Global Health Nutrition

by Hannah Meredith and Devon Paul

In Dr. Steinberg’s lecture, we heard an overview of nutrition issues on a global scale.  Interestingly, these issues ranged from overnutrition to undernutrition with both obesity and malnutrition being major causes of morbidity and mortality in the world.  With such a range of nutritional issues and they underlying causes, how can we make meaningful dietary recommendations for people? Before addressing this question, there are a number of interesting factors at play that need to be understood.

The world is currently going through a significant nutritional transition. There are 5 different patterns associated with the nutrition transition: hunter gatherer, early agriculture, end of famine, overeating and obesity-related diseases, and behavior change. Currently, many low- and middle-income countries (LMICs) are transitioning from the “end of famine” pattern to the “overeating, obesity-related disease” pattern. This transition is happening as Western-styled diets infiltrate different cultures and replace the traditional diet. Couple this introduction of diet high in animal and partially hydrogenated fats and low in fiber with a more sedentary lifestyle, and the result is an obesity epidemic that is beginning to affect low- and middle-income countries. These dietary and lifestyle changes in LMICs are an effect of a recent demographic transition from a primarily rural, agrarian society to an urbanized society centered on large cities. Migrants leave behind a food safety net of family, friends, and farms for the promise of a better life in the city; however, in the poorest countries, unemployment rates are crushing, and people try to make a living on $1-2 per day.  With that money, the city workers not only have to pay for or build their own shelter, but also have to buy the food that they once grew themselves. It is both a curse and a blessing that large-scale production has decreased the price of processed food and drink. On one hand, these foods are affordable to people who do not have much income. On the other hand, these foods form an unhealthy bulge in the top of the food pyramid for many.  I have seen plenty of soda bottles and potato chip bags being consumed by children with evidence of protein malnutrition and stunting.  Given the struggle with food insecurity, economic hardship, and a ready supply of cheap junk food and empty calories, how we can make meaningful dietary recommendations for people? 

In the US, we have tackled the issue of food insecurity with a variety of piecemeal programs:  food subsidies for those living below a certain income threshold, subsidized school lunches (and sometimes breakfast and dinners), food pantries, “soup kitchens”, or community farmer’s markets that intend to provide low cost fresh fruits and vegetables in food deserts.  Yet even in our own country, we struggle to meet the nutritional needs of the most vulnerable. What should a program look like that addresses those living at risk of malnutrition? 

Demographic Transition: Aging and Migration

by Hanzhang Xu and Nan Sandi

Dr. Jessica Ho discussed the determinants (fertility, mortality, and migration) of demographic transition and its impact on global health. Here we would like to provide two examples of demographic transition: one is the aging situation in China, and the other is the migration influx in Europe.

Gray dawn: the aging crisis in China

The older adult population in China has been growing dramatically in the past few decades. In 2000, nearly 90 million adults age 65 or above were living in China, and this number increased to 202 million in 2013. The elderly population is predicted to increase to over 300 million by 2050, accounting for 30% of the population. As the elderly population increase, so as the prevalence of Non-communicable diseases (NCD) such as CVD and diabetes. In addition, the older populations are more likely to suffer from several type of NCDs and more severe complication that can be more expensive to cure.

Several factors contributed to the rapid aging population in China. First, the average life expectancy in China has been improved tremendously—from 68 in 1981 to 74 today, because of the robust economic growth over the past few decades. Second, baby boomers, who were Chinese in the 1950s and 1960s, has started to fall into the older adults category. Third, an extremely low fertility rate due to the “one child” policy further speed up the demographic transition in China.

Recently, China ended its decades-old “one child” policy so that all married couples would be allowed to have two children. Demographers argued that this decision might be a step in the right direction, but probably too little too late to make a big difference in the aging trajectory happening in China. One of the concerns is that many eligible couples would not act on it, as the cost in raising children especially in urban setting is very high in China. Even in rural China, families which have been exempt from the “one child” policy are not willing to have more children because of the costs and efforts.

Still, many citizens and social media thumb up for this announcement. This adjustment on birth restrictions might lead to a decline in the trend of birth tourism in recent years that many Chinese parents went overseas to places like Hong Kong and the U.S. to have a second child.

