First lesson

The course aims to provide the theoretical and experiential bases of reference in the relationship
between 'Health' and 'Globalization' through the proposal and explanation of the following
concepts and approaches: 'Health as a fundamental human rights' internationally recognized; the
'Determinants of Health'; 'Inequities in health and healthcare' (among different countries and
within individual countries); the role of 'Health Systems'; ‘Global Health Actors and Governance’.

Participants will learn to recognize the interrelationships among these concepts, including through
insights into specific policy arenas that significantly impact populations’ health rights in the world,
and become aware of the importance of the 'Health Promotion' approach, with particular
reference to the need for health promotion and the activation of ‘Intersectoral policies’ and
‘Empowerment’ (at individual and community level) for Health.

HEALTH and THE RIGHT TO HEALTH

What is health? Why Health is important? What is the right to health? Common misconceptions
about the right to Health. Link between the right to Health and other human rights. The right to
Health in international human rights law. The right to Health and health duties in the Constitutions
of different countries.

1948 WHO definition of health “A state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity” – Preamble to the Constitution of WHO as adopted by
the International Health Conference, New York, 19 June – 22 July 1946, signed on this day by the
representatives of 61 States and entered into force on 7 th April 1948. The definition has not been
amended since 1948.

"Health is not a fixed entity. It varies for each individual in relation to circumstances.
Health is defined not by the doctor, but by the person, in relation to his or her functional
needs. The doctor's role is to help people adapt to new conditions".
-'The Normal and the Pathological' by Georges Canguilhem [French physician and
philosopher], 1943

Coping = ability to cope and manage illnesses; ability to adapt and self-manage

"Canguilhem's definition allows us to respond to disease globally, taking into account the
context of conditions, in that particular place and time. By replacing perfection with
adaptation we move closer to a more inclusive, supportive and creative programme for
medicine, one to which we can all contribute”.
- Editorial. What is health? The ability to adapt. Lancet 2009; 373: 781

Evolution of the concept over time: from the mere absence of illness or infirmity, to the state of
complete physical psychological and social well-being (1949), to the best quantity and quality of
life achievable in a given geographical, political and social context (?), to the ability to adapt to
surrounding environment (?) https://www.youtube.com/watch?v=AJQ04Af_XxI
NU, June 2008: The right to health.

https://www.ohchr.org/sites/default/files/Documents/Publications/Factsheet31.pdf

As human beings, our health and the health of those we care about is a matter of daily concern.
Regardless of our age, gender, socio-economic or ethnic background, we consider our health to be
our most basic and essential asset. Ill health, on the other hand, can keep us from going to school
or to work, from attending to our family responsibilities or from participating fully in the activities
of our community. By the same token, we are willing to make many sacrifices if only that would
guarantee us and our families a longer and healthier life. In short, when we talk about well-being,
health is often what we have in mind.

The right to health is a fundamental part of our human rights and of our understanding of a life in
dignity. The right to the enjoyment of the highest attainable standard of physical and mental
health, to give it its full name, is not new. Internationally, it was first articulated in the 1946
Constitution of the World Health Organization (WHO), whose preamble defines health as “a state
of complete physical, mental and social well-being and not merely the absence of disease or
infirmity”. The preamble further states that “the enjoyment of the highest attainable standard of
health is one of the fundamental rights of every human being without distinction of race, religion,
political belief, economic or social condition.

The 1948 Universal Declaration of Human Rights also mentioned health as part of the right to an
adequate standard of living (art. 25). The right to health was again recognized as a human right in
the 1966 International Covenant on Economic, Social and Cultural Rights. Since then, other
international human rights treaties have recognized or referred to the right to health or to
elements of it, such as the right to medical care. The right to health is relevant to all States: every
State has ratified at least one international human rights treaty recognizing the right to health.
Moreover, States have committed themselves to protecting this right through international
declarations, domestic legislation and policies, and at international conferences.

In recent years, increasing attention has been paid to the right to the highest attainable standard
of health, for instance by human rights treaty monitoring bodies, by WHO and by the Commission
on Human Rights (now replaced by the Human Rights Council), which in 2002 created the mandate
of Special Rapporteur on the right of everyone to the highest attainable standard of physical and
mental health. These initiatives have helped clarify the nature of the right to health and how it can
be achieved.

Key aspects of the right to health

• The right to health is an inclusive right. We frequently associate the right to health with access
to health care and the building of hospitals. This is correct, but the right to health extends further.
It includes a wide range of factors that can help us lead a healthy life. The Committee on
Economic, Social and Cultural Rights, the body responsible for monitoring the International
Covenant on Economic, Social and Cultural Rights,2 calls these the “underlying determinants of
health”. They include:

● Safe drinking water and adequate sanitation;

● Safe food;

● Adequate nutrition and housing;

● Healthy working and environmental conditions;

● Health-related education and information;

● Gender equality.

• The right to health contains freedoms. These freedoms include the right to be free from non-
consensual medical treatment, such as medical experiments and research or forced sterilization,
and to be free from torture and other cruel, inhuman or degrading treatment or punishment.

• The right to health contains entitlements. These entitlements include:

The right to a system of health protection providing equality of opportunity for everyone to enjoy
the highest attainable level of health;

● The right to prevention, treatment and control of diseases;

● Access to essential medicines;

● Maternal, child and reproductive health;

● Equal and timely access to basic health services;

● The provision of health-related education and information;

● Participation of the population in health-related decision-making at the national and

community levels.

All services, goods and facilities must be available, accessible, acceptable and of good quality.

● Functioning public health and health-care facilities, goods and services must be available
in sufficient quantity within a State.
 ● They must be accessible physically (in safe reach for all sections of the population,
including children, adolescents, older persons, persons with disabilities and other
vulnerable groups) as well as financially and on the basis of non-discrimination.
Accessibility also implies the right to seek, receive and impart health-related information
in an accessible format (for all, including persons with disabilities), but does not impair the
right to have personal health data treated confidentially.
● The facilities, goods and services should also respect medical ethics, and be gender-
sensitive and culturally appropriate. In other words, they should be medically and
culturally acceptable.
● Finally, they must be scientifically and medically appropriate and of good quality. This
requires, in particular, trained health professionals, scientifically approved and unexpired
drugs and hospital equipment, adequate sanitation and safe drinking water.

Common misconceptions about the right to health

The right to health is NOT the same as the right to be healthy.  A common misconception is that
the State has to guarantee us good health. However, good health is influenced by several factors
that are outside the direct control of States, such as an individual’s biological make-up and socio-
economic conditions. Rather, the right to health refers to the right to the enjoyment of a variety of
goods, facilities, services and conditions necessary for its realization. This is why it is more accurate
to describe it as the right to the highest attainable standard of physical and mental health, rather
than an unconditional right to be healthy.

The right to health is NOT only a programmatic goal to be attained in the long term. The fact that
the right to health should be a tangible programmatic goal does not mean that no immediate
obligations on States arise from it. In fact, States must make every possible effort, within available
resources, to realize the right to health and to take steps in that direction without delay.
Notwithstanding resource constraints, some obligations have an immediate effect, such as the
undertaking to guarantee the right to health in a non-discriminatory manner, to develop specific
legislation and plans of action, or other similar steps towards the full realization of this right, as is
the case with any other human right. States also have to ensure a minimum level of access to the
essential material components of the right to health, such as the provision of essential drugs and
maternal and child health services. (See chapter III for more details.)

A country’s difficult financial situation does NOT absolve it from having to take action to realize
the right to health. It is often argued that States that cannot afford it are not obliged to take steps
to realize this right or may delay their obligations indefinitely. When considering the level of
implementation of this right in a particular State, the availability of resources at that time and the
development context are taken into account. Nonetheless, no State can justify a failure to respect
its obligations because of a lack of resources. States must guarantee the right to health to the
maximum of their available resources, even if these are tight. While steps may depend on the
specific context, all States must move towards meeting their obligations to respect, protect and
fulfil.

Link between the right to health and other human rights

Human rights are interdependent, indivisible and interrelated. This means that violating the right
to health may often impair the enjoyment of other human rights, such as the rights to education
or work, and vice versa. The importance given to the “underlying determinants of health”, that is,
the factors and conditions which protect and promote the right to health beyond health services,
goods and facilities, shows that the right to health is dependent on, and contributes to, the
realization of many other human rights. These include the rights to food, to water, to an adequate
standard of living, to adequate housing, to freedom from discrimination, to privacy, to access to
information, to participation, and the right to benefit from scientific progress and its applications.

Links between the right to health and the right to water. Ill health is associated with the ingestion
of or contact with unsafe water, lack of clean water (linked to inadequate hygiene), lack of
sanitation, and poor management of water resources and systems, including in agriculture. Most
diarrhoeal disease in the world is attributable to unsafe water, sanitation and hygiene. In 2002,
diarrhoea attributable to these three factors caused approximately 2.7 per cent of deaths (1.5
million) worldwide.

It is easy to see interdependence of rights in the context of poverty. For people living in poverty,
their health may be the only asset on which they can draw for the exercise of other economic and
social rights, such as the right to work or the right to education. Physical health and mental health
enable adults to work and children to learn, whereas ill health is a liability to the individuals
themselves and to those who must care for them. Conversely, individuals’ right to health cannot
be realized without realizing their other rights, the violations of which are at the root of poverty,
such as the rights to work, food, housing and education, and the principle of non-discrimination.

The right to health in international human rights law

The right to the highest attainable standard of health is a human right recognized in international
human rights law. The International Covenant on Economic, Social and Cultural Rights, widely
considered as the central instrument of protection for the right to health, recognizes “the right of
everyone to the enjoyment of the highest attainable standard of physical and mental health.” It is
important to note that the Covenant gives both mental health, which has often been neglected,
and physical health equal consideration.

International Covenant on Economic, Social and Cultural Rights, art. 12

1. The States Parties to the present Covenant recognize the right of everyone to the enjoyment of
the highest attainable standard of physical and mental health.

2. The steps to be taken by the States Parties to the present Covenant to achieve the full
realization of this right shall include those necessary for:

(a) The provision for the reduction of the stillbirth rate and of infant mortality and for the
healthy development of the child;
(b) The improvement of all aspects of environmental and industrial hygiene;
(c) The prevention, treatment and control of epidemic, endemic, occupational and other
diseases;
(d) The creation of conditions which would assure to all medical service and medical
attention in the event of sickness.
Subsequent international and regional human rights instruments address the right to health in
various ways. Some are of general application while others address the human rights of specific
groups, such as women or children.

International human rights treaties recognizing the right to health

• The 1965 International Convention on the Elimination of All Forms of Racial

Discrimination: art. 5 (e) (iv)
• The 1966 International Covenant on Economic, Social and Cultural Rights: art. 12
• The 1979 Convention on the Elimination of All Forms of Discrimination against
Women: arts. 11 (1) (f), 12 and 14 (2) (b)
• The 1989 Convention on the Rights of the Child: art. 24
• The 1990 International Convention on the Protection of the Rights of All Migrant
Workers and Members of Their Families: arts. 28, 43 (e) and 45 (c)
• The 2006 Convention on the Rights of Persons with Disabilities: art. 25.

The right to health and health duties in the constitution of different countries

Finally, the right to health or the right to health care is recognized in at least 115 constitutions. At
least six other constitutions set out duties in relation to health, such as the duty on the State to
develop health services or to allocate a specific budget to them.

The Italian Constitution (1948), 32nd Article

“The Republic safeguards health as a fundamental right of the individual and as a

collective interest, and guarantees free medical care to the needy. No one may be obliged
to undergo any given health treatment except under the provisions of the law. The law
cannot under any circumstances violate the limits imposed by respect for the human
person”.

HEALTH DATA IN OUR WORLD, GLOBAL HEALTH DEFINITION

Data sources: our world in data and world-mapper

Life expectancy: number of years of living from a newborn. 32 years ago the situation was worst.
Life expectancy and income goes together. It also grows together with healthcare expenditure.
Same with GDP per capita. (Gross Domestic Product)

Child mortality: child dying before 1, 3 or 5 years, depending on the investigation.

There was a millennium desire (ONU) to reduce the child mortality, but although in generally
decreased, in some countries it stayed the same. Fewer children die as more money is spent on
health.

Maternal mortality ratio: dies of pregnant women or 32 days after being with child. It’s important
to compare it with the live births. We can compare it with births attended by skilled health staff
(university or just a few trying for months), which means the money that is invest in health.

The differences that we can find or inequalities are strongly related to the resources of the country
and their statement.
Obese: Overweight and obesity are defined as abnormal or excessive fat accumulation that
presents a risk to health. A body mass index (BMI) over 25 is considered overweight, and over 30 is
obese. The issue has grown to epidemic proportions, with over 4 million people dying each year as
a result of being overweight or obese in 2017 according to the global burden of disease.

Rates of overweight and obesity continue to grow in adults and children. From 1975 to 2016, the
prevalence of overweight or obese children and adolescents aged 5–19 years increased more than
four-fold from 4% to 18% globally.

Obesity is one side of the double burden of malnutrition, and today more people are obese than
underweight in every region except sub-Saharan Africa and Asia. Once considered a problem only
in high-income countries, overweight and obesity are now dramatically on the rise in low- and
middle-income countries, particularly in urban settings. The vast majority of overweight or obese
children live in developing countries, where the rate of increase has been more than 30% higher
than that of developed countries. The change to have money is tending to be more protected.
Countries with really good social economical levels and public health.

Task for next Friday: go to our world in data. Select the health topic specific, related an age group
from my country, report them with the country with best and worst data and build a small
summary table.

Julian Tudor Hart: The inverse care law. The availability of good medical care tends to vary
inversely with the need for it in the population served.

Outcomes: result of the intervention, in terms of improvement or not.

Impact of global crises on health, Margaret Chan. The economy can affect health and health can
affect the economy, such as the COVID-19 pandemic.

Differences in between the countries poor people vs. rich people exists, even in wealthy western
countries.

1996: The big idea. The important is how evenly wealth is distributed. Gini coefficient index 0%-
100%. Look for it.

Search for World Inequality Report 2022.

Global Health Definition: There is an historical attempt of definition by the Institute of medicine,
USA, 1997. There is another one by Kaplan.

All health is global health, is the intersection among equity, participation and

New paradigm for health and grounded in the theory of health determinant. Alma ATA declaration
(1978). Medicine, socio eco, political, demographic, juridical and environment determinants.
Points out health inequalities both within and among countries, framing them through the lens of
social justice.

Individual lifestyle factors are influenced by social and community determinants. Social and
community networks are influenced by job, work environment, education, health care services
(not the most important determinant), etc. The main important is general socio-eco, cultural and
environmental conditions.

Social gradients: it is based on education and compares it with different variables, such as
diseases, addiction.

Methodological approach: transdisciplinary and multimethod one, social sciences, natural and
more.

DETERMINANTS OF HEALTH, SOCIAL JUSTICE and ADVOCACY FOR HEALTH

Global health issues: Structural violence

About Mary Bassett: New York City Public Health Commissioner Mary Bassett has been a health
activist since her Radcliffe days of volunteering at a Black Panther Clinic.

She began her career on the medical faculty at the University of Zimbabwe, a position she held for
17 years. The valuable lessons she learned in Harare, including the development of one of the first
HIV awareness programs, gave her a unique perspective in tackling community health challenges
for New York City’s diverse populations.

She has led the charge to nudge healthier behaviors, including pushing for higher cigarette taxes
and banning artificial trans fats in restaurants.

In her current role, she has called for the medical community’s deeper engagement in the
#BlackLivesMatter movement and efforts to tackle institutional racism.
Physician advocacy: Action by a physician to promote those social, economic, educational and
political changes that ameliorate the suffering and threats to human health and well-being that he
or she identifies through his or her professional work and expertise.

TRIPs: the globalization of patents

1995 WTO TRIPS Agreement (Trade related aspects of intellectual property rights)

• Few standards of protection for intellectual property rights (mainly for more
developed countries)
• Length of patent: 20 years
• No differences between medicines and other goods
• No differences between essential medicines and trivial good
• Obligation for countries

Compulsory Licence (art 30 – 31 TRIPs)

In case of national health needs, the government can allow the production of an essential drug
without the authorization from the patent holder.

Conditions:

● Only after failure of the negotiation with the patent holder

● Prevailing domestic market use

● Limited use to the emergency situation

 ● The patent holder receives a compensation fee

Parallel Importation (art. 6 TRIPs)

In case of national health needs, the government can allow the importation of the pharmaceutical
product from the country where it costs less (always due to local generic production and price
competition)

Structural violence describes social structures (economic, political, legal. Religious and cultural)
that stop individuals, groups and societies from reaching their full potential. It is often embedded
in longstanding “ubiquitous social structures, normalized by stable institutions and regular
experience”

Because they seem so ordinary in our ways of understanding the world, they appear almost
invisible. Disparate access to resources, political power, education, health care, and legal standing
are just a few examples. The idea of structural violence is linked very closely to social injustice and
the social machinery of oppression.

Health inequalities: generic term for differences that are genetic, generic term for differences (i.e.
random genetic mutation or life stage differences)

Health inequities: Unfair systematic and avoidable differences, stemming from some form of
injustice. Talking about health inequities imply a moral judgement. The term inequity has a moral
and ethical dimension. It refers to differences which are unnecessary and avoidable but, in
addition, are also considered unfair and unjust.

Health system

The set of organizations, institutions and resources that are devoted to producing health actions.
Their mission is to improve the health status of the population, responsiveness and fair financing.

Health action: any effort/activity, whether in personal health care, public health services, or
through intersectoral initiatives, whose primary purpose is to improve health.

● Improving the health status of the population (Better health)

● The ability - and sensitivity - to respond to the needs of patients a capacità - e la sensibilità
- di rispondere alle esigenze dei pazienti (Responsiveness)
● Equity in the financing of the system (Fair financing)
Access to health and coverage are not the same.

What is a health system? A health system consists of all the organizations, institutions, resources
and people whose primary purpose is to improve health.1,2 This includes efforts to influence
determinants of health as well as more direct health-improvement activities. The health system
delivers preventive, promotive, curative and rehabilitative interventions through a combination of
public health actions and the pyramid of health care facilities that deliver personal health care —
by both State and non-State actors. The actions of the health system should be responsive and
financially fair, while treating people respectably. A health system needs staff, funds, information,
supplies, transport, communications and overall guidance and direction to function. Strengthening
health systems thus means addressing key constraints in each of these areas.

Key characteristics of good service delivery

Good service delivery is a vital element of any health system. Service delivery is a fundamental
input to population health status, along with other factors, including social determinants of health.
The precise organization and content of health services will differ from one country to another,
but in any well-functioning health system, the network of service delivery should have the
following key characteristics.

1. Comprehensiveness: A comprehensive range of health services is provided, appropriate to the

needs of the target population, including preventative, curative, palliative and rehabilitative
services and health promotion activities.

2. Accessibility: Services are directly and permanently accessible with no undue barriers of cost,
language, culture, or geography. Health services are close to the people, with a routine point of
entry to the service network at primary care level (not at the specialist or hospital level). Services
may be provided in the home, the community, the workplace, or health facilities as appropriate.

