Konsep Sehat dan Determinan

Kesehatan
Antonius N W Pratama
Farmasi Klinik dan Komunitas
Fak Farmasi Univ Jember
 Outline
• Sehat
• Determinan kesehatan
• Determinan biologis
• Determinan sosial
• Determinan lingkungan
 Apa itu sehat?
KBBI:
• se·hat /séhat/
1. baik seluruh badan serta bagian-bagiannya
(bebas dr sakit); waras: sampai tua ia tetap --
krn rajin berolahraga;
2. (yg) mendatangkan kebaikan pd badan:
makanan dan lingkungan yg -- diperlukan bagi
pertumbuhan anak-anak;
3. sembuh dr sakit: dokter yg merawatnya
menyatakan ia telah -- dan boleh pulang segera;
 Apa itu sehat?
4. baik dan normal (tt pikiran);
5. boleh dipercaya atau masuk akal (tt
pendapat, usul, alasan, dsb);
6. berjalan dng baik atau sebagaimana
mestinya (tt keadaan keuangan, ekonomi,
dsb);
7. dijalankan dng hati-hati dan baik-baik (tt
politik dsb)
 WHO definition
• “ … a state of complete physical, mental and
social well-being and not merely the absence
of disease or infirmity” (1946)
• “It is a positive concept emphasizing social
and personal resources as well as physical
capabilities“ (1986)
 Kesehatan mental
• “a state of well-being in which every individual
realizes his or her own potential, can cope
with the normal stresses of life, can work
productively and fruitfully, and is able to make
a contribution to her or his community.”
(WHO 2009)
 Pengaruh budaya
• For some cultures, the concept of health includes
religious aspects
• E.g. Australian Aboriginal people have a concept
of health which includes their relationship to
their “land, family and community” and includes
“control over their physical environment, of
dignity, of community self-esteem and of
justice”...not just “doctors, hospitals, medicines
or the absence of disease and incapacity”
(National Aboriginal Health Strategy Working Party 1989, cited by Fleming and Parker
2009)
 Pengaruh budaya
• Diskusi: Bagaimanakah arti sehat menurut
budaya (termasuk agama) di lingkungan
Anda?
 Health determinants
• “A factor or characteristic that brings about
change in health, either for the better or for
the worse.”
(Keleher and MacDougall 2009, p. 380)

