Inter-Generational Influences in Developing Countries: understanding years of malnutrition

Inter-Generational Influences in Developing Countries: understanding years of malnutrition  

The last class’ discussion got me really into maternal health and child nutrition patterns and wanting to know what factors in terms of mother’s composition might limit the ability for a child to be fully healthy. Are there certain pre-genetically determined characteristics that are out of the control of those in developing countries that might deter any kind of intervention program from actually being effective? I realize that yes, stress, height, body mass index etc., can be related to ability to be fertile but wanting to see if there was any research out there that had found anything in particular with regards to growth of the child and correlation with maternal characteristics such as BMI.

Among my search I found this great article from the Journal of Pediatrics where researchers found that maternal height was a significant indicator of child growth patterns (Addo et al., 2013). Of course height can be something attributed to genetics but what they did discuss was the fact that these ‘genetic’ characteristics can indeed be the cause of “nutrition-related inter-generational influences” on something like height and growth (Addo et al., 2013).  This really got me thinking about the potential for communities in developing countries to be so limited by the past before them that even includes genetic composition.

You see, although we get frustrated week by week in our discussions regarding how long development and health programs take to show results, we need to be humbled by the fact that we are not combating 10 years of globalization and neoliberalism ideologies in all cases and all that have come with it. Sometimes we are reversing ages of genetic code that have been the result of several limiting factors such as improper nutrition from generations before them. To really see such impactful results in these communities will not only take time, but also requires us to not attach to one factor that might be the cause and know that there are so many identifiers that we are probably not even aware of as of yet as public health professionals. Let’s not have our frustrations fog our abilities to critically analyze these situations, but use our frustrations to motivate us to move things forward.

References

Addo, O. Y., Stein, A. D., Fall, C. H., Gigante, D. P., Guntupalli, A. M., Horta, B. L., … Martorell, R. (2013). Maternal Height and Child Growth Patterns. The Journal of Pediatrics, 163(2), 549–554.e1. https://doi.org/10.1016/j.jpeds.2013.02.002

Health and community

Being in poor health is not something that happens in a vacuum or isolated to the person suffering. When we think of global health we don't put ourselves in the position of those who are disproportionately affected by disease outcomes. We also don't really think about what effect the health outcome has on the family and communities, because we focus more on the problem than on the people.  My sister has just her final round of chemotherapy to battle breast cancer.  Whenever my sister is deployed our family has gone through the stress of wondering whether she will come home safely and when she comes home will she be mentally stable and with all her appendages. This stress and apprehension would last until she was back safely in the states. It's easy to understand the stress that military families feels during times of war, however what happens when military families have to watch a family member suffer through the damaging effects of chemotherapy. Chemotherapy damages the healthy as well as unhealthy cells in a persons body.  It does damage to the mental psyche of the individual as they are mentally preparing for life and death at the same time.  The family deals with the stress of medical procedures that seems to do more damage than good.  They also face the psychological effects of living and dying and the emotional response of this.  I see my sister alternate between anger, and resignation to hurt and loathing.  I see the effects of what may have been and what may never be in her actions, tears and how she now lives.  Watching my sister and reading the articles makes it rather difficult to process at times because they really resonate with me.  I look at health not from the perspective of they are without proper health but the damage that it causes not only to the person but to the family and community.  When a member of the community is hurting and without good health it removes them as a productive member of the community and depresses the livelihood and mental health of others in the family and community.  Health is a shared experience and is not isolated. Good health is a right that everyone  should have access to. 

Can public health interventions be structural violence practices?

While reading for our next class, these questions came in my mind:  Can our practices to help people increase their sufferings? Can our good intentions bring harm rather than good? Can our interventions be structural violence practices?

Dealing with health problems in the developing world is a critical issue especially when dealing with sensitive issues such as HIV/AIDS. Public health planners, service delivery personnel and NGOs policy makers used to deal with such problems from a single perspective. They usually blame the individuals for their practices and consider them as being guilty rather than victims. They neglect how world is changing in the era of globalization and how the neoliberal ideologies put these populations under continuous pressure to gain their normal rights of just keeping alive through the extreme harsh economic, political and social challenges that they face. They tend to follow the up-down approach in dealing with health issues for these suffering populations that is focused on practices targeting individual behavior change and then got surprised why they are not effective as they are in western world. People in western world have the ACTUAL choice to change their behaviors to be healthy. However; in the developing world, people tend to have the choice THEORITICALLY but not practically. I remember the story of the Haitian girl “Acephie” who lost her life from AIDS that we read about a couple of weeks ago. Are we brave enough to blame her for her behavior and consider her to be guilty?! Did she really have the choice?!