It might be too early to jump to the conclusion at this point. The debate over whether abandoning one-child policy will be effective to solve China’s aging crisis will be going on for years. But overall, China is a country that should be watching over the next few decades.

Is the migrant crisis an opportunity for an aging and demographic decline Europe?  

Today, the world faces the largest migrant crisis since World War II. Due to war, civil conflict, persecution, climate change, and poverty, millions of people risk their lives in the Mediterranean Sea in order to flee from their homes in the Middle East and sub-Saharan Africa to Europe. According to UNHCR (2015), 34 percent of these migrants are from Syria, 12 percent are from Afghanistan, 12 percent are from Eritrea, 5 percent are from Somalia, and 5 percent are from Nigeria.

The UN estimated that number of migrants entering Europe will continue to grow; however, the European Union (EU) hasn’t come out with the long-term solution to tackle migrant crisis yet. The EU proposed to use mandatory quotas to allocate migrants across its 28 member states. However, since there are costs (such as housing, healthcare, education, and other social welfare services) associated with accommodating migrants, some governments in the EU rejected the proposal.

            It is undeniable that hosting migrants can be costly in Europe. But, isn’t the migrants influx a good opportunity for an aging and demographic decline Europe? 

            Europe’s aging population has gradually increased, mainly due to low birthrates, high levels of young people emigration, and high life expectancies. As a result, working-age population has tremendously decreased. According to United Nations’ Population Division (2013) the populations in the Baltic countries and Bulgaria has been shrunk by more than 15 percent, Croatia by 10 percent, and Romania and Hungary by 5 percent. At the same time, the populations who are above 65 have increased by more than a third between 1990 and 2010 in the countries of Central Europe and the Baltics. The aging and demographic decline is likely to accelerate. This will harm the economy and demand more resources to accommodate aging population (such as, old age pensions and healthcare services).  Migrants come to Europe with children, skills, motivation, and innovative ideas. Therefore, it is now the time for Europe to accept migrants and turn migrant crisis into an opportunity.

Reference:

Wang, X.-Q., & Chen, P.-J. (2014). Population ageing challenges health care in China. The Lancet, 383(9920), 870. http://doi.org/10.1016/S0140-6736(14)60443-8

Wu, Y., & Dang, J. (2013). China Report of The Development on Aging Cause (2013)-2013-Yearbook-SOCIAL SCIENCES ACADEMIC PRESS(CHINA). Retrieved October 20, 2015, from http://www.ssapchina.com/ssapzx/c_00000009000200010005/d_0759.htm

Smoking in developing countries

by Jihye Suk and Hanati Hailati

Smokers are great supporters of positive psychological effects of smoking. However, according to the CDC, smoking causes diseases such as lung cancer, diabetes, and erectile dysfunction on males. Smoking not only harms people with various diseases, but it will also cause 8 million deaths annually in 2030 if current trend continues [1]. What we need to focus on here is that the 8 million people are mostly from developing countries or from low-educated population. The correlation between education level and smoking in India, as Dr. So indicated in class, supports this presumption. Moreover, as he emphasized, while tobacco consumption in developed countries decreases by 0.2%, it is increasing by about 3.4% in developing countries each year.

Tobacco industry is getting smarter and more powerful based on their wealth. In contrast, our countermeasures are still stymied by the barrier of individual freedom issue. If it is truly personal choice, why does research show that developing country populations are more likely to choose smoking? Why even among developed countries, disadvantaged population is the group of main smokers?

Today, commonly utilized smoking cessation strategies are as follows: cigarette taxes, comprehensive bans on tobacco advertising and promotion, prominent warning labels, restrictions on smoking in public places, and increased access to nicotine replacement treatments.

As one of the readings by Dr. So noted, the economics of global tobacco control, written by Prabhat Jha and Frank J. Chaloupka, the threat posed by smoking to global health is extraordinary, but so is the potential for preventing millions of smoking related deaths with highly effective policies [2]. This article also states that tax increases are the single most effective intervention to reduce demand for tobacco [2]. WHO also notes that the most potent and cost-effective option for governments everywhere is the simple elevation of tobacco prices by use of consumption taxes [3]. Tobacco includes excise taxes, value added taxes (VAT) or general sales taxes and import duties.

