It is due to a growing attention given to the cross-national migration of capital, people, and products as well as their means of production [ 12 ]-[ 14 ]. It is due to a conviction that the world is an ever-smaller place because of increasing population density, rising rates of international migration, and the rapidly accelerating pace of information transfer [ 4 ].
In these two countries, as in many other low- and middle-income countries, vast wealth and miserable poverty literally collide: high-class condominiums and boutique shops face newly renovated roads while corrugated tin shacks fill in the neglected areas that line their backyards. One cannot help but see the stark consequences of these troubling realities. How do we comprehend differences between what we are accustomed to in our countries of origin and what we see in other places around the world?
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How is it that we open ourselves to hear the stories born of these divisions, and how do we integrate them into our daily lives and personal histories? Why is it that some can see, reflect on, and address the causes and consequences of social determinants, while others cannot or choose not to do so? How each of us perceives, explores, and acts upon social determinants and health disparities depends on many factors, including historical, cultural, ideological, and psychological characteristics, along with other influences such as ethnic heritages, professional socializations, and families of origin [ 16 ]-[ 18 ].
Our cultural and social baggage shapes how we view and understand the problems we see; it also guides whether and how we choose to address them.
Regardless of whether we are new to the field of global health or old hands in its study, teaching, and practice, our willingness to witness and attend to issues of social determinants and health disparities depends on our ability to ask deep and thought-provoking questions. In this article, we share questions we have asked ourselves in the face of obvious inequity, and review, in two short vignettes, key moments in the development of our self-awarenesses.
We share these questions and vignettes to model our own processes of reflection. We do so hoping that global health professionals might become more conscious of the burdensome realities of social determinants and their consequences. We do so, as well, hoping that global health professionals, especially those from high-income countries, might begin to examine thoughtfully how their every day work either perpetuates or breaks down barriers of social difference.
We believe such examination can enhance capacities to work toward ameliorating inequities in ways that are supportive, sustainable, and satisfying. Common questions can be asked of all those engaging in the work of global medicine and public health. What are our interests in and motivations for exploring beyond the relatively comfortable boundaries of training and practice at home?
What are our preconceptions built from personal and professional history, previous socialization, and sense of self in relationship to others? How do we recognize our preconceptions when confronting that which is new and different? How do we manage these preconceptions when working with peers in low-resource settings? Do our cultural upbringings enable or inhibit us from seeing underlying social factors that contribute to poor health? Both at work and in our home communities, how can we productively contribute to minimize community-level health disparities?
Are we profoundly shocked, indignantly outraged, merely uncomfortable, or at ease with it all? Is anger mixed in, or pity, or rejection, or any one of numerous other possible feelings?
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Are we even aware of our emotional responses? How do we balance the clinical detachment of our professional socializations and the profound need for empathy in times of suffering? Alternatively, are we simply overwhelmed by encounters with social problems and thus not able to absorb the cognitive and emotional confusion that often accompanies witnessing them? If we see work in global health as a reciprocal undertaking, one in which we both give and receive, teach and learn, nurture and grow—and we acknowledge that not all share our view in this regard—can we sense our interconnectedness with the workings of the world around us?
Our responses in turn depend on how feelings and thoughts inform our values. Each of us enters into global health work holding ingrained values based on previous experiences. It would be unusual were we not to challenge our values in the face of new wisdom gained from the voices, words, and actions we hear, read, and see in our ventures domestically and abroad.
It would be surprising to see people living in situations vastly different than those which we are accustomed to and not expect some change in these values.
It would be an opportunity missed were such experiences not to enhance our capacities to act with authenticity and integrity. We believe that understanding and addressing the social determinants of health and health disparities starts by contemplating questions such as those above. We encourage practitioners, educators, and learners in public health and medicine to ask these questions of themselves and reflect on them before, during, and after global work experiences.