The strategies of tackling health issues among those on the bottom of the socio economic gradient should be reformed. Taking structural barriers and inequalities in consideration is a must if we really need to help. Empowerment of the community and using the bottom-up approach is an urge. Culture is not usually impeding. If we understand it and its associated conditions well and pay attention to the voice of those whom we are planning to change their lives, culture can be turned into a facilitating factor in order to avoid wrong, ineffective and structural violent interventions.

Three Forms of Compensation

This past week I had the opportunity to attend the IPHA Celebration and Hulman Health Achievement Awards. The main speaker, Jennifer Wathall, MD, MPH, Deputy State Health Commissioner and Director for Health Outcomes, spoke of an interesting topic that related to global health. She told of a book, written by Adam Braun, called The Promise of a Pencil. In this story, a young college graduate just out of school begins to travel the world, and in each country he visits he asks a child what he wants most in the world. This question stemmed from his thoughts back to his own childhood, when he chose what he wanted most in the world (to have lots of money) and worked toward that goal. So, he was curious what other kids wanted most. During his visit in India, he came across a young homeless boy and asked him this question, to which the boy responded, "a pencil". So Adam gave him his pencil and the boy's face lit up.

From the experience with this young boy and growing up as a basketball player (he describes how a lot of his teammates had varying degrees of education levels), Adam went on to found Pencils of Promise, a non-profit organization that builds schools and increases access to education for children in the developing world.

His book is more than just his story and his NGO.  It details how each person has a purpose in life, and that purpose could be for many to help others in need. I think a lot of us in this class could identify with this.  What do you feel your purpose in life is?  He also describes a "normal" person can have an extraordinary impact by simply dreaming big but remembering small.  An excerpt from the book describes how although he was on the exact “right” path, with a very lucrative career, nice clothes, an impressive business card, something was missing: “...deep down inside, I was no longer enamored with the life I’d created. The only purpose I was serving was self-interest. While I rarely showed it to outsiders, my happiness waned day after day. A restless voice kept me up at night, telling me that until I found meaning, the money wouldn’t matter. It told me that I’d find far more fulfillment if I measured my life in purpose, not profits.”  One major take away from this story is how he describes that there are three forms of compensation: money, mastery, and meaning.  What do you guys think about these three forms of compensation?  When would each be important in your future career?

I haven't read this book, I just described in secondhand from the speech Ms. Wathall gave. However, I really look forward to reading it!

Vision and Priorities for Global Health by WHO Director General Candidates 2016

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31847-5/fulltext

The above has the extremely interesting interviews of the 6 candidates. You might have to create an account with Lancet (free) to access the report if accessing from home. Through library it is free!! Read and post comments. I will discuss this in class coming Tuesday!!

These perspectives are very important for us as WHO is a global health agency and highly influential in setting directions, taking leadership.

Effective Health Communication

Before reading the articles for next week's class, I was reading for my Theory of Health Behavior class which we are also talking about health communication in. The main take-away I had from these readings is that not only do you need to use scientific theory and research in health promotion and communication, but you also need to take your population into account when designing your intervention. You need to assess they're environment and culture, as these could provide barriers to behavior change.

After reading the articles for International Health, I had the same take-away except with a different view. Again, looking at the culture of your population is very important for behavior change, but it should not be seen as a barrier. Close-knit communities and a strong sense of culture can be beneficial for behavior change interventions. The way researchers of Western societies want to change behaviors, does not always work in developing countries. Developing nations such as sub-Saharan Africa, have very strong community ties. One will not adopt a behavior if it is not accepted by their family and if it is not a norm in the society. For nations like this, we need to tackle disparities at more of a community level, rather than at the individual level. Their strong culture and community ties can help everyone achieve a goal together. If the leaders of the community show support, odds are that the rest of the community will follow.

In conclusion, researchers need to pay very close attention to the culture and environment of their target population. We cannot tell a vulnerable population to fear a disease and promote behavior change if they do not have the resources to do so, or if it does not follow their beliefs. We need more models that can be customized to specific regions and populations and we need put importance on the targeted population's opinions.

How to Improve Cafeteria Food

A large number of United States’ young adult population can look back and cringe at what they were served for lunch.  U.S. high school cafeterias are notorious for producing some interesting concoctions for their students.  I have been looking at the health benefits of community gardens for another class. I came across a gem of a study that while not the best resource for my other assignment; I felt it needed to be shared.  This particular study shows that not all school cafeterias are created equal.  It also displays that some educational systems are striving to improve their students’ nutrition.  In this article, Pearson (2008) looked at a nine different schools in the Eastern European Republic of Moldova.  These schools were auxiliary/boarding schools.  They received a support from the Monsanto Fund and a project grant from the International Federation of Home Economics (IFHE).  The project lasted 2.5 years and their ultimate goal was to improve the nutrition of the students.  Their master scheme was to have gardens on the school grounds.  They started out with educational workshops to introduce what good nutrition was.  The nine schools that were selected to receive the necessary equipment for this project were in picked out of a total of 50 schools.  The IFHE grant and Monsanto Fund allowed the schools to receive seeds, gardening supplies, and fruit trees/bushes, seeds for two seasons.  The employees of the schools were the ones that took care of these gardens and orchards.  Any produce that was not used by the schools was given to the local community.  The students themselves were given 3 meals a day full of diverse produce.  This means the schools were able to meet their goals of better food options for their students.  The students also gained life skills on gardening and proper nutrition education.  Do you think we could apply some type of program like this in the United States?  Would the students have to be the ones to grow their own fresh produce?  Please let me know your thoughts!

