Global health and the global economic crisis

Aboriginal Community Controlled Health Services: An Act of Resistance against Australia's Neoliberal Ideologies

The individualistic and colonial foundations of neoliberal socio-political ideologies are embedded throughout Australian health systems, services, and discourses. Not only does neoliberalism undermine Aboriginal and Torres Strait Islander collectivist values by emphasizing personal autonomy, but it has significant implications for Aboriginal and Torres Strait Islander health. Aboriginal Community Controlled Health Services (ACCHS) operate within Community-oriented holistic understandings of well-being that contradict neoliberal values that Western health services operate within. Therefore, this paper aims to explore the role of ACCHS in resisting the pervasive nature of neoliberalism through the prioritization of self-determination for Aboriginal and Torres Strait Islander Peoples. Utilizing a critical evaluative commentary, we reflect on Aboriginal political leadership and advocacy during the 1970s and 1980s and the development of neoliberalism in Australia in the context of ACCHS. Community controlled primary health services across Australia are the only remaining government-funded and Aboriginal-controlled organizations. Not only do ACCHS models resist neoliberal ideologies of reduced public expenditure and dominant individualistic models of care, but they also incontrovertibly strengthen individual and Community health. ACCHS remain the gold standard model by ensuring Aboriginal and Torres Strait Islander rights to the self-determination of health in accordance with the United Nations Declaration of the Rights of Indigenous Peoples.

Does Economic Overheating Provide Positive Feedback on Population Health? Evidence From BRICS and ASEAN Countries

This paper explores the relationship of real GDP per capita with cancer incidence applying panel threshold regression model in BRICS and ASEAN countries. The empirical results highlight that the business cycle has an inverted-U correlation with population health indicators and a non-linear single threshold effect. In BRICS countries, the health-promoting effect of economic growth is significantly weaker when exceeding the threshold. Similarly, economic growth in ASEAN countries, even worsens population health, after the turning point. These asymmetric effects are strongly related to the response of regional economic globalization health policies. Changes in economic expansion and overheating may have serious adverse effects on health care systems in emerging economies. Governments should adopt more aggressive health care policies during economic overheating, to avoid wasting health care resources.

COVID-19: Can this crisis be transformative for global health?

The UN has described the health, social and economic consequences of Covid-19 as a global crisis unlike any other encountered in its history. Although a pandemic of this nature was not unforeseeable, its arrival seems to have caught the world off guard, hurling us into a state of partly haphazard disaster mitigation. It has shed sharper light on the failure of global health in its current form to tackle acute and systemic challenges in a rapidly changing world, and the unequal patterns in society that leave us vulnerable. This commentary argues that, despite its devastating effects, the Covid-19 pandemic can be a longer-term positively transformative event for global health. However, this will require going beyond the development of more effective plans for health emergency preparedness, to confront the crisis in global health governance and leadership, and rethink the roles of key actors involved in world health. It ultimately calls us back to the very concept of 'global health': the values it should encompass, what we should expect from it and how we might envisage reshaping or 'co-creating' it for the future.

Instruments of health and harm: how the procurement of healthcare goods contributes to global health inequality

Many healthcare goods, such as surgical instruments, textiles and gloves, are manufactured in unregulated factories and sweatshops where, amongst other labour rights violations, workers are subject to considerable occupational health risks. In this paper we undertake an ethical analysis of the supply of sweatshop-produced surgical goods to healthcare providers, with a specific focus on the National Health Service of the United Kingdom. We contend that while labour abuses and occupational health deficiencies are morally unacceptable in the production of any commodity, an additional wrong is incurred when the health of certain populations is secured in ways that endanger the health and well-being of people working and living elsewhere. While some measures have been taken to better regulate the supply chain to healthcare providers in the UK, further action is needed to ensure that surgical goods are sourced from suppliers who protect the labour and occupational health rights of their workers.

