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work. Um, I also work, um, in gynecology. Um, one day a week. So, um, I'm really humbled to teach you all today. Um, today's public health lecture is about global health. Um, and, um, hopefully this will give you a snippet of information. I have to give a big thanks to, um, our public health registrars who we got in our training program. Um, they've developed the slides, so the slides are not mine. Um, they developed the slides for training. Our foundation doctors, Um, and I'm using their slides. So, um, I have to acknowledge that they are doing that. So you will see that, um, the slides say they are for our foundation doctors. And, um, we, um um you know, we we we kind of use these kind of slides to teach them as well. So next, lightly. Thank you. Um, Claudia? Uh, yeah. So what do we want to do in the next couple of minutes? We want to talk about what global health means. Um, what you will get to see is that measuring health outcomes in different between different countries is quite a complex situation, but it's quite an important situ. So when you become doctors. Um, uh, and you start to practice. The world has become quite a global melting pot, isn't it? Um, it's not like we don't have people from other parts of the world that were looking after whichever country we are in. Um, And when we are doing that, we need to somehow understand how the health structures in other parts of the world are well, understand about the key determinants of global health. We'll understand a little bit about the epidemiological transition theory, which, which is what I was talking about. We'll talk and understand a little bit about the key global health challenges and some of the governance. Global health governance. Okay, moving on. So what is global health? Um, and you might think global health. What does that actually mean? Because we talk about international health. We talk about public health. Um, uh, what is global health? Um, and particularly because these slides are more relevant to our teaching and our practice in the United Kingdom. Um, we start to discuss why global health is important for the UK, but this could be relevant for where you are, as in why global health relevant to yourselves in, um, in in Ukraine, particularly in this time. But more importantly, why is global health important? So we heard one of your friends is in Budapest. So how are they accessing healthcare there? Um, some of my friends are in other parts of the world. How are they accessing healthcare there? So it's important for us to just understand what are the global health challenges that's affecting all of us across the piece. Next slide, please. Okay, so we're trying to get towards a common definition of global health, and here you find the three sort of, um aspects of sort of, um descriptions of what global health means, what international health means and what public health means. So what you'll find the two areas that makes them, um, slightly different is the level of cooperation and the access to health. Now, global health focuses on issues that are directly or indirectly affect the health but can be transcended international boundaries. So when we had the pandemic, um, we were familiar with some of our governance around our borders and how we could work together, and we did that very well across different countries. And we did that properly. Um, global health also helps us to understand health equity among nations. So how do we access diabetes care in in in the United Kingdom? How does that differ from diabetes care in Ukraine? Um, and you can understand it can start to understand why the outcomes and the access also differs in international health. We focus on health issues across the country's um, which is other than their own. So again, you know, we've got Global Pandemic as one of the examples, but we've also got other big, uh, aspects that were working and collaborating internationally as well. So, for example, climate change and its impact on health public health affects the health of a population of a particular community or country. So in your own country, wherever you are wherever you're located now you might want to find out what the public health problems are. So what are the public health problems in Senegal or Congo might be different to the public. Health problems in India are made different to the public health problems in the United Kingdom, so public health really problems are the problems that are for a defined geography or a defined country. Next likely. Yeah. Oh, there you go. So just go back. One more slide. Yeah, and just the next. Just press. Yeah, and the okay, Just leave it there for two seconds. So if you if you look at these definitions here in global health is an area of study, research and practice, that place is a priority of improving health and achieving equity and help for all across the world. And that's the definition by Copeland. Very well known definition in international health is the application of the principles of fabric, cultural problem and challenges that affect middle income countries to the complex areas of global and local forces that influence them. Very complex, calm concept. But you know, obesity, big problem across the world. How does that affect low as well as middle income country and the public health is the efforts to protect, promote and restaurant people's health in combination with sciences skills. And it's maintained some improving health of, uh, one ge geographical areas of one country. So those are some of the definitions that kind of give us a more important idea about the global health concept. Next. Likely. Okay. Why is it important now? Why am I teaching this to you? And why you kind of thinking Oh, my God. It's another dry lecture. What does it actually mean? How does this actually, um, relate to me? I want to be going away and listening to somebody talk to me about, um, gynecological problems or respiratory issues or or management of cardiac disease or heart attacks. And why is this important? The important the thing is, it's a moral duty for us to know. So when you have a patient in front of you and they've crossed over into your country from