3. Coverage: Service delivery is designed so that all people in a defined target population are
covered, i.e. the sick and the healthy, all income groups and all social groups.

4. Continuity: Service delivery is organized to provide an individual with continuity of care across
the network of services, health conditions, levels of care, and over the life-cycle.

5. Quality: Health services are of high quality, i.e. they are effective, safe, centred on the patient’s
needs and given in a timely fashion.

6. Person-centredness: Services are organized around the person, not the disease or the financing.
Users perceive health services to be responsive and acceptable to them. There is participation
from the target population in service delivery design and assessment. People are partners in their
own health care.

7. Coordination: Local area health service networks are actively coordinated, across types of
provider, types of care, levels of service delivery, and for both routine and emergency
preparedness. The patient’s primary care provider facilitates the route through the needed
services, and works in collaboration with other levels and types of provider. Coordination also
takes place with other sectors (e.g. social services) and partners (e.g. community organizations).

8. Accountability and efficiency: Health services are well managed so as to achieve the core
elements described above with a minimum wastage of resources. Managers are allocated the
necessary authority to achieve planned objectives and held accountable for overall performance
and results. Assessment includes appropriate mechanisms for the participation of the target
population and civil society
Universal health coverage means that all people have access to the full range of quality health
services they need, when and where they need them, without financial hardship. It covers the full
continuum of essential health services, from health promotion to prevention, treatment,
rehabilitation and palliative care.

The delivery of these services requires health and care workers with an optimal skills mix at all
levels of the health system, who are equitably distributed, adequately supported with access to
quality assured products, and enjoying decent work.

Protecting people from the financial consequences of paying for health services out of their own
pockets reduces the risk that people will be pushed into poverty because unexpected illness
requires them to use up their life savings, sell assets, or borrow – destroying their futures and
often those of their children.

Achieving UHC is one of the targets the nations of the world set when they adopted the 2030
Sustainable Development Goals (SDGs) in 2015. At the United Nations General Assembly High
Level Meeting on UHC in 2019, countries reaffirmed that health is a precondition for and an
outcome and indicator of the social, economic and environmental dimensions of sustainable
development. WHO’s Thirteenth General Programme of Work aims to have 1 billion more people
benefit from UHC by 2025, while also contributing to the targets of 1 billion more people better
protected from health emergencies and 1 billion more people enjoying better health and well-
being.

Can UHC be measured? Yes. Monitoring health inequalities is essential to identify and track
disadvantaged populations in order to provide decision-makers with an evidence base to
formulate more equity-oriented policies, programmes and practices towards the progressive
realization of UHC. In the SDG’s, progress on UHC is tracked using two indicators:
 ● coverage of essential health services (SDG 3.8.1); and

● catastrophic health spending (and related indicators) (SDG 3.8.2).

● Detailed data is provided in the WHO Global Health Observatory Data Repository for UHC.

Every country has a different path to achieving UHC and deciding what to cover based on the
needs of their people and the resources at hand. However, the importance of access to health
services and information as a basic human right is universal.

To make health for all a reality, all people must have access to high quality services for their health
and the health of their families and communities. To do so, skilled health workers providing
quality, people-centred care; and policy-makers committed to investing in universal health
coverage are essential.

Universal health coverage requires strong, people-centred primary health care. Good health
systems are rooted in the communities they serve. They focus not only on preventing and treating
disease and illness, but also on helping to improve well-being and quality of life.

Key facts

● The UHC service coverage index (SDG indicator 3.8.1) increased from 45 in 2000 to 67 in
2019.
● Almost 2 billion people are facing catastrophic or impoverishing health spending (SDG
indicator 3.8.2).
● Inequalities continue to be a fundamental challenge for UHC as aggregated data masks
within-country inequalities in service coverage.
● The COVID-19 pandemic further disrupted essential services in 92% of countries.

● To build back better, WHO’s recommendation is to reorient health systems to primary

health care (PHC). Most (90%) of essential UHC interventions can be delivered through
PHC and 75% of projected health gains from the SDGs could be achieved through PHC.

Prior to the COVID-19 pandemic, there was worldwide progress towards UHC. The UHC service
coverage index (SDG indicator 3.8.1) increased from 45 in 2000 to 67 in 2019, with the fastest
gains in the WHO African Region. However, 2 billion people are facing catastrophic or
impoverishing health spending (SDG indicator 3.8.2).

Inequalities continue to be a fundamental challenge for UHC. Even where there is national
progress on health service coverage, the aggregate data mask within-country inequalities. For
example, coverage of reproductive, maternal, child and adolescent health services tends to be
higher among those who are richer, more educated, and living in urban areas, especially in low-
income countries. On financial hardship, people living in poorer households and in households
with older family members (those aged 60 and older) are more likely to face financial hardship and
pay out of pocket for health care. Monitoring health inequalities is essential to identify and track
disadvantaged populations in order to provide decision-makers with an evidence base to
formulate more equity-oriented policies, programmes and practices towards the progressive
realization of UHC. Better data also are needed on gender inequalities, socioeconomic
disadvantages, and specific issues faced by indigenous peoples and refugee and migrant
populations displaced by conflict and economic and environmental crises.

During COVID-19, 92% of countries reported disruptions to essential services. Some 25 million
children under 5 years missed out on routine immunization. There were glaring disparities in
access to COVID-19 vaccines, with an average of 24% of the population vaccinated in low-income
countries compared to 72% in high-income countries. Potentially life-saving emergency, critical
and operative care interventions also showed increased service disruptions, likely resulting in
significant near-term impact on health outcomes.

As a foundation for and way to move towards UHC, WHO recommends reorienting health systems
to primary health care (PHC). PHC enables universal, integrated access in everyday environments
to the full range of quality services and products people need for health and well-being, thereby
improving coverage and financial protection. Most (90%) essential UHC interventions can be
delivered through PHC and there are significant cost efficiencies in using an integrative PHC
approach. Some 75% of the projected health gains from the SDGs could be achieved through PHC,
including saving over 60 million lives and increasing average global life expectancy by 3.7 years by
2030.

Strengthening health systems based on PHC should result in measurable health impact in
countries.
The principles of the National Health Service

a) universality, both in terms of accessibility and all-inclusiveness of services

(comprehensiveness);
b) financing through general taxation, whereby everyone contributed according to his or her
means and received services according to need;
c) free of charge at the point of provision of services.
Sickness 🡨 🡪 poorness

GLOBALIZATION AS A DETERMINANT OF HEALTH, DEREGULATION

Health is an indicator to show how societies work.

Globalization as a determinant of people’s health

Accountability, terrorism, shrinking world, technology, free trade, culture, capitalism, monopoly,
environment, integration economy, brands, poverty, exploitation, recognition.

Ronald Reagan and Margaret Thatcher as the heads of the beginning of globalization.

Epidemiological evidence from the Sentieri research (period 2006-2013)

 ● Excessive risk exposure for people living in Taranto, both in terms of mortality trends
overall and for large specific groups;
● Increased death risks concerning pathologies that are considered a priori as diseases
associated with the specific site’s industrial exposure, particolarly in the case of lung
cancer, mesotelioma and respiratory diseases (in forms that are acute among men and
chronic among women);
● Increased hospitalization for kidney diseases;

● From 2002 to 2015: 600 children were born with deformations;

● More than 40 affected by paediatric cancers, including in the first year of their life

World Trade Organization (1995) is the institution by excellence of the globalization.

FMI = IMF

Till 2008 the financial capitalism growth a lot, until the collapse of 2007/2008 “Liberalization”

Since then and for now, we can call that globalization is in a slow move.

Extraction resources is a globalization problem; it has a huge impact on the right to health and
human rights, it only benefits in terms in economy. It is not just the mining industry, it also
happens with steel industries: Taranto and ILVA (Italy). How to make up together the right to work
and the right to live.

Planetary rights

Search for the 2030 agenda for sustainable development “Sustainable development goals” and the
millennium goals.

This agenda tries to be wider, not only looking for exact problems. For instance, to end hunger
worldwide by 2030.

Deregulation: The role of the state to control de economy has to be less, “the market can control
itself”. Process through which government and states cease to control markets and they eliminate
restrictions on economic activities to encourage market transactions. In this scenario, the market
is considered as an organism capable to self-regulate. It’s connected with monopoly.

Take the case of non-communicable diseases (NCDs)

Charting the rise of non-communicable diseases (NCDs) in the global burden of disease and health
inequalities, we need to outline the role of unhealthy commodity industries as structural drivers of
health inequalities.

While contemporary strategies for tackling NCDs focus their preoccupation with individual
behaviours, they neglect of the role that private corporations play in these ‘industrial epidemics’,
with the only exception of tobacco companies increasingly being perceived as vectors of disease
from which health policy requires protection, in contrast to alcohol and processed- food
industries, which are widely depicted as potential partners in health policy.
Non communicable diseases: unhealthy commodity industries as structural drivers of health
inequalities. Production of commodities that harm. Privates continue to fuel this industry. WHO is
with the lobby of the private.

About deregulation and «industrial epidemics»

«Today, the tables are turned. Instead of diseases vanishing as living conditions improve, socio-
economic progress is actually creating the conditions that favour the rise of non-communicable
diseases [...] getting people to lead healthy lifestyles and adopt healthy behaviours faces
opposition from forces that are “not so friendly.”

“Efforts to prevent non-communicable diseases go against the business interests of powerful

economic operators. In my view, this is one of the biggest challenges facing health promotion. It is
not just Big Tobacco anymore. Public health must also contend with Big Food, Big Soda, and Big
Alcohol. All of these industries fear regulation, and protect themselves by using the same tactics,
including front groups, lobbies, promises of self-regulation, lawsuits, and industry-funded research
that confuses the evidence and keeps the public in doubt»

-Margaret Chan, 8th Conference on Health Prevention, June 2013

Food trends related to globalization

• Consistent and aggressive market penetration of Big Food companies and fast
food industries in middle income countries (MICs);
• In several developing countries, increased prosperity and purchasing power =
greater exposure to Western toxic food
• Feticism of fast food in Ghana, valued as a precious good, a status symbol, the
image of health and colours of life
• In between 2011 and 2016, eating fast food in India has grown by 113.6% - a true
transformation of the national food system;
• The rapid economic growth in China has been accompanied by alarming rise in
obesity. Recent National survey data (2020) suggest that more than half of
Chinese adults are now living with overweight and obesity, with obesity rates
likely to increase.

The strange story of turkey tails (which speaks a lot about our global food systems)

U.S. commercial turkey production increased from 16 million pounds in January 1960 to 500
million pounds in January 2017. That includes a quarter-billion turkey tails. The tail is actually a
gland that attaches the turkey’s feathers to its body. It is filled with oil that the bird uses to preen
itself, so about 75% of its calories come from fat.

Rather than letting turkey tails go to waste, the poultry industry saw a business opportunity. The
target: Pacific Island communities, where animal protein was scarce. In the 1950s U.S. poultry
firms began dumping turkey tails, along with chicken backs, into markets in Samoa, and later
Micronesia and Tonga. Turkey tails became social food in Samoa, although it is not nutritious food
at all.
Cheap food like turkey tails began displacing traditional foods, as the latter became costlier than
imports and more time-consuming to prepare. So successful was this process of gastronomic
integration that, over a generation or two, foods like duck tongue, turkey tails, and chicken feet
began to be viewed not as foreign but as part of local cuisine.

Turkey tails also come up in discussions of the health epidemic gripping these islands. In American
Samoa more than half of the population was obese. Samoan officials grew so concerned that they
banned turkey tails imports in 2007, bringing the case to the World Health Organization (WHO).

The US opposed the ban. Under World Trade Organization rules, countries and territories
generally cannot unilaterally ban the import of commodities unless there are proven public health
reasons for doing so. Samoa was forced to lift its ban in 2013 as a condition of joining the WTO,
notwithstanding its health worries on obesity, diabetes and heart diseases.

According to a study of the Brown University, in 2013, 23% of boys and 16 per cent of girls in
American Samoa are obese by 15 months of age. Turkey tails are also common street food
throughout the Pacific Islands, making them an important source of income for many lower-
income families.

The gastronomic operation so successful for the highly concentrated poultry farming industry in
the US.

Philip Morris against governments trying to safeguard public health: the case of Uruguay

In 2008 and 2009 Uruguay adopted two new laws, the first to address the tobacco industry’s use
of brand variants that falsely imply some cigarettes are less harmful and tobacco industry tactic of
replacing misleading terms with colors; and the second to introduce more effective health
warnings, and to implement Uruguay’s obligations under the WHO Framework Convention on
Tobacco Control.

In February 2010, three subsidiary companies of Philip Morris International – the largest cigarette
manufacturer - filed an international arbitration lawsuit against Uruguay, claiming that two of the
country’s tobacco control laws violated a Bilateral Investment Treaty (BIT) between Uruguay and
Switzerland and demanding $ 25 US dollars in compensation for damage to its brands.

The case was heard at the International Centre for the Settlement of Investment Disputes (ICSID),
an arbitration panel of the World Bank based in Washington. Prior to Philip Morris’ claim at ICSID,
legal challenges brought by the company against the same tobacco control laws had already been
dismissed by Uruguay’s Administrative Court and Supreme Court.

THE STRANGE CASE OF PHARMA COMPANIES, the WTO and the TRIPs

One out of three people in the developing world doesn't have access to medicines.

Essential medicines are those that satisfy the priority health care needs of a majority of the
population.
Then the WTO arrived in 1995: The quintessential multilateral institution that embodies the spirit
of globalization, and which drives trade as the main engine of international diplomacy. Free trade
and human rights for all: really?

The TRIPs (trade-related aspects of intellectual property rights) agreement:

• March 1986: Pfizer & IBM found the Intellectual Property Committee (IPC), at the margin of the
Uruguay Round on international trade.

• May 86: creation of «the Friends of Intellectual Property”, a group of governments that support
the idea of a multilateral agreement on intellectual property (IP): US, Europe, Japan, Switzerland,
Canada, Australia, Singapore.

• March 1987: week of IPC meetings

• October 1987: the IP issue is finally introduced in the GATT negotiation thanks to an IPC policy
paper concerning intellectual property standards

• The US government openly supports the idea and the paper, the IPC starts rolling out a lobby
campaign towards governments.

TRIPS & the globalization of patents

TRIPS Agreement is a key instrument of the WTO, having an immense impact on health rights
globally. It stands minimum standards of intellectual property protection, defined by highly
industrialized countries

● 20 years of exclusive rights on all processes and products – for all commercial goods
● No difference between medicines and other industrial goods,
● No difference between essential medicines and other types of drugs
● Forced enforcement calendar for the national ratification of the trade agreement (2000-
2005 for LICs, 2006 for LDCs ð2016 after Doha)

Compulsory Licence (art 30 – 31 TRIPs): In case of national health needs, the government can
allow the production of an essential drug without the authorization from the patent holder.

Conditions:

❖ Only after failure of the negotiation with the patent holder

❖ Prevailing domestic market use
❖ Limited use to the emergency situation
❖ The patent holder receives a compensation fee

Parallel Importation (art. 6 TRIPs): In case of national health needs, the government can allow the
importation of the pharmaceutical product from the country where it costs less (always due to
local generic production and price competition).

1997: 39 pharmaceutical companies sue Nelson Mandela's South Africa.

The case of the drug against hepatitis C

Hepatitis C is a serious liver disease produced by the HCV virus that causes generalized
inflammation capable of leading to cirrhosis and liver cancer – 71 million people affected
worldwide.

The previous molecules had a healing outcome of 50% and strong side effects caused by
interferon. Sofosbuvir is able to interfere with the replication of the virus, allowing its elimination
in over 90% of cases, and without interferon. A life-saving drug for a small number of patients, but
also a very useful drug for a large proportion of people with chronic hepatitis.

In the US, a 3-month cure: US$84,000. A pill cost €600 in Italy. €45,000 for a therapeutic cycle
(€52,000 in the Netherlands) until the end of 2017.

Price hurts our budgets,” complained 15 EU governments in negotiations with Gilead Sciences in
2016.
HEALTH, TRADE and ACCESS TO MEDICINES IN PANDEMIC TIMES

Doha Declaration on TRIPS and Public Health (Nov. 2001).

1. We recognize the gravity of the public health problems afflicting many developing and least-
developed countries, especially those resulting from HIV/AIDS, tuberculosis, malaria and other
epidemics.

2. We stress the need for the WTO Agreement on Trade-Related Aspects of Intellectual Property Rights
(TRIPS Agreement) to be part of the wider national and international action to address these problems.

3. We recognize that intellectual property protection is important for the development of new
medicines. We also recognize the concerns about its effects on prices.

4. We agree that the TRIPS Agreement does not and should not prevent members from taking
measures to protect public health. Accordingly, while reiterating our commitment to the TRIPS
Agreement, we affirm that the Agreement can and should be interpreted and implemented in a
manner supportive of WTO members' right to protect public health and, in particular, to promote
access to medicines for all.

In this connection, we reaffirm the right of WTO members to use, to the full, the provisions in the TRIPS
Agreement, which provide flexibility for this purpose.

5. Accordingly and in the light of paragraph 4 above, while maintaining our commitments in the TRIPS
Agreement, we recognize that these flexibilities include:

1. In applying the customary rules of interpretation of public international law, each

provision of the TRIPS Agreement shall be read in the light of the object and purpose of
the Agreement as expressed, in particular, in its objectives and principles.
2. Each member has the right to grant compulsory licences and the freedom to determine
the grounds upon which such licences are granted.
3. Each member has the right to determine what constitutes a national emergency or other
circumstances of extreme urgency, it being understood that public health crises,
including those relating to HIV/AIDS, tuberculosis, malaria and other epidemics, can
represent a national emergency or other circumstances of extreme urgency.
4. The effect of the provisions in the TRIPS Agreement that are relevant to the exhaustion
of intellectual property rights is to leave each member free to establish its own regime
for such exhaustion without challenge, subject to the MFN and national treatment
provisions of Articles 3 and 4.

6. We recognize that WTO members with insufficient or no manufacturing capacities in the

pharmaceutical sector could face difficulties in making effective use of compulsory licensing under the
TRIPS Agreement. We instruct the Council for TRIPS to find an expeditious solution to this problem and
to report to the General Council before the end of 2002.

7. We reaffirm the commitment of developed-country members to provide incentives to their

enterprises and institutions to promote and encourage technology transfer to least-developed country
members pursuant to Article 66.2. We also agree that the least-developed country members will not
be obliged, with respect to pharmaceutical products, to implement or apply Sections 5 and 7 of Part II
of the TRIPS Agreement or to enforce rights provided for under these Sections until 1 January 2016,
without prejudice to the right of least-developed country members to seek other extensions of the
transition periods as provided for in Article 66.1 of the TRIPS Agreement. We instruct the Council for
TRIPS to take the necessary action to give effect to this pursuant to Article 66.1 of the TRIPS
Agreement.