• “The drivers for health lie outside of the

health sector”
(Keleher p. 47, in Keleher, MacDougall and Murphy 2007)
BIOLOGICAL DETERMINANTS
 Biological determinants
• A quick reminder...
• Major three:
– Genes
– Age
– Gender (male or female)
 Genes
• Genes provide much of the underlying variation
between people.
• Human genome sequenced in 2001 but no
immediate, complete answers.
• Not a simple one mutant gene per disease
situation.
• 95% same as rats & mice.
• 98% same as apes.
• Between humans, tiny subtle differences in gene
sequences make us unique.
 Polymorphism
• Differences between genes which still code
information properly.
• Quite common.
• May assist human health/performance (e.g.
Angiotensin Converting Enzyme (ACE) better
performance and gain more from same
amount of physical training).
 Mutation
• Change in code which affects way information
coded.
• Less common.
• May cause or increase susceptibility to health
problems.
 Genetic diseases
• Single gene disease – sickle cell anaemia,
cystic fibrosis.
• Multi-gene disease – dozens to hundreds of
key genes contribute and often the
environment will trigger an individual to
manifest the problem – e.g. obesity,
depression.
 Epigenetics
• Newer field of research.
• DNA sequence unchanged but change can
occur to surrounding chemicals that effects
how genes are expressed and can be inherited
across generations.
• Environment can cause change in the next
generation (e.g. diet and diabetes or CVD;
carcinogens and cancer; toxins and birth
defects).
 Race
• Populations with high rates of Type 2
Diabetes:
– Native Americans and Australian Aboriginals.
• Genetic influence within group.
• Brought to other groups they mix genetically
with.
• However socio-economic effect on diet, stress,
physical activity levels.
 Age
• Most potent with huge effects on mortality
and morbidity.
• Developed country = the older you get the
more likely you are to get sick and die because
you live to an older age.
• Developing country = Higher infant, childhood
and maternal mortality through obstetric
problems and infectious disease.
 Gender
• Across various societies there is evidence of
biological effects:
– Females live longer than men.
– Increasing safety of childbirth has increased
women’s life expectancy.
– Male foetuses & babies more vulnerable.
– Hormones protective effect: women against CVD
and men against osteoporosis.
SOCIAL DETERMINANTS
 Social determinants
• “the causes of the causes of ill health and
emphasise social context, social stratification, the
differential exposure people experience and their
vulnerability to illness and injury” (Baum 2008)
• This approach recognises the strong influence of
society on health and that some groups of
people, due to their position and role in society,
do not have equitable access to the resources
that they need to ensure their good health
 WHO’s CSDH Report in 2008
• “Social injustice is killing people on a grand
scale”
• Children have dramatically different life
chances depending on where they were born
• Health and illness follow a social gradient: the
lower the SES, the worse the health
• “It does not have to be this way and it is not
right that it should be like this”
(Commission on Social Determinants of Health 2008)
 The 10 Solid Facts
• Wilkinson and Marmot from UK
• ‘Whitehall Studies I and II’ in 70s, 80s & 90s –
poorer health for lower grade employees
• Asked to identify ‘causes of the causes’ by
WHO
• Statement of global social determinants
 1. Social gradient (class)
• “Position in a system of structured inequality
based on the unequal distribution of power,
wealth, income, and status. People who share
a class position, typically share similar life
chances.”
(Germov 2005)
 Lower verses higher class
• 50% higher death rate
• Higher illness and disability – 37% male & 27%
female increased ‘burden of disease’ for lowest
status
• More likely to go to GP, hospital and out-patients
• Less likely to participate in prevention (e.g.
dentist, screenings)
• More risky behaviour (e.g. substance use,
accidents)
• For all ages
 2. Working Conditions
• Need to be safe
• Need to be not too monotonous
• Workers need to feel some control and
security
• Important for self-esteem and socialisation
• May cause stress
 3. Stress
• Fight or flight response
• Causes changes in bodily function
• Repeated frequent response causes negative
longer term changes in body function
• Diabetes
• CVD, HBP, Stroke
• Immune function
• Depression, aggression
 4. Unemployment
• Stress
• Poverty
• Mental health problems
• Suicide
 5. Social exclusion
• Being left out of society
• Marginalization
• Inequity
• Discrimination
• Active or passive
• Denied due to explained, ‘important’ reasons
• Just not considered important
 6. Social support
• Feeling loved and valued
• Feeling like you belong
• Resources supplied by others
• Social cohesion/social capital = Respect, trust
and ‘reciprocity’ (do unto others…)
 7. Early Life
• Nutrition
• Good parenting
• Emotional care
• Physical care
• Clean environment
• Education
 8. Addiction
• Alcohol, tobacco, illegal drugs and prescription
medications
• Cause or effect?
• Helps them cope with problems but creates
more problems
• Individual choice but strong influence of social
setting
 9. Transport policy
• Reduced physical activity levels
• Cars unsustainable
• Pollution
• Stress
• Accidents
 10. Healthy food
• Both an environmental and social determinant
• Food safety/contamination
• Problems of scarcity and excess
• Poverty, geography and access
• Political issue
• Food industry has large role
ENVIRONMENTAL DETERMINANTS
 Human-Environment Interactions
• Natural - undeveloped landscape; naturally
occurring, e.g. water, air, trees …
• Built – developed environment; roads, homes
…
• Our lives (literally) depend on the
environment
• Our actions may either enhance or diminish
its suitability as a home, either now or in the
future
 21stC Fukushima Disaster 11.3.2011
Earthquake tidal wave Fukushima nuclear meltdown
• 15,854 deaths, 26,992 injured, 3,155 missing (JNP)
• 130K buildings collapsed, 250K 'half collapsed', 700K
partially damaged
• heavy damage to roads & railways
• fires, dam collapse
• ~ 4.4mil no electricity
• 1.5 mil without water
• RA cesium, iodine, strontium in soil,
• water, fish
 How much global ill health is
attributable to environmental
factors?
• ~ 25-33% of the global burden of disease
attributed to env. risk
• factors
• <5 y.o. bear the largest burden
• proportion decreases with economic
development