Congo, um, if you do not know the endemic conditions that, um that are prevalent in Congo, you will miss out a whole lot of information gathering from the patient to make the right management plan for them. Um, so it's a moral duty for us to know what's happening across the globe and and just understanding and just be at least aware of some of the key global problems. Um, there's public diplomacy, of course. So, for example, like, you know, if there is anything that relates, um, to sort of, um uh, you know, uh, drugs, you know, HIV medication in the eighties when we had the HIV pandemic. Um, there was major public diplomacy to make sure that we got the right HIV medication to the right people. So it just couldn't be that because the HIV, um uh, drugs were made available and the Western countries and the more rich middle income countries could buy bulk of that and give it to their people that HIV people in South Africa or other parts of deprived parts of the world didn't need to access them. So we needed to get diplomacy in to make make sure that there was equitable access. A similar kind of thing happened with the vaccine. So it was not that we gobble up everything that comes in the in in in the world that can buy and and and leave the countries that cannot buy, um, to to sort of, uh to to kind of just manage their own, because that will only divide the world even more, and it will not get rid of the problem. Um, the key key factors to future direction is expand a talent pool in the developing world. So we get need to get more people trained up in public health and global health, Um, and effective systems of disease prevention and treatment. Now, it all came to roost. We all thought our surveillance around the infection disease, control's we're all up to scratch. We've been running, um, sort of, um uh, you know, exercises and making sure that we're all on top. However, when it came to a pandemic, we found ourselves all in a bit of a mess because the pandemic absolutely overruled all of the processes that we've had. Um, so but the fact that you've had an infrastructure made us then realize that we could develop a vaccine quickly, get it out to the developed country, quickly get it across the world quickly. So the importance of global health is very important. And so that it also help. It meant health infrastructure as well. So, for example, when there is a good time and you come out of a war zone, um um and you start to redevelop your health structure, you get support from all over the world in all of their health infrastructures to build in the expertise, Um um and and make sure that the countries that have fallen can come back again, and people get the right kind of support. Next slide, please. Okay, so, carrying on, then, um so global health priorities. Prioritization of goals. Um, so it can be around specific disease, but also could be general health status. So in the UK, one of the main priority priority areas is we want to improve life expectancy. You want people to live longer? Um, than what they are. We want everybody in the deprived and well as the non deprived areas to live longer. So it's imp important for us to prioritize our goals. Funding, allocation, um, funding, allocation. How much we're going to spend on health also comes from, um, you know, our local needs. But also in many parts of the world, unfortunately is, um is sort of, uh, dogged by bureaucracy and corruption. And with health, diplomacy and global health communications, we might be able to influence some of that. The change of focus. We're now trying to make sure that mothers survive longer. We know mothers play a big role in families and also making sure that babies are healthy and they are the future of any nation. And the idea is that we increase overall life expectancy across the piece across everybody. Not just the most rich. Um, we get the people who are most deprived with us next, like please. So, um, what are the global health challenges? And these are only a few. So if you look at the slide, it leaves you quite stunned, then it leaves you quite sort of, Um uh, reflective, isn't it? You've got one billion people lacking access to healthcare in the systems in this world. So you know where I sit. I know we are crying out loud. We don't have to have enough GPS. We need more g P time. But at least you know, if you don't have a g p um uh, call. You can call 111. You can call another service. You will get some kind of support, at least available. If nothing, you can walk into the hospital and I know several hours later, but you get to see somebody. However, in certain parts of the world, they do not have any access to healthcare. If you go into sub Saharan African countries, I come from India in certain parts of India, accessing a doctor or a clinician or a midwife or a trained nurse. You have to walk miles, or you have to really travel far. Things are changing, but not at the at the rate that we want it to be. So one billion people across, um, across the world don't have access to healthcare, and this applies even to sort of developed countries. So in Australia there are certain parts of Australia where it's so remote that we, you know, I've got friends who fly in, um, have have kind of got little chartered flights into certain parts to go and provide their healthcare. But that means you don't have an access to a doctor every day. If you suddenly got, um, uh, something that's a cute you need to be flown across to another part of the country to get the care so it leaves. You keep kind of thinking, doesn't it? Nutrition related factors contribute to about 45% of deaths in Children under five years of age. Can you believe that? Even in this day and age, Children are dying of hunger? Now I know where you are. I'm sure it's It's even more prevalent, um, in war zones, but also in some very deprived parts of the world. Malnutrition causes a significant amount of morbidity and mortality in Children under the age of five. It still is the major cause of mortality. Vaccines available for infectious disease are not always available to the developing countries. And as I said when we had the covid vaccines, it almost felt like, you know, we needed to equally distribute. There