Lesson 10: Global Health

• Global Health is an evolving field of study, research, and practice that places a priority on improving health outcomes and achieving health equity for all people worldwide, paying particular attention to the health of vulnerable populations. Global health initiatives recognize that health disparities are often rooted in social, economic, and environmental factors that transcend national borders.

• It emphasizes transnational health issues, determinants, and solutions, addressing challenges that require cross-border collaboration and shared responsibility. These issues include infectious disease outbreaks, antimicrobial resistance, climate change, and access to essential medicines and technologies.

• It involves many disciplines within and beyond health sciences, including medicine, public health, epidemiology, social sciences, economics, and political science, and promotes interdisciplinary collaboration to foster innovation and comprehensive solutions.

• It synthesizes population-based prevention strategies with individual-level clinical care, integrating public health interventions with personalized medical approaches to address both the underlying causes of disease and the immediate needs of individuals.

• Global health bridges the individual focus of doctor-patient relationship with a worldwide concern for collective health, fostering a sense of global citizenship and shared responsibility for health outcomes.

• A slogan developed around Covid-19 says that 'no one is safe until all are safe', highlighting the interconnectedness of global health security and the recognition that health threats can rapidly spread across borders, requiring collective action.

• It is a construct of globalization, shaped by increased interconnectedness, trade, travel, and migration, which have both positive and negative impacts on health.

Annual Hours Worked

• Average annual hours worked by employed persons varies significantly across countries, reflecting differences in labor laws, economic development, and cultural norms. These variations have implications for worker well-being, productivity, and economic growth.

• Some of the countries with the highest average annual hours worked include Greece (2036), Poland (2023), and Russia (1965), indicating longer working hours compared to other developed economies. These countries may have different labor regulations and economic priorities that contribute to extended work schedules.

• Some of the countries with the lowest average annual hours worked include Denmark (1,381), Norway (1,384), and Germany (1,386), reflecting a greater emphasis on work-life balance, worker protections, and higher productivity with shorter hours. These countries often have strong labor unions and social welfare systems that support reduced working hours.

Class Essay Instructions

• Essay due date is approaching, requiring careful planning and time management to ensure timely submission.

• PowerPoints and lectures cannot be cited as primary sources, as they do not represent original research or analysis. Instead, they should be used for guidance and synthesis of information from credible sources.

• Only cite material from the course syllabus or textbook to maintain academic integrity and ensure that all sources are reliable and relevant to the course content.

• No outside sources are permitted, as the essay is designed to assess comprehension and application of course material. Reliance on external sources may indicate a lack of engagement with the assigned readings.

• Different chapters count as different academic sources, recognizing that each chapter may present unique perspectives, evidence, and arguments that should be cited appropriately.

• Forget the hats heuristic to pick good articles, focusing instead on the strength and relevance of the evidence and arguments presented in each source.

• Just use authors and sources that help your argument, selecting those that provide the most compelling evidence and logical support for your claims.

• Make strong, well-substantiated claims from anywhere and use any section of the textbook, demonstrating a comprehensive understanding of the material and the ability to synthesize information from across the text.

• Use any source on the course outline or the supplementary readings, ensuring that all sources are appropriately cited and contribute to the overall argument of the essay.

Enduring Question

• Since diseases cross borders indiscriminately, can health be an issue that unites us, fostering collaboration, solidarity, and shared responsibility in the face of global health challenges? This question prompts consideration of how shared health threats can transcend political, cultural, and economic divides, encouraging collective action and cooperation.

Key Terminology

• Global Health: An area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide, addressing health disparities and promoting wellness across diverse populations and regions.

• Public Health Emergency of International Concern (PHEIC): Can be declared by the WHO Director-General after an expert panel agreement that an emergency is serious enough to affect the international community, triggering coordinated international responses and resource mobilization to address the crisis.

• GAVI (the Vaccine Alliance): Aims to increase global access to vaccines, particularly in low- and middle-income countries, by facilitating partnerships between governments, international organizations, and the private sector to improve vaccine coverage and reduce vaccine-preventable diseases.

Values Underpinning Global Health

• Four basic morals of biomedical ethics:

  • Autonomy: Respect for the patient, including their right to make choices about their healthcare, ensuring informed consent and shared decision-making.