First scientific approaches to tackle the new coronavirus:

• The WHO R&D BLUEPRINT meeting in February 2020, sounding the alert on the need for sharing
scientific knowledge immediately, to contain the spread of the new highly contagious virus

• The Oxford University research based on previous work developing an adenovirus-based vaccine
against the Middle Eastern Respiratory Syndrome (MERS) coronavirus that had been funded by the
UK Vaccines Network, a partnership between the Department of Health and Social Care (DSC) and
UKRI’s Medical Research Council (MRC) and Biotechnology and Bioscience Research Council
(BBSRC). It provided an obvious platform from which to start.

• The Oxford University announcement in March 2020 that they would make freely able to anyone
interested the fruits of their research work.

A modest proposal of international law: a waiver of TRIPS to deal with the pandemic (Oct. 2020)

At the beginning of the pandemic, many promises of “global public good” and “international
solidarity” were made. Yet one year on, a vast disparity remained in access to COVID-19 medical
products between the high-income countries and low-middle-income countries. The high-income
countries were vaccinating about 25 times faster than those with the lowest income. The current
system of production and supply is built on monopolies and control over technology and
knowledge and is failing to mobilize global production capacity. COVID-19 pandemic is an
unprecedented crisis and market-based approaches have been unsuccessful in effectively
responding to the pandemic, including ensuring equitable and affordable access to vaccines,
diagnostics and therapeutics.
12th WTO ministerial meeting in June 2022: New TIPs waiver proposal

● Just vaccines, no tests or therapeutics

● doesn’t cover all IP
● entire countries excluded

Here, we have 3 years of state and pharma failures. 3 years after the declaration of the pandemic,
the WHO counts 759.4 bl of confirmed COVID-19 cases, 13.22 bl COVID vaccines doses
administered and 6.9 ml deaths.

More than one million lives might have been saved if COVID-19 vaccines had been shared
equitably with lower-income countries in 2021, according to mathematical models incorporating
data from 152 countries (Nature, Nov. 2022)

As of June 2022, only 30% of the WHO member states had reached the 70% target of vaccine
coverage. As of December 2022, only 24.9% of people in Africa had received one dose (Africa CDC)

The pandemic has disrupted livelihoods and somewhat naturalized inequalities globally, in a
scenario where health systems are on the brink of collapse in most countries The pandemic has
revealed the deep structural flaws of a global knowledge economy tailored to advance health
privatization and health financialization strategies, with governments’ complacency and
pharmaceutical TNCs exploiting the emergency to fuel extraordinary pandemic profits: USD 90
billion in 2021 and 2022.

The pandemic came as a result of a myriad of failures, gaps and delays – a major global
governance failure (WHO IPPPR 2021) – but was also a crucial test for decision makers to fulfil
their public health responsibilities and obligations. Of all the injustices that emerged, the lack of
cooperation to secure universal access to COVID-19 vaccines was perhaps the most outrageous,
given that immunization lowered the rate of severe cases and reduced the risk of more contagious
variants emerging – Lancet estimates claim that vaccinations prevented up to 19.8 million deaths
in 185 countries, in 2021 alone.

Racial discrimination

The UN rapporteur on the contemporary forms of racism addressed the global covid-19 vaccine
inequality as a “racialized health inequity” throughout the pandemic.

“The distinction between ”high-income” and “low-income” countries is directly related to the
racist economic extraction and exploitation that occurred during the colonial era, showing that
there is a direct link between covid-19 global inequality and systemic racial injustice in the world”
(un report, 25 oct. 2022)

Industry influence magnified during the pandemic in the European context

June 2020: The EU originally advocated for global solidarity and for vaccines to be considered
“global public goods”, but then it quickly abandoned this public health approach;

2022: EU has purchased 4.6 billion vaccine doses, more than 5 times what was needed to fully
vaccinate its entire population (Euractiv)

Now: The EU has signed agreements cloaked in secrets and – up to now – the EC resists efforts to
disclose relevant information on pricing, IP commitments, delivery schedules, dose transfer
requirements.

Pharma legal restrictions accepted by the European Commission: a very disquieting precedent

The EU lagged behind the US and the UK in the early days of the pandemic when it came to
securing vaccines through Advanced Purchase Agreements – though it caught up quite quickly, in
circumstances shrouded in opacity.

The EC’s lack of any experience in procurement for medical technologies and in negotiating with
pharma companies likely to have contributed to lack of transparency, especially when
pharmaceutical industry is traditionally viewed as ”partner”. The Big Feast for European
companies holding IP rights on vaccines platforms (mostly in Germany)

Global access to vaccines entailed competition, not just to save lives but also about who is going to
be the first to reopen their industry, markets, bars, economic life altogether. As well as saving
lives, vaccines could provide a competitive economic advantage: pharma industry understood the
implication well and used it to its advantage.

Which policy strategies, after the pandemic?

1. The accelerated diplomatic pathway towards a new WHO binding pandemic accord by May
2024;

2. The first treaty negotiation based on the multi stakeholder paradigm

3. The zero draft text released last 1st Feb and negotiation started, with exclusion of civil society
organizations
4. The route towards institutionalization of private entities at the WHO?

Concerns:

● No safeguards to be seen in the text of the zero draft regarding the role of the private
sector – open arms to corporate entities in their multiple variants
● A credible accountability and compliance framework is missing
● Arrangements widely based on soft norms and voluntary mechanisms
● A rather illusionary financial agenda for the treaty: is a new pandemic fund at the WB
sufficient?
● A narrow focus on biomedical approaches. No surveillance provided on the drivers of
spillovers and zoonotic events at the animal-human interface (One Health, banning of
wildlife trading, etc)

WATER AND HEALTH

The 2030 Agenda for Sustainable Development, adopted by all United Nations
Member States in 2015, provides a shared blueprint for peace and prosperity for
people and the planet, now and into the future. At its heart are the 17 Sustainable
Development Goals (SDGs), which are an urgent call for action by all countries -
developed and developing - in a global partnership. They recognize that ending
poverty and other deprivations must go hand-in-hand with strategies that improve
health and education, reduce inequality, and spur economic growth – all while
tackling climate change and working to preserve our oceans and forests.

The SDGs build on decades of work by countries and the UN, including the UN
Department of Economic and Social Affairs
 ● In June 1992, at the Earth Summit in Rio de Janeiro, Brazil, more than 178
countries adopted Agenda 21, a comprehensive plan of action to build a
global partnership for sustainable development to improve human lives and
protect the environment.
● Member States unanimously adopted the Millennium Declaration at the
Millennium Summit in September 2000 at UN Headquarters in New York.
The Summit led to the elaboration of eight Millennium Development Goals
(MDGs) to reduce extreme poverty by 2015.
● The Johannesburg Declaration on Sustainable Development and the Plan of
Implementation, adopted at the World Summit on Sustainable Development
in South Africa in 2002, reaffirmed the global community's commitments to
poverty eradication and the environment, and built on Agenda 21 and the
Millennium Declaration by including more emphasis on multilateral
partnerships.
● At the United Nations Conference on Sustainable Development (Rio+20) in
Rio de Janeiro, Brazil, in June 2012, Member States adopted the outcome
document "The Future We Want" in which they decided, inter alia, to launch a
process to develop a set of SDGs to build upon the MDGs and to establish
the UN High-level Political Forum on Sustainable Development. The Rio +20
outcome also contained other measures for implementing sustainable
development, including mandates for future programmes of work in
development financing, small island developing states and more.
● In 2013, the General Assembly set up a 30-member Open Working Group to
develop a proposal on the SDGs.
● In January 2015, the General Assembly began the negotiation process on
the post-2015 development agenda. The process culminated in the
subsequent adoption of the 2030 Agenda for Sustainable Development, with
17 SDGs at its core, at the UN Sustainable Development Summit in
September 2015.
● 2015 was a landmark year for multilateralism and international policy
shaping, with the adoption of several major agreements:
● Sendai Framework for Disaster Risk Reduction (March 2015)
● Addis Ababa Action Agenda on Financing for Development (July
2015)
● Transforming our world: the 2030 Agenda for Sustainable
Development with its 17 SDGs was adopted at the UN Sustainable
Development Summit in New York in September 2015.
● Paris Agreement on Climate Change (December 2015)
● Now, the annual High-level Political Forum on Sustainable Development
serves as the central UN platform for the follow-up and review of the SDGs.

Today, the Division for Sustainable Development Goals (DSDG) in the United
Nations Department of Economic and Social Affairs (UNDESA) provides
substantive support and capacity-building for the SDGs and their related thematic
issues, including water, energy, climate, oceans, urbanization, transport, science
and technology, the Global Sustainable Development Report (GSDR), partnerships
and Small Island Developing States. DSDG plays a key role in the evaluation of UN
systemwide implementation of the 2030 Agenda and on advocacy and outreach
activities relating to the SDGs. In order to make the 2030 Agenda a reality, broad
ownership of the SDGs must translate into a strong commitment by all
stakeholders to implement the global goals. DSDG aims to help facilitate this
engagement.

Water storage refers to holding water in a contained area for a period of time. Water storage can
be natural or artificial. Natural water storage occurs in all parts of the hydrologic cycle in which
water is stored in the atmosphere, on the surface of the Earth, and below ground. Artificial water
storage is done for a variety of reasons and is done on small and large scales. Water storage
locations are commonly referred to as reservoirs.

Natural water storage and the Hydrologic Cycle: Each stage of the hydrologic cycle involves the
storage of water (Figure 1). Water can be stored in the atmosphere, on the surface of the Earth, or
underground. These water storage areas are most commonly known as reservoirs. Natural
reservoirs include oceans, glaciers and ice sheets, groundwater, lakes, soil moisture, wetlands,
living organisms, the atmosphere, and rivers.
Water stress and scarcity:
Health aspects related to water

Sources of water contamination: Pesticides, Fertilizers, Industry and chemical spills, Toxic waste,
Gas tanks…

2 Billion people use a water source that is contaminated with feces. This can lead, for instance, to
four main impacts of using unsafe water:

1. Diarrheal diseases caused by unsafe water and poor sanitation are the second biggest
child killer.
2. 50% of children malnutrition is associated with unsafe water, inadequate sanitation and
poor hygiene, placing a huge burden on fragile healthcare systems.
3. Walking, queuing and carrying water wastes time: women issue
4. Business' productivity is hit hard by staff absenteeism, turnover and low morale related to
lack of access to clean, safe water in workplaces.
The Affordability of Water around the world: the unsustainable/unfair Price of Drinking Water in
many countries
Human right to water and sanitation

The right to water entitles everyone to have access to sufficient, safe, acceptable, physically
accessible, and affordable water for personal and domestic use.

The right to sanitation entitles everyone to have physical and affordable access to sanitation, in all
spheres of life, that is safe, hygienic, secure, and socially and culturally acceptable and that
provides privacy and ensures dignity.

● Sufficient. The water supply for each person must be sufficient and continuous for
personal and domestic uses. These uses ordinarily include drinking, personal sanitation,
washing of clothes, food preparation, personal and household hygiene. According to the
World Health Organization (WHO), between 50 and 100 liters of water per person per day
are needed to ensure that most basic needs are met and few health concerns arise.
● Safe. The water required for each personal or domestic use must be safe, therefore free
from microorganisms, chemical substances and radiological hazards that constitute a
threat to a person's health. Measures of drinking-water safety are usually defined by
national and/or local standards for drinking-water quality. The World Health Organization
(WHO) Guidelines for drinking-water quality provide a basis for the development of
national standards that, if properly implemented, will ensure the safety of drinking-water.
● Acceptable. Water should be of an acceptable color, odor and taste for each personal or
domestic use. [...] All water facilities and services must be culturally appropriate and
sensitive to gender, lifecycle and privacy requirements.
● Physically accessible. Everyone has the right to a water and sanitation service that is
physically accessible within, or in the immediate vicinity of the household, educational
institution, workplace or health institution. According to WHO, the water source has to be
within 1,000 meters of the home and collection time should not exceed 30 minutes.
● Affordable. Water, and water facilities and services, must be affordable for all. The United
Nations Development Programme (UNDP) suggests that water costs should not exceed 3
percent of household income.
Physical presence is not the same as access. A water or sanitation service does not serve the whole
community if it is too expensive, unreliable, unhygienic, unsafely located, unadapted for less able
groups or children, or non gender-segregated, in the case of toilets and washing facilities.

All people are entitled to water and sanitation without discrimination. Marginalized groups –
women, children, refugees, indigenous peoples, disabled people and many others – are often
overlooked by, and sometimes face active discrimination from, those planning and governing
water and sanitation improvements and services, and other service users.

Monitoring the SDGs Goal 6 Targets

Water policies and commitments

FOOD AND HEALTH

The right to food is an inclusive right. It is not simply a right to a minimum ration of calories,
proteins and other specific nutrients. It is a right to all nutritional elements that a person needs to
live a healthy and active life, and to the means to access them.

Food insecurity: Lack of access to enough safe and nutritious food for normal growth and
development and an active and healthy life.

Hunger: An uncomfortable or painful physical sensation caused by insufficient consumption of

dietary energy.

After remaining relatively unchanged since 2015, the prevalence of undernourishment jumped
from 8 to 9.3 percent from 2019 to 2020. The number has growth by about 150 million since the
COVID-19 pandemic.

As the country income level falls, the total prevalence of food insecurity and the proportion of
severe food insecurity tends to increase.

Malnutrition and its different dimensions

Malnutrition refers to deficiencies or excesses in nutrient intake, imbalance of essential nutrients

or impaired nutrient utilization. The double burden of malnutrition consists of both undernutrition
and overweight and obesity, as well as diet-related noncommunicable diseases. Undernutrition
manifests in four broad forms: wasting, stunting, underweight, and micronutrient deficiencies.

● Malnutrition, in all its forms, includes undernutrition (wasting, stunting, underweight),

inadequate vitamins or minerals, overweight, obesity, and resulting diet-related
noncommunicable diseases.
● 1.9 billion adults are overweight or obese, while 462 million are underweight.
● Globally in 2020, 149 million children under 5 were estimated to be stunted (too short for
age), 45 million were estimated to be wasted (too thin for height), and 38.9 million were
overweight or obese.
● Around 45% of deaths among children under 5 years of age are linked to undernutrition.
These mostly occur in low- and middle-income countries. At the same time, in these same
countries, rates of childhood overweight and obesity are rising.
 ● The developmental, economic, social, and medical impacts of the global burden of
malnutrition are serious and lasting, for individuals and their families, for communities and
for countries.

Malnutrition refers to deficiencies, excesses, or imbalances in a person’s intake of energy and/or

nutrients. The term malnutrition addresses 3 broad groups of conditions:

● undernutrition, which includes wasting (low weight-for-height), stunting (low height-for-

age) and underweight (low weight-for-age);
● micronutrient-related malnutrition, which includes micronutrient deficiencies (a lack of
important vitamins and minerals) or micronutrient excess; and
● overweight, obesity and diet-related noncommunicable diseases (such as heart disease,
stroke, diabetes and some cancers).

Various forms of malnutrition

Undernutrition: There are 4 broad sub-forms of undernutrition: wasting, stunting, underweight,

and deficiencies in vitamins and minerals. Undernutrition makes children in particular much more
vulnerable to disease and death.

Low weight-for-height is known as wasting. It usually indicates recent and severe weight loss,
because a person has not had enough food to eat and/or they have had an infectious disease, such
as diarrhoea, which has caused them to lose weight. A young child who is moderately or severely
wasted has an increased risk of death, but treatment is possible.

Low height-for-age is known as stunting. It is the result of chronic or recurrent undernutrition,

usually associated with poor socioeconomic conditions, poor maternal health and nutrition,
frequent illness, and/or inappropriate infant and young child feeding and care in early life.
Stunting holds children back from reaching their physical and cognitive potential.

Children with low weight-for-age are known as underweight. A child who is underweight may be
stunted, wasted, or both.

Micronutrient-related malnutrition

Inadequacies in intake of vitamins and minerals often referred to as micronutrients, can also be
grouped together. Micronutrients enable the body to produce enzymes, hormones, and other
substances that are essential for proper growth and development.

Iodine, vitamin A, and iron are the most important in global public health terms; their deficiency
represents a major threat to the health and development of populations worldwide, particularly
children and pregnant women in low-income countries.
Overweight and obesity: Overweight and obesity is when a person is too heavy for his or her
height. Abnormal or excessive fat accumulation can impair health.

Body mass index (BMI) is an index of weight-for-height commonly used to classify overweight and
obesity. It is defined as a person’s weight in kilograms divided by the square of his/her height in
meters (kg/m²). In adults, overweight is defined as a BMI of 25 or more, whereas obesity is a BMI
of 30 or more.

Overweight and obesity result from an imbalance between energy consumed (too much) and
energy expended (too little). Globally, people are consuming foods and drinks that are more
energy-dense (high in sugars and fats), and engaging in less physical activity.

Diet-related noncommunicable diseases: Diet-related noncommunicable diseases (NCDs) include

cardiovascular diseases (such as heart attacks and stroke, and often linked with high blood
pressure), certain cancers, and diabetes. Unhealthy diets and poor nutrition are among the top
risk factors for these diseases globally.
Food security

Food security exists when all people, at all times, have physical and economic access to sufficient
safe and nutritious food that meets their daily needs and food preferences for an active and
healthy life.
The importance of a healthy diet

Consuming a healthy diet throughout the life-course helps to prevent malnutrition in all its forms
as well as a range of noncommunicable diseases (NCDs) and conditions. However, increased
production of processed foods, rapid urbanization and changing lifestyles have led to a shift in
dietary patterns. People are now consuming more foods high in energy, fats, free sugars and
salt/sodium, and many people do not eat enough fruit, vegetables and other dietary fibre such as
whole grains.

The exact make-up of a diversified, balanced and healthy diet will vary depending on individual
characteristics (e.g. age, gender, lifestyle and degree of physical activity), cultural context, locally
available foods and dietary customs. However, the basic principles of what constitutes a healthy
diet remain the same.

● A healthy diet helps to protect against malnutrition in all its forms, as well as
noncommunicable diseases (NCDs), including diabetes, heart disease, stroke and cancer.
● Unhealthy diet and lack of physical activity are leading global risks to health.
● Healthy dietary practices start early in life – breastfeeding fosters healthy growth and
improves cognitive development, and may have longer term health benefits such as
reducing the risk of becoming overweight or obese and developing NCDs later in life.
● Energy intake (calories) should be in balance with energy expenditure. To avoid unhealthy
weight gain, total fat should not exceed 30% of total energy intake (1, 2, 3). Intake of
saturated fats should be less than 10% of total energy intake, and intake of trans-fats less
than 1% of total energy intake, with a shift in fat consumption away from saturated fats
and trans-fats to unsaturated fats (3), and towards the goal of eliminating industrially-
produced trans-fats (4, 5, 6).
● Limiting intake of free sugars to less than 10% of total energy intake (2, 7) is part of a
healthy diet. A further reduction to less than 5% of total energy intake is suggested for
additional health benefits (7).
 ● Keeping salt intake to less than 5 g per day (equivalent to sodium intake of less than 2 g
per day) helps to prevent hypertension, and reduces the risk of heart disease and stroke in
the adult population (8).
● WHO Member States have agreed to reduce the global population’s intake of salt by 30%
by 2025; they have also agreed to halt the rise in diabetes and obesity in adults and
adolescents as well as in childhood overweight by 2025 (9, 10).

