is 185 per 100,000. Well then, what, Rachel, is going on with a lot of other women in Pakistan, for example? >> That would suggest that a large population of the women who die of pregnancy related causes in Pakistan are lower income women. Because their rates of maternal mortality are even higher than the average. >> Right, if the average is 185 and the better off people, even though they may not constitute more than 10% or something of the population have very low rates. Then these people who are worse off economically, their families must see women dying at much higher rates. So in fact if you look at places like Balochistan or North-West Frontier Province, they are places in which the maternal mortality rate in Pakistan probably goes up to something like 700 or 800 per 100,000 live births. So the point I want make here again is, we have to use averages. And some of the time using them will make very good sense and help us in our understanding. Be we also need to be really careful about when we use them. We must also remember to keep in mind not only differences across countries and across regions but also differences within regions and within countries as well. Hopefully by now you have a better understanding then you had earlier at key health indicators, some important progress in improving global health. Some important parts of the unfinished agenda in global health. You also know that there are two regions in particular, Sub-Sahara Africa and South Asia. Whose health indicators lag much of the rest of the world. You've seen how some of these health indicators play out for life expectancy, maternal mortality. Infant mortality, neonatal mortality, excuse me, infant mortality under five child mortality. And you also have an understanding of when it's useful to use averages. And when one needs to focus in particular on not only the differences across countries, but also the differences within countries as well. In the next session, we're going to speak about the links between demography and health.