According to the "WHO Report on the global tobacco epidemic 2015," 33 countries levy cigarette taxes that represent more than 75% of the retail price of a packet of cigarettes, but many countries have extremely low tax rates, and some countries even have no special tax on tobacco products at all [4]. Take China as an example. China has the largest smoking population in the world and bears the largest disease burden from smoking as the chart shows below. A research model in China suggests that raising cigarettes taxes so that they account for 75% of retail prices- up from 40% of the share of price in 2010- would prevent nearly 3.5 million deaths that would otherwise be caused by cigarette smoking [4]. However, levying cigarette taxes still faces lots of challenges. Recently the City of Beijing, one of top three populated city in China, just started its strictest bans on smoking in public places since this October.

Dr. So finished his lecture with suggesting our new challenge at the emerging of e-cigarette. The latest released presentation [5] by CDC indicates very few clinical trials are conducted to evaluate the impact of e-cigarette. Cultivating adolescent as a future smoker seemed to be e-cigarette industry’s main aim, but it is not yet regulated in many countries.

Source: Institute for Health Metrics and Evaluation

[1] World Health Organization. (2011). WHO Report on the Global Tobacco Epidemic, 2011. Geneva: World Health Organization, 2011. [accessed 2015 Nov 5]

[2] Jha, P., & Chaloupka, F. J. (2000). The Economics of Global Tobacco Control. BMJ: British Medical Journal, 321(7257), 358.

[3] World Health Organization. (2010). WHO Technical Manual on Tobacco Tax Administration. Geneva: World Health Organization, 2010.  [accessed 2015 Nov 5]

[4] World Health Organization. (2015). WHO Report on the Global Tobacco Epidemic, 2015. Geneva: World Health Organization, 2015.  [accessed 2015 Nov 5]

[5] CDC. E-cigarettes: An Emerging Public Health Challenge (10.20.2015.) by Brian King, PhD, MPH, Jonathan M. Samet, MD, MS, John Wiesman, DrPH, MPH, Matthew L. Myers, President of Campaign for Tobacco-Free Kids.

“Accidents” Don’t Happen, But Preventable Injuries and Violence Do

By:

Adriana Lein

Brian Meier, MD

“Accidents happen.” We’re all likely familiar with this adage that suggests unfortunate happenings are unpredictable and unavoidable. While it may be true to some degree that tragedy strikes in unexpected ways, a closer look at the global burden of disease reveals that events such as road traffic injuries, which are significant contributors to global mortality and morbidity, are anything but unpredictable and unavoidable. In fact, all of the primary contributors to what the World Health Organization has termed Global Injury Burden follow patterns that disproportionately affect certain groups based on demographic differences, whether gender-based, grounded in socioeconomic inequality, or specific to regional and political factors. Among these contributors to Global Injury Burden are road traffic injuries, suicide, homicide and war (a breakdown shown in the below chart of World Health Organization).

Source: http://www.who.int/violence_injury_prevention/key_facts/en/

Delivering a guest lecture to the first-year Master’s in Global Health cohort at Duke University on October 20^th, 2015, Dr. Catherine Staton explained why she doesn’t like to use the word “accident” in her work. An Emergency Medicine physician and an expert on road traffic injuries, Dr. Staton has worked extensively abroad, in places including South Africa, Georgia, Armenia, and, recently, Brazil and Tanzania. According to Dr. Staton, the word “accident” implies a spontaneous and independent incident. Such levity towards serious phenomena overlooks the potential for injury and violence prevention by addressing risk factors through interventions at the community and policy levels. Dr. Staton went on to outline the clear patterns of predictability that road traffic injuries follow, a theme central to her work. Dr. Staton and her colleagues have conducted mapping of deemed road traffic “hotspots” on Brazilian highways and found that crash occurrences could be modeled after variables related to regional differences and built-environmental analyses and mainly fell into 5 different patterns. However, traffic accidents are not the only component of injury burden that could be reduced through understanding ecological determinants.

Consider interpersonal violence, a subject that receives considerable attention due to politicized discussions of mass shootings and gun control. Returning to the above example of Brazil, homicides were the leading causes of premature mortality in 2010 (reported in Years of Life Lost). As the Los Angeles Times highlighted in a recent profile, Brazil’s homicide rate actually increased between 2000-2012, despite that  "in the same period…the world overall got about 16% safer from murder, while developed countries saw a drop of 40%." The profile continued, noting that violence, not surprisingly, disproportionately affects the economically disadvantaged regions of the Northeast and its victims are overwhelming young, black males. Emphasizing the link between violence and social injustices, Christopher Mikton, a technical officer of the WHO team on Violence Prevention stated, "all else being equal, we expect that if there is a major drop in inequality, homicide rates go down."