Pearson, J. M. (2008). Improving nutritional health in schools: Gardens in moldova. Journal of

Family and Consumer Sciences, 100(3), 42-43. Retrieved from

http://search.proquest.com.ezproxy.lib.purdue.edu/docview/218174971?accountid=13360

Nurse-Family Partnership.... Globally?

This week’s topic on maternal and child health got me thinking about some options I have considered in my nursing career.  I have not always been interested in obstetric nursing, one could even say I am probably the opposite of interested due to my faintness at seeing C-sections and general uneasiness of children.  However, I am really intrigued by how much a mother influences her child’s health both before and after actual birth.

I aim to complete my practicum with Nurse-Family Partnership (NFP), a nurse-visit program that involves a nurse going into the home of first-time, at-risk moms to give them care and assistance with everything from prenatal to finishing high school.  This program has been incredibly successful for moms in the US, and after taking this course I can only speculate how successful it would be globally.  As I was reading for this week, I read about Lay Health Workers and Community Health Workers and thought, how awesome would it be if NFP could pair up with a global health group to teach their program to other developing countries, using these workers as their “nurses”?

In regards to malnutrition, I recall a story a nurse from NFP told me once.  She spoke about a soon-to-be mom whose boyfriend had just gotten a job at Taco Bell and was able to bring home food after closing each night.  Since the couple had limited income, they mostly ate the food he was able to bring home.  The nurse told me that while obviously she should be only teaching about fruits & veggies and healthy eating, she had to work with her patient from where she was.  She had the boyfriend bring home a nutrition menu from Taco Bell and helped them dissect it so that they were able to choose the healthiest items for the pregnant patient.  I like this story because it’s very real.  If we were to go into a developing country and start teaching four fruits a day, 6 ounces of meat, etcetera ecetera, how far would we really get?  How much impact would we have?  I think it’s important as global health professionals to work with patients and people from where they are and make the best of it, especially when it comes to pregnant moms.

I look forward to class discussion on Tuesday!

When is it time to break the rules?

Earlier in the week Dr. Acharya shared this short reading with me; it is a commencement speech from a medical school graduation, but I think its message can be applied not only to MDs but across the field of public health and maybe even more broadly to life.  Feel free to read it for yourself (not a long read) at this link, but I’ll provide my perspective.

http://pulsevoices.org/archive/stories/234-stepping-into-power-shedding-your-white-coat-donald-berwick-s-graduation-address

 Rules tend to exist for a reason.  In the hospital setting, these rules are made for safety and efficiency.  In the speech, the author reads a letter from a woman whose husband had passed away, spending his last few weeks in the intensive care unit.  She had very restricted visiting hours due to hospital policy and lost a lot of time she could’ve spent soaking up their last few moments together.  Why were these rules in place?  It surely wasn’t because some evil hospital administrator sat in his office and scoffed and decided to make things hard on her.  It probably had to do with the fact that people in the ICU are very sick and there is a lot of equipment and medication and other patients to be dealt with, and that if all their visitors were coming in and out all the time as they pleased it could become a hectic, dangerous, and infection-prone environment for the other patients.  Still, that does not make the rule just.  That does not make it fair.  That does not mean it is always best for those it was meant to protect, because the husband dying in his hospital bed surely would’ve preferred his wife by his side.  Whether it is as a doctor or a health care professional, a public health crusader, or as a parent or friend or fellow human being, we have to be able to see past the rules.  Sometimes they must be broken; sometimes it is possible to challenge them in an attempt to cause more lasting change.  We also must not vilify those who made the rules, or even those who enforce them.  What if the nurse, who told that wife that she could not visit her husband at that time, did so because she feared losing her job, as a single mom with two kids at home?  Breaking the rules wasn’t worth it to her.  But that doesn’t mean it can’t be to us.  Progress is made by challenging a problematic status quo.  In the medical setting and beyond, the “rules” must not be taken as an unquestionable dogma written in stone, but as what someone thought was best at the time they were developed.  That doesn’t mean they can’t be reevaluated, and we must recognize when this is necessary and take appropriate action.