Universities as catalysts of social innovation in health systems in low-and middle-income countries: a multi-country case study

Background

Social innovation (SI) in health holds potential to contribute to health systems strengthening and universal health coverage (UHC). The role of universities in SI has been well described in the context of high-income countries. An evidence gap exits on SI in healthcare delivery in the context of low- and middle-income countries (LMICs) as well as on the engagement of universities from these contexts. There is thus a need to build capacity for research and engagement in SI in healthcare delivery within these universities. The aim of this study was to examine the adoption and implementation of network of university hubs focused on SI in healthcare delivery within five countries across Africa, Asia and Latin America. The objectives were to describe the model, components and implementation process of the hubs; identify the enablers and barriers experienced and draw implications that could be relevant to other LMIC universities interested in SI.

Methods

A case study design was adopted to study the implementation process of a network of university hubs. Data from documentation, team discussions and post-implementation surveys were collected from 2013 to 2018 and analysed with aid of a modified policy analysis framework.

Results/discussion

SI university-based hubs serve as cross-disciplinary and cross-sectoral platforms, established to catalyse SI within the local health system through four core activities: research, community-building, storytelling and institutional embedding, and adhering to values of inclusion, assets, co-creation and hope. Hubs were implemented as informal structures, managed by a small core team, in existing department. Enablers of hub implementation and functioning were the availability of strong in-country social networks, legitimacy attained from being part of a global network on SI in health and receiving a capacity building package in the initial stages. Barriers encountered were internal institutional resistance, administrative challenges associated with university bureaucracy and annual funding cycles.

Conclusions

This case study shows the opportunity that reside within LMIC universities to act as eco-system enablers of SI in healthcare delivery in order to fill the evidence gap on SI and enhance cross-sectoral participation in support of achieving UHC.

Disconnections between medical education and medical practice: A neglected dilemma

Medical practice has changed profoundly over the past 60 years. Many changes have also been made in medical education, often with a view to countering adverse aspects of highly specialised, commercialised and bureaucratised modern medical practice. Regardless of the state of the world today and of the variety of changes that may occur in the years ahead, excellence in the application of bedside skills and technological advances, accompanied by excellence in humanistic aspects of caring for patients as people, will remain preeminent goals at the heart of medical practice. Powerful social forces that negatively influence practice cannot be counteracted through changes in medical education alone and need to be addressed directly within health systems. Shifting healthcare towards a valued social service is arguably essential for improving both public and individual health through more widespread universal access to high quality and effectively integrated health care.

Social inequities and contemporary struggles for collective health in Latin America

As part of a planned series from Global Public Health aimed at exploring both the epistemological and political differences in diverse public health approaches across different geographic and cultural regions, this special issue assembles papers that consider the legacy of the Latin American Social Medicine and Collective Health (LASM-CH) movements, as well as additional examples of contemporary social action for collective health from the region. In this introduction, we review the historical roots of LASM-CH and the movement's primary contributions to research, activism and policy-making over the latter-half of the twentieth century. We also introduce the special issue's contents. Spanning 19 papers, the articles in this special issue offer critical insight into efforts to create more equitable, participatory health regimes in the context of significant social and political change that many of the countries in the region have experienced in recent decades. We argue that as global health worldwide has been pushed to adopt increasingly conservative agendas, recognition of and attention to the legacies of Latin America's epistemological innovations and social movement action in the domain of public health are especially warranted.

Relieving the tension between national health equity strategies and global health equity

Globally, numerous national strategies have taken aim at reducing health inequities. An ever-present tension characterizing these strategies, however, is their lack of attention to the global political economy. This commentary argues that national policies which target only domestic factors (without engaging with the global political economy) will be limited, both, in their ability to address national levels of health equity and the larger global health inequity problem. Meaningful proposals to reduce health inequities have been made that take into account a global political economy perspective. National health equity strategies could provide the lacking momentum to advance such proposals, but will require united and sustained advocacy by global health and health equity scholars. Ultimately, relieving the tension between national health equity commitments and global health equity concerns could be one of the new approaches needed to improve health equity worldwide.

