Nov 4, 2013
Taylor Burbach

Paradox of Success in Public Health… Where do we go from here?

Carol Worthman received her PhD at Harvard in 1978, after first attending Pomona College for her BA in Botany and biology, and subsequently the University of California at San Diego Medical School and Massachusetts Institute of Technology. Her interests include biological anthropology, human reproduction, human development, biocultural and life history theory, and developmental epidemiology. These interests are bioculturally focused. She also has worked with the University of Alabama’s own Dr. Jason DeCaro on various projects concerning stress and developmental biology.

Brandon Kohrt is an assistant professor at Duke Global Health Institute and Department of Psychiatry and Behavioral Sciences. He conducts global mental health research focusing on populations affected by war-related trauma and chronic stressors of poverty, discrimination, and lack of access to healthcare and education. His research is conducted in Nepal, and he has worked closely with the Transcultural Psychosocial Organization (TPO) Nepal, the Carter Center Mental Health Liberia Program, and was a co-founder of the Atlanta Asylum Network for Torture Survivors. His interests include culture, health economics, health systems, and mental health.

Worthman and Kohrt are concerned with how our current approach to public health is dissonant with contemporary health concerns. They call this phenomenon a “paradox of success,” which is characterized by historical accomplishments in public health perpetuating paradigms which cannot be applied globally or to recent emerging health concerns. Sometimes these paradigms result in negative effects on health, which I will explain below. According to multiple sources, only 2-60% of health outcome variation is explained by the models we currently use in public health (see Worthman & Kohrt 2005). In order to evaluate and adjust public health models, Worthman and Kohrt identify five paradoxes stimulating morbidity instead of expected success.

  1. Unmasking is characterized by changes in morbidity patterns. Advances in health care have created an epidemiologic transition from infectious disease to chronic degenerative and mental illnesses. Think cancer, Alzheimer’s, etc… The example used in the article was depression, although the rise in mental illness could also be a result of historically unreliable data.
    What other examples of unmasking can you think of?

    Simplified model of epidemiological transition.

  2. Localization is an important paradox resulting from globalization of public health paradigms. It is becoming increasingly evident that biological function and regulation are heavily dependent on context. Vaccinations sometimes fail as a result of locally derived immunocompetence. Fetal/childhood development also play a role, as shown by the relationship between breastfeeding/birth spacing and infant survival/health.
    The article talked about fetal programming as a factor of localization. What about research in fetal programming is relevant here (in the article or outside)?

    Anti-vaccine propaganda. Success of vaccination can be affected by malnutrition, pathogen load, stress, and immune development of individual.

  3. Socialization in this context applies to the enhancement or diminishing of vulnerability to disease based on cultural factors. HIV/AIDS prevalence in African countries are exacerbated by cultural attitudes toward sex and the availability of sex education, as opposed to Western countries.
    What are some examples of cultural practices that perpetuate disease?

    Fast food culture… you can find these anywhere!


  4. Re/emerging disease is a resurgence of disease patterns, sometimes in more virulent forms. Tuberculosis is an important example, responsible for 3% of all mortality in 1999. Diabetes and asthma are other examples, although literature on  re-emergence of non-infectious disease is currently limited.
    What factors contribute to re/emergent diseases?

    Travel is just one factors contributing to re/emerging disease.

  5. Savage inequity adds fuel to the previously mentioned paradoxes. Poverty, inequality, and inequity are all included under this paradox. Global media especially perpetuates inequity and can be the cause of varying psychosocial factors that contribute to morbidity.
    What is the difference between inequality and inequity, and what are the health implications of each?

    Link between risk factors and income levels.

I thought about tuberculosis as an historical disease until I had to take my TB test before entering college. I wasn’t positive, but the test indicated that I had been in contact with the disease at some point. I didn’t realize that our health practices were, in a way, catalyzing the resurgence of antibiotic-resistant tuberculosis. Savage inequity is also a concept the resonates with me. Intuitively, I know that mental health is just as important as physical health, but this knowledge conflicts with what I’ve observed in medicine and health research. I only recently realized that this is a problem with the paradigm, not my understanding or health.

I also think it’s important to note that, although socialization and local biology seem obvious contributing factors to health in our class, we are anthropology students. It appears to me that medical students are vastly under-educated regarding biocultural models of medicine. I won’t pretend to know how to change education policies in medical school, but it is important to recognize that a global public health paradigm isn’t going to satisfy our global health needs.


EDITED 12-9-2013


  • The recent rise in SIDS or Sudden Infant Death Syndrome is an example of an unmasking (i.e., change in morbidity patterns). As far as researchers can tell this is not an infectious disease, but it the causes of SIDS continue to be poorly understood.

    A cultural practice here in the United States that perpetuates disease is the amount of working hours that individuals put in each week. The average American works 60 hours a week, well above the full-time mark of 40 hours. Since, Americans spend so much time at work that usually consists of sedentary positions they have little time for exercise and sleep. The lack of exercise in combination with poor diets and along with sleep deprivation can all be linked to the rise in chronic diseases and mental illness.

    One factor that is contributing to the re/emergent of diseases is the population density around the world. On average individuals come in contact with more people everyday than ever before, which is contributing to the spread of disease. Technology is another contributing factor to the re/emergence of disease through increasing travel time and travel locations. Populations that once were traditionally isolated are no longer isolated, which is bringing those once isolated populations in contact with diseases they had never been exposed to.