was big lobbies to say. We just cannot have, um, you know, vaccination programs that it's just been gobbled up by countries that are more wealthy and have got a better infrastructure because we will not be able to break down the pandemic. The virus will continue to more will continue to multiply. Um, if the if everybody in the world is not being vaccinated and then widening the gaps in health inequalities, uh, worldwide happens because of that because of that fact that we are not aware of some of the needs, uh, and the wants of of the people across the world, overall, 35% of Africa's Children at a high risk of death, um, than they were 10 years ago. So have we actually made a dent? Have you made a change. Have you improved? We haven't because even now, certain parts of Africa are saying the risk of dying, um is kind of got worse. Um, for all kinds of reasons, you know, dry out climate change, um, effect of wars. There are certain parts of Africa where it's just, you know, people have lived through their life through kind of unrest and war. Um, so, uh, I mean, life expectancy, as I said. And there's an example here, life expectancy is always shorter. Uh, almost anywhere else is shrinking in some African countries that has been cut out by 20 years, and life expectancy for men is less than 46 years. Can you imagine where the rest of the world is thinking of the forties to be the new kind of twenties and try to kind of live their life and live there most productive life in Africa. Men are dying because of all kinds of reasons. So it's important for us. These are some of the global health challenges that we need to tackle together, and they're important to the African continent. But they're equivalently important to us as well. Wherever we are next slide please. Okay, so the global health challenges the infectious disease are the communicable diseases. But there are elements of Western lifestyle such as dietary changes, the lack of physical activity, reliance on auto, mobile transport, smoking, stress organization, which is also affecting some of our, um, uh, least deprived countries as well, because they remember we didn't have McDonald's people didn't have KitKat. Um, and we are consuming these things now. People want to, um, kind of travel around in cars, you know, it's it's it's much more, um, feasible for us to get cars. Um, in in India where I come from, there was a time in my lifetime where not everybody had a car, had a car. Now we've got people dying of air pollution because there's too many cars on the streets of India. Um, and everybody you know any any if you've got, um, some kind of means and, you know, uh, of good sort of good livelihood, you are going to have a car. Um, so things, um uh, that affect the more developed world also affects, um, the least developed world as well. And these global health challenges continue to plague all of us. together. Next slide, please. So, um, key concepts of relation to global health, The things that we need to understand. Um, what are the things that actually influence us? Um, in making our global health policies, the determinants of health will come back to them in a minute. How do we actually measure health status Will come that come to that as well? The importance of culture to help. So, for example, I do a lot of work in my patch in one part of our part. We've got a lot of population from sub Saharan Africa from, um, the Arab world from, um, uh, sort of South Asian communities. What? When they migrate even to a country like the United Kingdom, they bring their culture with them. So if I say to my pregnant mom, you need to register with your g p or register with your midwife by 10 weeks in pregnancy, they might be looking Let me in shock and horror. What do you mean? I don't tell anybody I'm pregnant till I'm about 16 weeks. Because I know in my culture, that's when you are actually pregnant. Anything before that. It's very, very, you know, we don't know what's going to happen, because pregnancies may not survive and it's a taboo and it's a stigma. And you shouldn't be telling, um, when you're when you're pregnant. That early, however, evidence has told us that the sooner we get to know somebody's, the sooner we can screen them for a whole lot of conditions. So so are black African mom's. You know, if they've got thalassemia or sickle disease or any of those conditions which we know are more prevalent. Mother's from the Asian subcontinent who are more prone to have gestational diabetes to know if they've got diabetes mothers with mental health issues. If we kind of diagnosed them early, we can make a lot of dent. But these cultural prevalence, although we got the support systems, doesn't help us to always get the right support to them at the right time. Because the cultural benefits, um, the cultural, um uh, sort of, um, uh, beliefs make them access healthcare later. Epidemiological transition is important. The key risk factors of various health problems, some plague us locally. Some plague us internationally, and those are important to understand as well. And then the organization and the function of health systems, which also varies from country to country. What? The system that you have in Congo, Senegal, Uganda, uh, South Africa might vary from, um, South America. Puerto Rico. Um, uh, Argentina were very significantly different to Saudi Arabia to well, very significantly to South Asian countries. So we need to understand that there is a variation in care, but the principles are the same. What we're looking to do is improve outcomes and and and reduce harm to people. Next slide, please. So this this map you may have come across. I know. I have certainly brought it in some of my lectures. This basically says, uh, and you can go and look up. Uh, this this, um, reference in your in your spare time. So, basically, what this says is we are who we are. Um, but we are always at every single point in time being influenced by a whole lot of set of things that are happening around us. Individual lifestyle factors, what we choose to eat, what we choose to do, how much we choose to, uh, to to exercise. Um, social and community networks. Who do we socialize with? You know, our our PR groups encouraging