  • Beneficence: Obligation to make contributions to a patient’s welfare, prioritizing actions that promote health, prevent harm, and improve well-being.

  • Non-maleficence: Harm must be avoided or minimized, taking precautions to prevent adverse effects and ensuring that interventions do not cause undue suffering.

  • Justice: Fair and equitable distribution of health resources and access to care, addressing health disparities and ensuring that all individuals have the opportunity to achieve their full health potential (does greatest good for greatest number of people).

• UN treaty (1966) recognized ‘the right of everyone to the enjoyment of the highest attainable standard of physical and mental health,’ establishing a fundamental human right to health and well-being.

• A global norm has emerged that all states have a duty to provide health services for their populations, reflecting a growing consensus on the responsibility of governments to ensure access to essential healthcare services for all citizens.

Distribution and Determinants of Global Health

• Appropriate policies and resource allocation are essential to deliver the best possible health outcomes in global health, guiding investments in healthcare infrastructure, human resources, and disease prevention programs.

• Accurate and accessible data on disease patterns and determinants are required, but getting reliable data from states can prove difficult due to political sensitivities, limited resources, and varying data collection standards. Addressing these challenges is crucial for effective global health surveillance and monitoring.

• ‘Global Burden of Diseases, Injuries, and Risk Factors Study’ (2016) is vital to the transparency of world health data, providing a comprehensive assessment of the burden of disease and injury across countries, enabling evidence-based policymaking and resource allocation.

• Inequalities in health stem from social determinants (conditions people are born, grow, live and work in, and the systems), including poverty, education, employment, housing, and access to healthcare, highlighting the need for intersectoral approaches to address the root causes of health disparities.

Framing Problems as Global

• Enlightenment reorganization of humans above nature, leading to the exploitation of natural resources and environmental degradation, which in turn impacts human health.

• Competition between capitalism and communism to extract resources, driving unsustainable development and exacerbating health inequalities.

• Emergence of market civilization - health framed in terms of the market, commodifying healthcare and prioritizing profit over population health.

• How naive should we be about health? This question prompts critical reflection on the assumptions, biases, and power dynamics that shape our understanding of health and healthcare.

Poverty, Inequality, and Health

• Gini coefficient: 0.44 in 1950, 0.54 in 2000, indicating a widening gap between the rich and the poor, with significant implications for health outcomes.

• Total poverty reduction, but increasing concentration of wealth at the top = differential health outcomes, as the benefits of economic growth are not shared equitably, leading to disparities in access to healthcare, nutrition, and other essential resources.

Disparities in Health

• Six key statistics:

  • Maternal mortality: Number of deaths per 100,000 live births, reflecting the quality of maternal healthcare services and access to reproductive health services.

  • Death rate under five years: Number of deaths per 1,000 live births among children under the age of five, indicating the overall health and well-being of a population.

  • Life expectancy at birth: Average number of years a newborn is expected to live, reflecting the overall health and longevity of a population.

  • Per capita income: Average income per person in a given area, reflecting economic prosperity and access to resources.

  • Annual per capita healthcare expenditure: Average amount of money spent on healthcare per person per year, indicating the level of investment in healthcare services.

  • Number of physicians per 100,000 people: Density of healthcare professionals in a given area, reflecting access to medical care and expertise.

• Outcomes not just related to health care expenditure, as social, economic, and environmental factors also play a crucial role in determining health outcomes.

• 2018 article focusing on infectious disease - ebola, highlighting the ongoing challenges of controlling and preventing infectious disease outbreaks in resource-limited settings.

• Conflict, failed states, refugees: Political instability, violence, and displacement contribute to health disparities by disrupting healthcare services, increasing exposure to infectious diseases, and exacerbating mental health issues.

• Climate change and environmental degradation contribute to health disparities by increasing the frequency and intensity of extreme weather events, spreading vector-borne diseases, and disrupting food and water supplies.

Distorted Value Systems

• Human rights treat property and health as equivalents, reflecting a tension between economic interests and social justice in global health governance.