Ethical Challenges in the Provision of Dialysis in Resource-Constrained Environments

The number of patients requiring dialysis by 2030 is projected to double worldwide, with the largest increase expected in low- and middle-income countries (LMICs). Dialysis is seldom considered a high priority by health care funders, consequently, few LMICs develop policies regarding dialysis allocation. Dialysis facilities may exist, but access remains highly inequitable in LMICs. High out-of-pocket payments make dialysis unsustainable and plunge many families into poverty. Patients, families, and clinicians suffer significant emotional and moral distress from daily life-and-death decisions imposed by dialysis. The health system's obligation to provide financial risk protection is an important component of global and national strategies to achieve universal health coverage. An ethical imperative therefore exists to develop transparent dialysis priority-setting guidelines to facilitate public understanding and acceptance of the realistic limits within the health system, and facilitate fair allocation of scarce resources. In this article, we present ethical challenges faced by patients, families, clinicians, and policy makers where dialysis is not universally accessible and discuss the potential ethical consequences of various dialysis allocation strategies. Finally, we suggest an ethical framework for use in policy development for priority setting of dialysis care. The accountability for reasonableness framework is proposed as a procedurally fair decision-making, priority-setting process.

Why equity in health and in access to health care are elusive: Insights from Canada and South Africa

Health and access to health care vary strikingly across the globe, and debates about this have been pervasive and controversial. Some comparative data in Canada and South Africa illustrate the complexity of achieving greater equity anywhere, even in a wealthy country like Canada. Potential bi-directional lessons relevant both to local and global public health are identified. Both countries should consider the implications of lost opportunity costs associated with lack of explicit resource allocation policies. While National Health Insurance is attractive politically, Canada's example cannot be fully emulated in South Africa. Short- and medium-term attempts to improve equity in middle-income countries should focus on equitable access to insurance to cover primary health care and on making more use of nurse practitioners and community health workers. In the longer-term, attention is needed to the economic and political power structures that influence health and health care and that ignore the social and societal determinants of sustainable good health locally and globally. This long-term vision of health is needed globally to achieve improvements in individual and population health in a century characterised by limits to economic growth, widening disparities, continuing conflict and migration on a large scale and multiple adverse impacts of climate change.

The macro-economic determinants of health and health inequalities-umbrella review protocol

BACKGROUND

The economic determinants of health have been widely recognised as crucial factors affecting health; however, to date, no comprehensive review has been undertaken to summarise these factors and the ways in which they can influence health. We conceptualise the economy as a complex system made up of underlying approaches, regulation from institutions, markets, finance, labour, the public-private balance as well as production and distributional effects, which collectively impact on health through the effect of moderators. This protocol details the methods for an umbrella review to explore the macro-economic factors, strategies, policies and interventions that affect health outcomes and health inequalities.

METHODS

We will identify relevant systematic reviews using search terms derived from the Journal of Economic Literature classification. Reviews will be included if they meet the Database of Abstracts and Reviews of Effects criteria for systematic reviews. Reviews of studies with and without controls will be included; both association and intervention studies will be included. Primary outcomes will include but are not limited to morbidity, mortality, prevalence and incidence of conditions and life expectancy. Secondary outcomes will include health inequalities by gender, ethnicity or socio-economic status. Six databases will be searched using tailored versions of our piloted search strategy to locate relevant reviews. Data will be extracted using a standardized pro forma, and the findings will be synthesized into a conceptual framework to address our review aim.

DISCUSSION

Our umbrella review protocol provides a robust method to systematically appraise the evidence in this field, using new conceptual models derived specifically to address the study question. This will yield important information for policymakers, practitioners and researchers at the local, national and international level. It will also help set the future research agenda in this field and guide the development of interventions.