Neglected Tropical Diseases "NTDs"

It is uncommon for those who live in developed countries to hear about someone who is suffering from elephantiasis, river blindness, snail fever, trachoma, round worm, whip worm or hook worm infections. However; these Neglected Tropical Diseases (NTDs) are considered a major threat affecting the bottom billion of people who are stuck in poverty traps, lack of education, and lack of health benefits.

Setting priorities to deal with such threats is a challenging condition. It is an issue of the developing world that, from the point of view of many, is not affecting those in the upper sector. Globally, dependence on DALYs as an estimate of the global burden of these diseases as a criterion for priority settings towards these neglected diseases is somehow misleading. According to (WHO, 2004) report, the DALYs burden due to neglected tropical diseases was estimated to be only 4% of the total due to infections diseases. Based on that, it is not considered a global health priority to be taken into consideration in relation to other global diseases that has higher DALYs. Is this completely accurate? Actually, it is not! Depending on Global DALYs for this kind of diseases is not precise because of the associated “hidden” co-morbidities such as anemia, diarrhea, weight loss and others. Besides, the associated co-infections such as malaria may mask the original problem of NTDs.

Although it is an ethical responsibility, modern world in the era of globalization, deal with health issues in poor areas from an economic point of view. Accordingly, it is worth to highlight that many heath interventions in the developing world have high rankings of cost benefit ratio. Based on that, cost effective interventions, that entails fixed cost to be spread over high number of people, should be prioritized. This cost effective approach will combine both health gain along with economic benefits by applying the vertical interventions (SPHC) in the form of massive chemotherapy or school based programs. Such approach might convince policy makers and economic powers to invest in this sector based on the return of their investments in the form of preserving global human capital, increasing productivity, lowering child mortalities with consequent lowering fertility rates hence increasing investments in low number of individuals.

Such neglected diseases, along with their associated co-morbidities and co-infections, are currently localized in certain geographic poor areas. However, there is a global risk of transmission, loss of global productivity, and increasing non cost effective interventions in the future if the problem is not paid attention to in the current time. Therefore; targeting this global threat is neither exclusive personal nor national responsibilities. It is an ethical, economic and political obligation of the developed world which should be an integral part of the global health improvement and poverty reduction strategies.

Reference:

Canning D. Priority setting and the 'neglected' tropical diseases. Trans R Soc Trop Med Hyg. 2006 Jun;100(6):499-504. 

Smoking and Its Risks for Children

The topic of smoking has been brought to my attention continuously in recent months.  It has been discussed with fellow members of the MPH program. Friends have talked about how people smoking on campus frustrate them.  The television is consistently running the Truth campaign commercials.  I have discussed tobacco-use and its effects on health in multiple classes.  The continued use of tobacco is obviously an issue in most societies.  In the United States, every single death certificate has a place to mark if tobacco was a contributing factor to death.  My biggest concern is why do people continue to smoke or start the destructive habit if they know it’s a terrible risk?  One interesting point is people continuing to smoke because of smoking allowing them to maintain a low body weight.  The Fernanda Rafaela de et al. article discussed this phenomenon.  The nicotine from cigarettes acts as an appetite suppressor.  Thus, people who smoke do not want to eat as often.  This allows them to more easily maintain a low body weight.  In their study, smoking was categorized as an independent risk factor for malnutrition.  Most of my research into smoking and malnutrition showed the most significant results to be affecting children.  It is the children of parents who smoke that appear to be having issues with their health.  Not only is smoking known to cause breathing problems in children like asthma, it also affects their growth.  Mushtaq et al. research lead to results showing Pakistani children have stunted growth.  In this particular study, smoking in the home was not shown to affect the thinness of the child.  The Semba et al. article best summarized the risk of parental smoking and child malnutrition.  This article looked at numerous urban and rural Indonesian families to determine the risks of smoking in a family.  The researchers discussed how funds which would otherwise go towards necessities are spent on cigarettes.  Their results showed that paternal smoking in Indonesia (a developing country) is connected to higher infant and < 5 aged children mortality.  These results are inspiring for those trying to end cigarette smoking.  People can often be persuaded to change when the health of their children is at risk.  Let’s hope some change will come from these troubling results.