• Science and innovation does not equal health outcomes, as translating scientific advances into tangible improvements in population health requires effective delivery systems, equitable access, and attention to social determinants of health.

• Many of the problems today already have scientific solutions but don't have distribution channels, highlighting the need for innovative approaches to bridge the gap between knowledge and practice.

• Hyper-individualism reinforces market-based solutions for health, potentially exacerbating health disparities and undermining collective action for public health.

Four Power Perspectives

• Hard Power:

  • Military: Use of military force to achieve health-related objectives, such as humanitarian assistance in conflict zones.

  • Money: Financial resources used to fund health programs and initiatives.

  • Power Over: Ability to exert control or influence over health-related decisions and policies.

  • Coercive Power: Use of sanctions or other coercive measures to promote compliance with health regulations.

• Neoliberalism:

  • Free Market: Reliance on market mechanisms to allocate healthcare resources and services.

  • Market Capitalism: Promotion of private sector involvement in healthcare delivery.

  • Regulated Market: Government oversight and regulation of healthcare markets to ensure quality and affordability.

• Communism:

  • Central Control: State-led planning and management of healthcare systems.

  • Social Democracy: Combination of market mechanisms and government intervention to achieve universal healthcare coverage.

• Soft Power:

  • Knowledge: Sharing of expertise, research, and best practices in global health.

  • Moral: Promoting ethical principles and values in healthcare decision-making.

  • Power With: Collaboration and partnership among diverse stakeholders to address health challenges.

  • Collective Power: Mobilizing collective action and advocacy to promote health equity and social justice.

New Paradigms for Health Economics

• People interpret the behavior of their healthcare system:

  • Naïve clinical: Dominant position of clinicians and the general public, makes politicians sensitive to opinions on healthcare, shaping policy debates and resource allocation.

  • Mainstream economic: Held by professional economists or those with conventional economic training, influences government when they hold positions, corporate world, business press, informing economic analysis and policy recommendations related to healthcare.

  • Eclectic structuralist: Health services researchers, health economists, officials and government ministries responsible for health and healthcare, as well as administrators or managers of healthcare institutions, shaping healthcare policy and management decisions.

• Is healthcare inherently ideological? This question prompts consideration of the values, beliefs, and power dynamics that shape healthcare systems and access to care.

Normative View

• Combination of science and rhetoric, shaping perceptions and beliefs about healthcare.

• Healthcare providers: ‘healthcare is underfunded,’ ‘there is a shortage of doctors and that’s just a fact,’ framing resource allocation and workforce issues as critical challenges.

• More money should be spent on healthcare? This question sparks debate about the appropriate level of investment in healthcare and the allocation of resources.

• All money should be spent on healthcare? This question challenges the limitations of healthcare spending and prompts consideration of alternative investments in social determinants of health.

• Shortage in inherently normative, reflecting societal values and priorities.

• How many in vitro fertilizations are the right amount? This question raises ethical and societal considerations about access to reproductive technologies.

• Clinical perspective – people should get the care they need regardless of the cost, emphasizing the moral imperative to provide healthcare to all who need it.

• ‘On balance, and allowing for uncertainties, is this intervention likely to do more good than harm to the patient’s health?’ This question guides clinical decision-making by weighing the potential benefits and risks of interventions.

• Prostate exams for men over 65, raising questions about the appropriateness and effectiveness of screening programs.

Normative Perspectives

• Mainstream economic perspective has alternative normative basis, emphasizing efficiency, cost-effectiveness, and consumer choice in healthcare decision-making.

• Consumer sovereignty – people should get whatever care they’re willing and able to parry for at prices that reflect the real opportunity cost of producing that care, prioritizing individual preferences and market-based solutions.

• People get to choose how to spend their incomes, even if they are unwilling or unable, they should not get those services, reflecting a tension between individual autonomy and social responsibility in healthcare.

• ‘value’ refers to not just preferences but ability to pay, potentially exacerbating health disparities and limiting access to care for vulnerable populations.

• Conflicts of moral principle cannot be resolved through rational argument, highlighting the role of values, ethics, and power dynamics in shaping healthcare policy.

• They fight or vote, reflecting the political nature of healthcare decision-making.