    Inequality refers to a social disparity between different groups of people (e.g., rich/poor, white/black). Inequity refers to favoritism or biases among different groups of people. The health implications that exists among the poor is their lack of access to proper healthcare/health insurance, thus they are more likely to have an illness or injury go untreated. The poor also often lack the knowledge or education for how to maintain a healthy lifestyle through diet and exercise.

  • An example of unmasking could be cardiovascular related diseases such as heart attacks. They rarely affect younger individuals, and as a population gets older, the frequency of cardiovascular related illnesses rises.

    Some religions or groups that do not believe in current medicine and vaccines, and subsequently do not vaccinate their children could perpetuate diseases by the fact that they are susceptible to said diseases.

    One factor that probably helps diseases re-emerge is that the average person travels more today than they have before. Students in college study abroad in foreign and remote countries and come into contact with a more diverse group of people. In this manner diseases can spread relatively far in a short amount of time.

    Inequity refers to a lack of fairness in a group, whereas inequality refers to the disparity between groups. Inequality causes different socioeconomic groups to have differing access to health care and information and lack of information can lead to unhealthy lifestyles.

  • I thought that the section on reemerging diseases was interesting. You would think that with our modern medicine we would have permanently eliminated some diseases, but they change and come back. Even diseases we commonly think have been eradicated, like the bubonic plague, are still around. When people don’t get their children vaccinated or insist on taking antibiotics for everything, it can allow the disease to reoccur or evolve.

    Is depression actually an increasing problem, or is it only now becoming noticed? I’ve read a few times that poorer countries (like Kenya) are actually less depressed than developed countries (like the US), but I’d like to see a legitimate study that can reasonable compare people from around the world. I think our cultures are so different that what we call depressed is not what another culture would call depressed.

  • I agree with Becca that our lifestyles are a huge part of a lot of the diseases we are experiencing. Personally I rarely get more than 6 hours of sleep, and I’m constantly stressed. I know all of us have different schedules but as college students we are all (probably) working way more than 40 hours a week. Stress plays a huge role in MANY diseases, and I think we need to focus more on cutting out stress in our lives to improve our health.

    I think a lot of the diseases that are associated with old age are becoming more and more common these days, because we are living longer. Most of these diseases have not been able to expose themselves because 300 years ago most humans didn’t live to be 80. These diseases might not have been noticed because we weren’t getting old enough for them to show up. So in a way our modern advances that allow us to live longer.. are also allowing more diseases to show up in old age.. things that haven’t been selected against. Speaking of which, most diseases associated with old age aren’t going to be selected against because by the time you develop the disease you have already had children and passed along your genes.

  • I agree with Emily that it is interesting that diseases that were believed to be eliminated can reemerge. I took a class called Culture, Health, and Healing last semester and we watched a video about how the bubonic plague was discovered in a nature park in California. Apparently, it can be carried by some of the squirrels and they can then pass it on which is kind of freaky.

    I think there a few contributors to the reemergence of some diseases are the fact that the majority of the earth’s population live within close proximity to each other. The fact that we travel so much more also contributes. When people travel they can be exposed to diseases that their immune system is not immune to.

  • Many people associate the emergence of agriculture with the first epidemiological transition (and I won’t argue with them), but I would also like to highlight how modern changes in food production and distribution have also affected our health. The fruits and vegetables bought at the store are no where near as healthy as the ones grown in your neighbors backyard. One main reason for this is that they were picked prior to complete ripeness and therefore did not have enough time to absorb all the nutrients that they possibly could. I had also heard another tidbit about the fertilizer: most companies use non-manure fertilizer, which results in the absence of some microorganisms with which the plants co-evolved into a mutualistic relationship and are now without this added benefit.

    Our “Western” medical system never seems to take any of this into account. Sure, doctors are consistently making small lifestyle recommendations: “go for a walk in the morning,” “eat your fruits and vegetables,” “don’t smoke.” But medical professionals tend to otherwise ignore most non-pharmaceutical cures. We are a nation that relies on our prescription drugs to stay “healthy” without a real understanding of what “healthy” actually is.

  • The wording of Point 3 is in direct contrast to the spirit of Point 5. To say that “HIV/AIDS prevalence in African countries are *largely due to cultural attitudes toward sex* and the availability of sex education, as opposed to Western countries,” is a damaging oversimplification that perpetuates prejudiced moral judgments of people living with this disease.

    I have no doubt that this course has the best of intentions! but if we’re willing to criticize media presentations of public-health issues, we need to exercise editorial judgment on our own posts to ensure we’re not making similarly shoddy logical shortcuts.

  • Christine, thank you for this observation. The original wording was meant to reflect the gravity of the structure-function problems with sex education in African countries. I was unaware of the connotation my words carried, and have changed the wording to hopefully represent the message intended by the original authors.

  • It is hard for me to believe that some of these diseases still occur, even with all of our modern medicine and practices. I too had a friend that on her tuberculosis test it showed that she had come into contact with it. I never thought of tuberculosis being a major issue, but obviously if we have to have the test for it before entering college, then it is still prevalent today. Other diseases that pop up again are weird to me too. Our lifestyles probably influence of our contact with and our likelihood to contract a disease. People that travel to remote areas of the world are probably more likely to contract certain diseases than I am. There have been outbreaks of certain diseases in the United States so your likelihood of catching a disease may depend on where in the US you live as well.

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