us to take up risky behavior. Um, you know, is that going to affect our lifestyles? Are employment. The atmosphere, the air we breathe all affects us every single day. Um, and we are then the products of everything that happens around us And that then results us in having, um either a condition, uh, life, you know, a disease or anything like that. Um and that is just not us. Because we don't live in isolation in a bubble bubble. All of these things affect us. And they're called the social determinants of health. Next slide, please. How do we measure difference between help between countries? So when we said life expectancy in Africa is shorter than the life expectancy in the United Kingdom Yes, well, life expectancy is measured in the same way. But what are the other measures that we can use? And what are the advantages and disadvantages of these measures? And what point? At what point can we make an international comparison? And do we need to make an international comparison? Are some of the discussion that we have in global health world next like please? Okay. So measuring global health So these are some of the indicators, as I was trying to, um, elicit date, um, that are used to compare the health status, health of nations across the world. So life expectancy, causes of death, infant infant, child mortality, years of life, lost measures of morbidity incidents, prevalence disability. So diabetes care, diabetes. Everybody in the world gets diabetes. In certain countries, people with diabetes live longer. Some people in people with diabetes in certain countries live shorter. Um, but, you know, how do we compare that? How do we know that, uh, what is causing people to live shorter in certain countries? Uh, and longer in other countries. And why? What are transferable skills or, um, information that can be. Can we support each other with? And so there is a YouTube video. You need to understand this by watching a YouTube video. The link is there, Which talks about the global global burden of disease study, uh, of 2015, which gives you more of an idea as to how measurement of global health workers across the across the world, um, dollies and qualities are important. So dollies are disability, um, affected life years and qualities are quality, adjusted life years, disability adjusted life years and quality of just quality adjusted life years. This mean these quantify and there's complicated ways of measuring this. So basically, you don't want to live longer, but live most of your life with the disability. So if you can't avoid it, if you've been born with a disability, of course you will live longer with, um, with your disability. But if you are born healthy but acquire a disease condition because of all kinds of things, obesity causes your diabetes. You then start to get, um, you know, uh, neuropathy and you start to lose your limbs. Then you become disabled it in early life, and you start to get plagued with it. You don't want to live with that kind of disability for for you know, because you could have done something about losing weight and and controlling your diet and controlling your diabetes, and then you would not develop those conditions. So disability adjusted life years calculates the number of life years that people can live without the disability. So in healthy, well being states and the quality adjusted life is another way of measuring that. What is the quality of your life as you live longer. It's not just about living. It's about staying without disability and having a quality of life. And so those are some of the indicators and trying to skim through all of this. But if you go through some of the references, you'll find that these are quite interesting measures of understanding. What? Um um, standards of healthcare and health needs are for a population next life, please. Okay, um, so again, just going on to describing the measurements of of sort of global health. So, you know, um and how do we access some of the data? So causes of death is obtained from death certificates? Life expectancy at birth? Um, it's it's sort of given to a newborn baby. So, um, it's a complicated calculation. By how long will this baby live? If they if they kind of, um, lived in this part of the world provided they've got, um, no other medical condition. A maternal mortality rate is an easy one to calculate. It's a very good, um, judge of what a country's health is like once you start to look at your child mortality, infant mortality, um, and maternal mortality rate. It gives you a clear indication. Now, I live in the UK. I work in the UK. I've worked here for the last 27 odd years. Um, you would like to think that I would think UK is one of the top places where maternity maternal mortality rate, infant mortality rate, neonatal mortality rates are at par with some of the best We're not. Some of the Scandinavian countries have got, you know, far better rates than us. They lose less mom's, they will lose less influence, less babies. Um, uh, and you we kind of don't don't do as well as them. However, we are better than, say, other parts of the world. Such as, say, India where I come from, or Africa, where some of these rates are really, really high. So that's the way we compare. Um, uh, those rates and we understand the health needs of a population across the world. Next slide, please. Okay. And just keep clicking. No, just yeah, that one. And then just go. Just click once more. Yeah. So exactly what I was trying to say to you that if you look at this death, um, so the first one here, the bar charts in, um um uh, in brown. Oops. And you will see that deaths globally by age we lose, we lose more of our under fives. And this is across the world. So under fives, die more than, say, for example, 40 year olds or 45 year olds. And again, when you come to the extremes of life, 85 to 89 year olds die more. Um, and of course, you know, the curves start to go down again as we start to lose more people. What does that show that in the age group, they across the world. It doesn't matter whichever part of the world you are. Although there is, uh, there is a There is sort of a kind of a curve around the around the age groups, but Children die more compared to