Preventing disease through healthy environments: towards an estimate of the

global burden of disease’ (WHO 2006)
http://www.who.int/quantifying_ehimpacts/methods/en/smith.pdf
(Epidemiology 1999;10:573-584)
 Water
• Drinking & recreational
• 1.1 billion without access to clean DW
• (~20% world’s popn)
• 2.6 billion without adequate sanitation
• Rapid urbanisation increases pressure on water
resources
• 30-40% of water lost through leaks and illegal
tapping
UN World Water Development Report 2009
http://www.unesco.org/water/wwap/wwdr/wwdr3/pdf/WWDR3_Facts_and_Figu
res.pdf
 Water Pollution
3 main categories of pollutants:
• Liquid organics (effluent)
• Liquid inorganic waste (agricultural run-off &
effluent) eg lead, arsenic, nitrites
• Waterborne / water-based pathogens e.g.
Giardia, Cryptosporidium, Shistosomes
 Ambient (Outdoor) Air Pollution
• Main Pollutants
– Nitrogen Dioxide (NO2)
– Carbon Monoxide (CO), Ozone (O3)
– Particulates (PM10, PM2.5, PM0.1)
– Sulphur Dioxide (SO2)
• Main sources
– vehicle emissions, combustion processes, agriculture
• Health effects: mild irritation respiratory illness,
death
 Indoor Air Pollution (IAP)
• 90% time indoors (sealed)
• associated with furnishings
• lack of adequate ventilation (build-up)
• Chemicals, e.g. formaldehyde
• Sick Building Syndrome
• Building Related Illness
 IAP in developing countries
• ~ 50% rely on coal / biomass/
wood/dung/crop residues for domestic
energy.
• typically simple stoves, incomplete
combustion
• women & young children exposed to high
levels on daily basis
Bulletin of the World Health Organization, 2000, 78 (9)
 IAP- Health Effects
• ~ 2 million excess deaths in developing countries
• ~ 4% of the global burden of disease

• likely to increase risk of

– chronic obstructive pulmonary disease
– acute respiratory infections in childhood

• associations with
– low birth weight
– increased infant and perinatal mortality, cataract
– pulmonary tuberculosis
– nasopharyngeal, laryngeal and lung cancer
 Land - Contamination
• range of chemicals & pathogens at above
background
– levels with the potential to cause adverse impacts
– direct (contact) / indirect effects (food, water)
– fixed or wind blown (tailings, remnants)
– arsenic, asbestos, lead, mercury, PCBs, dust
particles
– acid sulphate soils
 Animals / Insects
• Zoonoses - Diseases shared between humans and
animals
• naturally occurring in animals
– humans accidental host / part of life cycle
– close association or destruction of natural habitat
– most new diseases e.g. bird flu, SARS, HIV
• vectors – able to carry / transmit disease
– mosquitoes – malaria, dengue, Ross River Virus
– Fleas on rats – plague
– Flies, cockroaches – food borne illness
 Food Contamination
Physical, chemical & biological contaminants
• bacteria, usually high protein foods, warm moist conditions
(meat, fish, rice) / viruses (by poor food handling /
inadequate storage)
• parasites – protozoa, tapeworms, roundworms
(undercooked or raw meat/fish)
• toxic chemicals – fertilisers, pesticides, herbicides, food
containers,
• contaminated land bioaccumulate eg DDT
• chemical additives allergies
– 150 to 200: Annual U.S. deaths from anaphylaxis because of
food allergy
SOURCE: The Food Allergy & Anaphylaxis Network
 Population & urbanisation
Traditional problems & new challenges
• tropical diseases
• inadequate water supply and sanitation
• solid waste and wastewater
• air quality
• transport & traffic, crowdedness, crime

• Strain on a given country’s financial and other

resources
• Poor planning & governance long term crisis
TERIMA KASIH