·         Fernanda Rafaella de, M. S., Mirella Gondim Ozias Aquino,de Oliveira, Alex Sandro, R. S., Jose, N. F., & Carmina, S. S. (2015). Factors associated with malnutrition in hospitalized cancer patients: A croos-sectional study. Nutrition Journal, 14 Retrieved from http://search.proquest.com.ezproxy.lib.purdue.edu/docview/1779687233?accountid=13360

·         Mushtaq, M. U., Gull, S., Khurshid, U., Shahid, U., Shad, M. A., & Siddiqui, A. M. (2011). Prevalence and socio-demographic correlates of stunting and thinness among pakistani primary school children. BMC Public Health, 11, 790. doi:http://dx.doi.org.ezproxy.lib.purdue.edu/10.1186/1471-2458-11-790

·         Semba, Richard D,M.D., M.P.H., de Pee, S., PhD, Sun, K., M.S., Best, C. M., M.H.S., Sari, M., M.Sc, & Bloem, Martin W,M.D., PhD. (2008). Paternal smoking and increased risk of infant and under-5 child mortality in indonesia. American Journal of Public Health, 98(10), 1824-6. Retrieved from http://search.proquest.com.ezproxy.lib.purdue.edu/docview/215091536?accountid=13360

Blue Zones

       I recently finished reading the book, The Blue Zones: 9 Lessons For Living Longer from the people who've lived the longest. Blue zones are defined as pockets in the world where people live measurably longer lives and have a higher rate of centenarians- people who live until 100 years of age. The story is told by the Author and describes his experiences visiting each of the 5 blue zones in the world: Sardinia, Italy; Loma Linda, California; Okinawa, Japan; Nicoya, Costa Rica; and Ikaria, Greece. The stories he told were absolutely mind-blowing. At the end of each chapter, the lessons of that blue zone were listed. How were these people living so long?
        Although each blue zone had there own unique characteristics and practices, there were a few common themes. First, all of the zones place high emphasis on the importance of spending time with friends and family. All of the communities are very close, they help each other out, and there is a sense of comfort and safety within their community. Next, mostly all zones consumed limited amounts of meat or were vegetarians. They grew just about all of their food in gardens, which means they barely ever ate processed foods- it was all organic and had to be prepared. Third, they all lived very active lifestyles. Although some did exercise by biking and weight lifting, their main forms of physical activity was walking and performing their daily tasks such as gardening. It was stressed that moderate-level exercise is all that is necessary and this should come from just making your daily life more active, not going to the gym for 1 hour everyday and then remaining sedentary for the rest of the day. The last thing they all seemed to have in common, which was called a different thing in each zone, was having a strong sense of purpose in life/ a reason to wake up in the morning.
     The quality of these people's lives were very high. They suffered from much lower rates of morbidity and mortality, and they were genuinely happy. However, already, the rates of centenarians are expected to decline with more urbanization in these areas. Kids are not growing up the same as their parents and grandparents that made it to this old age. Do you think it is even possible to adopt a lifestyle similar to those in the blue zones? Or is it impossible because of how our lives and environments are structured? Instead of living active lifestyles and eating highly plant-based diets, we are overwhelmed with technology that makes us lazy and convenience foods that are necessary for our busy work weeks.

                                                          

Linking Theory to Practice

There was a discussion question raised in this week’s class regarding how we can link the theories that we are exposed to from our education and linking it to practice as Public Health professionals. We can often get wrapped up in our studies so much so they we may often forget why we are doing what we’re doing, but it is great to contemplate the purpose of all we are being exposed to. I like to think of it as training, we are in specified programs with specific course requirements to go out into the field that we each desire and utilize what we have learned. As such, it is important for us as students to take the initiative in asking ourselves “how can I use this when I am out in the field?”; whatever ‘field’ that may be, whether it be as researchers, community health workers, doctors etc.

So in reflecting on my research interests and linking to practice, I found this great article on linking CBT (Cognitive- Behavioral Techniques) to improve breastfeeding rates in a marginalized community in Pakistan (Rahman et al., 2012). Here, the researchers aimed to integrate CBT into the maternal counselling programs that were carried out by the community health workers (CHW). After conducting qualitative research, Rahman et al, (2012) were able to identify the cultural behaviors and practices that shaped breastfeeding attitudes and used this data to design a counselling program using cognitive-behavioral techniques. The CBTs included integrating organized dialogue between the health worker and the mother into the counselling practices; dialogues were based on various elements such as establishing a CHW and patient relationship, brainstorming sessions for problem solving and reflection, as well as timed session visits based on infant’s age. After assessing the CHW’s feedback on the intervention after implementation, it was found that the program was useful and had a positive influence on increasing the exclusive breastfeeding rate within the community (Rahman et al., 2012).

Articles such as this made me realize the importance for public health workers and researchers to critically analyze the theories that we are exposed to in order to be able to utilize them and translate them into the work that we do. Behaviors and attitudes are what shapes the health outcomes in any population, whether it be towards breastfeeding practices or deciding on a health policy for a given country. By understanding the theories behind behavior change or psychology as a whole, we can positively influence how communities, government workers, and other healthcare professionals see intervention programs and utilize them to their full advantage.