adults. Um, and it doesn't have to be that you are in the most affluent countries and you're in the most deprived countries. Whichever country you are, whichever population you belong to under 45 mortality rate is quite high. And then if you look at the child death, um, in the first five years of um um life by age group. And then you start to look at, um uh, the time period in which they died, and you look at the trend by years, um, you start to see that they've all come down. However, the 0 to 6 year age group it it hasn't done the same kind of decline as we'd like it to be. I know this data is old 2015 to 2017, however, as you can see, So when you're zero day 02 days, uh, six of your bath across the world, the chance of babies dying is still high. And and the decline, as you can see in other age groups, is much further than than that. That age group. Um, it's It's just because when babies are born, they're very vulnerable. They're the babies are born, um, and and the whole lot of circumstances work on on their survival rates where they're born, how they are born. What was the condition of mother when they were born, where there are other adverse effects that were being affected in the pregnancy that affected them. So more babies die in the first few days of their life? next slide, please. So I was talking about global inequalities, and this is the stark reality. So we can we're comparing to countries were comparing Congo, um, on the left and we're comparing United Kingdom so you can see infant mortality per 1000 live birds in Congo is 68.2. Okay, whereas in the United Kingdom is 3.8 And even then, we're not the best in the world. There are other parts of the world like the Scandinavian countries where this this this rate is even even low. And even within the United Kingdom, you see certain parts of the country. The infant mortality rate is even higher. Uh, compared to the rest child mortality rates in Congo, 88.1 per 1000 live births. In the United Kingdom, it's 4.3. Life Life expectancy at birth is 59.62 whereas in the United Kingdom is 80.96. A child born in the Congo, five virtue of birth. You know, we could be born anywhere in the world. But if you're born in Congo, the chances of a child surviving passed their 60th. But there is very less, um whereas in the United Kingdom you could expect that they could live over eight years. And as I said before, huge amount of social determinants of health, you know, just can you take me back to that slide with the big arch is so three or four slides back if you just take me back. Yeah. Back, back, back, back, back, back. Yeah, that one. So, as you can see, a child born to any part of the world will be influenced by all of those things that affect them. And that may then decide for the child how long they survive or or not and and what their life expectancy is going to be. And that is why it's so important. All of those factors are different in different parts of the world. Next slide, please. Just if you keep going back again to the same to that slide where you are. Thank you, Claudia. Sorry. Okay. Yeah. And the next slide, please. Okay. Yeah. So this is interesting. It's a very, very well established fact that women's health, education, women's education is one of the strongest predictors of child mortality, and here is is sort of some of the factors why it's important female. So if you look at the left side of it, if you improve education amongst women, the help with improved health choices, nutrition, hygiene they take up more immunization and preventive healthcare not for just themselves, but their families. They also space their pregnancy so that they know that having too many Children, that is shorter frequency does not help with their well being, but also the child's well being. And in then you see decreased infant mortality. And those, um, countries with more established, um, programs for female education thrive and survive and have more life expectancy. There is also other wide effects. Other wider effect that, um, they they you know, there's these examples to say those nations also have greater productivity and more economic development because women engage in agriculture in innovative firming, uh, they apply for credit. They kind of really build that infrastructure around their families to make sure that they really, really pull up your family and and and develop their social structures happens with female education. Unfortunately for us, it's not universal. Look around you. You know there are so many of us. We have women. We've come from families who have supported us, who have supported us to get our education. But not everybody. Not every woman, not every girl, um, in the world is fortunate to have that. And, you know, the the best example that I can think about straight off is Malala Yousafzai, who who is probably more famous because she wanted to bring it, bring female education to Pakistan. And and, of course, her efforts are well regarded and her intentions is well regarded. And she's still persevering to do that. And there are so many Malala Yousef size in lots of, uh, countries in the world who are trying to do that. Why? Because there is established evidence that female education improves the overall health of the nation, which means improved productivity and improved, um, uh, sort of wealth within that nation. Next light, please, if you just click one. And and this is, um, this is a graph, and you can and see it at at at your at your leisure. So what we see is that, um, where there is more, uh, women. Um uh, studying in schools. The child mortality rate is lower. Um, I've lost the slides Is that just me. Oh, Claudia, I've lost the slides. Can you still show me the slide? Can everybody see the slides, or is it just me? Can some somebody shout out, please? Okay. Perfect. Thank you. Um, can everybody see the slides? Yes. Yes. You can see the slides. Okay, fine. Okay. I've got them back again now. Okay, we can see it. Excellent. So, what you Yeah. So just one slide back then. I've, um, the one before the one before. Uh, yeah, thank you. So I was just gonna say that what you can see is, um, that, um, women's health education. Where countries have got more women educated, the child