Only by opening ourselves to such self-dialogue can we develop abilities to see others from positions of equity and solidarity, rather than from dominance and exploitation. Only by probing deeply into our own personal consciousnesses can we know others as real people living in real situations, rather than as intellectualized variables in uncontrolled environments.
Only by examining individual presences relative to the much larger political, economic, ideological, and social forces many of which have created environments that frame the very problems we aim to eliminate can we effectively address pressing issues of disease management [ 19 ].
Even if we enter into our global health endeavors with good intentions—and we are inclined to believe that few in the healing professions do not—by avoiding such introspection we limit our capacity to see and understand, with eyes and minds wide open, the reality and meaning of life concerns as they are seen from perspectives of those who are foreign to us.
What new understandings might such an introspective gaze offer us? First, we believe such a gaze helps us assume postures of inquiry rather than expertise.
Regardless of what knowledge we might already possess, we also have much to learn by asking, questioning, and wondering. Such a gaze allows us to begin by scratching our heads, with interest in discovery and intention to comprehend, before contemplating physical diagnosis or program implementation [ 20 ]. Demonstrating a humble curiosity—defining humble as respectfulness not subservience, and curiosity as genuine concern not academic nosiness—broadens our outlooks beyond comfort zones based on professional status or sphere of knowledge [ 21 ],[ 22 ].
It improves our skills in crossing borders of culture and class.
The CC allowed us to measure the distribution of the use of eye screening services or visual impairment by aggregating across individuals for income rankings. The line of equity i. After obtaining the RCIs, we applied the decomposition method proposed by Wagstaff et al. The basic idea of decomposition is to measure whether the specified factors of health and health care contribute to the overall income-related inequality by quantifying contribution of each factor.
More details about these methods are found in Supplementary Appendix. Sampling weights provided by Statistics Canada were applied in the analyses. This result indicates that more visual impairment was concentrated in diabetic patients with lower income. The magnitude of the RCI for preventive eye screening services, which only included type 2 diabetic patients without visual impairment, was slightly larger than the RCI for eye screening services in all patients with type 2 diabetes 0. The first column in each table shows elasticity for each contributor, or the percentage of visual impairment or eye screening services associated with a percentage change in each contributor.
Concentration index for each contributor shows the expected distribution of contributors in income groups. Finally, the last three columns report, respectively, absolute, percentage and aggregated contributions to total income-related inequality. A positive contribution of each socio-demographic factor indicates that the factor is associated with both income and a visual impairment or b eye screening services. The contribution of each factor is a function of the elasticity of visual impairment or eye screening services with respect to the particular contributor and the degree of income-related inequality.
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Therefore, a large contribution is observed when a factor has either large elasticity or large CI or both. The second greatest contributor was marital status. Sex and duration of diabetes contributed respectively 9. The decomposition analyses for eye screening services and preventive eye screening services indicate that horizontal inequity exists. Having private insurance, discussion of complications with health professionals, marital status and region of residence also contribute to the pro-rich inequality in the use of eye screening services.
In addition to these three main contributors, marital status and regions of residence contributed to pro-rich inequality in the use of preventive eye screening services. Using RCI, and its decomposition, we measured income-related inequalities in both visual impairment and the use of eye screening services among patients with type 2 diabetes in Canada. For visual impairment, our RCI results showed that individuals with lower income tend to have more visual impairment than individuals with higher income.
The findings from our decomposition analysis showed that age and marital status were the major contributors to the existing pro-poor inequality, suggesting the observed inequality is mainly because of older or single patients in the lower tail of the income distribution. In relation to eye screening services, our RCI results for both regular and preventive eye screening services showed pro-rich directions, suggesting the use of eye screening services was concentrated in individuals with higher income, even under Canada's universal healthcare system, which aims to minimize financial barriers to medically necessary services.
In addition, the observed inequalities in eye screening services can be interpreted as inequities that are unnecessary and should be modified as HIs had positive values for both screening services. In our decomposition analysis, income had the largest contribution to inequalities in both eye screening and preventive eye screening services.