For adults. A healthy diet includes the following:

● Fruit, vegetables, legumes (e.g. lentils and beans), nuts and whole grains (e.g. unprocessed
maize, millet, oats, wheat and brown rice).
● At least 400 g (i.e. five portions) of fruit and vegetables per day (2), excluding potatoes,
sweet potatoes, cassava and other starchy roots.
● Less than 10% of total energy intake from free sugars (2, 7), which is equivalent to 50 g (or
about 12 level teaspoons) for a person of healthy body weight consuming about 2000
calories per day, but ideally is less than 5% of total energy intake for additional health
benefits (7). Free sugars are all sugars added to foods or drinks by the manufacturer, cook
or consumer, as well as sugars naturally present in honey, syrups, fruit juices and fruit
juice concentrates.
● Less than 30% of total energy intake from fats (1, 2, 3). Unsaturated fats (found in fish,
avocado and nuts, and in sunflower, soybean, canola and olive oils) are preferable to
saturated fats (found in fatty meat, butter, palm and coconut oil, cream, cheese, ghee and
lard) and trans-fats of all kinds, including both industrially-produced trans-fats (found in
baked and fried foods, and pre-packaged snacks and foods, such as frozen pizza, pies,
cookies, biscuits, wafers, and cooking oils and spreads) and ruminant trans-fats (found in
meat and dairy foods from ruminant animals, such as cows, sheep, goats and camels). It is
suggested that the intake of saturated fats be reduced to less than 10% of total energy
intake and trans-fats to less than 1% of total energy intake (5). In particular, industrially-
produced trans-fats are not part of a healthy diet and should be avoided (4, 6).
● Less than 5 g of salt (equivalent to about one teaspoon) per day (8). Salt should be
iodized.

For infants and young children

In the first 2 years of a child’s life, optimal nutrition fosters healthy growth and improves cognitive
development. It also reduces the risk of becoming overweight or obese and developing NCDs later
in life. Advice on a healthy diet for infants and children is similar to that for adults, but the
following elements are also important:

● Infants should be breastfed exclusively during the first 6 months of life.

● Infants should be breastfed continuously until 2 years of age and beyond.
● From 6 months of age, breast milk should be complemented with a variety of adequate,
safe and nutrient-dense foods. Salt and sugars should not be added to complementary
foods.
Practical advice on maintaining a healthy diet
Fruit and vegetables
Eating at least 400 g, or five portions, of fruit and vegetables per day reduces the risk of NCDs (2)
and helps to ensure an adequate daily intake of dietary fibre.
Fruit and vegetable intake can be improved by:
● always including vegetables in meals;
● eating fresh fruit and raw vegetables as snacks;
● eating fresh fruit and vegetables that are in season; and
● eating a variety of fruit and vegetables.
Fats
Reducing the amount of total fat intake to less than 30% of total energy intake helps to prevent
unhealthy weight gain in the adult population (1, 2, 3). Also, the risk of developing NCDs is lowered
by:
● reducing saturated fats to less than 10% of total energy intake;
● reducing trans-fats to less than 1% of total energy intake; and
● replacing both saturated fats and trans-fats with unsaturated fats (2, 3) – in particular,
with polyunsaturated fats.
Fat intake, especially saturated fat and industrially-produced trans-fat intake, can be reduced by:
● steaming or boiling instead of frying when cooking;
● replacing butter, lard and ghee with oils rich in polyunsaturated fats, such as soybean,
canola (rapeseed), corn, safflower and sunflower oils;
● eating reduced-fat dairy foods and lean meats, or trimming visible fat from meat; and
● limiting the consumption of baked and fried foods, and pre-packaged snacks and foods
(e.g. doughnuts, cakes, pies, cookies, biscuits and wafers) that contain industrially-
produced trans-fats.
Salt, sodium and potassium
Most people consume too much sodium through salt (corresponding to consuming an average of
9–12 g of salt per day) and not enough potassium (less than 3.5 g). High sodium intake and
insufficient potassium intake contribute to high blood pressure, which in turn increases the risk of
heart disease and stroke (8, 11).
Reducing salt intake to the recommended level of less than 5 g per day could prevent 1.7 million
deaths each year (12).
People are often unaware of the amount of salt they consume. In many countries, most salt
comes from processed foods (e.g. ready meals; processed meats such as bacon, ham and salami;
cheese; and salty snacks) or from foods consumed frequently in large amounts (e.g. bread). Salt is
also added to foods during cooking (e.g. bouillon, stock cubes, soy sauce and fish sauce) or at the
point of consumption (e.g. table salt).
Salt intake can be reduced by:
 ● limiting the amount of salt and high-sodium condiments (e.g. soy sauce, fish sauce and
bouillon) when cooking and preparing foods;
● not having salt or high-sodium sauces on the table;
● limiting the consumption of salty snacks; and
● choosing products with lower sodium content.
Some food manufacturers are reformulating recipes to reduce the sodium content of their
products, and people should be encouraged to check nutrition labels to see how much sodium is in
a product before purchasing or consuming it.
Potassium can mitigate the negative effects of elevated sodium consumption on blood pressure.
Intake of potassium can be increased by consuming fresh fruit and vegetables.
Sugars
In both adults and children, the intake of free sugars should be reduced to less than 10% of total
energy intake (2, 7). A reduction to less than 5% of total energy intake would provide additional
health benefits (7).
Consuming free sugars increases the risk of dental caries (tooth decay). Excess calories from foods
and drinks high in free sugars also contribute to unhealthy weight gain, which can lead to
overweight and obesity. Recent evidence also shows that free sugars influence blood pressure and
serum lipids, and suggests that a reduction in free sugars intake reduces risk factors for
cardiovascular diseases (13).
Sugars intake can be reduced by:
● limiting the consumption of foods and drinks containing high amounts of sugars, such as
sugary snacks, candies and sugar-sweetened beverages (i.e. all types of beverages
containing free sugars – these include carbonated or non‐carbonated soft drinks, fruit or
vegetable juices and drinks, liquid and powder concentrates, flavoured water, energy and
sports drinks, ready‐to‐drink tea, ready‐to‐drink coffee and flavoured milk drinks); and
● eating fresh fruit and raw vegetables as snacks instead of sugary snacks.

Promoting healthy diets: Diet evolves over time, being influenced by many social and economic
factors that interact in a complex manner to shape individual dietary patterns. These factors
include income, food prices (which will affect the availability and affordability of healthy foods),
individual preferences and beliefs, cultural traditions, and geographical and environmental aspects
(including climate change). Therefore, promoting a healthy food environment – including food
systems that promote a diversified, balanced and healthy diet – requires the involvement of
multiple sectors and stakeholders, including government, and the public and private sectors.

Governments have a central role in creating a healthy food environment that enables people to
adopt and maintain healthy dietary practices. Effective actions by policy-makers to create a
healthy food environment include the following:

● Creating coherence in national policies and investment plans – including trade, food and
agricultural policies – to promote a healthy diet and protect public health.
 ● Encouraging consumer demand for healthy foods and meals
● Promoting appropriate infant and young child feeding practices

World Health Organization response

The “WHO Global Strategy on Diet, Physical Activity and Health” (14) was adopted in 2004 by the
Health Assembly. The strategy called on governments, WHO, international partners, the private
sector and civil society to take action at global, regional and local levels to support healthy diets
and physical activity.

In 2010, the Health Assembly endorsed a set of recommendations on the marketing of foods and
non-alcoholic beverages to children (15). These recommendations guide countries in designing
new policies and improving existing ones to reduce the impact on children of the marketing of
foods and non-alcoholic beverages to children. WHO has also developed region-specific tools (such
as regional nutrient profile models) that countries can use to implement the marketing
recommendations.

In 2012, the Health Assembly adopted a “Comprehensive Implementation Plan on Maternal, Infant
and Young Child Nutrition” and six global nutrition targets to be achieved by 2025, including the
reduction of stunting, wasting and overweight in children, the improvement of breastfeeding, and
the reduction of anaemia and low birthweight (9).

In 2013, the Health Assembly agreed to nine global voluntary targets for the prevention and
control of NCDs. These targets include a halt to the rise in diabetes and obesity, and a 30% relative
reduction in the intake of salt by 2025. The “Global Action Plan for the Prevention and Control of
Noncommunicable Diseases 2013–2020” (10) provides guidance and policy options for Member
States, WHO and other United Nations agencies to achieve the targets.

With many countries now seeing a rapid rise in obesity among infants and children, in May 2014
WHO set up the Commission on Ending Childhood Obesity. In 2016, the Commission proposed a
set of recommendations to successfully tackle childhood and adolescent obesity in different
contexts around the world (16).

In November 2014, WHO organized, jointly with the Food and Agriculture Organization of the
United Nations (FAO), the Second International Conference on Nutrition (ICN2). ICN2 adopted the
Rome Declaration on Nutrition (17), and the Framework for Action (18) which recommends a set
of policy options and strategies to promote diversified, safe and healthy diets at all stages of life.
WHO is helping countries to implement the commitments made at ICN2.

In May 2018, the Health Assembly approved the 13th General Programme of Work (GPW13),
which will guide the work of WHO in 2019–2023 (19). Reduction of salt/sodium intake and
elimination of industrially-produced trans-fats from the food supply are identified in GPW13 as
part of WHO’s priority actions to achieve the aims of ensuring healthy lives and promote well-
being for all at all ages. To support Member States in taking necessary actions to eliminate
industrially-produced trans-fats, WHO has developed a roadmap for countries (the REPLACE action
package) to help accelerate actions (6).

THE UPHILL ROAD TO GLOBAL HEALTH JUSTICE; MULTISTAKEHOLDERISM

● Free Markets
 ● Small government role
● Strong private rights
● Market efficiency
● All that matters can be priced (if it can’t be priced it doesn’t matter)
● Homo oeconomicus
● Erosion of social expenditures, perceived as ”non productive”

Policies: Free trade, Free capital movement, Deregulation, Low taxes, Institutional hybridization.

Privatization: Outsized role of intellectual property and the intangibles, Commodification,

Commercialisation and Corporatisation, Financialization.

Inequalities: a question of governance

The current rules of our global economy reproduce a vicious circle of inequality: growing economic
inequality and wealth concentration increase political inequality by expanding the ability of
corporate and financial elites to influence policy-making and protect their wealth and privileges.
Higher levels of inequalities are then passed on to the next generations, culminating in long-term
disparities and unfairness felt by marginalized groups.

The multiple domains and dimensions of inequality

The Alma-Ata Declaration of 1978 emerged as a major milestone of the twentieth century in the
field of public health, and it identified primary health care as the key to the attainment of the goal
of Health for All. The following are excerpts from the Declaration:

The Conference strongly reaffirms that health, which is a state of complete physical, mental, and
social well-being, and not merely the absence of disease or infirmity, is a fundamental human right
and that the attainment of the highest possible level of health is a most important world-wide
social goal whose realization requires the action of many other social and economic sectors in
addition to the health sector.

The existing gross inequality in the health status of the people, particularly between developed
and developing countries as well as within countries, is politically, socially, and economically
unacceptable and is, therefore, of common concern to all countries.
The people have a right and duty to participate individually and collectively in the planning and
implementation of their health care.

Primary health care is essential health care based on practical, scientifically sound, and socially
acceptable methods and technology made universally accessible to individuals and families in the
community through their full participation and at a cost that the community and country can
afford to maintain at every stage of their development in the spirit of self-reliance and self-
determination. It forms an integral part both of the country's health system, of which it is the
central function and main focus, and of the overall social and economic development of the
community. It is the first level of contact of individuals, the family, and community with the
national health system bringing health care as close as possible to where people live and work,
and constitutes the first elements of a continuing health care process.

An acceptable level of health for all the people of the world by the year 2000 can be attained
through a fuller and better use of the world's resources, a considerable part of which is now spent
on armaments and military conflicts. A genuine policy of independence, peace, détente, and
disarmament could and should release additional resources that could well be devoted to peaceful
aims and in particular to the acceleration of social and economic development of which primary
health care, as an essential part, should be allotted its proper share.

III: Economic and social development, based on a New International Economic Order, is of basic
importance to the fullest attainment of health for all and to the reduction of the gap between the
health status of the developing and developed countries. The promotion and protection of the
health of the people is essential to sustained economic and social development and contributes to
a better quality of life and to world peace.

IV: The people have the right and duty to participate individually and collectively in the planning
and implementation of their health care.

Alma Ata and the lessons learnt from COVID-19

• The neocolonial legacy of multilateralism

• The need for overcoming the past «global health» doctrine and its underlying colonial inspiration
and implementation

• The growing multiplicity of health determinants requires policies and not anthropocentric
pragmatic solutions

• Health interconnecting with planetary concerns related to the current development model: de-
growth?

• Health interconnecting with financial and economic justice (austerity measures, debt
cancellation, illicit financial flows)

• The role of the big government and the failure of market orthodoxies in healthcare

• Global solutions and their national implementation: a dilemma?

Civil Society: a dwindling definition

Civil society is seen as a social sphere separate from both the state and the market. The
increasingly accepted understanding of the term civil society organizations (CSOs) is that of non-
state, not-for-profit, voluntary organizations formed by people in that social sphere. This term is
used to describe a wide range of organizations, networks, associations, groups and movements
that are independent from government and that sometimes come together to advance their
common interests through collective action. Traditionally, civil society includes all organizations
that occupy the 'social space' between the family and the state, excluding political parties and
firms. Some definitions of civil society also include certain businesses, such as the media, private
schools, and for-profit associations, while others exclude them.

The multi-dimensional nature of mobilization & advocacy

• Information within the network: share, to keep everyone in the loop & get ideas, suggestions

• External information sharing and networking: expand your sphere of influence

• Education/training: strenghten skills & build on people’s capacity (target groups, the media,
delegates)

• Branding & marketing: orient people’s choices

• The media/social networks: seek the good story, the health issue has a human experience/face
and a relevant original angle – pusue this angle

• Lobbying: set the policy target and work for it as a catalyst of change (pressure + negotiation)

• Societal mobilization, react to the changes produced

• Outside or inside the decision rooms?

The Geneva Global Health Hub (G2H2)

• Clear vision of what you want to achieve, and the initiative(s) to be undertaken to this end: a
common understanding is key;

• Understanding the risks and benefits of specific tactics

• Ready for the time it demands?

• Robust communication and advocacy

• Penetration capacity assessment, both in terms of “mobilization” outreach and “influence”

capability

• The implications of your communication, and the flexibility to adapt and timely respond

• Few, pointed, actions!

Situation Analysis is key: the group/ the coalition

● know yourself before deciding what to achieve, how to get there and with whom.
● Assessing the strengths and weaknesses of the group, including resources and
sustainability criteria.
 ● How to deal with diversity of approaches within the same group?
● Reaching the common notion of the goals to be achieved, the core inspiring principles
driving the endeavor

Situation Analysis is key: landscaping the national/regional/global context

● Make sure you know well the context in which you start your initiative
● Identify key targets, as well as any other actors that can help build the campaign’s
influence map at the national level (the potential allies)
● Map the campaign’s opponents, wherever they may be found
● Search for any country/region/global specific opportunity or hurdle that may impact on
the campaign's action

Answering objections: Look for those arguments that make sense to you or that seem reasonable,
even if you don't agree with them; The more you can answer objections, the stronger you'll make
your case; Need for answering objections even if you don't think the objections are reasonable

The cult of multistakeholderism and the need for a critical look

GLOBAL ORAL HEALTH: CHALLENGES, STRATEGIES and CRITICAL ISSUES

In 2003, WHO defined Oral Health as "a state of absence of chronic pain in the mouth and face,
oral and throat cancer, oral infections and sores, periodontal disease, tooth decay, tooth loss and
other diseases and disorders that limit an individual's ability to bite, chewing, smiling, talking while
limiting his psychosocial well-being".

In 2016, the FDI (World Dental Federation) implemented the definition defining Oral Health: "an
essential component of overall health and is a fundamental human right and reflects the
physiological, social and psychological characteristics that are essential for the quality of life, and is
influenced by the changing experiences, perceptions, expectations and adaptability of the
individual".

WHO implemented further the definition defining OH such as "that state of the mouth, teeth and
orofacial structures that allows individuals to perform essential functions, such as eating,
breathing and speaking, and includes psychosocial dimensions, such as self-confidence, well-being
and the ability to socialize and work without pain, discomfort and embarrassment. Oral health
varies throughout the life course from early childhood to old age, is an integral part of overall
health and supports people in participating in society and reaching their potential”. (Global Oral
Health Status Report 2022)

Oral diseases – a large group of diseases. The five main diseases:

● caries of deciduous teeth,

● caries of permanent teeth,
● severe periodontal disease,
● edentulism
● lip and oral cavity cancer;

Many other diseases are relevant for oral health:

 ● oral manifestations of systemic diseases (HIV etc.);
● oral mucosa diseases;
● erosion and tooth wear;
● oral impacts of substance abuse;
● noma;
● congenital malformations of teeth and the enamel;
● viral, fungal and bacterial infections;
● trauma (including physical and chemical injuries);
● cysts and tumours of odontogenic origin;
● salivary gland diseases;
● disturbances in the development and growth of oral structures.

Noma is a marker of absolute poverty and is a serious gangrenous disease of the mouth and the
face. Initial lesions then develop into a rapidly progressing acute necrotizing gingivitis, destroying
the soft tissues and further expanding to the hard tissues and skin of the face.

Without early treatment, noma is fatal in about 90% of cases. Noma mostly affects children
between the ages of 2 and 6 living in extreme poverty and suffering from malnutrition, infectious
diseases and poor oral and general hygiene or with weakened immune systems. Noma occurs
predominantly in an area of sub-Saharan Africa In 1998, WHO estimated an annual incidence of
more than 140 000 cases worldwide.

Approximately 3.5 billion people worldwide were affected by oral diseases in 2019, making them
the most prevalent conditions among the more than 300 diseases and conditions affecting
humanity. (GBD study 2019; 7, 9, 14)

Between 1990 and 2019, estimated case numbers grew by more than 1 billion: a 50% increase,
higher than the population increase of about 45% during the same period. In 2019, among the
main oral diseases:

● untreated caries of permanent teeth is the most common oral disease with about 2 billion
cases
● severe periodontal disease follows with about 1 billion cases
● then untreated caries of deciduous teeth with about 510 million cases

The estimated combined number of oral disease cases globally is about 1 billion higher than the
cases of all five major non-communicable diseases (mental disorders, cardiovascular disease,
diabetes mellitus, chronic respiratory diseases and cancers) combined.

During the same period, case numbers in low-income countries more than doubled (114%), and
they increased by 70% in lower-middle income countries and by 33% and 23% in upper-middle and
high income countries, respectively.