So is there really such a thing as an “accident” when it comes to health or can the global injury burden best be understood through the application of Paul Farmer’s well-known extension of structural violence theory to health outcomes? The evidence points to the latter.

Nature Matters

By Loise Ng'ang'a and Sumedha Roy

Industrialisation, urbanisation and globalisation have brought about revolutionary advances to the human race. These advances have resulted in increased food security, reduction in poverty rates, access to better health care and availability of more domesticated land. However, these have been achieved through intense exploitation of the earth’s natural resources, which has in turn jeopardised the health of our planet and its ability to sustain healthy human life. The writing on the wall has been evident for a long time, but has only recently gained public recognition after the publication of the report by the Rockefeller Foundation–Lancet Commission on planetary health. 

Source: http://www.elementshealthspace.com/wp-content/uploads/2009/10/WHO-climate-change-chart.jpg

Scientists have mapped out nine planetary boundaries within which human development must occur for our continued survival on earth. The shocking revelation is that four out of the nine boundaries have already been crossed, which just reiterates that we have reached a point where the depletion of natural resources poses immeseaurable danger to human health and the future of generations to come.

Source: http://www.stockholmresilience.org/21/research/research-programmes/planetary-boundaries/planetary-boundaries/about-the-research/the-nine-planetary-boundaries.html

Dr. Subhrendu Pattanayak’s recent lecture highlighted the effect of various environmental damages and depletion of natural resources on health of the population. For example, frequent and intense forest fires started manually for clearing land for production has caused rising carbondioxide levels in the atmosphere, ultimately resulting in the infamous Indonesian haze. Such grave are the implications of this haze, that it has been shown to stunt height and lung function of children in conception or in their first few months. Breathing polluted air has also been correlated with an increased incidence of cardiovascular diseases, cancer and respiratory illnesses. According to WHO, approximately 7 million premature deaths were attributed to air pollution in 2012 alone.

Dr. Pattanayak also emphasized on the need to design and implement strategies that can ameliorate the situation, rather than simply acknowledging the problem of planetary health. Starting with a hypothesis and strategy at a smaller scale would allow testing of scalability and better utilization of resources. It is important to remember that the worst outcomes of this environmental destruction will have to be borne by the poor, as the wealthy and middle income populations have other means of escaping. This is just one of the many challenges in attracting funding and research towards a seemingly distant problem that disproportionately affects the population. He listed three main challenges that need to be adressed to protect human health against the threat posed by environmental changes. These include the lack of imagination, knowledge gap, and innovative research, all of which could be better utilized to identify the social and environmental drivers of health. Also, in order to overcome implementation failures, he suggested critically identifying how the various players in planetary health are interacting with drivers of the problem. For instance, promoting collaboration between governments, private sectors, non govermental organisations (NGOs) and the local community is absolutely fundamental for finding a solution to this omnious threat.

The fate of nature is intricately linked with ours. The state of nature, health of people, and economy of nations have always been inter-dependent, and hence there is an urgent need for all policies to take that into account. For the sake of the present and future generations, we must consciously devise strategies to conserve nature. 

Redefining the Cultural Norm

by Konyin Adewumi

I have lived under the umbrella of a patriarchal African society all my life.

Chimamanda Ngozi Adichie was the first self proclaimed African Feminist that I had ever encountered. To me, she was a glimmer of hope of what could be. However, I believe the rest of the world needs to reevaluate the reality. It is a dangerous game to look at Africa with a savior complex, deep rooted in the history of the white man’s burden.

My mother is the strongest person I know. Growing up, I learned to fear and admire a woman who was over a foot shorter than me. And though I loved my father with the heart of any young girl whose father has shown her nothing but kindness, I knew that nothing in my life could function without my mother.

My mother could come home from a long day of work, cook my family dinner, drive us anywhere we needed to go, tidy up, adorn herself in anti aging creams, and wake up to do it all over again. She served as both breadwinner to my family and the glue that shouted us all together, because if you have ever encountered an African mother, she was probably shouting.