The Eclectic Structural Perspectives

• People should get the care they need, emphasizing the importance of universal access to healthcare.

• The public wants a healthcare system, reflecting a desire for collective action and equitable distribution of healthcare resources.

• But practitioners want to be paid – on some element of choice, public provision, highlighting the need to balance the interests of healthcare providers with the needs of the public.

• Tension with economic rationality, reflecting the challenges of balancing ethical considerations with economic efficiency in healthcare decision-making.

• Well-off individual who gets in a serious car crash or is diagnosed with cancer has a change in rational preferences very quickly, illustrating the unpredictable nature of healthcare needs and the importance of comprehensive coverage.

• Is illness a choice? is treatment a choice? This question challenges assumptions about personal responsibility for health and access to care.

• What kind of consumption is health? What is the demand for health? This question explores the economic and social dimensions of healthcare demand.

Insurance Providers

• Selling insurance as a commodity ‘financial product,’ commodifying healthcare and prioritizing profit over population health.

• Public expenditures are still primary 1 out of 3 dollars is insurance, reflecting the significant role of government funding in healthcare.

• Healthcare is assumed to be a good like any other, despite its markets not reacting like other goods, highlighting the unique characteristics of healthcare and the limitations of market-based approaches.

• Provides actors with a perception of market choice, potentially masking the challenges of accessing affordable and quality healthcare.

Inherent Limitations

• Clinical perspective largely silent on the relationship between the structure and financing of care, neglecting the systemic factors that influence healthcare access and outcomes.

• American clinicians have argued against public insurance – ideological convictions, reflecting the influence of political beliefs on healthcare policy.

• Economic perspective as perfectly coherent story about how for-profit provision supplies healthcare, potentially overlooking the ethical and social implications of market-based healthcare systems.

• Coherent story about an imaginary world, highlighting the limitations of economic models in capturing the complexities of healthcare.

• Purchasers aren’t competitive for-profit firms = ?, raising questions about market power and consumer choice in healthcare.

• Unions, drug companies, suppliers = tiny monopolies all over the place, contributing to high costs and limited competition in healthcare.

• Eclectic structuralist perspective, providing a more holistic understanding of healthcare systems.

• People should get the care they need but says nothing about positive presumptions, highlighting the need for proactive measures to promote health equity.

• Can’t explain how in the US more splendid and doesn’t equal better outcomes, challenging assumptions about the relationship between healthcare spending and health outcomes.

• ‘Underfunding is always framed as the issue,’ neglecting other factors that contribute to healthcare challenges.

• ‘a built bed is a filled bed?’ – a built and reimbursed bed is a filled bed, reflecting the influence of financial incentives on healthcare utilization.

Primer: Is US Healthcare a Market?

• Market = Supply and demand = efficiency, reflecting a belief in the power of market mechanisms to allocate resources efficiently.

• Abstract, aspacial, apolitical, unfalsifiable (ideology), highlighting the limitations of economic models in capturing the complexities of healthcare.

• US Health Care (‘market’ based), reflecting a reliance on private insurance and market-based approaches.

• Some level of private provision of health services, products, supplies, contributing to the complexity of the US healthcare system.

• Market ideology assumes:

  • Many options (competition), but often limited choices for consumers.

  • Lack of state intervention (easy entry and exit), but significant government regulation in healthcare.

  • Informed consumers (choice), but information asymmetry and complexity in healthcare decision-making.

The Logic of the Quasi-Market

• Neoclassical economics frames actual capitalist economy as messy, imperfect copy of perfect benchmark, idealizing market mechanisms and overlooking real-world complexities.

• Unsatisfactory results must be linked to a specific divergence from the fictional utopia, blaming market failures on deviations from idealized market conditions.

• Technocratic and philosophical sides collide, reflecting tensions between economic efficiency and ethical considerations.

• Policy proposal may be advocated; but the moral-philosophical framework must be respected, highlighting the influence of values and beliefs on healthcare policy.

• We can fail at the model, but the model can never fail, reinforcing a belief in the inherent superiority of market-based approaches.

Problem: Geography

• Over 3000 hospitals, but uneven distribution and access to care.

• People tend to be landlocked, limiting mobility and access to healthcare services.