mortality rate is lower and that, you know, the the slide shows you that and those countries are more economically well developed because, you know, there is a direct association between this, um, that women's education improves the overall health of the nation by improving productivity. Next, like please. Okay. And these are some of the other things that are important in global health. Because when you become a doctor, as I said, you'll not be treating. Only the people sit in front of you are are going to be from the nation that you've trained in or the countries that you have. Um, so there are cultural beliefs and attitudes that influence people that, you know, travels across boundaries. There is traditional health systems. Um, you know, um, certain parts of the world home birthing is very, very traditional. So my colleague from Amsterdam, where home birthing is very important, can't believe that women actually going to the hospitals and have their babies there, even if there's not everything was fine with them. Um, and she had three of her babies at home. Um, whereas, you know, um, where I practice in the United Kingdom, So just one slide back, please. Um, you know, women are given a choice if you if you want to have a home birth, do have a home birth. But of course, you know, if you have got complications of you're not feeling confident of having a birth at home, then yes, of course, the hospital offer is there, or midwifery led units are there. Then there are certain health beliefs about health. So, um, epilepsy is a known treatable condition. But in certain parts of the world, epilepsy is considered to be some some kind of pills possession, some kind of a bad omen. Um, and you kind of think, um, you know, cultures and traditions try and and think that they use some kind of ostracizing ation or some kind of local ways of trying to get rid of it. However, it's a treatable condition. Perfectly treatable. Condition it, you know, once treated, you know, people live quite productive lights with epilepsy, saying things happens with psychosis, you know, again, preventable, but treatable. Um, but people in certain parts of the world consider psychosis to be, um, problem that is inherited in families. People shy them away, lock them up or provide sort of, um, all kinds of other other ways because it's a belief in culture that that is run run down. And once they get to know about the pathophysiology, once you you you kind of can reach out to them and start to talk to them. It makes a completely different change in the way that they're thinking, and we can treat the people with these conditions Now. Um, well, I don't have to tell you more about diversity, diversity, marginalization and vulnerability to to race, gender and ethnicity because those are even within countries divide us constantly. Which means we don't have equitable healthcare. Um, uh, and support for your health needs, Um, even within nations. Um, not not just outside as well. Next one, please. Okay, so what have the A theory of epidemiology of population change, and you might look at you want to look up? Look up, that, um uh, that reference there, um, mortality decline, rising in life experience is accompanied by changes in the burden of disease and the burden of disease. Uh, that that occurs across the country are due to to infectious disease, which is, you know, communicable disease. And this is not just pandemics. Diarrheal disease take most lives across the world. Um, flu, influenza, respiratory, nations, HIV, These are all infectious diseases. Some of the endemic, um, sort of parasite, uh, that that we know in some sub Saharan Africa and South American continues, uh, countries take a lot of life. Um, but there's now the rise of non communicable diseases and cardiovascular disease. Cancers and, um, diabetes are are are are taking up and causing a lot of burden. And so if you want to look at the epidemiological transition. So maybe 30 40 years ago that infectious disease killed more people, whereas now it's more than non communicable disease. Heart attacks and cancers are killing people early, and it's quite interesting because the epidemiology has shifted. Um uh, and that is quite an interesting concept. It's just the way humans have survived in this world. And we have taken up different lifestyles. That social determinants around this has changed means the dynamics has also changed around the population and health burden of disease. Next lightly. Okay, so total disease burden by cause in the world, this is quite interesting. So if you have a look at it, the the burden of disease from noncommunicable diseases. So this is heart attacks, diabetes, cancer, all of those I pull them new age diseases, um, has grown. Okay, I know the slide goes up to 15. 17, But if you look at the newer world, I think pandemic will take a slice of the, uh of this. But it'll still be the non communicable disease which is killing more people earlier. And if you see the red section, that's a communicable disease. There used to be the bigger bit of the bigger bit of the, uh of the structure in the 19 nineties. But they are getting smaller. Why? Because we've got antibiotics. We've got vaccines. We've got infrastructures to get vaccine early. We've got, um, prevention measures such as sort of, you know, hygiene is getting better. Um, infrastructures are improving so that the communicable disease cycles are broken. So the people dying from communicate cable disease is reducing, and the non communicable diseases such as heart attack um, cancers are increasing. And that is quite a paradigm shift that we've seen just in our own lifestyle. And then if you look at the top injuries cause, you know, road traffic accidents and other injuries cause a lot of deaths as well, and that hasn't changed much at all over the years. But the dynamic shift between the communicable and non communicable disease is quite stark and is palpable. Next life, please. However, when you look at it in different parts of the world, how does that look like? So ***, you've got a big burden of disease from infectious disease till because the infrastructure is still not right. Poverty rise. Um, you know, uh, long decades of war still takes a