Reference

Rahman, A., Haq, Z., Sikander, S., Ahmad, I., Ahmad, M., & Hafeez, A. (2012). Using cognitive-behavioural techniques to improve exclusive breastfeeding in a low-literacy disadvantaged population. Maternal & Child Nutrition, 8(1), 57–71. https://doi.org/10.1111/j.1740-8709.2011.00362.x

Child Mortality

Usually during the springtime, while walking pass the memorial mall, someone will accost me with images of dead fetuses, and a plug for pro-life.  I usually smugly reply what is life and how is that life supported.  Then I go on to ask, whether they support welfare, which usually ends up being NO, because it’s a handout. If then say well if you believe in the sanctity of life then you should also believe in supporting that life financially once it is born. Regardless of your believe, while we sit and debate pro-life or pro-choice, there are children in the US and around the globe dying from lack of nutrition and adequate health care where health and nutrition interventions for both mother and child could have saved a life and reduced the traumatic burden that sometimes leads to psychosis.

In areas hardest hit by infant mortality you have TNC like corporations that will market formula to new mothers. In developing countries, infants who are not breast fed have seven-fold and five-fold risk of death from diarrhea and pneumonia respectively.  They are not getting the necessary immunity from their mothers. Risk factors of child mortality: unhygienic and unsafe conditions, ingestion of unsafe water, inadequate availability of water for hygiene, lack of access to sanitation, 88% of death from diarrhea. Clinical cause of infant mortality around the globe range from Neonatal disorders, diarrhea, pneumonia, malaria, AIDS, measles and other.  Some of these diseases are preventable as there are vaccines, however Neoliberalism and TRIPS have created a political and health structure, Biopolitics, that those in need are not seen as a viable economic profit market, therefore not as valuable. Usually children don’t just die of one disease but multiple or co-morbidity. One co-morbidity that is heavily overlooked is malnutrition and hunger which is prevalent in low-income and middle-income countries.

Child mortality is concentrated in regions such as south Asia specifically, and sub-Saharan Africa. The  top 6 countries with a large proportion of child death in order from greatest to least is India, Nigeria, China, Pakistan, DR Congo, and Ethiopia.  If you look at these countries you would also see that in the last 2-3 decades these counties have been faced with political uprising and unrest as well as occupational environmental exposures.

Health and nutrition interventions should be in place for both mother and child that incorporate some form of education that will lessen the impact of the disease burden. Health and nutrition of the mother is important as if the mother is not healthy then the child in-utero will lack the necessary nutrients to develop appropriately and may not survive, or survive but with DALYS, that place an economic burden on an already strapped economy. I consider the least of these and most vulnerable and where we should put aside profit and politics is with children.   

Too Much of a Good Thing: Combatting Globalization of Overused Cesarean Sections

Last week in class we discussed globalization and how ideas and practices are so easily passed around the world.  One global health issue that has been able to do so is the growing rate of birth by Cesarean section.  Bringing this procedure to parts of the world that did not have it before has helped to reduce infant and maternal mortality from medically complicated births.  However, this is only up to a point. The procedure is often viewed casually here, as it occurs in about 1 of 3 births, but in less industrialized settings it can be very dangerous to do such a major surgery in an already critical moment.  Even in the developed world, the procedure has likely become overused for various reasons.  Due to stress on hospitals to see many women, a C-section may be seen as a method to quickly and efficiently move through patients.  Some women also see it as an easier or more ideal method of giving birth.   In countries, increased access to hospitals has caused the C-section rate to skyrocket, in Mexico up to about 50%.  These women face a burden of a long recovery and the need to have C-sections for their subsequent births.  The consequences go beyond this to the biological level; their child may face trouble with their immune system due to the lack of microbiome exposure that occurs during the normal labor and birth process, leading to higher risk of asthma, allergies, celiac disease, obesity, and more.

What can be done to reverse this trend?  The WHO has identified two points to address. First, population data needs to be continuously studied to determine an appropriate C-section rate.  Currently, they have set a global number at 10% of births, because once the rate goes higher than this no decrease in maternal or infant mortality is seen.  While this may be a good place to start, I think more population-specific study is necessary as well; for example, in a country with higher weights of overweight and obesity, such as the US, the optimum number of women to receive C-sections to yield the most benefit may actually be higher than 10%.  Still, I think this is a great place to start to understand the state of the problem.  Secondly, they have developed a classification system called the Robson scale that is simple enough to be implemented in all health care systems to determine what groups of women should have/are getting C-sections (see link below for more detail).  Getting data specific to birth history and complications is important to identify where we could target to reduce the C-section rate, as opposed to women who actually would benefit from the procedure.

As globalized as this life-saving surgery has become, we must now begin to globalize a more nuanced view of both its power to help and its potential to harm.  Rather than striving for a specific rate of Cesarean sections, our number one global health goal should be to make sure that this procedure is getting to the women who need it and not being forced upon women who don’t.  The rate targets are simply a crude tool to help us get there.  Gaining a better understanding of when and why this procedure is necessary will temper its use to the healthiest level possible in a given population.