Similar trends are observed for DALYs resulting from oral diseases, with a global average increase
of 75%. The highest increase was observed in low-income countries (123%), followed by lower-
middle income countries (98%), upper-middle income countries (78%) and high-income countries
(37%).
The increasing burden of oral diseases is largely due to:

● epidemiological transition
● nutrition transition
● demographic changes such as population expansion, ageing, urbanization and population
movement,
● social and commercial determinants of health

This increasing burden is also a clear indication that many people do not have access to adequate
oral health care, which includes prevention, risk protection and various rehabilitation services.

Oral pathologies can be a clinical indicator of social and economic deprivation and it can be said
that they are also an important indicator of the deterioration of general health. Oral diseases
disproportionately affect the poor and other vulnerable segments of society, in fact there is a wide
and persistent correlation between socioeconomic status and the incidence and severity of oral
diseases where these are a classic example of the "social gradient" in health that is systematic and
progressive throughout the social hierarchy, with severe and persistent socio-economic
inequalities.

Oral disorders are preventable and treatable, but they can have negative effects on individuals,
communities, and society as a whole. The poor, disadvantaged and other vulnerable populations
are social groups that are at greater risk of poor physical, psychological and/or social health
because of their socio-economic position and social status.

Despite an increased need for dental care and although difficulties in accessing dental services
have been shown as one of the pathways contributing to inequalities, vulnerable people are prone
to oral diseases and less likely to receive routine dental care.

Evidence indicates that there are several shared risk factors between oral diseases and NCDs
including: tobacco use, alcohol consumption, a diet high in free sugars, the Social and Commercial
determinants of Health-

Therefore «addressing both the common risk factors and the Social and Commercial Determinants
of Health is essential if improvements are to be made to improve health and reduce inequalities in
oral and general health globally». Oral diseases share determinants and risk factors with other
NCDs. The circumstances in which people are born, grow, live, work and age determine the
behaviors that people adopt and the opportunities and choices available to them.
Barriers for Oral Health

The cost of oral health care is high, with most care provided by the private sector: the average
spending per capita in low-income countries is $0.52, while high-income countries spend an
average of $260 per capita, 500 times as much. The ratio of total amounts spent on oral health
care is even worse: all low-income countries combined spend 800 times less than all high-income
countries combined. Oral health care is in its «sylos», still separated from other health services
(the biggest challenge to overcome to improve oral health) and still «treatments focused»

Why the burden of Oral diseases? - lack of adequate public/global health policies, - lack of Oral
Health Literacy, education and promotion, - lack of universal (oral) health coverage - unequal
distribution of oral health professionals and healthcare facilities.

These challenges are limiting the effective prevention and treatment of oral health conditions.

Dental disorders represent a significant economic burden on society. Their economic burden
includes:
 ● direct costs (treatment costs),
● indirect costs (loss of production due to absence from work and school, transport, etc.)
● intangible/disability costs (pain, problems in biting, chewing and eating, tasting, talking,
the expression of emotions such as smiling, all of which are involved in social and family
activities.)

In a comparison of disease expenditure in the 28 EU Member States in 2015, dental disorders (€90
billion) came in third place, after diabetes (€119 billion) and cardiovascular disease (€111 billion).

In 2015, the global economic impact of oral health disorders amounted to $544.41 billion in direct
and indirect costs. Over 80% of these expenditures occurred in high-income countries,
demonstrating inequalities in oral health care globally. Individuals with low SES are subject to the
direct and indirect costs of dental care and face a significantly higher risk of poor oral health,
depletion, and catastrophic expenses than those in higher SES.

SDG 1 and 2 (No poverty and zero hunger): Oral health problems place a great burden on
individuals and society in terms of human suffering and financial costs. Poverty, economic and
social inequalities have a direct impact on oral health including: unhealthy diets and malnutrition,
substance abuse, harmful behaviors.

Individuals and families may become poor due to severe medical expenses and the evidence
suggest that, because of oral diseases, there is an increase in absenteeism from school and work
and therefore reduced productivity.

Living in surroundings where there are barriers to food and to access nutritious foods, as well as
situations strongly influenced by epidemiological transition and commercial determinants of
health, contribute to the high prevalence of oral diseases.

Good health and education (3 and 4):

Promoting good health and well-being: Public health actions and policies to reduce sugar
consumption as part of a healthy diet have the greatest potential to improve oral health. At the
same time, it also targets diabetes, obesity and other NCDs.

Increase the effectiveness of substance abuse prevention and treatment: Actions aimed at
improving oral health and lowering alcohol and drug consumption will support and improve efforts
at all levels of health.

Reduce premature mortality from NCDs: oral problems can be a sign, precursor, or result of
chronic diseases. Addressing the comorbidity between oral diseases and other NCDs requires the
implementation of CRFA and an integrated, person-centered approach (precision medicine).

Achieving U(O)HC: oral health should be part of UHC. Oral diseases are mostly preventable and
treatable, but due to insufficient availability of services and access, a considerable number of
people with oral diseases cannot get treatment and are prone to the effects of oral diseases.

SDG 10 (Inequalities): Oral health disorders disproportionately affect the poor and the most
disadvantaged segments of society. Oral diseases are influenced by social inequalities that are
defined as: "systematic, avoidable and unjust differences in health outcomes that can be observed
between populations and between various social groups within the same population".

These discrepancies are evident in the literature and numerous studies have found causal links
between socioeconomic status and oral health. All this evidence highlights the need and the
importance of aligning the next oral health strategy towards the goal of reducing inequalities in
health and then towards the UHC.

Oral Health and Anti-microbial resistance (AMR): Dentists are responsible for about 10% of all
antibiotic prescriptions for humans globally and despite attempts to limit the use of dental
antibiotics, dentists continue to administer too many antibiotics. Research in the UK found that
80% of antibiotics used to treat acute dental problems were unnecessary, while a study in the US
found that 80% of antibiotics used for prophylaxis were neither suitable nor suggested.

Global Oral Health, Key Facts:

● Oral diseases, despite largely preventable, have serious health and economic impacts on
the society worldwide
● Oral diseases affect people during their life-course, disabling those affected with pain,
discomfort, disfigurement and even death and greatly reducing their quality of life.
● Poor oral health is costly, accounting for 4.6% (equivalent to US$356.80 billion) of health
expenditure globally
● Globally, there is a very strong and consistent association between SES and the prevalence
and severity of oral diseases that disproportionally affect the poor and socially
disadvantaged members of society.
● Oral diseases are caused by a range of modifiable risk factors and their underlying social
and commercial determinants of health, that are in common with the 4 leading NCDs.
● Over 2 billion people are suffering from caries of permanent teeth and over 520 million
children suffering from caries in primary teeth
● Severe gum diseases affect around 14% of the global adult population, representing more
than one billion cases worldwide.
● Lip and oral cavity cancers ranked 16 th among the most common cancers worldwide, with
177.757 deaths and 377.713 incident cases in 2020 (Globocan).
● Around 20% of people suffer from trauma to teeth at some point in their life
● Noma, according to latest estimates (from 1998) has an incidence of 140.000 new cases
annually and without treatment is fatal in 90% of cases
● Oral diseases are a major cause of disability, with estimates from 2019 indicating that such
diseases caused 23.1 million (95% UI 13.6–37.4) Years Lived with Disabilities (YLD).

Part 2:

Reasons of oral health neglect in the international agenda the most sustainable approaches to
address the global oral health needs according to the WHO (oral health needs perception is based
on the situation of high and middle income countries):

● Oral disease is not life threatening

● Burden of disease has decreased in the last 50 years and remains high only in the most
disadvantaged groups
 ● Oral health is not perceived as a public health priority

Consequences of oral health not perceived as public health priority:

● Public oral care is poor and fragmented

● Dental treatment is mostly provided by private dentists
● Model of care focuses on curative and rehabilitative aspects
● Lack of integration in general public services
● Indifference of local policy makers
● Commercial determinants: pressure from private sector in prioritizing the needs, conflict
of interest

The Lancet

Modern dentistry has failed the global challenge of oral diseases. The dental care systems today:
treatment oriented, high-technology focused on providing aesthetic treatments driven by profit
and consumerism. Access to care is inequitable: a social determinant of health approach is the
only way to improve outcomes.

The Lancet oral health series: Detailed analysis and proposals

Accessibility, integration of dental services into health-care systems, oral health should be
included in universal health coverage.

In May 2021 the World Health Assembly adopted Resolution WHA74.5 on oral health requesting
to draft a global strategy on tackling oral diseases. The strategy aims to develop a global action
plan on oral health, with clear measurable targets to be achieved by 2030.

Vision of the global strategy on oral health: UHC for oral health for all individuals and communities
by 2030. Achieving the highest attainable standard of oral health is a fundamental right of every
human being

Six objectives of the global strategy

1. Improve political and resource commitment to oral health, strengthen leadership and
create win-win partnerships within and outside the health sector.
2. Oral health promotion and oral disease prevention – Enable all people to achieve the best
possible oral health and address the social and economic determinants and risk factors of
oral diseases.
3. Health workforce - Develop innovative workforce models and revise and expand
competency- based education to respond to population oral health needs
4. Integrate essential oral health care and ensure related financial protection and essential
supplies in primary health care.
5. Update and strengthen oral health information systems
6. Oral health research agendas – Create and continuously update context and needs-specific
research that is focused on the public health aspects of oral health.

Emerging problems in dental aid:

● Adoption of a “Western" system of dentistry

 ● Reliance on sophisticated technology
● Unsuitability and ineffectiveness in different contexts
● Money and energy for transportation
● Deterioration due to absence of necessary maintenance.

The main problem is untreated dental caries. Dental caries is the gradual loss of substance from
the mineral coating of the tooth, the enamel and the dentine, gradually destroying the tooth. This
happens through the demineralization caused by acids produced by the oral bacterial flora in the
presence of carbohydrates, especially free sugars. Risk factors are: high consumption of sugars;
poor hygiene for bacterial plaque removal; poor enamel resistance.

In nature, fluoride is commonly found as the F- fluoride ion. Its correct concentration in the water
is essential to strengthen the mineralized structure of the tooth: enamel and dentine. Fluoride acts
on the ename: reduction in acid solubility, remineralization of the early carious lesions. Excess
fluoride is harmful and causes fluorosis of teeth and bones.

Public health approaches:

● water and salt fluoridation (cheap, cost- effective, needing infrastructures

recommendation on fluoride addition to toothpaste)
● Water fluoridation: addition of fluoride where scarce is cost effective: 0,0054 per person/
year. Countries: USA, Canada, Australia, New Zealand, SouthAfrica, Ireland, Switzerland
Protests and controversies, conspiracy theories.
● Salt Fluoridation: A free choice of the consumer and most effective: $0.06 per person.
● Toothpaste is the most feasible means of exposing the population to fluoride.

FT is essential for preventing dental caries, but its current affordability remains unclear. The most
recent study has been conducted in 78 countries. There are significant differences. FT was strongly
affordable in high-income countries, relatively affordable in upper middle-income countries, and
strongly unaffordable in lower middle-income and low-income countries.

The three pillars of the Basic Package for Oral Care

1. OUT Oral Urgent Treatment: Resolution of emergencies, the main need of the population
(pain, infection, dental trauma). Relief from dental pain is the first and basic demand of
patients and therefore OUT should be accessible on a large scale. “Divinum opus est
sedare dolorem” (Pain alleviation is a divine act)
2. AFT Affordable Fluoridated Toothpaste: access to fluoride ( among the 50 essential drugs,
best tool to prevent carious pathology and improve its course). Strategies to Improve
Affordability and Availability of Fluoride Toothpaste: Reducing/eliminating taxes and tariffs
on quality fluoride toothpaste, which is considered a cosmetic; Local production or generic
production of toothpaste; Cheaper packaging and ingredients; Economic use of fluoride
toothpaste. Therefore, synergy between governments, manufacturers, physicians and
nongovernmental organizations is essential to make the product affordable and achieve
universal exposure to the correct amounts of fluoride.
3. ART Atraumatic Restorative Treatment: basic minimum care with low-cost materials that
allow healing of affected dental tissues.
One of the COI projects in Burkina Faso intended to replicate some of the BPOC inputs, in
particular the OUT and the health promotion activities at school: washing hands and brushing
teeth. The commitment and determination of many, who have worked hard and patiently over the
years to fight the root causes of enormous suffering in the mouths of the most fragile people, now
show clearly the way forward.

14th and 16th (april 28 and may 8): MIGRATION AND HEALTH (I and II)

There is a lack of universally accepted definitions in the area of international migration. Definitions
in this area are often vague, controversial or contradictory. This stems to some extent from the
fact that migration is a phenomenon which has traditionally been addressed at the national level.
Therefore the usage of migration terms differs from country to country. Furthermore, within a
country, terms can vary in meaning or implication. Definitions may also vary according to a given
perspective or approach.

IOM Definition of "Migrant": An umbrella term, not defined under international law, reflecting
the common lay understanding of a person who moves away from his or her place of usual
residence, whether within a country or across an international border, temporarily or
permanently, and for a variety of reasons. The term includes a number of well-defined legal
categories of people, such as migrant workers; persons whose particular types of movements are
legally-defined, such as smuggled migrants; as well as those whose status or means of movement
are not specifically defined under international law, such as international students.

Note: At the international level, no universally accepted definition for “migrant” exists. The
present definition was developed by IOM for its own purposes and it is not meant to imply or
create any new legal category.

International migrant: Any person who is outside a State of which he or she is a citizen or national,
or, in the case of a stateless person, his or her State of birth or habitual residence. The term
includes migrants who intend to move permanently or temporarily, and those who move in a
regular or documented manner as well as migrants in irregular situations.

Immigrant: From the perspective of the country of arrival, a person who moves into a country
other than that of his or her nationality or usual residence, so that the country of destination
effectively becomes his or her new country of usual residence.

internal migration: The movement of people within a State involving the establishment of a new
temporary or permanent residence. They can be temporary or permanent and include those who
have been displaced from their habitual place of residence such as internally displaced persons, as
well as persons who decide to move to a new place, such as in the case of rural–urban migration.

Economic migrant: While not a category in international law, the term is sometimes used to refer
to any person who is moving or has moved across an international border or within a State, solely
or primarily motivated by economic opportunities.

Migrant worker: A person who is to be engaged, is engaged or has been engaged in a

remunerated activity in a State of which he or she is not a national.
Environmental migrant: A person or group(s) of persons who, predominantly for reasons of
sudden or progressive changes in the environment that adversely affect their lives or living
conditions, are forced to leave their places of habitual residence, or choose to do so, either
temporarily or permanently, and who move within or outside their country of origin or habitual
residence.

Internally displaced persons: Persons or groups of persons who have been forced or obliged to
flee or to leave their homes or places of habitual residence, in particular as a result of or in order
to avoid the effects of armed conflict, situations of generalized violence, violations of human rights
or natural or human-made disasters, and who have not crossed an internationally recognized State
border.

Stateless person: A person who no is considered as a national by any state under the operation of
its law.

Irregular stay: The presence on the territory of a State, of a non-national who does not fulfill, or
no longer fulfills the conditions of entry, stay or residence in the State.

Migrant in an irregular situation: A person who moves or has moved across an international
border and is not authorized to enter or to stay in a State pursuant to the law of that State and to
international agreements to which that State is a party.

Undocumented migrant: A non-national who enters or stays in a country without the appropriate
documentation. Migrants can find themselves as undocumented in one of the following two ways.
First, they have documentation that acts as proof of identity but they do not have documentation
that proves their right to enter and stay in the country, or such documentation is fraudulent or no
longer valid. In this meaning, this expression is used as a synonym of “irregular migrant”. Secondly,
they do not hold any form of documentation that proves their identity nor do they have any other
proof of their right to enter and stay in the country. Undocumented migrants who lack any identity
document usually experience more difficulties in accessing services, in obtaining permits to reside
or work, or in returning to their countries.

Long-term migrant: A person who moves to a country other than that of his or her usual residence
for a period of at least one year, so that the country of destination effectively becomes his or her
new country of usual residence.

Seasonal migrant worker: A migrant worker whose work, or migration for employment is by its
character dependent on seasonal conditions and is performed only during part of the year

Applicant: In the migration context, a person who formally requests administrative or judicial
action, such as the granting of a visa, work permit or refugee status

Refugee (mandate): A person who qualifies for the protection of the United Nations provided by
the High Commissioner for Refugees (UNHCR), in accordance with UNHCR’s Statute and, notably,
subsequent General Assembly’s resolutions clarifying the scope of UNHCR’s competency,
regardless of whether or not he or she is in a country that is a party to the 1951 Convention or the
1967 Protocol – or a relevant regional refugee instrument – or whether or not he or she has been
recognized by his or her host country as a refugee under either of these instruments.
Right to seek and enjoy asylum: The right of individuals to seek and enjoy asylum from
persecution in a country other than the person’s State of nationality or habitual residence.

Non-refoulement (principle of): The prohibition for States to extradite, deport, expel or otherwise
return a person to a country where his or her life or freedom would be threatened, or where there
are substantial grounds for believing that he or she would risk being subjected to torture or other
cruel, inhuman and degrading treatment or punishment, or would be in danger of being subjected
to enforced disappearance, or of suffering another irreparable harm

Relocation: In the context of humanitarian emergencies, relocations are to be considered as

internal humanitarian evacuations and are understood as large-scale movements of civilians, who
face an immediate threat to life in a conflict setting, to locations within the same country where
they can be more effectively protected.

Return migration: In the context of international migration, the movement of persons returning to
their country of origin after having moved away from their place of habitual residence and crossed
an international border. In the context of internal migration, the movement of persons returning
to their place of habitual residence after having moved away from it.

Migrants in vulnerable situations: Migrants who are unable to effectively enjoy their human
rights, are at increased risk of violations and abuse and who, accordingly, are entitled to call on a
duty bearer’s heightened duty of care.

Separated children: Children, as defined in Article 1 of the Convention on the Rights of the Child,
who have been separated from both parents, or from their previous legal or customary primary
caregiver, but not necessarily from other relatives. These may, therefore, include children
accompanied by other adult family members.

Unaccompanied children: Children, as defined in Article 1 of the Convention on the Right of the
Child, who have been separated from both parents and other relatives and are not being cared for
by an adult who, by law or custom, is responsible for doing so.

Smuggled migrant: A migrant who is or has been the object of the crime of smuggling, regardless
of whether the perpetrator is identified, apprehended, prosecuted or convicted.

Stranded migrant: Migrants who are unable to return to their country of origin, cannot regularize
their status in the country where they reside, and do not have access to legal migration
opportunities that would enable them to move on to another State. The term may also refer to
migrants who are stranded because of humanitarian or security reasons in the country of
destination, transit or origin preventing them to return home while they are also unable to go
elsewhere.

Person with a migratory background: A person who has: (1) migrated into their present country of
residence; (2) previously had a different nationality to that of his/her present country of residence;
and/or (3) at least one of his/her parents previously entered the present country of residence as a
migrant.
Migration health: A public health topic which refers to the theory and practice of assessing and
addressing migration associated factors that can potentially affect the physical, social and mental
well-being of migrants and the public health of host communities.

Healthy migrant effect: The observation that immigrants are on average healthier than the native-
born, possible due to health screening by recipient countries, healthy behaviour prior to migration,
and immigrant self-selection.