lot of people out with their infectious disease, access to healthcare, um, access to antibiotics. So the infectious disease still occupies a lot of, you know, a burden of disease in *** and interestingly, the non communicable disease. So heart attacks, cancers and diabetes probably don't take as many lives Now, is that true? Do we know how the data is captured? Because, you know, you could have diabetes, but still then makes your immune system so so difficult. Um, that you you, you you die. You pick up a communicable disease and you die from it. And your death certificate then says you've died of a communicable disease. So although your underlying condition was diabetes, you died of a communicable disease. Then you get logged as a death from a communicable disease. So we don't know some of the infrastructures are quite difficult. Whereas if you look in Armenia quite interesting that that blue section of the non communicable disease is is is sort of, you know, quite stark. And then the infectious disease is quite low. And you can see that um uh, you know, the injuries kind of stay there as as as as as as as as kind of as as as a constant. And then, like in India again, infectious disease takes a lot of people. Um uh, and the non communicable disease is climbing, so we're having more and more deaths from cancers and and and and sort of, um um um, diabetes and stuff like that. Whereas in Brazil, it's a completely different structure. Again, the infectious disease are starting to come down because the infrastructure in Brazil is improving, but the non communicable disease are coming over. Interesting concept, So you might want to look at wherever you are. Um, Ukraine is obviously quite difficult now, and and decades will tell the impact on war on on the overall health. But wherever you are saying for Depeche, you might just want to look at what? What is the burden of disease next? Like please, I think we're running out of time quite quickly, isn't it? Claudia, how much do we have? Okay. Um um, okay. Key risk factors. Now, you know this, um, key risk factors for various health conditions? Um, yeah. So these are important. Um, and and as I was talking through them you know, for them, um, that they are. You know, uh, they're well known to us tobacco use. Unfortunately, still is one of the top causes of mortality, and it's worldwide. Next, like please, I think I'm getting some questions as well. Claudia, Um, just give me two seconds. Let me so saying, um, right with psychosis specially in pregnancy or those just giving birth, do you see cultural issues whereby patient's are taken to spiritual healers? How do you challenge this? Yes, you're absolutely right. Challenging is the only, uh, the only way. The only thing we can do as as people in the health sector is educate, educate, educate, change will come. It will come slowly by education and any cultural beliefs. Once you start to take the evidence to the people, Um, particularly to our mom's, particularly to the people who are influential in making policy change or making cultural change, um, and point out the reason for evidence. That's the only way we can get back, get back and and sort of change some of it. I can't say there's an easy answer, but the answer is in education and getting the evidence to the people who are concerned. It's a number of deaths by risk factor in the world by 2017. Okay. And will you believe it? Most people die of high BP and smoking. And if you look at this list here, you know, it's kind of mind boggling, isn't it? Because all of these things that cause people to die across the world if you look at these risk factors, there might not be the top things that would come to your mind when you kind of actually think about why somebody would die in a particular country. But they do. They do make a contribution, and high. And as you can see, smoking is still there. But high BP has taken that over. Um, because more less people are smoking. But more people are obese, which causes high BP. Next light, please. Okay. I'm going to run through this quite quickly. How long do we have? Um, just about five minutes. Okay. Now, um, again, each each country have got their own health system, which is organized, and they function, and some of them are private, public. Some of them are traditional. Some of them are informal sectors not to say that traditional medicine is not good, because in certain cultures, certain medications do work for those communities. Now, are there evidence based for me with my public health hat on, I would like people to practice evidence based practice and sometimes the traditional, uh, informal sectors. The evidence base is not well established. Not to say they don't work. It's just that we need to develop the evidence around them. So it's about cultural beliefs and using them. But making sure, um, that you look for the evidence to say what works and what doesn't work. Next slide, please. Okay. And this is quite important. So again, go and look this up. If you google this, there are some websites wh has got this sustainable development goals and we've taken a plage across the world. Everybody, every country in the world has agreed and signed up to making sure, um, that there are sustainable development Goal, um, and the w h o monitors. This, um as to the fact that we each country, however deprived you are however rich you are, you make sure that these sustainable development goals are are enshrined in your health and care policy sector, and you make sure that you contribute to to kind of contribute to making sure that the sustainable goals, um are there and and and and making an impact in your population. And it's only through these kind of efforts that we can make a change across the world. Okay, this is an interesting slide which talks about global health funding. And if you look at it, how much does each country, um, spend on healthcare? Um uh, and you know, um uh, what does that actually look like? And has that changed your on your on your and it's on us dollars. And absolutely, um uh, and you can see that there is still huge variation. So what sub Saharan countries spend on health is different to what Latin American countries spend on health or and and and