Reference:

Human Reproduction Program. 2015. WHO Statement on Cesarean Section Rates. Available from: http://apps.who.int/iris/bitstream/10665/161442/1/WHO_RHR_15.02_eng.pdf?ua=1

First Black President

            This morning, my boyfriend and I read the news, and like every morning there was yet another article about Hillary Clinton & Donald Trump (election season!). As we talked about the possibility of having a woman for president for the first time in history I said out loud "Wow, we could have our First Black President and First Woman President back to back! What a time in history." And then it kind of hit me. Obama becoming the first black president was a big deal. But then, why was it such a big deal? Why is someone having a different color of skin becoming the first fill-in-the-blank-here such a big deal? I was not diminishing the accomplishment like you may be thinking. I was wondering, why does race even matter to begin with? Of course, I was thinking idealistically. In an ideal world race wouldn't matter. But this is not an ideal world and race does so unfortunately matter. I realized slowly that such great suppression of the black race in this country, that spread globally, really happened just yesterday – it was not that long ago in history. The same with women's rights. I am just hoping as time and history go on, that slowly this accomplishments, first black president, and accomplishments like it won't be such a big deal because they will simply be commonplace.

            As I was reading "Representations That Frame Health and Development Policy" from Global health: Why cultural perceptions, social representations, and biopolitics matter (Nichter, 2008) for our readings next week, I found the words I was lacking to convey this morning: "The questions of how and why [groups at risk] are exposed are often left unasked - and this can be highly problematic. Simply identifying a group as being at risk from an illness is an invitation for others to think that this is due to an inherent genetic or behavioral group trait. This impression all too often plays into a pre-existing negative stereotypes" (112). He later goes on to explain that we (researchers, students, health professionals) should consider rewording our questions from What risk factors does a person have to disease X? to What protective factors within a group prevent a problem from being worse than it is or from developing? He also describes how representations of "groups at risk" need to be seen in light of environments of risk if the group is not to be stigmatized. Race of course has implications nationally and globally. Although this book was written before 2000, I haven't seen this type of wording before. I wonder if we rephrased our research questions and took "at risk" groups on from a different angle, if we could begin, or increase, the reduction of racism and negative health and negative stereotypes.

Nichter, M. (2008). Global health: Why cultural perceptions, social representations, and biopolitics matter. University of Arizona Press.

The Obesity Pandemic and How to Fix It

We have discussed the spectrum of malnutrition.  Obesity and undernutrition are, ironically enough, both concerns of the world.  Obesity has become a pandemic in all honestly.  One issue we face with obesity is viewing it as a disease. I do not believe this is accurate.  Obesity should be categorized more as state of being than a disease.  This being said, it is definitely a risk factor for other diseases.  I was required to read an article called Fat Britain.  This article went into detail about how the “Americanized” United Kingdom is becoming obese.  I think part of addressing obesity is looking at the nutrition of the people it is affecting.  It is become apparent that countries with the “Western diet” are more often the obese countries.  A Western diet includes lots of animal-source protein and fatty oils.  I am not suggesting we eliminate these types of food completely.  That is both largely unrealistic and people would rebel.  Look at what happened when large soda pop beverages were threatened in New York!  People went ballistic when a soda tax was suggested and it was an ineffective solution.  I suggest that we concern ourselves more with better educating people to indulge in moderation.  You can have potato chips, but not with every meal.  Another factor to consider is the biology behind obesity.  My mother had gestational diabetes when she was pregnant with me.  Because of this, my body is more inclined to store fat.  That is only part of the obesity equation, but it is part I feel is too often overlooked.  Living in the age of technology is also contributing to obesity because of the sedentary lifestyle it allows us.  What do you think would be the best way to get this health education to people?  Should there be more restrictions on “junk” food?  I would love to see your opinions!

·          Cohen, Roger. "Fat Britain." The New York Times (2014).

Globalization and Gender Inequality

Although some claim that globalization has a global long term positive health and social influences by increasing growth rates, employment and financial autonomy, it has been shown that this “trickle down” theory is not correct. Money and wealth are definitely appropriate and beneficial to those on the top of the socioeconomic gradient. However, the assumption that such financial and social benefits will trickle down to the needy is not a real fact.

 Despite that both genders in the low socioeconomic gradient are negatively affected by globalization, women seem to be more at risk. Women are considered as “shock absorbers” of the economy in the developing countries. Although our readings last week addressed lower wage, dead end jobs, food insecurity and other financial, health and social factors as negative influences of globalization on women, I want to target the psychological aspect.

Being from one of the developing countries, I personally encountered the taste of inequality when I was declined my right to be honored as a top student in the high school due to not being among regular school students. Homeschooling was treated as an option for criminals, elders or FEMALES! The Egyptian community, till now, has abasement thinking to homeschooling females. When I started working and become affiliated with the department of Pediatric Dentistry and Dental Public Health, I suffered again the gender inequality problem. Despite being highly educated, some of my colleagues and professors treated me in a way of being a person with half efficiency, only, due to being a working wife and a mother. It took me a couple of years of extreme hard work and stress to prove them wrong.