• Emergency and local services, prioritizing immediate and local healthcare needs.

• Medicaid/Medicare: Pays for poor, elderly, and indigent.

  • Single payer – direct leverage, giving government greater negotiating power with healthcare providers.

• Insurance companies:

  • Limit payment for procedures, controlling costs but potentially limiting access to care.

  • Many payers – varied leverage, reducing negotiating power and increasing administrative complexity.

• Individuals:

  • Pay the costs determined by Medicaid and insurance companies, bearing the financial burden of healthcare.

  • Infinite payers – little leverage, reducing individual negotiating power and increasing vulnerability to high costs.

Hospital Prices Vary Wildly

• Variation in cost for chest pain treatment in NYC, highlighting the lack of transparency and standardization in healthcare pricing.

• Source: CENTERS FOR MEDICARE & MEDICAID SERVICES, providing data on healthcare costs and utilization.

Actual Markets are Rare

• Quasi markets = bureaucracy:

  • Canada ~2% on insurance administration, reflecting the efficiency of a single-payer system.

  • US ~30% on insurance administration, highlighting the administrative complexity and costs of a multi-payer system.

• Efficiency is subjective, depending on values and priorities.

• Multiple buyers = multiple costs, increasing administrative complexity and costs.

• Monopoly = inflated costs or lower costs, depending on market dynamics and regulation.

• If goal = lowest cost = market= Vegas shipping patients, prioritizing cost savings over quality and access.

• If goal = most patients = socialist = limited choice, balancing access with individual choice.

• Worst case = single individual consumer = constrained non-market choice, highlighting the vulnerability of individuals in healthcare markets.

Canadian Healthcare

• Canada receives benefits of US market system:

  • Lower bulk costs, leveraging the size and scale of the US market to reduce costs.

  • Generic versions of US drugs, providing access to affordable medications.

  • Access to private treatments and actors, supplementing the public system with private options.

• Universal systems can be ‘efficient’ but non-markets, demonstrating that market mechanisms are not always necessary for efficiency.

• Social values embed ‘market’ goals, reflecting the influence of social priorities on market outcomes.

• Capitalism may not exist – markets are different everywhere (hence Softwood Lumber), highlighting the diversity of market arrangements and the influence of local context.

Income Distribution

• Income distribution is a process of active conflict, not just supply and demand, reflecting the influence of power dynamics and social forces on economic outcomes.

• Incomes tend to be the baseline around which the rest of the economic system adjusts, shaping consumption patterns and economic inequality.

• Income distribution is an evolutionary process, shaped by norms and institutions inherited from the past, highlighting the persistence of historical inequalities.

American Medical Association

• Responses to Obama care, reflecting the ongoing debate about healthcare reform in the US.

• 25 million still uninsured, highlighting the challenges of achieving universal coverage.

• Universal coverage requires:

  • Subsidy to those who are poor, ensuring access to care for low-income individuals.

  • Compulsion for everyone to participate, promoting shared responsibility and risk pooling.

• US life expectancy is lower, inequality is greater, reflecting the impact of social and economic disparities on health outcomes.

• SDH’s, highlighting the importance of addressing social determinants of health.

• High cost per person - \$10,000 per year, 18% of GDP, reflecting the high cost of healthcare in the US.

• Fears about lack of innovation, raising concerns about the impact of healthcare reform on medical innovation.

• Does the rest of the world subsidize their medical innovation of the backs of the US dead? This question provokes moral reflection on global healthcare financing.

What is a Price?

• Assumption:

  • Supply and demand, reflecting a belief in the power of market mechanisms to determine prices.

• Today:

  • Individual means of exchange (rewards points), rewarding consumer loyalty and incentivizing purchasing behavior.

  • Individual costs based on loyalty (membership), providing discounts and benefits to loyal customers.

  • Individual prices disclosed on purchase (sales), promoting transparency and price comparison.

Four Different Types of Systems

• Traditional sickness insurance - private market with state subsidy (Germany), combining private insurance with government support.

• National health insurance - single payer health insurance (Canada), providing universal coverage through a government-run system.

• National health services - state provides healthcare (UK), offering healthcare services directly through government-owned and operated facilities.