and and say what? What? Uh, Central Europe spends on health. And what is the division between, um, you know, um, how they're allocating their expenditure is quite interesting as well. Um, and I think it's worthwhile looking. I'm not going to spend a lot of time, but you can look it up yourself. Next slide, please. Okay. Do you remember, I talked about disability adjusted life years versus, um, major health funders. So, um, so you know, um, what do you spend in tuberculosis in maternal health in water and sanitation? HIV aids, and how does that contribute to how many people are Are are sort of have having disability, less disabled life in their lifetime. And this kind of gives, um, sort of an estimate around sort of the and you can look up. You can look up the the reference here, so because, um, I will not be able to go through it in detail. So, um, if you look at the distribution, how much you spend on each of these programs and how many people, um uh then survive on it. Uh, and I think it's quite important for us to say that that they will. You know, some programs make people live longer. So HIV, now we've got medication. Um, we we detect early, we've had a whole pandemic. We've come, So people are living longer now, even if they've had HIV, which is different to when in the eighties, when they lived shorter, because we've invested in those programs nationally across the world, whatever little you spend you spend on people with HIV. And now we've made a change in how many years of productive life that people with disability, um, with HIV have. So I've lost my slides again. I don't know what's going on, Claudia. I don't know. It looks like people can see it, but I can't. Okay. Prioritizing Different. Yeah, moving on then. Okay. Okay. We've talked enough about about the covid 19 situation. And as you can see, um um, covid 19 has also, um, you know, divided the world, uh, and and put more people into poverty. And and that's that's that's kind of like this slide talks about that. Um uh, and you know, uh, the recession that's caused by covid 19. Um, So even pandemics, if you don't have a good infrastructure and good health of the population, you you will suddenly see something like the pandemic pandemic widening that gap even more because the people who are on that lower strata who are more deprived we got, uh, less reserve in health will die quicker from, uh, from a global pandemic or something like that. Or a hurricane or a war. People who don't have, uh, good health will just die earlier. And I think that's the kind of inequality that the COVID. 19 show showed. Okay, next slide, please. Okay, So the 10 threats to Global Change in 2019, and I think if you look at it now, it hasn't changed more, much, much more. Um, you all know that there is, uh, happening around air pollution and climate change. That is the singular problem that's gonna wipe out our nation. So our nation's across the world. Um, and every spect every person that you see, um is impacted by it. You know, we've got more obesity in the world. Why? Because we don't have any sustainable places for people to exercise. We've kind of made life difficult for people to commute. Um and so they are. They are taking cars journeys, which has reduced their exercise activity that you know, the food, um uh, is got more sugar in it. The portion sizes, all of this is impacting the is impacting by the climate that we live in air pollution. You know, COPD deaths are one of the highest, and they're from, um from the pollution that we have even in the UK, we've We're having little Children die from asthma because of air pollution, and you think that can't happen. So these are all the 10 big threats to the global health. Next slide, please. And then each of those and the scale of the problem that they bring and the and the burden of disease and and how many people they're affecting. And as you can see, um, infectious disease is not the biggest burden of disease. Now it's more cardiovascular disease. Heart disease is the main problem across the world. Next slide, please. Oh, that brings me nicely to the slide to to to a one minute over. So in conclusion, um, in all these slides and it might be quite complex, I know this might not be something. This is the only one ever time you hear this lecture and never probably hear about it again unless you want to do public health. Um, what I'm trying to say to you is, when you become a doctor, don't ignore the fact that you need to know about the health of nations around you outside of where you practice, because that will influence how you practice and how you look after your patient's because the patient in front of you may have travel cold may have had cultural beliefs. Um, from other parts of the world that they've traveled, they may have, um, live somewhere else. You know, people commute and and and and and go and live in particular parts of the world and pick up endemic conditions. So global health is very important. And please ignore. Please don't ignore it. Just be aware of it. And just make sure that you're tuned to it wherever you do. And when you become a doctor, use it and get get to know more about it. Okay, Okay. I'm just going to just say by because it's one minute past and I'm gonna put my email address on here. Um, if you have any questions, because I've done a bit of a cantor, and this is quite complex topic. If anybody's got any questions or you want to contact me for anything at all, Um um and you haven't understood anything. Um, then please drop me an email. Um, and, um, I will answer your question. Thank you, doctor. And thank you. Everyone for attending the feedback link has been sent and so has a certificate. So please sure to fill that in. Thank you, Doctor, for your time. Not a problem at all. Thank you and stay safe, guys. And I'll catch you in a week's time. Sorry. Was somebody going to ask me something? No. Was somebody talking? Sorry, I'm not sure. But we have one over time anyway. And the neck is fine. OK, next lecture. Take care. Stay safe and goodbye. Bye bye. No, thank you. Everyone, please be sure to download a certificate and fill in the feedback form. The doctor has s the email and the natural will end now. Thank you guys.