Following income, private health insurance for eye care was the second largest contributor to the existing inequalities in the use of these services — this is also an income related finding. The higher concentration of visual impairment in diabetic patients of lower SES is not a new or surprising finding. It is commonly believed that income plays a crucial role in determining health.
With respect to eye screening services, previous studies have often found unequal use of health care, with the main contributor to the observed inequality being income. Although assessing inequalities between two groups is often based on the central tendency e. Our study moves beyond other research methods by defining the degree of inequality using RCI, a standard inequality index in population-based health research. Lastly, by standardizing for differences in need of eye screening services, our study provided evidence on whether the observed inequality is a matter of inequity. In our findings, age and marital status were the largest contributors to the existing pro-poor inequality in visual impairment; however, these factors may be difficult to modify considering the fact that greater age is one of risk factors for eye disease such as DR, glaucoma, and cataracts, and eye complications are more prevalent in older age groups.
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Lastly, older patients are more likely to be living alone. Although Canada's publicly funded health care system aims to minimize economic barriers, our findings suggest that income still play an important role in the use of eye screening services. Following income, private health insurance for eye care was the second largest contributor to the existing inequalities in the use of these services—this is also an income-related finding. Under the Canada's healthcare system, private health insurance could be a crucial factor in the use of eye screening service because eye screening services by an optometrist may not be covered by provincial health care plan.
For example, prior to , eye screening services by an optometrist for patients with diabetes was not reimbursed by the Alberta provincial health care plan. Importantly, discussion of diabetic complications with health professionals was also an important contributor to the use of eye screening services, associated with more use of eye care services.
A qualitative study suggested that detailed information from a primary care provider is a pivotal factor in adherence to recommended eye screening services in diabetes management. We have identified several limitations. First, decomposition analysis is not able to provide causal pathways between the individual factors and inequality.
Second, the decomposition method is a deterministic approach: there may be other factors, not included in our model, that have may contributed to the observed inequalities.
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Although we included age, sex, duration of diabetes, and self-rated health as need factors for eye screening services, there are many other important clinical indicators of need for eye screening services, such as glycemic control and blood pressure. Unfortunately these clinical data are not available in the survey data used in this analysis. For future study, it may need to be considered to have a separate analytic group for patients with glaucoma or cataract, as the recommended clinical ocular assessment interval is not same as those without eye complications, when more clinical data including a date of diagnosis for eye complications are available.
And wage increases may be needed not only to attract high-quality workers, but also to avoid a large consumer class with limited purchasing power. Second, business leaders realize they must develop stronger and more value-driven cultures. In their eyes, achieving this requires building more engaged, productive, innovative, customer-centric and ultimately more productive, more profitable, and more socially aware organizations.
Inclusive and engaging cultures go a long way toward addressing 's top-voted CEO concern: the ability to attract and retain talent. The premium placed on talent comes as no surprise, since executives must navigate increasingly tight labor markets, exacerbated by a faster pace of digital transformation. In other words, what has often been seen as the "soft stuff" no longer seems so soft. Third, one of the most critical themes centers on communications. Business leaders are vowing to better and more effectively communicate within their organizations - up, down, and across.
Being more open, transparent, and inclusive starts at the top, and is critical to building a culture where everyone can be heard, feel safe, and have their ideas count. When deliberating and applying their business acumen at this week's conference, business leaders might think of the Greek philosopher Plutarch as their guiding light. He once said that "An imbalance between rich and poor is the oldest and most fatal ailment of all republics. While Plutarch was sounding the alarm about financial inequity, a sense of inequity also extends to the workplace and the environment.
Judging from this year's theme, the WEF believes creating a shared future lies within reach. While it may not be in the sole purview of CEOs to re-unite an uncertain and fragmented world community, it is in their power to address the issues that divide their own workplaces.