• Mixed systems - combination of traditional sickness insurance and national health coverage (US), blending private and public insurance options.

• Which would you prefer? What is the basis of that preference? This question promotes critical thinking about healthcare systems and values.

Folland, Goodman, and Stano Data

• Substantial variation in health expenditures across countries.

• European countries spend more on inpatient care than the US.

• US actually spends the lowest amount per capita on pharmaceutical but is highest overall, reflecting differences in drug pricing and utilization.

• Canada has lower death rates, indicating better health outcomes.

• Many countries have higher life expectancies than the US, suggesting that healthcare systems and social factors play a role in longevity.

• US spends the most and most as a percentage of GDP, highlighting the high cost of healthcare in the US.

• Spending doesn’t necessarily mean one thing, as health outcomes are influenced by multiple factors.

• High expenditures can have three different meanings:

  • High average level of services, indicating greater access to healthcare services.

  • High resource cost for services, reflecting higher prices for healthcare goods and services.

  • Inefficient provision of services, suggesting waste and duplication in the healthcare system.

• What’s your guess? This question encourages reflection on the factors driving high healthcare expenditures in the US.

Folland, Goodman, and Stano - UK

• UK - 1946 - funded by taxes and insurance, reflecting a combination of public and private financing.

• Some cost for prescriptions, balancing access with cost control.

• GP as primary form of care, emphasizing primary care and prevention.

• Less than half of US cost, about the same mortality (still class differences), demonstrating the potential for cost-effective healthcare delivery.

• Rationing, some long wait times = private, highlighting the trade-offs between universal access and timely care.

Folland, Goodman, and Stano - Canada

• Canada - US similar systems until 1971, reflecting a divergence in healthcare policy choices.

• 1947 Saskatchewan provincial health care, pioneering universal healthcare in Canada.

• Opposed by organized medicine in both Canada and US - fear of socialism stronger in the US, highlighting the political and ideological dimensions of healthcare reform.

• Federal legislation 1957, establishing a national framework for universal healthcare.

• 1972 - every province and territory has universal coverage, achieving universal access to healthcare in Canada.

• Coverage universal, comprehensive, portable, ensuring equity and access for all Canadians.

• Canadian physicians private practice, 90% fee for service, combining private practice with public funding.

• Hospitals are not-for-profit, budgets from provinces, ensuring accountability and public oversight.

• Some fee surgeries to decrease wait times (cataracts, joint replacement, cardiac bypass), addressing wait times through targeted interventions.

Folland, Goodman, and Stano – comparative

• How is it paid for - Canada Health Transfer (CHT) cash contributions from the federal government to the provinces to support healthcare spending.

Folland, Goodman, and Stano - comparative data

• Systemic issues:

  • Nurse and doctor population 20% lower than the US, highlighting workforce challenges in Canada.

  • Linked to provincial capacity for doctors, reflecting provincial control over healthcare workforce planning.

  • Canadians drink less alcohol and smoke slightly more than Americans, suggesting differences in lifestyle factors.

  • Health indicators more favorable in Canada, demonstrating the potential benefits of universal healthcare.

  • Canadian support for the public system is much stronger, reflecting social values and political preferences.

• Does universal healthcare make society more reckless? This question challenges assumptions about individual behavior and healthcare policy.

Folland, Goodman, and Stano

• Canadian lower costs:

  • Physician fees negotiated through collective bargaining, controlling costs through collective bargaining.

  • Provinces regulate capital expenditures - centralization of resources, promoting efficiency and preventing duplication.

• US was more high tech most countries catch up, reflecting technological diffusion and adoption.

• Canadian-style health coverage in US would save 0.71 of every \$1 of American administrative costs, highlighting the potential for cost savings through administrative simplification.

• US spends 31% on administration, 16% in Canada ($232B per year in 2001), demonstrating the high administrative costs of the US healthcare system.

Folland, Goodman, and Stano - Limits Inherent the Canadian System

• Federal deficits in the 90s reduce cash transfers, impacting provincial healthcare budgets.

• Provinces have forced reduction in hospital capacity (devolution of decision-making as well), leading to challenges in access and quality of care.