Although, in the era of globalization, women can have more opportunities, they are usually under threat not only from a financial aspect but also from a psychological one. They are usually under-estimated, ignored and under continuous psychological stress which eventually destroy their health, families, communities and that will, consequently, have serious global implications. Such culture that lead to the social construction of reality in a majority of developing countries that females are low standard citizens should be addressed. In my opinion, It is considered as a severe sort of structural violence and social injustice towards females. Building successful communities and achieving progress in every aspect is mainly based on females who should gain not only their financial rights but also their psychological ones!

Double Burden of Malnutrition

Double Burden of Malnutrition

This week’s discussion led me to reflect on how globalization has had an impact on maternal nutrition in developing countries. In my search, I came across many articles discussing the concept of Double Burden of Malnutrition (DBMN) which is defined by the World Bank as both under and overnutrition being present in the same population; often “across the life course” (Shrimpton & Rokx, 2013). A very interesting phenomena that is often attributed to the rise of globalization (Winichagoon, 2013). Many countries such as Cambodia, Democratic Republic, Bangladesh, and Vietnam, have now been having to deal with undernutrition in infancy and obesity in later years in the life course of an individual (Haddad, Cameron, & Barnett, 2014; Shafique et al., 2007; Shrimpton & Rokx, 2013).

One study in particular by Winichagoon (2013) studied DBMN with regards to maternal and child nutrition in Thailand by examining both food and nutrition data from national surveys between 1960 and 2009. They found that although progress was made in maternal and child undernutrition, many primary concerns still exist post globalization including nutrient deficiencies and anemia. The alarming result was the rise in not only obesity, but various diseases among women and children over the course of almost 50 years (Winichagoon, 2013). I admire one of the author’s recommendations that he refers to in the paper in that intervention programs with regards to maternal and child nutrition need to be based on findings studied over a longer period of time in order to communicate its importance in developing countries. It is through these measurable results that DBMN may be seen as a prevailing issue and appropriate nutrition programs can be implemented in the right outlets and at multiple life stages of those in the impacted communities.

However, how can we address this effect of globalization in a sustainable way in order to leverage its benefits such as developing infrastructure, increase healthcare access, food security, and trade yet at the same time, eliminate the DBMN risk?

A guided ‘framework’ that I found to be most appropriate in approaching DBMN that also touched on a lot of the points we have been discussing in class, was brought up by Pinstrup-Andersen & Babinard (2001). Here, the researchers discuss the importance of needing to manage the degree in which globalization is infiltrated through policy implementation, standards that are customized by region, and having the national institutions be the driver of these decisions. On this incremental basis, things such as food safety standards and food security can be looked at through a microscope when implementing factors of globalization such as trade agreements in order to minimize its impact on the nutrition status of both parties involved. Two primary questions when approaching policy reformation and standard creations should be examined:

            (1)   Whose standards will be used as a norm? Having customization food safety standards is important in order to outweigh high or low food prices that often come as a result

            (2)   Is there a trade-off between food safety and food security? In the evolution of an increase in trading amongst countries, high food safety standards in a more wealthier area may impact the food security of the smaller community farmer (Pinstrup-Andersen & Babinard, 2001).

It is through these open discussions that globalization can be optimally used for its many benefits to global public health initiatives as well becoming the driving force towards progress for the human race- a progress that is built on the foundation of health and opportunity for all. Perhaps its not the black and white argument of globalization being 'bad' or 'good', but the need to think of it as an intrinsic process as part our evolution. 

Would love to hear any comments or thoughts! 

References 

Pinstrup-Andersen, P., & Babinard, J. (2001). GLOBALIZATION AND HUMAN NUTRITION: OPPORTUNITIES AND RISKS FOR THE POOR IN DEVELOPING COUNTRIES. African Journal of Food, Agriculture, Nutrition and Development, 1(1), 9–18.

Shafique, S., Akhter, N., Stallkamp, G., Pee, S. de, Panagides, D., & Bloem, M. W. (2007). Trends of under- and overweight among rural and urban poor women indicate the double burden of malnutrition in Bangladesh. International Journal of Epidemiology, 36(2), 449–457. http://doi.org/10.1093/ije/dyl306

Shrimpton R, Rokx C. World Bank Health, Nutrition and Population (HNP) Discussion Paper. Washington, DC; 2013. The double burden of malnutrition: a review of global evidence.

Winichagoon, P. (2013). Thailand nutrition in transition: situation and challenges of maternal and child nutrition. Asia Pacific Journal of Clinical Nutrition, 22(1), 6–15.