SYSTEMATIC REVIEW REGISTRATION

This umbrella review protocol has been registered with PROSPERO CRD42017068357 .

Explaining Continuance Intention of Fruit and Vegetable Consumption among the Rural Elderly: An Application of the Expectancy Confirmation Model

Background and Aim

Healthy aging is the permanent right of all people. Thus, the purpose of this work was to investigate the expectation confirmation model constructs on intention of continuing to consume fruit and vegetables among the rural elderly.

Materials and Methods

This cross-sectional study was conducted on 332 elderly. The expectation confirmation model served as a theoretical framework. A random sampling was recruited. Data were collected through face-to-face visit in the second 6 months of 2016. The data were then analyzed using LISREL 8.5 and SPSS 16 software.

Results

This model could explain 79% of intention to continue fruit and vegetable consumption. The usefulness and satisfaction had the most effect on the intention to continue the consumption of fruit and vegetables.

Conclusion

Expectation confirmation model depicted a proper application in explaining the intention to continue the consumption of fruit and vegetables in the elderly. Since perceived benefits were the most important factor in determining the intention to continue F&V consumption in this study, it is required that policymakers utilize suitable efficient strategies to promote the perception of benefits of F&V consumption in the elderly by means of campaigns in the society, organizations, and families.

Health inequities in the age of austerity: The need for social protection policies

This commentary assesses the impacts of the global austerity drive on health inequities in the aftermath of the global financial crisis of 2008. In doing so, it first locates the origins of austerity within the 40 year history of neoliberal economic orthodoxy. It then describes the global diffusion of austerity since 2008, and its key policy tenets. It next describes the already visible impacts of austerity-driven welfare reform on trends in health equity, and documents how austerity has exacerbated health inequities in countries with weak social protection policies. We finally identify the components of an alternative policy response to the financial crisis than that of austerity, with specific reference to the need for shifts in national and global taxation policies and public social protection policies and spending. We conclude with a call for a reorientation of public policy towards making human health an overarching global policy goal, and how this aligns with the multilaterally agreed upon Sustainable Development Goals.

Perceptions of Factors Impacting Longevity among Hawai'i Older Adults

With increased life expectancy, people need more education about healthy aging. This paper examines older adult perceptions regarding various factors impacting longevity, including genetics, lifestyle, and the environment. Data were collected from 733 Hawai'i adults age 50 years and older (39% Caucasian, 27% Japanese, 19% Native Hawaiian and Pacific Islander (NHOPI), 9% Chinese, and 7% Filipino) through randomized telephone interviews. Participants were asked to rate a variety of factors as having "great impact," "some impact," or "no impact" on lifespan. Regardless of ethnicity, more than half of the participants felt that eating habits, exercise, health information, health care, and the environment had great impact on lifespan. Less than half felt that economic status and community had great impact. Compared to the all ethnic groups, Filipino respondents were significantly less likely to feel that smoking (44%, compared with an average across all race/ethnicities of 64%) and stress (48%, average 62%) had great impact. Chinese participants were more likely to feel that drinking alcohol (64%) had great impact (average 38%). Filipinos and Chinese were more likely to perceive that working conditions have great impact (65% and 56%, respectively; average 45%), and NHOPI and Filipinos were more likely to perceive the natural environment as having great impact (59% and 54%, respectively; average 46%). Findings suggest that cultural values and experiences may shape older adults' perceptions of factors associated with lifespan, providing guidance for health professionals on how to tailor health messages to older adults in different ethnic groups.