• Constant struggle between quality and cost while maintaining universal principles, highlighting the ongoing challenges of healthcare policymaking.

• Supplemental insurance markets, providing coverage for services not fully covered by the public system.

• Partial private services, supplementing the public system with private options.

Folland, Goodman, and Stano - Defense of the American System

• Waiting and queues in Canada is unacceptable to US patients, reflecting different values and preferences.

• Hard to measure that in terms of cost, highlighting the difficulty of quantifying the value of timely access to care.

• Attitude of the public is key, reflecting the influence of public opinion on healthcare policy.

Fat Studies

• Fat Studies is the first academic journal in the field of scholarship that critically examines theory, research, practices, and programs related to body weight and appearance, promoting critical inquiry and dialogue about weight and body image.

• Content includes original research and overviews exploring the intersection of gender, race/ethnicity, sexuality, age, ability, and socioeconomic status, emphasizing the social and cultural dimensions of fatness.

• Articles critically examine representations of fat in health and medical sciences, the Health at Every Size model, the pharmaceutical industry, psychology, sociology, cultural studies, legal issues, literature, pedagogy, art, theater, popular culture, media studies, and activism, addressing a wide range of topics and perspectives related to fatness.

Case: Global Obesity

• Primer: Diets don't work, challenging conventional approaches to weight loss and promoting alternative strategies for health and well-being.

• WHO 2013 – global action plan for prevention and control of non-communicable diseases, recognizing obesity as a major public health challenge.

• Improvements in food environments at local, national, and transnational levels, addressing the environmental factors that contribute to obesity.

• Food environments are behind the obesity epidemic, highlighting the influence of food availability, affordability, and marketing on dietary choices.

• Broad agreement – government policies and regulations such as restrictions on unhealthy food marketing to children, front of pack labeling, healthy food policies in the public sector, and taxes on unhealthy products are needed, promoting policy interventions to create healthier food environments.

• Cost feasible, effective, population-wide effects, sustainable, emphasizing the importance of evidence-based and sustainable interventions.

Case: Global Obesity - Individualism

• Individualism is killing us, challenging the emphasis on personal responsibility and promoting collective action to address obesity.

• Bootstrap/moral failings equal obesity, reinforcing stigma and blame towards individuals struggling with weight.

• Is Instagram unhealthy? Should it be regulated? This question explores the potential impact of social media on body image and dietary choices.

• Deregulation and shift of health care responsibilities to the individual are present in the dominant culture of neoliberal policies, highlighting the influence of ideology on health policy.

• Food industries are pushing more consumerism as a solution to problems, exacerbating the obesity epidemic.

• Government regulatory and fiscal intervention needed instead of soft approaches, emphasizing the importance of government action to create healthier food environments.

• The power of transnational food corporations and progressive deregulation of markets = serious health costs and concerns, highlighting the influence of corporate power on public health.

• ‘Big food’ ‘big soda’ = corporate disease vectors, framing food corporations as drivers of the obesity epidemic.

• Should any food marketing be allowed to be targeted to children? This question challenges the ethical implications of marketing unhealthy foods to vulnerable populations.

Key Messages

• Major improvements are needed in the healthiness of food environments if the global targets of halting the rise in obesity and type 2 diabetes are to be met, emphasizing the need for comprehensive action to address the obesity epidemic.

• The proposed four-step accountability framework aims to ensure progress towards the achievement of the WHO obesity and diabetes targets, promoting accountability and transparency in the implementation of obesity prevention strategies.

• Governments probably need improved regulatory mechanisms to ensure private sector accountability, several non-regulatory mechanisms are underutilized, highlighting the importance of government oversight and regulation of the food industry.

• The process of food policy development needs increased protection from the vested interests of the processed-food industry, ensuring that policy decisions are based on evidence and public health considerations.

• Where food systems are not yet highly dependent on transnational food corporations, efforts should concentrate on preservation and strengthening of national food sovereignty and agro-food-biodiversity and prevention of food systems from becoming highly dominated by big food corporations, promoting sustainable and equitable food systems.

Case: Global Obesity - Accountability

• Accountability – requires recognition of achievements and enforcement of performance, ensuring that actors are held responsible for their actions.