Migrant-friendly health systems: Health systems that consciously and systematically incorporate
the needs of migrants into health financing, policy, planning, implementation and evaluation,
including such considerations as the epidemiological profiles of migrant populations, relevant
cultural, language and socioeconomic factors and the impact of the migration process on the
health of migrants.

Mixed migration flows (reflexion of the diversity in migration)

● Economic migrants, low and high skilled

● Refugees
● Victims of trafficking
● Smuggled migrants
● Unaccompanied minors
● Stranded migrants
● Migrants moving for environmental reasons

WHAT IS HUMAN TRAFFICKING?

Human trafficking is a global crime that trades in people and exploits them for profit. People of all
genders, ages and backgrounds can become victims of this crime, which occurs in every region of
the world. Traffickers use violence, fraudulent employment agencies, and fake promises of
education and job opportunities to trick, coerce and deceive their victims. The organized networks
or individuals behind this lucrative crime take advantage of people who are vulnerable, desperate
or simply seeking a better life. Human trafficking is defined in the UN Trafficking in Persons
Protocol, which supplements the United Nations Convention against Transnational Organized
Crime, as "the recruitment, transport, transfer, harbouring or receipt of a person by such means as
threat or use of force or other forms of coercion, abduction, fraud or deception for the purpose of
exploitation".

The definition of trafficking consists of three core elements:

● The act of trafficking, which means the recruitment, transportation, transfer, harbouring
or receipt of persons.
● The means of trafficking which includes threat of or use of force, deception, coercion,
abuse of power or position of vulnerability.
● The purpose of trafficking is always exploitation.
HOW IS HUMAN TRAFFICKING DIFFERENT FROM MIGRANT SMUGGLING?

These are two distinct but interconnected crimes. Both are illegal activities that treat people as
commodities. While trafficking in persons is a crime that aims to exploit a person who may or may
not be a migrant, smuggling of migrants does not, by definition, involve the exploitation of the
migrant. Trafficking victims can be trafficked within their home country or internationally, whereas
migrant smuggling always crosses national borders. Some trafficked people might start their
journey by being smuggled into a country illegally, not knowing the intention of the trafficker to
exploit them, or find themselves deceived, coerced or forced into an exploitative situation later in
the process, for example being forced to work for no or very little money to pay for their
transportation. Criminals may both traffic and smuggle people, employing the same routes and
methods of transporting them.

WHO ARE THE VICTIMS OF HUMAN TRAFFICKING?

Victims of trafficking can be any age, any gender and from anywhere in the world. According to
UNODC’s 2020 Global Report on Trafficking in Persons which is compiled using official figures from
over 148 countries, female victims continue to be the primary targets. The Report shows that in
2018 46 percent of detected victims were women and 19 percent girls. For male victims the
Report shows that 20 per cent of detected victims were men and 15 per cent were boys. The
Report shows that the share of children among detected trafficking victims has tripled while the
share of boys has increased five times over the past 15 years. Globally, one in every three victims
detected is a child. Girls are mainly trafficked for sexual exploitation, while boys are used for
forced labour. The share of detected male victims has risen from around 10 per cent in 2003 to 20
per cent in 2018.

WHY ARE PEOPLE TRAFFICKED?

Traffickers target people who are marginalized or in difficult circumstances. Undocumented

migrants and people who are in desperate need of employment are vulnerable, particularly to
trafficking for forced labour. Victims may be forced or tricked into an exploitative situation which
constitutes trafficking after the traffickers uses violence, deception or blackmail. Criminals
trafficking children target victims from extremely poor households, dysfunctional families or those
who are abandoned and have no parental care.
People have been migrating all over time. The contribution of genetics and paleoanthropology to
overcoming the concept of race and to the scientific reconstruction of the mobility of the human
species on the planet. Important scientific acquisitions have been possible through studies on
mitochondrial DNA haplogroups and Y chromosome markers. “The haplogroup that came out of
Africa (L3) dates back to a period between about 63,000 and 83,000 years ago. Modern humans
entered Europe about 45,000 years ago.” (Prof. Antonio Torroni, Università di Pavia, Intervento
all’ISS del1.06.2016).

Factors involved in migration

PUSH Factors PULL Factors

● Escape from poverty ● Availability of job

● War / political instability ● Peace /political stability
● Persecution ● Protection /respect of civil rights
● Natural disasters ● Safe nature / climate
● Lack of opportunities/services ● Education, health care
● Family separation ● Family reunification

Choice factors

● Cultural affinity
● Same/similar/easier language
● Presence of a strong own community
● Better climate
● Traditional sports
● Believes / legends

+ different degree of freedom in migration experience

Migration in the world at a glance

What is new?
 ● 3.8 millions are Venezuelans displaced abroad;
● A total of 4.9 million Venezuelans have left their country at the end of 2020;
● People are leaving Venezuela for many reasons including violence, shortages of food and
medicine;
● Ukraine crisis.

The health needs of refugees from Ukraine

● The vast majority of refugees are women, children, and older people
● Routine vaccination coverage in Ukraine was low before the war (susceptible to infectious
diseases).
● Vulnerable to covid-19 (only 36% of the population fully vaccinated)
● For women, need to access to sexual and reproductive healthcare
● Pre-existing chronic conditions (about a third have hypertension and 7% have diabetes;
one of the highest burdens in Europe of chronic infectious diseases, especially HIV and
tuberculosis)
● Mental disorders (exposure to traumatic events and ongoing daily stressors)

«Missing Migrants Project records since 2014 people who die in the process of migration towards
an international destination, regardless of their legal status. As collecting information is
challenging, all figures remain undercounts. The locations in most cases are approximate. Each
number represents a person, as well as the family and community that they leave behind.»

Migration and law: the effect of policy

From 2018 to 2019 regular migrants decreased in Italy from 3,717,000 to 3,615,000 (-2.7%)

● “Security decrees” (2018 and 2019) and abolition of residence permit for humanitarian
● reasons;
● Decline of recognition of international protection (from 32.2% in 2018 to 19.7% in 2019);
● No repatriating;
● “Closing ports” to migrants.

A preliminary and general consideration: Although the recent waves of migration - characterized
by international protection seekers - are of significant size and are putting pressure on the welfare
systems of European countries, we must not take the risk of restricting the whole phenomenon of
migration to a partial and contingent component of it.

2,470,000 families: More than 7% of all families in Italy have at least one foreign component. The
70% has all foreigners components.
Health aspects of migration

The groups who have experienced (or have a previous experience/family background of) migration
have in average:

❖ a life expectancy lower than the general population

❖ an increased infant / child mortality
❖ more often reports of a status of poor health
❖ more frequent mal-treated access to the health services (either over- or under-used, or
both)
❖ a higher risk to be treated insufficiently by the health services

They tend to be forced to reside/ to dwell in settings of low quality (poor conditions),
overcrowded, often marginalized in degrading urban areas, where there is limited access to
services and high levels of criminality. Also, they have on average higher incidence of poverty,
higher incidence of unemployment, receive lower salaries, and usually are depending on public
financial support (whenever this is available), compared to the rest of the population.
The immigrant workers are more often subjected to a role of “not trained”, to a situation of
irregularity/illegality and under-payment, frequently undertake jobs of a high risk of accident,
because of exposure to toxic or to unhealthy work environment, with inadequate measurements
of protection and inadequate or absent equipment, with more working hours than normal and
insufficient insurance.

The situation is becoming worse by the addition of problems of linguistic and cultural nature,
which are likely to increase the risk factors at work. In fact, the incidence of work accidents among
the immigrants in Europe is nearly double as much as the incidence of work accidents among
“natives”.

Health conditions at the place of origin: It’s not easy to have reliable information, because the
more the country has geopolitical or socioeconomic problems, the weaker its Health System and
the Information systems arranged by it.

The healthy migrant effect: A strong body of literature describes the fact that on many measures,
first generation immigrants are often healthier than country-born residents who are of similar
ethnic or racial background. In this sense, they are generally in good health conditions.

This is mainly explained with a self-selection at migration, where healthier and wealthier people
tend to be migrants, but it is likely that in the case of international protection seekers self-
selection does not always act.

Health condition and travel: It depends on the type of the travel - which in turn depends on the
economic availability of the person / family (by airplane, by a tourist bus, bay train, bay boat, by
foot, hidden in or under a truck)
Health conditions related to the interception context:

Health conditions at destination (after a certain period):

The exhausted migrant effect: Over time, (family reunion, 2nd generation), the migrant health
advantage can diminish dramatically according to the success or failure of the migration project
and the consequent life conditions.

Salmon effect: “the compulsion to die in one’s birthplace”

“Compared with natives, immigrants generally have a lower all-cause mortality rate despite their
lower socioeconomic status, which is associated with poor health in terms of both morbidity and
mortality. Several explanations have been proposed for this epidemiological paradox. The healthy
migrant effect hypothesis posits that migration is selective of healthier individuals: migrants are
healthier than the native people both of the country of origin and of the country of destination.

A second hypothesis is the so-called salmon bias effect, an expression first used by Pablos-Mendez
to describe “the compulsion to die in one’s birthplace”. This hypothesis asserts that many
immigrants return to their country of origin when they expect to die shortly. If deaths occurring in
their country of origin are not registered in the mortality statistics of the country of residence,
some individuals become “statistically immortal”, resulting in an artificially low immigrant
mortality rate. The salmon bias was advanced as a possible explanation of the “Hispanic paradox”,
the lower mortality rate of Hispanics than of non-Hispanic whites in the United States, despite the
former having a more disadvantaged risk factor profile.

Several studies have evaluated the hypothesis that any survival advantage for immigrants
compared to natives may merely be a statistical artifact; the mobility of immigrant populations
may cause an undercoverage of deaths and/or an overcoverage of the resident population in
demographic registers.

However, the salmon bias has not been convincingly documented, and, to our knowledge, it has
never been evaluated in Italy. Previous Italian studies found that immigrants showed a lower risk
of mortality compared to Italians, although unregistered remigration (delays in registration in
municipal registries of the final return to the country of origin), which inflates the mortality rate
denominators, has been postulated”.
Migrant’s health a few years ago:

● GROWING ACCESS TO NHS

● GROWING SOCIAL FRAILTY: Growing work accidents, Abortion rate 3-4 times higher than
in Italian women, Inappropriate recovery
● EFFECT OF AN UNCERTAIN WELCOME
● EFFECT OF A NON GOVERNED MIGRATION
● EPIDEMIOLOGICAL TRANSITION

Covid-19: incidence in migrant communities. In Europe, significant over-representation of

immigrants in the incidence of COVID-19 (confirmed cases). In Norway, 31% are foreign-born,
almost twice as much as their In Sweden, 32% of cases being immigrants (against 19% in the
population). In Denmark, immigrants account for 18% of the infected, twice as many as their share
in the Danish population. In Portugal, 24% of COVID-19 infections in Lisbon are immigrants (mainly
from Africa). Outside Europe, immigrants are also disproportionately affected by COVID-19 (es. in
Ontario, 43.5% of cases).

In Italy data from the Superior Institute of Health showed that 5% of cases concerned foreigners,
only about half of their share in the population.

● different demographic composition (immigrants are younger on average and are less likely
to show COVID-19 symptoms);
● The number of confirmed cases is driven by the national testing strategy.
● Limited testing capacities in some countries in the early phases of the pandemic hampered
large-scale population testing;
● the number of confirmed cases by origin is also impacted by the ability of each country to
reach the most vulnerable groups, among them immigrants and their specific issues (e.g.
lack of host-country language proficiency, legal status).

Immigrants have paid a higher toll with respect to the incidence of COVID-19, with higher infection
risk and higher mortality, despite having a younger age on average.

COVID pandemic enhanced the meaning of global health, showing the deep relation among health
and health determinants, as work, environment and economy.

● Living in crowded conditions, with difficulty in self-isolating and maintaining social

distancing (e.g. reception centers);
● Poor hygiene and reduced access to clean water;
● Reduced access to knowledge and information about COVID-19;
● No socioeconomic or technical means (such as Internet access) to care for themselves and
their families during isolation.

European Public Health Agency and European WHO:

● Develop health-related messages that reach everyone in the community contributes to

promotion of behaviors that can contain or stop the outbreak;
● All national health-care initiatives must be afforded to all migrants to ensure the
protection of the human right to health;
 ● Specific measures to reach marginalized or hard-to-reach groups;
● Provide information in appropriate languages by translating written materials;
● Ensure that fear of registration for some groups of migrants and refugees will not prevent
them from seeking health care

Access to vaccination in Italy for migrants:

● starting in June 2021, in some Regions irregular migrants have been vaccinated in an
inhomogeneous and irregular way.
● People who risk remaining on the sidelines or to be excluded by the system are:
● 500,000 immigrants without a stay permit who can have the STP code to access medical
services;
● an additional tens of thousands of EU citizens who are irregularly residing in the country
(very difficult to quantify) who can apply for an ENI card to get health benefits;
● 200,000 foreigners who have requested a regular stay permit and have not received a
reply yet and are in an "administrative limbo".
● Caritas said there are also over 500,000 homeless people, including many who are not in
contact with volunteer organizations.

Some critical situations for migrants health:

● Forced migrants
● Mental health (specially asylum seekers and refugees)
● Occupational health (higher risk for some unskilled workers...)
● Prisoners (> 30% vs. 8%, a few communities among 200...)
● Discriminatory behaviors in some health services
● Reproductive health (abortion rates, oncological screening...)

Forced migration is a general term to describe a migratory movement in which an element of

coercion exists, including threats to life and livelihood, arising from natural or man-made causes,
such as movements of refugees and internally displaced persons as well as people displaced by
political instability, conflict, natural or environmental disasters, chemical or nuclear disasters,
famine, or development projects.

Under the UN Convention 1951, a refugee is a person who, “owing to well-founded fear of
persecution for reasons of race, religion, nationality or membership of a particular social group or
political opinion, is outside the country of his/her nationality and is unable or, owing to such fear,
is unwilling to avail him/herself of the protection of that country; or who, not having a nationality
or being outside the country of his/ her former habitual residence, is unable or, owing to such fear,
is unwilling to return to it.”

An asylum-seeker is an individual who is seeking international protection. In countries with

individualized procedures, an asylum-seeker is someone whose claim has not yet been finally
decided on by the country in which he or she has submitted it. Not every asylum-seeker will
ultimately be recognized as a refugee, but every refugee is initially an asylum-seeker.

Internally displaced persons, or IDPs, are among the world’s most vulnerable people. Unlike
refugees, IDPs have not crossed an international border to find sanctuary but have remained
inside their home countries. Even if they have fled for similar reasons as refugees (armed conflict,
generalized violence, human rights violations), IDPs legally remain under the protection of their
own government – even though that government might be the cause of their flight. As citizens,
they retain all of their rights and protection under both human rights and international
humanitarian law.
Policies for health
Quantitative studies on administrative and other health information systems e.g. hospital
admissions – DRGs, outpatients dataset, disease registers… on ad hoc studies

Qualitative studies on ad hoc studies (ethnographic observation, focus group, interviews...)

The shadow areas: available and affordable data source about health and health care: inadequacy
of health information systems; to evaluate health needs of immigrant population on the target
population: inadequacy of demographic information systems lack of a universally agreed definition
of what constitutes a migrant; the “denominator problem” absent / difficult registration of
irregular migrants; the data interpretation.
Health policies: values and approaches

● The right to health (ethics and laws)

● A correct information on the right to health care (health information)
● The real possibility of using (what makes the practical and effective use of) the health care
services (organization)

Access to health care by all must be considered as a prerequisite for public health in Europe and
an essential element for its social, economic and political development, as well as for the
promotion of human rights.

The European Parliament: “whereas universality, access to high-quality care, equity and solidarity
are common values and principles underpinning the health systems in the EU Member States”
(point A); "whereas health inequalities are not only the result of a host of economic,
environmental and lifestyle-related factors, but also of problems relating to access to healthcare”
(point P); "whereas in many EU countries equitable access to healthcare is not guaranteed, either
in practice or in law, for undocumented migrants" (point AD)

"Calls on the Member States to ensure that the most vulnerable groups, including undocumented
migrants, are entitled to and are provided with equitable access to healthcare; calls on the
Member States to assess the feasibility of supporting healthcare for irregular migrants by
providing a definition based on common principles for basic elements of healthcare as defined in
their national legislation; (point 5)

“Calls on the Member States to promote access to high-quality legal advice and information in
coordination with civil society organizations to help ordinary members of the public, including
undocumented migrants, to learn more about their individual rights; (point 8)

"Calls on the Member States to ensure that all pregnant women and children, irrespective of their
status, are entitled to and actually receive social protection as defined in their national legislation;
" (point 22).

The real possibility of using the health care services:

● bureaucratic / administrative
● economical / financial
● organizational
● psychological
● linguistic - cultural
“Developing and training staff to be culturally competent”: The resource of Medical Education

“In confronting health care disparities and addressing the increasing racial and ethnic diversity of
the U.S. population, the development and implementation of cultural competence training
programs for health care providers has emerged as a key intervention strategy.

Cross-cultural education programs, another term for this type of training, are viewed as a means
to enhance health professional’s awareness of how cultural and social factors influence health
care. Effective training programs promote and provide methods to obtain, negotiate, and clinically
manage this information”.

The case of Italy

Starting in 1860, and for a period of nearly 100 years, more than 27 millions of Italians migrated
abroad. During the first 10 years of the 20th century, the Italians who had moved abroad for work
counted on average 600.000 persons per year (on a total Italian population of about 33,5 millions
in the year 1900). The highest number was recorded in 1913, with approximately 900.000 persons
leaving the country. It is estimated that, at the moment, there are about 4 millions of Italians living
abroad, whereas the people of Italian origin represent a number of about 60 millions worldwide.

The Italian Constitution (1948)

32nd Article: “The Republic safeguards health as a fundamental right of the individual and as a
collective interest, and guarantees free medical care to the needy. No one may be obliged to
undergo any given health treatment except under the provisions of the law. The law cannot under
any circumstances violate the limits imposed by respect for the human person”.

The Italian Law on the Migrant Rights to Health Care: In Italy the current regulations on the
available health care services for immigrants date back to a comprehensive law, entitled “Single
Text on Immigration” (D.Lgs. 286, articles 34th, 35th and 36th) approved in 1998, and successive
regulatory provisions (mainly the DPR 394/1999, articles 42nd, 43th and 44th and the Circular n. 5
del 2000 of the Health Department).
Legal migrants: Complete equality of rights and obligations with italians, universal health coverage
from the NHS.

Essential health care levels (LEA), schematically:

1. Community health care in living and working environment

2. District Health Care
3. Hospital Health Care

In Italy the registration to the National Health System is mandatory for asylum seekers and
refugees.

Undocumented migrants (STP and ENI): Broad possibility of health protection and health
assistance.

● Provision of hospital and outpatient care, albeit continuous, for emergency, essential
illness conditions, preventive medicine and rehabilitation by the delivery of 'STP’ Card
(valid on national territory, semi-annual and renewable) and contrast of economic barriers
in case of indigence
● Particular protection for women and children
● Special attention to infectious diseases and international prophylaxis
● Prohibition of reporting undocumented immigrants who have applied for or received a
health service to the Police authority.