 I could say the same about many of the African women I grew up around. I had aunties whose strengths and talents were unparalleled. So much so that when I see a picture of an African woman with a basket of yams on her head and baby wrapped in eccentrically colored cloth hanging from her back, I see a woman that can do anything. There is power beyond belief in the African woman, this is what I hope others will one day see.

However, I do not hide behind cultural pride and regional dedication, as a means to ignore a greater issue. Global problems such as the rapid spread of HIV in sub-Saharan Africa have made the problems of patriarchy almost impossible to ignore. HIV disproportionately affects girls and young women throughout Africa, often attributed to the over arching culture of male dominance. Women are less in control of reproductive justice, cliterodectomy are practiced in villages around the continent, female literacy rates continue to be much lower than men, while child marriage remained highly prevalent among young girls.

Women of Africa have historically shown the world what they are capable of. They have played pivotal roles in the ending of apartheid, they have mobilized to end civil wars, they have served as voices to end female genital mutilation, and they have served as powerful heads of states. If global burdens of disease disproportionately affect women, what is the role of women in creating policy, as opposed to men? Audre Lorde once said that the master’s tools will never dismantle the masters house, does this place the burden of change upon the backs of women?

It is not a secret that cultures continue to change. No culture that has refused to adapt has survived the constant transitions and transformations of globalization. So I then pose the question, what would the changing of the gender culture look like in Africa? Can it be implemented into African culture, without breaking down walls of the culture itself? Khadija Gbla, a brilliant African feminist who works to end female genital mutilation, once said that culture is not an excuse for abuse. Do we sacrifice health for the sustainment of a culture or culture to promote health? Are the two mutually dichotomous? I believe we are in a time where women and men of Africa work to cultivate a reality of African Feminism rather than aspire to westernized ideas of female rights.

This begins by asking women of all ethnicities, what does empowerment look like to you and who can help you attain it?

Stereotypes of gender- who said men cannot be good nurses

by Jing Wang

Dr.Watt mentioned in class that: “Gender is the social construction of the biological differences between men and women.”  When I sit down and think about words such as “women,” “female,” “feminist,” “men,” “male,” “patriarchy,” and “masculine,” I feel that yes, gender is “a learned and socially determined behavior.”  Then I start to reflect on how people tend to tag men and women in different countries and cultures.  In fact, it is unfair to both men and women when people assume how men and women should perform regardless of their individual characteristics.

 Adichie talked about the stereotypes that people have for feminists in South Africa: they should look sexless, single, aggressive and not feminine at all, which reminded of people’s attitudes towards feminists in China.  Feminists should be a neutral word but it is more of a negative word in China.  One of the famous sociologists specialized in gender studies in China, who is definitely a feminist, told me that never claim yourself as a feminist if you want to achieve success in this research field.  People will regard you as radical and aggressive and question your work as biased. 

 Another thing that Adichie mentioned was that some of her male friends do not understand why women still think there was gender inequality since the society has given tremendously more rights to women in the past twenty years.   I still remember the student Union election back in high school. Our director said that this school valued gender equality very much so we needed one girl there to show this.    Many people understand gender equality in this way. It is something that we should show and brag about. I do not care who this woman is and what she can do. All that I care about is that she is a woman and be there to show how much I value gender equality.  I am not denying that it has been great progress since the time when women could not vote back in the early 20^th century. But what I am saying is that it is far from enough.  This so-called equality has tricked us and blinded us with ignorance and indifference.   

All these stereotypes and tags are unfair to both women and men.  I question why men must be masculine, what is the whole point of this since we are not cavemen and will not starve to death if men did not go hunting.  And I do believe that there should be some cavemen who loved and were better at caring for babies and sewing while they were forced out to hunt.   Just like how people talked about “male nurses” in China. And to be honest, I doubted their ability to be nurses as well because I have been taught and seen a lot how women are born caregivers.  But it turned out they can be great nurses not only in ICU and OR, but also in neonatal department.  I was wondering how many good male nurses we have missed because of the stereotypes and to generalize it, how many good career women we have missed in traditionally men-dominated fields. Almost all of us tend to assume what women and men should do and be like to different extents.  Just to keep in mind, even baby steps from thinking in this way will take us to a better world.