• Do corporations need to diet? This question challenges corporate practices that contribute to the obesity epidemic.

• Voluntary partnerships – belief that governments, private sector, civil society, donors, and other stakeholders have a greater effect by joining their efforts, promoting collaboration and shared responsibility.

• No transparency, no public accountability, no way to manage conflicts of interest, highlighting the limitations of voluntary partnerships.

• Little evidence that public-private partnerships make any meaningful contribution, challenging the effectiveness of public-private partnerships.

• To what extent is food ideological? This question explores the influence of values and beliefs on food production and consumption.

Case: Global Obesity - Measuring Progress

• Need to measure progress to achieve goals, ensuring that interventions are evaluated and adjusted as needed.

• High body mass index is rapidly increasing, highlighting the urgency of addressing the obesity epidemic.

• Monitor children, have clear goals and feedback, promoting early intervention and monitoring of childhood obesity.

• Do we need a surveillance regime for food consumption? This question raises ethical considerations about data collection and privacy.

Case: Global Obesity - Hunger and Nutrition Commitment Index

• Clear set of 22 indicators to address hunger and undernutrition, measuring progress towards food security and nutrition goals.

• Put mechanisms into trade agreements, integrating nutrition considerations into trade policy.

• EU-USA TTIP public investment provisions, ensuring that trade policies promote public health and nutrition.

• Ability of stakeholders to challenge one another, promoting accountability and transparency.

• Civil society versus corporations, highlighting the power dynamics in food policy.

• Improve food systems – palm oil restrictions in Mauritius replaced with soybean oil = 15\% drop in cholesterol, demonstrating the potential impact of food policy interventions.

• Restriction on saturated fat, Samoa bands Turkey tail imports – WTO overturns, highlighting the challenges of implementing food policy in a globalized world.

Governments vs. Private Sector Accountability

*Direct regulation through laws and regulations specifying required conduct

*Regulatory institutions through monitoring of compliance, investigation of complaints, and law enforcement by designated agencies, auditors, inspectors, commissioners

*Procurement contracts and grant requirements for government agreements-requiring food supplies (e.g., to schools and hospitals) to meet nutrition standards

Litigation against food industry for breaches of the law

Legislative and regulatory support to strengthen and improve private sector initiatives so they are more accountable, credible, and better able to achieve public interests and objectives

Regulatory probability in which governments create a credible expectation that, unless measurable improvements in voluntary performance are achieved, more direct forms of regulation will be introduced

Access to policy processes by promoting civil society access to policymaking processes (eg, membership on government committees) but restricting food industry if potential conflicts of interest exist

Fiscal instruments such as taxes subsidies, and concessions to influence market behavior through their impact on price, and by changing the costs of corporate and individual behavior

• Government procurement to the market dynamics in favor healthy foods

• Public feedback(praise or criticism)through the media from politicians on the performance of food companies

• Private feedback on performance to key people written companies and body from politicians or civil servants

Case: Global Obesity - Fiji

*2000: Fiji bands the sale of mutton chops

*New Zealand criticizes on trade grounds

Advertising is integral to food preferences

Pushing investors to demand nutritional practices. investment firms have between \$2-6 trillion of assets and management

no daily recommended intake of sugar on nutritional guidelines*

Calorie Reduction Pledge

In March 2011, the UK Coalition government launched five Public Health Responsibility Deal Networks to Address major publichealth Challenges in England

Inspired by nudge theory or libertarian paternalism: the goal is make small changes in people's environments to affect their choices and facilitate healthy lifestyles

Brazilian Food and Nutrition Security System

was established by law in 2006

ensure public systems and services are built to full human rights:was implemented

federate the National conference comprised of government and civil society and delegates

The government is generally required to enact policies and actnecessary to promote the population and nutrition security

and to b PublicProsecutors government can prosecute those actors responsible for nutritional security of the most susceptible populations

Frame the obesity issues in the terms of exploitation of human vulnerability

Reduce bias to increase services

Act on marketing of unhealthy foods to children as a priority

Strengthen the health professional leadership

Marketing practices are taking place

Food preferences from market intrusion

Join efforts on over and under nutrition

WHO has been pushing for top down