The Italian Society of Migration Medicine (SIMM) was established at the beginning of 1990. With
about 500 active members, SIMM can be considered not merely a Scientific Society, but also a
national "policy network" for exchanging experiences, data, scientific evidence and considerations
on health policy, including at the local level, relating to migrants' right to health care. Since its
founding it has influenced, through its constant action of advocacy, most national health care
policy decisions in this sector, which has led to the enactment - not without controversy and
difficulty - of the Italian inclusive laws.
A recent and important success: Children of immigrants without a stay permit may have their own
personal pediatrician ‘of trust’

2017-2018 : elaboration of the 3 Guidelines produced by the Italian Society of Migration Medicine
(SIMM) in collaboration with the Ministry of Health (victims of psychological, physical or sexual
violence) and with the INMP and the ISS (Border Checks... and Control of TB...): valuable tools for
the dissemination of an evidence-based culture and therefore of good governance, as well as anti-
discrimination in public communication.

Guidelines for the planning of care and rehabilitation interventions and for the treatment of
psychological disorders of refugee and subsidiary protection status holders that have suffered
torture, rape or other forms of psychological, physical or sexual violence.

15th (may 5): GENDERING MIGRATION POLICIES AND PRACTICES

Migration flows: the missing voices of migrating women

Migration is a structural phenomenon of human history: the journey is one experience that is
changed with violence and abuse for all. Yet, there is profound difference in the journey for
women, who are the most vulnerable migrant people, since there is a recurrent use of violence on
women’s bodies in the different routes. Women have traditionally been a significant portion of
migrants to Italy, and their number has increased in the last few years especially – but not
exclusively - due to the figures related to refugees from the war in Ukraine.

There is an inexhaustible strength of women – they are survivors, but they are generally
represented as victims; and they are also not only as migrating mothers. In this sense, we need a
feminist approach as an element of innovation, mutual recognition and design of a diverse society.

Women moving before industrialization in Italy

Women were central to migration to the burgeoning city of Turin, capital of the Duchy of Savoy in
Italy in the 18th and 19th centuries. EU-funded research found that women were not mere
followers of male migrants, but proactive players, as well as working extensively in the service
sector as servants, waitresses, chambermaids and governesses, female migrants also pushed into
the craft and manufacturing sectors. They spun and wove silk, made laces, ribbons and trimmings,
sewed and knitted from their homes and also worked in workshops and the first factories. Some
were shoemakers and cobblers. In the 19th century an increasing number of them joined the
tobacco industry.

What do women escape from?

● Women escape from wars and conflicts (of course)

● They escape to escort their children to a better life (Eritrea, Afghanistan, Yemen)
● They escape from patriarchal societies – male dominance over women is the harshest of
wars, even when the country is at peace!
● They run away from social conventions, and the women enforcing them – such as forced
marriages
● They escape from female gential mutilations (and take their girls to spare them)
● They choose to live life in freedom and in dignity – education, professional achievements,
independence from ..
● They escape for health reasons (cancers /children’s illness)

Human trafficking: for 70% of the trafficking, 20% are girls and 50% women.

Beyond the neutral narrative

Humanitarian assistance and migrants’ care and social assistance are still gender blind, in Italy and
elsewhere, and only with difficulty do they acknowledge the gender factor in dealing with
migration flows.

Through migrant women’s life stories, it is possible to adjust and focus reception policies and the
forms of assistance to tailor protocols that are more reliably based on the multiple realities of
women’s needs and aspirations.

Training curricula for health personnel and migrants’ assistance teams must be changed to gain
capacity for better service provision, including advocating for national policies recognizing the
opportunity of migrant womens’ presence in a given reception country.

The stories migrant women have to tell are important because there is an urgency to bridge a gap
- the stories of migrant women have not yet been heard and collected; there is no memory of
them.

Also, storytelling helps manage loneliness, fear, and women's sense of impotence. Words may
even project scenarios of individual life-rebuilding.

Memory serves the purpose of a deep reconstruction of women’s cultural identity and experience.
Through memory, women can elaborate counter-narratives, through their protagonism, beyond
false representations and stereotypes;

● Storytelling seen as self-empowerment: truth, justice and reparation

● Narrative as an advocacy tool, primarily to improve current shelter services
● Political and cultural urgency of the operation

17th (may 12): DIGITALIZATION AND HEALTH

https://drive.google.com/file/d/1dsKf0cRA2bHRmFRYHBm07bAAAcrcmAli/view

18th (may 15): UNIVERSAL HEALTH COVERAGE

The UHC theme draws its cultural-historical origin from the 1978 Alma Ata Conference with its
hopeful slogan "Health for All by the year 2000" The Alma Ata Declaration introduced the concept
of Primary Health Care (PHC) as the key to succeeding in providing better health for all. It called for
urgent and effective action at the national and international levels to develop and implement
primary health care in all parts of the world, particularly in developing countries, in a spirit of
technical cooperation and in accordance with a new international economic order.

A further and complementary cultural elaboration can be traced to the 1986 Ottawa Charter,
which was drafted at the first International Conference on Health Promotion organized by WHO,
Health and Welfare Canada and the Canadian Public Health Association.

Among the Charter's innovative concepts-aside from a strong emphasis on concepts related to
community participation such as empowerment -was the understanding of health as a resource
for everyday life and not as a goal to be achieved.

The conception of health thus acquires a broader vision by also including education, hygiene, and
attention to healthier lifestyles and eating styles.

Therefore, health promotion was no longer seen as the responsibility of the health sector alone,
but had to be expanded to other sectors (e.g., agriculture, food, housing, education, etc.) in an
intersectoral policy perspective.

The revolution wrought through the concept of health promotion, schematically understood as a
process resulting from the involvement of multiple dimensions and the concurrence of multiple
actors, led in 2000 to the identification of the Millennium Development Goals (MDGs), to be
achieved by 2015.
The 8 Goals identified aimed, among others, to halve extreme poverty and halt the spread of
HIV/AIDS.

The concept of UHC was formally introduced in the United Nations General Assembly Resolution
on Global Health and Foreign Policy and passed (unanimously) on 12 December 2012.

It is recognized that health is an important cross-cutting policy issue in the international agenda, as
it is a precondition, an outcome and an indicator of all three dimensions (social, environmental
and economic) of sustainable development.

The resolution therefore calls on Member States to adopt a multi- sectoral approach and to work
on the social, environmental and economic determinants of health to reduce inequalities and
enable sustainable development.

In 2015 the United Nations launched the 2030 Agenda for sustainable development in which,
among the other targets of the SDGs (evolution of the previous MDGs), UHC is recognized as a
pillar to guarantee the development of the poorest sections of the population The Agenda offers a
new opportunity to ensure that all people can live in health, dignity and equality.

The slogan "Health for All and All for Health", which recalls the principles previously expressed by
the Alma-Ata Declaration and the Ottawa Charter, captures the commitment to leave no one
behind and to involve all actors in a new global partnership to achieve the proposed goals,
considering UHC the perfect goal to ensure inclusion, equity and reduce health inequalities.

Good health and well-being, formally focused on in the 3rd of the 17 SDGs, are central to and
actually closely related to many other formal goals.

SDG 3 consists of 13 targets, v additional targets closely related to health are present in other
SDGs:

● 2.2 on malnutrition,
● 6.1 on drinking water;
● 6.2 on sanitation;
● 7.1 on energy sources;
● 11.6 on air quality and waste management;
● 13.1 on climate-related hazards and natural disasters;
● 16.1 on violence;
● 17.19 on data recording

Target 3.8. Universal Health Coverage: Universal health coverage (UHC) means that all people have
access to the full range of quality health services they need, when and where they need them,
without financial hardship. It covers the full continuum of essential health services, from health
promotion to prevention, treatment, rehabilitation, and palliative care across the life course.
An ideal health care system should be able:

● to reach the entire population by extending health care coverage even to those who were
excluded from it (universality),
● to guarantee all necessary services and benefits (comprehensiveness)
● to do so without burdening the population with additional direct costs (free of charge).

WHO uses a cubic scheme to represent and assess the degree of UHC present within a country.

1. the horizontal axis characterizes the population, that is, how much of the people who
need the services are reached (universality);
2. the depth-related axis represents services, that is, how much of the services the
population needs are provided (comprehensiveness);
3. finally, the vertical axis characterizes costs, i.e., the contribution of public health
expenditures for health services needed by the population (free of charge).

The case of Senegal showing estimable deficiencies relative to the three descriptive dimensions of
UHC:

- the horizontal axis shows that only 25% of the population has access to health care, in fact
coverage is low especially in informal sector workers and rural areas

- the depth axis is not complete, with poor services especially for drugs and outpatient visits.

- in the vertical axis we see that costs are covered at nearly 80% when having employer-based
mandatory insurance (mandatory schemes), while government medical assistance and subsidized
care (MASC) covers a lower percentage.

Finally, voluntary community-based health insurance (CBHI) covers only a small portion of the
costs incurred by the population.

How to measure the UHC?

3.8.1 The UHC Service Coverage Index seeks to assess the universality of the population covered
and the comprehensiveness of the services provided. It considers 16 tracer indicators, 4 for each
of the following 4 areas:

a) reproductive, maternal, newborn and child health;

b) infectious diseases;

c) non-communicable diseases;

d) ability to offer services and their accessibility.

UHC SCI values range from 25.0 to 88.7. The data were divided into 6 classes, the same as those
used by WHO, and each was assigned a value ranging from 0 (very poor) to 5 (0 very good).

3.8.2 The incidence of catastrophic expenditure on health This indicator is measured by the
number of households in which out-of-pocket expenditure on health exceeds 10% or 25% of the
total income (or consumption) of the household, considered as the threshold of a household's
ability to pay.

Incidence of catastrophic expenditure on health

● The threshold is presented that shows the best situation, i.e., that of 10% (without using
the worst threshold of 25%).
● The percentage of population with catastrophic expenditures varies between 0.2% and
54.2%.
● The data were divided into 6 classes, the same as those used by WHO, and each was
assigned a value ranging from 0 (very poor) to 5 (0 very good)

Combination of indicators 3.81 and 3.8.2: Joint levels of service coverage and financial protection
are available limited to those 76 countries (62% of the world's population in 2015) with primary
data on catastrophic health expenditure for the period 2008-2015 and simultaneously with
primary data for at least half of the components of the services coverage index.

● 9 countries classified as low-income (equal to 32% of the population living in low-income

countries in 2015),
● 23 low-middle income countries (equal to 87% of the population of in 2015),
● 21 upper-middle-income countries (37% of the population of upper-middle-income
countries in 2015),
● 23 high-income countries (69% of the population in high- income countries in 2015) .

The population of low-income countries is underrepresented due to the lack of data for one or
both indicators.

The Cartesian plane is divided into four zones delimited on:

● the X axis by the median value of the UHC SCI (equal to 65 calculated on 183 countries)
● the Y axis by the median of the ICHS considering the 10% threshold (equal to 7 .1%
calculated on 132 countries for which there are primary data).
 ● a total of 22 countries, out of the 76 considered, have relatively high indices of coverage of
services and financial protection, which is the objective of the UHC (in area Z-IV);
important to underline that it is only about 12% of the world's population, while the
remaining 88% do not fully benefit from UHC.
● 22 other countries have high values of the services coverage index, but the incidence of
catastrophic expenses is also relatively high (in area Z-I).

All 23 high-income countries (defined in the figure by the red triangle) have above-median levels
of service coverage, occupying zones IV and I, although those in zone I do not deal equally well
with protect families from catastrophic health-related spending.

● in 16 countries, out of the 76 considered, many people sustain high out-of-pocket

expenses, but the average coverage of services is low (in area Z-II);
● for the other 16 countries (which have low both coverage of services and the percentage
of population with catastrophic health expenditure), the challenge would be to increase
coverage of services without increasing financial hardship (in area Z-III);

Out of 9 low-income countries (defined in the figure by the blue circle), 7 are in quadrant Z-III,
where service coverage is low, but this may be why even the fraction of the population spending
more than 10% of their budget on health is low.

There are relatively few countries that occupy the most critical areas in terms of service coverage
(zone II and III). However this could depend on the fact that there is no data on catastrophic
expenditure for countries that have a very low level of UHC.

In fact, the figure shows the situation of only 76 countries due to the lack of economic data for the
others.

Not unexpectedly, only 13 of the 35 countries with a very low UHC SCI level (below 45) are
available, with no data from Afghanistan, Benin, Burundi, Chad, Eritrea, Ethiopia, Guinea-Bissau,
Kiribati, Liberia, Madagascar, Mali, Mauritania, Papa New Guinea, Rep. of Central Africa,
Democratic Rep. of Congo, Sierra Leone, Somalia, South Sudan, Sudan, Togo, Uganda, Yemen.

SDG 1 indicator: Health-related impoverishment (of SDG 1) occurs when a household is forced by
an adverse health event to divert related costs from non-medical budget items such as food,
shelter and clothing. It is based on internationally established poverty lines, specifically $1.90 per
day using 2011 purchasing power parity (PPP) for extreme poverty and $3.20 PPP per day for
moderate poverty.

Of the indicator, the threshold of $3.20 PPP per day is presented (without using the extreme
poverty line set at $1.90).

• The percentage of the population impoverished due to health varies between 0 and 6.18%.

• The data were divided into 6 classes, the same as those used by WHO, and each was assigned a
value ranging from 0 (very poor) to 5 (0 very good).

Composite indicator values and score assigned: The average of the scores of the first 3 indicators
for each country (UHC-SCI, the incidence of catastrophic
spending on health and Impoverishment due to health expenditures) was calculated, in which

-the UHC SCI has weight equal to 100% of its value,

-while the two financial indicators (health spending above 10% and impoverishment below the
$3.20 threshold) are worth 50%of their value.

In relation to the average if a country is:

-in the top two levels is in acceptable situation (dark and light green)

-in the middle level it is in a warning situation (yellow)

-in the two worst levels it is in a catastrophic situation (red and orange)

In addition to the color representation each score has been associated with a notch symbol.

Gini coefficient: The data are updated to the latest available year for each country with variations
between 59.1 and 24.9. The data were divided into 6 classes, the same as those used by WHO, and
each was assigned a value ranging from 0 (very poor) to 5 (0 very good)

Simulations: Simulations can provide “food for thought” from the data presented, remembering
the need for contextualization and adaptation to the case of interest.

The choice of countries on which to run the simulations was made trying to cover differences in:

● geographic area
● data availability (comprehensive, lacking, missing)
● socio-economic differences
● contingent historical facts and economic reforms

Simulation Romania

- Romania's situation in terms of universal health coverage is improvable. In particular, the most
worrying aspect relates to catastrophic health expenditures

- For 0.55% of the population, these expenses result in falling below the poverty line of $3.2 PPP
per day

- In addition, the Gini index gives us a picture of a country where there are inequalities in terms of
income distribution in the population but they do not seem so pronounced (in terms of
comparison, the Gini index for Italy in the same year -2017- was 35.9)

UHC SCI = Value 74; GOOD

ICHS = Value 13.42%; VERY LOW

Impoverishment = Value 0.55%; MEDIUM GOOD / CRITICAL

Average of the three indicators = Value 2.8; GOOD

GINI Index = Value 36; GOOD

Simulation Senegal
• UHC SCI = Value 45; assigned score 1; POOR score

• ICHS = Value 3.33%; assigned score 2; score MEDIUM

• Impoverishment for health expenditure = Value 1.13%; assigned score 2; score MEDIUM
POOR/MOST CRITICAL

• Average of the three indicators = Value 1.5; assigned score 1; score POOR

• GINI index = Value 40.3; assigned score 1; score POOR

The level of health coverage in Senegal appears largely improvable. In fact, both the level of
coverage of health services identified as essential (shown by the UHC Service Coverage Index) and
impoverishment due to health expenditures highlight clear critical issues in the system.

Comparison of the data involving the financial protection aspect (catastrophic health expenditures
and impoverishment due to health expenditures) shows that although the percentage of the
population forced to incur out-of-pocket expenses for health exceeding 10% of household income
does not seem particularly worrisome, when compared with the other countries, the effect in
terms of reduction in poverty for these expenses is dramatic. Moreover, the Gini index gives us a
picture of a country where income inequality is considerable.

Simulation Nepal

• UHC SCI = Value 48; assigned score 1; score POOR

• ICHS = Value 10.71 %; assigned score 1; score POOR

• Impoverishment for health expenditure = Value 3.68 %; assigned score 0; score VERY LOW

• Average of the three indicators = Value 0.8; assigned score 0; score VERY LOW

• GINI index = Value 32.8; assigned score 3; score GOOD

Nepal's situation in terms of universal health coverage is problematic. Both the level of coverage
of health services identified as essential (shown by the UHC Service Coverage Index) and the
indicator for catastrophic health expenditures indicate difficulties in ensuring that the population
has adequate access to health services. Moreover, the percentage of people impoverished due to
health expenditures is among the highest globally, adding a note of urgency to the overall picture.

Simulation Chile

• UHC SCI = Value 70; assigned score 4; score GOOD

• ICHS= Value 14.6%; assigned score 0; score VERY LOW

• Impoverishment for healthcare costs = Value 0.06%; assigned score 4; score GOOD

• Average of the three indicators = Value 3.0; assigned score 3; score GOOD

• GINI index = Value 44.4; assigned score 0; score VERY POOR

Chile is able to offer the population good health coverage, albeit with several critical issues.
Indeed, if the level of coverage of essential services appears to be satisfactory, the level of
catastrophic health expenditures is critical: the percentage of the population that spends more
than 10 percent of their income on out-of-pocket expenses for health is high, ranking in the "poor"
and "very poor" classes. Although many people thus incur large expenditures on health, such
expenditures are rarely such as to push them below the poverty line identified as $3.2 PPP per
day.

Access to vaccination for newly arrived migrants

Specific Objective 2: To characterize system barriers that hinder the immunization of NAM and to
identify possible solutions.

19th (may 19): SCIENCE & SOCIETY

Science is the pursuit and application of knowledge and understanding of the natural and social
world following a systematic methodology based on evidence. It’s the observation, identification,
description, experimental investigation, and theoretical explanation of natural phenomena.

Science is the study of the nature and behaviour of natural things and the knowledge that we
obtain about them. It includes any system of knowledge that is concerned with the physical world
and its phenomena and that entails unbiased observations and systematic experimentation. In
general, a science involves a pursuit of knowledge covering general truths or the operations of
fundamental laws.

Technology is the application of scientific knowledge to the practical aims of human life or, as it is
sometimes phrased, to the change and manipulation of the human environment.