Austerity and the embodiment of neoliberalism as ill-health: Towards a theory of biological sub-citizenship

This article charts the diverse pathways through which austerity and other policy shifts associated with neoliberalism have come to be embodied globally in ill-health. It combines a review of research on these processes of embodiment with the development of a theory of the resulting forms of biological sub-citizenship. This theory builds on other studies that have already sought to complement and complicate the concept of biological citizenship with attention to the globally uneven experience and embodiment of bioinequalities. Focused on the unevenly embodied sequelae of austerity, the proceeding theorization of biological sub-citizenship is developed in three stages of review and conceptualization: 1) Biological sub-citizenship through exclusion and conditionalization; 2) Biological sub-citizenship through extraction and exploitation; and 3) Biological sub-citizenship through financialized experimentation. In conclusion the paper argues that the analysis of biological sub-citizenship needs to remain open-ended and relational in order to contribute to socially-searching work on the social determinants of health.

Economic shocks and health resilience: lessons from the Russian Federation

Background

Despite extensive research on determinants of health, there is much less information on factors protecting health among those exposed to economic shocks. Using longitudinal data from the Russian Federation in the post-Soviet period, we examined individual-level factors that enhance resilience of health to economic shocks.

Methods

Logistic regression analysed factors associated with good self-assessed health (SAH) and health resilience, using pooled samples from the Russia Longitudinal Monitoring Survey-Higher School of Economics (1994–2012).

Results

The general population consistently reported ‘average’ SAH, indicating almost invariant trends over the years. Male gender was the strongest predictor of good SAH and health resilience. Other factors positively associated with good SAH were age, higher education, employment, residing in rural areas, living in a larger and/or non-poor household. Among unemployed and those remaining unemployed, residing in rural areas, living in a larger and/or non-poor household remained the strongest predictors of good SAH and health resilience. These same factors were also important for males with recent job loss.

Conclusions

Several factors predicting good SAH in the general population also influence health resilience factors among those remaining unemployed and experiencing a job loss. Such factors help to identify those most vulnerable and aid targeting assistance during economic crises.

Use of the 'Accountability for Reasonableness' Approach to Improve Fairness in Accessing Dialysis in a Middle-Income Country

Universal access to renal replacement therapy is beyond the economic capability of most low and middle-income countries due to large patient numbers and the high recurrent cost of treating end stage kidney disease. In countries where limited access is available, no systems exist that allow for optimal use of the scarce dialysis facilities. We previously reported that using national guidelines to select patients for renal replacement therapy resulted in biased allocation. We reengineered selection guidelines using the ‘Accountability for Reasonableness’ (procedural fairness) framework in collaboration with relevant stakeholders, applying these in a novel way to categorize and prioritize patients in a unique hierarchical fashion. The guidelines were primarily premised on patients being transplantable. We examined whether the revised guidelines enhanced fairness of dialysis resource allocation. This is a descriptive study of 1101 end stage kidney failure patients presenting to a tertiary renal unit in a middle-income country, evaluated for dialysis treatment over a seven-year period. The Assessment Committee used the accountability for reasonableness-based guidelines to allocate patients to one of three assessment groups. Category 1 patients were guaranteed renal replacement therapy, Category 3 patients were palliated, and Category 2 were offered treatment if resources allowed. Only 25.2% of all end stage kidney disease patients assessed were accepted for renal replacement treatment. The majority of patients (48%) were allocated to Category 2. Of 134 Category 1 patients, 98% were accepted for treatment while 438 (99.5%) Category 3 patients were excluded. Compared with those palliated, patients accepted for dialysis treatment were almost 10 years younger, employed, married with children and not diabetic. Compared with our previous selection process our current method of priority setting based on procedural fairness arguably resulted in more equitable allocation of treatment but, more importantly, it is a model that is morally, legally and ethically more defensible.

Taking action on violence through research, policy, and practice

BACKGROUND

Violence is a critical public health problem associated with compromised health and social suffering that are preventable. The Centre for Global Health and Health Equity organized a forum in 2014 to identify: (1) priority issues related to violence affecting different population groups in Canada, and (2) strategies to take action on priority issues to reduce violence-related health inequities in Canada. In this paper, we present findings from the roundtable discussions held at the Forum, offer insights on the socio-political implications of these findings, and provide recommendations for action to reduce violence through research, policy and practice.

METHODS

Over 60 academic researchers, health and social service agency staff, community advocates and graduate students attended the daylong Forum, which included presentations on structural violence, community violence, gender-based violence, and violence against marginalized groups. Detailed notes taken at the roundtables were analyzed by the first author using a thematic analysis technique.

FINDINGS

The thematic analysis identified four thematic areas: 1) structural violence perpetuates interpersonal violence - the historical, social, political and economic marginalization that contributes to personal and community violence. 2) social norms of gender-based violence-the role of dominant social norms in perpetuating the practice of violence, especially towards women, children and older adults; 3) violence prevention and mitigation programs-the need for policy and programming to address violence at the individual/interpersonal, community, and societal levels; and 4) research gaps-the need for comprehensive research evidence made up of systematic reviews, community-based intervention and evaluation of implementation research to identify effective programming to address violence.

CONCLUSIONS

The proceedings from the Global Health and Health Equity Forum underscored the importance of recognizing violence as a public health issue that requires immediate and meaningful communal and structural investment to break its historic cycles. Based on our thematic analysis and literature review, four recommendations are offered: (1) Support and adopt policies to prevent or reduce structural violence; (2) Adopt multi-pronged strategies to transform dominant social norms associated with violence; (3) Establish standards and ensure adequate funding for violence prevention programs and services; and (4) Fund higher level ecological research on violence prevention and mitigation.

Narratives of Food Insecurity in Tippecanoe County, Indiana: Economic Constraints in Local Meanings of Hunger

Food insecurity and its most extreme form, hunger, have increased exponentially in the United States since 2006. This essay seeks to contribute to our understanding of hunger by attending to the context of the financial crisis as an organizing frame for understanding local meanings of hunger. Within a broader framework of the culture-centered approach (CCA) that works to identify and develop locally rooted solutions to food insecurity, we describe through locally grounded stories of food insecurity the financial climate where large percentages of U.S. households have been cast into poverty because of the crash of an unregulated economy. These local understandings of hunger in the context of the economy offer entry points for organizing a food-insecure coalition that seeks to address the stigma around food insecurity.

Lessons for Health From Insights into Environmental Crises

The health of whole populations within nations and globally and the implications of climate change are two of the most important challenges facing humanity in the 21st century. Both are components of a complex global crisis that must be acknowledged and addressed. Here we draw the attention of health professionals to some emerging threats and insights from key works of environmentalists in the hope that these may catalyze reflection on the broader challenges facing human health at a time of deep planetary malaise.

The global financial crisis and health equity: early experiences from Canada

BACKGROUND

It is widely acknowledged that austerity measures in the wake of the global financial crisis are starting to undermine population health results. Yet, few research studies have focused on the ways in which the financial crisis and the ensuing 'Great Recession' have affected health equity, especially through their impact on social determinants of health; neither has much attention been given to the health consequences of the fiscal austerity regime that quickly followed a brief period of counter-cyclical government spending for bank bailouts and economic stimulus. Canada has not remained insulated from these developments, despite its relative success in maneuvering the global financial crisis.

METHODS

The study draws on three sources of evidence: A series of semi-structured interviews in Ottawa and Toronto, with key informants selected on the basis of their expertise (n = 12); an analysis of recent (2012) Canadian and Ontario budgetary impacts on social determinants of health; and documentation of trend data on key social health determinants pre- and post the financial crisis.

RESULTS

The findings suggest that health equity is primarily impacted through two main pathways related to the global financial crisis: austerity budgets and associated program cutbacks in areas crucial to addressing the inequitable distribution of social determinants of health, including social assistance, housing, and education; and the qualitative transformation of labor markets, with precarious forms of employment expanding rapidly in the aftermath of the global financial crisis. Preliminary evidence suggests that these tendencies will lead to a further deepening of existing health inequities, unless counter-acted through a change in policy direction.