SCIENCE, A RELATIVELY NEW HUMAN ENDEAVOR

https://www.britannica.com/science/history-of-science/Newton

Man has existed for about 1,000,000 years, Writing for 6000 years but SCIENCE:

● 6th century BCE pre-Socratic philosophers Thales and Anaximander studying nature to
understand it purely for its own sake
 ● 1543 SCIENTIFIC REVOLUTION: Copernicus, De revolutionibus orbium coelestium libri VI
(“Six Books Concerning the Revolutions of the Heavenly Orbs”)
● 17TH CENTURY: SCIENTIFIC METHOD, CREATION OF SCIENTIFIC SOCIETIES, To provide a
firm basis for SCIENTIFIC discussions, societies began to publish scientific papers.
● SECOND SCIENTIFIC REVOLUTION: 21st century. physics spilled over into chemistry and
biology and led to hitherto undreamed-of capabilities for the manipulation of atoms and
molecules and of cells and their genetic structures (Genetic engineering, Gene editing)

SCIENCE HAS TWO FUNCTIONS (Bertrand Russell, The impact of science on society, 1953)

● To enable us to KNOW things

● To enable us to DO things

These are two tracks that today constantly intersect (TRANSLATIONAL RESEARCH).

● TECHNOLOGY is as old as humans, however, only by the second half of the 19th century
science was able to provide truly significant help to industry (INDUSTRIAL REVOLUTION)
● 20 and 21st Century: TECHNICAL INNOVATION (new technologies: Computation,
Comunication, Artificial Intelligence).

EFFECTS OF SCIENCE

INTELLECTUAL EFFECTS: dispelling traditional beliefes and adoption of other sugested by scientific
method. E.g.: origin of the universe, nature of health and disease, ecology

SOCIAL EFFECT: technological driven social and political changes. E.g.: Globalization, humanity w/o
borders; humanity in the cyberspace, redifinition of privacy, public heath.

ENVIRONMENTAL EFFECTS: management of our environment. E.g.: new responses to global

climate changes (Green transition), adsquisition and loss of biodiversity.

Science, technology and innovation must drive our pursuit of more equitable and sustainable
development. Governments and citizens alike must understand the language of science and must
become scientifically literate.

Scientists must understand the problems policy-makers face and endeavor to make the results of
their research relevant and comprehensible to society.

SCIENCE IN A NEW CONTEXT

Science must respond to societal needs and global challenges. Public understanding and
engagement with science, and citizen participation including through the popularization of science
are essential to equip citizens to make informed personal and professional choices.

Governments need to:

1) understand the science behind major global challenges such as climate change, ocean
health, biodiversity loss and freshwater security.
2) make decisions based on quality scientific information on issues such as health and
agriculture
 3) Parliaments need to legislate on societal issues which necessitate the latest scientific
knowledge

21st CENTURY CHALLENGES FOR SCIENCE

The challenging environment for science in the 21st century. Nithaya Chetty
https://www.universityworldnews.com/post.php?story=20191111072602690

Politicization of research: The efforts required to advance knowledge for societal benefit are not
always understood and appreciated by society, including by decision-makers.

Global challenges: The world-wide science system has become enormous, and it is proving to be
extremely difficult to keep up with research outputs. The flood of information is overwhelming
with high risk of loss of impact or proliferation of duplicating efforts. Artificial Intelligence: a
solution or a threat?

Developing science responsibly: The big science questions need big – meaning expensive –
research infrastructures. This calls for large, multidisciplinary teams and multinational
collaborations. Avoid collateral damage and unintended consequences. E.g., harmful
environmental effects. Scientific endeavors and technologies with a military/dominance purpose.

Limited global resources: Power struggle for limited resources, risk of scientific colonization.

THE 21st CENTURY SCIENTIST

Up to the end of the third quarter of the 20th century the knowledge generating scientist (in the
biomedical sector) was an academic based in higher level educational institutions. Success was
determined by pier recognition and creation of “schools of thought”. Economic for profit
associations were considered as an aberration.

From the last quarter of the 20th century, academic institutions driven by the high costs of
research, political presure, opened to “investments from interested parties”. The most brillant
scientist were drawn into a “Business Model” of research that was rapidly incorporated within the
higher education institutions. Besides a high scientific profile, institutions also welcomed the
enterpreneur profile of the scientist, allowing the proliferation of research organizations
(BIOVENTURES) funded by capital venture financers that expect high retur on their investment.

SCIENCE IN TIMES OF CRISIS, Lessons learned from COVID-19*

https://read.oecd-ilibrary.org/science-and-technology/oecd-science-technology-and-innovation-
outlook-2023_0b55736e-en#page3

https://www.oecd-ilibrary.org/sites/855c7889-en/index.html?itemId=/content/component/
855c7889-en#wrapper

The pandemic did not wait for science, the pandemic dramatically disrupted normal scientific
practice itself.

NEED FOR ACCELERATING INNOVATION: Rather than simply producing excellent research, science
has had to engage rapidly with other sectors on a major scale to develop “fit-for-purpose”
technological tools and evidence”
Therefore, there was the need at a global level to urgently address:

Policy for science, i.e. the policies adopted to facilitate the necessary research for
addressing the pandemic. Access to data and scientific information; Mobilization of research
infrastructures; development of transdisciplinary research and multinational partnerships.

Science for policy, i.e. the policies adopted to ensure that research agendas reflected
policy needs, and that research evidence effectively informed policy and decision-making
(including by citizens). Ensuring that research addresses policy needs; The operation of science
advisory systems; public communication and engagement.

Partnerships are essential to deliver research and innovation for global health and partner
development. Much can be learned from successful co-operation between various actors during
the pandemic, but reinforcing these relationships over the longer term may require significant
change to academic culture, structures, incentives and rewards.

CHALLENGES TO THE OECD VALUES BASED MODEL

Research Partnerships are formed within a lack of global health ethics against an intricate
backdrop of many types of inequitable conditions and practices.

Low investment in research and development perpetuates the reliance on a small number of well-
resourced funders, philanthropies, and private industry, which gives them disproportionate power
to shape the global research and development agenda.

The wealthiest and best-equipped institutions and organizations have a significant advantage in
their competitiveness for research funding, and for exercising control over the goals and terms of
research partnerships.

This results in systematically unfair outcomes between partners in their ability to shape the
research agenda, their competitiveness for scientific productivity, impact, capacity building and
innovation.
 ● Current transdisciplinary, multilateral and global cooperation is contextualized within
political, economic, cultural and social narrative from the rich NORTH.
● The global development needs (health sector) are mainly framed within the PUBLIC
PRIVATE, NORTH/SOUTH scientific cooperation model.
● The OPEN SCIENCE AND OPEN DATA principle of cooperation is challenged as THE SECOND
CIENTIFIC REVOLUTION is happening in the NORTH, driven by the need of ECONOMIC
GROWTH FOR GEOPOLITICAL DOMINANCE
● Geopolitical tensions are contributing to strategic competition in emerging technologies

The OECD framework for emerging technology governance while highlights a series of standards
lacks: a benchmarking framework standards of best practice on which to model governmental,
corporate, non-profit, or academic collaborations, particularly for international collaborative
research and innovation involving low- and middle-income countries

There is a need for a tool that encourages all stakeholders in research and innovation for health to
begin reporting what is actually done within their organization to promote fair partnerships and
what improvements are being planned for going forward.

COHRED is an international non-governmental organization whose primary objective is to

strengthen research for health and innovation systems, with a focus on low- and middle-income
countries. COHRED supports countries to use research for health and innovation.

It sets a metric to address institutional fairness capacity for collaboration with other institutions /
organizations. RFI addresses 3 FAIRNESS DOMAINS FOR PARTNERSHIPS, each domain covers 5
topics, each topic can be measured through 3 indicadors. RFI has been recognized as a valid
reference tool by high level organizations however, it struggles to be implemented.

DOMAIN 1 FAIRNESS OF OPPORTUNITY

● Improve the participation of all concerned in research– often well before research even
begins.
● Sets the scene for the fair and efficient research conduct and the fair and efficient sharing
of costs and benefits later on.
● Fosters respect for the interests and limitations of other partners

DOMAIN 2 FAIRNESS OF PROCESS

● improve fairness in how research is conducted and research partnerships and programmes
are implemented.
● Encourages all who engage in research collaboration to make explicit their actions.
● It creates clarity in how different organisations deal with challenges, reducing negative
consequences of miscommunications or misunderstandings.
● Increases the capacity of all partners to live up to the expectations that others may have of
them.

DOMAIN 3 FAIR SHARING OF BENEFITS, COSTS & OUTCOMES

● Deals with improving fairness in sharing the costs, benefits and outcomes of research
EXAMPLES OF INDICATORS

- What would you consider ‘fair’ or ‘equitable’ if there are great differentials in purchasing
power among partners?
- Is there a potential that the research partnership may reduce the ability for normal service
delivery because of reducing access to staff and facilities?
- Does your organization have explicit pre- and post-research discussions and negotiations
with all partners concerning the sharing of IPR, Authorship, etc – now and in the future?

THE KEY QUESTION FOR COLLABORATION IN SCIENCE (or any other human endeavor): “Where is
your institution (that does or has some kind of part in the global research agenda) on the
colonizer/decolonizer scale?”

20th (may 22): THE STRUGGLE FOR HEALTH

Thoughts in/on/for times of transition

• From when and where

• The core challenge of a provoking title

• Key-words for a world of research laboratories networks

Chronological, geographical, thematic map

• 1945-75: UDHR, WHO, Constitutions, Decolonisation, Cold War

• 1976-79: Essential drugs, Alma Ata- HFA 2000, UDPR- Permanent Peoples Tribunal

• 1980-89: VLSRCT (population trials); IMF-WB ‘prescriptions’ as crimes against humanity; TINA
(there is no alternative); end of Cold War

• 1994-2002: IPPNW (Nobel prize); WTO; GBD (Global Burden of disease); Genocides- ICC; 9/11;
war as a condition for democracy...

• 2008-...: WHO-SDH; Acronyms vs reality: MDG, SDG, UHC… The first economic financial crisis of
globalization, Syndemics....Wars...COPs...

Human Rights in a Post-Human Era?(U. Baxi): Challenges-PERSPECTIVES

● Global vs Universal: Markets vs Humans: as ‘subjects’ of international laws, plannings,

contracts, conventions
● The global school of pandemia on the methodology for statistical genocides
● Evidences which quantify causes and outcomes vs Accountability, Avoidability, Impunity,
Repetition
● Relations, dialogue, dialectic vs virtual reality and AI
● Is to be ‘humans’ (with-not- against the rights of nature) a sufficient qualification for being
inviolable subjects of the right to an individual and collective life in dignity?

21st (may 26): HEALTH AND HUMAN RIGHTS INSIDE THE IMMIGRATION DETENTION FACILITIES

Health and human rights inside the Immigration Detention Facilities in Italy
Immigration detention is only meant to be used as a last resort and where it is necessary,
reasonable, and proportionate to a legitimate government objective:

• When someone presents a risk of absconding from future legal proceedings or

administrative processes

• When someone presents a danger to their own or public security.

Administrative deprivation of liberty should last only for the time necessary for the
deportation/expulsion to become effective. Deprivation of liberty should never be indefinite.

Immigration detention facilities: Possibility of arranging the detention of asylum seekers in special
rooms of the hotspots for the time strictly necessary, and in any case for a maximum period of 30
days, for the determination or verification of identity or citizenship.

"A foreigner found on the occasion of the irregular crossing of the internal or external border or
who arrived in the national territory following rescue operations at sea is taken for rescue and first
aid needs to special crisis points set up within the structures referred to in the decree-law of 30
October 1995, n. 451, converted, with modifications, by law 29 December 1995, no. 563, and of
the structures referred to in article 9 of the legislative decree 18 August 2015, n. 142. At the same
hotspots, photo dactyloscopic detection and signaling operations are also carried out, also for the
purposes referred to in articles 9 and 14 of EU regulation no. 603/2013 of the European
Parliament and of the Council of 26 June 2013 and information on the procedure for international
protection, on the relocation program in other Member States of the European Union and on the
possibility of using assisted voluntary repatriation is ensured.”

Hotspots → 4 Centers with a total Capacity of 890. During 2020 there was 24.884 people held in

Pre-removal Detention Centres

"When it is not possible to carry out immediately the expulsion by means of accompaniment to
the border or the refoulement, due to transitory situations which hinder the preparation of the
repatriation or the carrying out of the removal, the questore orders that the foreigner be held for
the time strictly necessary at the nearest detention center for repatriation, among those identified
or established by decree of the Minister of the Interior, in agreement with the Minister of
Economy and Finance. To this end, he submits a request for assignment of the post to the Central
Management of immigration and border police of the Department of Public Security of the
Ministry of the Interior, pursuant to article 35 of the law of 30 July 2002, n. 189. Among the
situations that legitimize the detention includes, in addition to those indicated in article 13,
paragraph 4-bis, also those attributable to the need to provide assistance to the foreigner or to
carry out additional checks regarding his identity or nationality or to acquire travel documents or
availability of a suitable means of transport.

• 10 Centers

• Total capacity: 1100

• Medium length of detention 2020: 14 days (Bari) – 74 days (Macomer).

• People detained in 2020: 4.387

Principle of Non-refoulement: Under international human rights law, the principle of non-
refoulement guarantees that no one should be returned to a country where they would face
torture, cruel, inhuman or degrading treatment or punishment and other irreparable harm. This
principle applies to all migrants at all times, irrespective of migration status.

Right to Health → Article 32 Italian Constitution: The Republic protects health as a fundamental
right of the individual and in the interest of the community and guarantees free care to the poor.
No one can be forced to undergo a certain medical treatment except by law. The law cannot under
any circumstances violate the limits imposed by respect for the human person.

The health condition of those who, due to their stay in detention centers, risk the aggravation of
previous pathological conditions or conditions that arose during detention itself, are
INCOMPATIBLE WITH DETENTION. Incompatibility must be assessed upon entry and be subject to
checks, both periodically and at the request of the migrant or the staff of the Centre. [UNHCR,
2012/2016]

Applicants whose health condition is not compatible with detention:

● minors
● disabled
● elderly people
● pregnant women
● victims of trafficking
● seriously ill or people with mental disorders
● victims of torture, rape, other forms of physical, sexual or psychological violence, or those
linked to sexual orientation or gender identity
● single parents with children can not be detained

Inadequate health assessment: «The migrant accesses the Center after a medical examination
carried out by the doctor of the ASL (Public Health System) or the hospital, who ascertains the
absence of obvious pathologies that make his entry and stay in the structure incompatible, such as
infectious or contagious and dangerous diseases for the community, psychiatric conditions, acute
or chronic degenerative pathologies that cannot receive adequate care in restricted communities»

• Lack of adequate premises of sanitary observation

• Presence of illegitimate isolation practices for suspects security reasons

The CPR provisions do not provide for, unlike the penitentiary system, the appeal to isolation (for
reasons of justice, health, disciplinary or security), but only the possibility to place the detainee in
a sanitary "observation" room, in case of presence of elements that may determine the
incompatibility with life in restricted community, which did not emerge during the eligibility
assessment.

CPR Torino - Ospedaletto

Guarantor of the rights of prisoners:

«Plexus located within the detention perimeter far from the medical center of the Center (located
in the building at the entrance) which differs from the ordinary detention sectors exclusively for
the presence of overnight rooms for two people. devoid of any assistance feature and without any
surveillance or communication device, such as an intercom, which allows you to come into direct
contact with the medical staff. The call system present inside the premises of the sector only
produces the activation of a signal on the push-button panels placed inside the sentry boxes where
the military personnel are stationed.

In addition to being inadequate as a health observation environment, the practice of use for
housing people with mental disorders connotes it as a place of segregation according to an
unacceptable mental asylum logic that responds solely to management needs harmful to the
dignity of the person "

Hossain Faisal, a Bengali citizen, born in 1987, died on 8 July 2019 in the CPR of Turin in the
Ospedaletto area. Hossain had been placed in solitary confinement since his arrival on February
16, 2019. The certification of suitability for detention drawn up by the internal doctor states that
the subject was compatible with detention at the CPR but given his confused and disoriented
state, the patient had to be kept under observation for a few days to establish whether he was
suitable to be detained. Two days later, in the doctor's statements, we read that "the guest
appears confused, not very present, he refuses any type of dialogue, always repeating the same
words". During two interviews with the psychologist on March 4 and May 6, Hossain remains
silent, does not answer questions, and the lack of knowledge of the Italian language makes
communication even more difficult. The man doesn't even respond to offers of clothing and
slippers and only asks for a cigarette. On July 8, 2019, Hossain died in the same cell n. 10 in which
he had been held almost five months earlier.

Due to the absence of health protocols between Prefectures and NHS, the psychiatric care in CPR
is almost completely absent as well as the monitoring of psychiatric cases and the administration
of psychiatric drugs is managed by psychologists and nurses appointed by the managing body.

No one is looking at us anymore: “Some of them were also found to be in a dazed state – with
shining eyes, thickened lips and mumbling – raising questions about whether they had been
administered psychiatric drugs.”

“Moreover, in most cases detainees complained that they were not fully aware of the drug
treatment they were taking and why they were administered it by the centre staff.”

In the CPR of Gradisca D'Isonzo, Orgest Turia, a 28-year-old Albanian, died on 14 July 2020, where
he had entered on 10 July 2020. On 10 July 2020 Orgest stole an unattended bicycle and was
arrested for resisting the police officers. He got a one-year suspended sentence. He was then
released, but as soon as he was released he was immediately taken to the Gradisca CPR because
his documents had expired.

A few days later, Orgest Turia was found lifeless in an isolation cell where he was staying for the
quarantine period. In the same room as him there were five other people, including a Moroccan
man found unconscious. The autopsy ascertained the cause of Orgest's death was an overdose of
methadone. Andrea Guadagnini, defense attorney appointed by the family, raised concerns about
how the young man could have come into possession of that substance and in such quantities as
to cause his death.

Self-harm and suicide: «Another event that can determine, let's say, the interruption of the stay
within the center or in any case a different course of the therapeutic relationship are the gestures
of self-harm, which are very frequent and which in some cases involve referring the health center
to the 'external, when it comes to therapies that cannot be administered inside the center. In
those cases, the choice that the doctor and the management must make is between
hospitalization and re-accompaniment within the facility. Evidently many people decide to injure
themselves to be hospitalized and then try to get away from the center, or at least get out, at least
temporarily.»

Recommendations for the public authorities

• HEALTH CARE: Proceed with the immediate transfer of the health care system within the CPR
entirely in the head of the National Health Service. Only in this way the detainees' right to health
can really be protected.

• COMPATIBILITY WITH DETENTION: Ensure that the medical examination for the attestation of
eligibility for detention is always carried out by a doctor of the NHS, with a punctual assessment of
physical and mental conditions that could not be compatible with the restricted community life.

• MEDICAL STAFF: Acknowledge the total insufficiency Minimum allocation scheme for internal
health. Prevent management bodies from hiring health personnel based on actual capacity and
not on the regulatory one.

• SOLITARY CONFINEMENT: End immediately to the unlawful practices of isolation for disciplinary,
safety, "protection" reasons. Such practices do not find legal basis and have to be considered
seriously detrimental to the rights of detainees.

• DRUG ADMINISTRATION: The administration of psychotropic drugs and anxiolytics to the

detainees takes place behind the sole prescription of NHS doctors, after having carried out an
adequate psychiatric visit in a public hospital.