CONCLUSIONS

This article documents some of the effects of financial crisis and severe economic decline on health equity in Canada. However, more research is necessary to study policy choices that could mitigate this effect. Since the policy response to a similar set of economic shocks has globally varied and led to differential health and health equity outcomes, comparative studies are now possible to assess the successes and failures of specific policy responses. This raises the question of what types of public policy can mitigate against the negative health equity effects of severe economic recessions.

Beyond 'run, knit and relax': can health promotion in Canada advance the social determinants of health agenda?

Can health promotion in Canada effectively respond to the challenge of reducing health inequities presented by the WHO Commission on Social Determinants of Health? Against a background of failure to take seriously issues of social structure, I focus in particular on treatments of stress and its effects on health, and on the destructive congruence of Canadian health promotion initiatives with the neoliberal "individualization" of responsibility for (ill) health. I suggest that the necessary reinvention of the health promotion enterprise is possible, but implausible.

Global health, vulnerable populations, and law

Given the fragility of individual and population wellbeing in an interdependent world threatened by many overlapping crises, the suggestion is made that new legal mechanisms have the robust potential to reduce human vulnerability locally and globally.

Understanding the impact of global trade liberalization on health systems pursuing universal health coverage

In the context of reemerging universalistic approaches to health care, the objective of this article was to contribute to the discussion by highlighting the potential influence of global trade liberalization on the balance between health demand and the capacity of health systems pursuing universal health coverage (UHC) to supply adequate health care. Being identified as a defining feature of globalization affecting health, trade liberalization is analyzed as a complex and multidimensional influence on the implementation of UHC. The analysis adopts a systems-thinking approach and refers to the six building blocks of World Health Organization's current "framework for action," emphasizing their interconnectedness. While offering new opportunities to increase access to health information and care, in the absence of global governance mechanisms ensuring adequate health protection and promotion, global trade tends to have negative effects on health systems' capacity to ensure UHC, both by causing higher demand and by interfering with the interconnected functioning of health systems' building blocks. The prevention of such an impact and the effective implementation of UHC would highly benefit from a more consistent commitment and stronger leadership by the World Health Organization in protecting health in global policymaking fora in all sectors.

Who and what is a "population"? Historical debates, current controversies, and implications for understanding "population health" and rectifying health inequities

CONTEXT

The idea of "population" is core to the population sciences but is rarely defined except in statistical terms. Yet who and what defines and makes a population has everything to do with whether population means are meaningful or meaningless, with profound implications for work on population health and health inequities.

METHODS

In this article, I review the current conventional definitions of, and historical debates over, the meaning(s) of "population," trace back the contemporary emphasis on populations as statistical rather than substantive entities to Adolphe Quetelet's powerful astronomical metaphor, conceived in the 1830s, of l'homme moyen (the average man), and argue for an alternative definition of populations as relational beings. As informed by the ecosocial theory of disease distribution, I then analyze several case examples to explore the utility of critical population-informed thinking for research, knowledge, and policy involving population health and health inequities.

FINDINGS

Four propositions emerge: (1) the meaningfulness of means depends on how meaningfully the populations are defined in relation to the inherent intrinsic and extrinsic dynamic generative relationships by which they are constituted; (2) structured chance drives population distributions of health and entails conceptualizing health and disease, including biomarkers, as embodied phenotype and health inequities as historically contingent; (3) persons included in population health research are study participants, and the casual equation of this term with "study population" should be avoided; and (4) the conventional cleavage of "internal validity" and "generalizability" is misleading, since a meaningful choice of study participants must be in relation to the range of exposures experienced (or not) in the real-world societies, that is, meaningful populations, of which they are a part.

CONCLUSIONS

To improve conceptual clarity, causal inference, and action to promote health equity, population sciences need to expand and deepen their theorizing about who and what makes populations and their means.