Environmental Inequity

As we discussed water sanitation and hygiene in class this week, it was significant to know that 2.5 billion people still don’t have access to safe water, every day around 2000 children under age 5 die globally and almost 1800 of the deaths are related to water sanitation and hygiene. Even though, unsafe water, hygiene, and excreta disposal are three environmental challenges of Global Health in developing countries but Public Health systems also in developed countries face such challenges as well and most of the times they fail to improve the health of low social groups. There are many factors beyond the control of Public Health systems such as policies, laws, “inequities in regulatory enforcement,” (Frumkin) disparity in socioeconomic status, funds, and the most important one in my view is people in the communities.  When we talked about water scarcity and sanitation, the comments were made in class about people fight over water because of water scarcity or water sanitation, made me think that if people knew their rights of having sanitary water they wouldn’t fight over it among themselves. Most of the time environmental health problems persist and remain unresolved despite all the efforts that the Health organizations have made; one reason is because people may not know it is their rights to have healthy environment. The other reason is that the government and public may not be informed clearly about existence of issues associated with environmental health problems, so the role of Public Health in this situation is to inform both public and the government about those issues and delineate the ways that they can overcome the problems. If health issues are identified by public then they get motivated to collaborate with public health officials to help resolve those problems. The goal of public collaboration is to engage people in a dialog regarding the current surrounding issues and help them to provide strategic plans that they know work the best for them and their culture. The result of such collaboration is associated with achievement in environmental equity and healthy environment in shorter time. The next step is addressing the environmental health issues to the government and those who provide funds to support such programs by demonstrating the collected data and evidence, and also encourage people to participate in order to have their voices heard. Public health organizations also should address “economic and social factors such as housing, transportation, job creation, green space, and recreation-factors,” (Frumkin) which contribute to health and well-being. In addition, the cost effectiveness of such programs seem superior to other interventions of public health programs in this matter. Last but not least all of these efforts are impossible without having motivated leadership, people commitment to change, and well establish strategic plans.

 

Clean Drinking Water | UNICEF USA www.unicefusa.org

Environmenta Health from global to local by Howard Frumkin

www.unicefusa.org On World Water Day Children Dying Because of Unsafe Water and Poor Sanitation

UNICEF/WHO: New Plan to Address Pneumonia and Diarrhea Could Save 2 Million Children a Year(April 12, 2013)

Cilantro for Safer Water?

As we have been discussing the importance of safe drinking water in class this week, I stumbled across an article in the Journal and Courier that addresses this issue and a potential solution (for some drinking water problems) that is coming right from our community. There is currently ongoing research at Ivy Tech (here in Lafayette, IN) that is examining the ability of cilantro to purify drinking water. According to the research cilantro is a “biosorbent’ substance that can absorb lead and other toxic heavy metals from water. The research team went to Mexico and experimented with various local plants and flowers to see if any had purifying effects and cilantro did! Other plants related to cilantro, such as parsley and cilantro, also seem to have some purifying capabilities.

Usually the only ways to remove these potentially harmful metals from the water is through extensive and expensive filtration systems, such as activated carbon filters, cation exchange softeners, distillers, and reverse osmosis ranging anywhere is price from about $40-$1200. These are often not an option for those communities who struggle with poor drinking water due to heavy metals. However, if cilantro (which is quite abundant in areas such as Latin America, the Mediterranean, the Middle East and Asia where people struggle with heavy metals in their water) could be used to purify water by simply placing cilantro into tea bags or reusable water filters that would be a much simpler and more feasible solution for many people than an expensive water filtration system. Another benefit is that cilantro is a renewable, fairly inexpensive resource that people could grow in their own backyard or even inside their households.

If the research truly proves that cilantro can effectively and safely remove heavy metals to a level where they are no longer toxic to humans, just imagine the health implications this could have for many people worldwide. For example, if the amount of lead and arsenic found in some drinking water could be lowered; fewer people would suffer from the life-long disabling effects of these metals.

I definitely believe that research, such as this project, are critical to solving some of the world’s health issues. This research team went to where the problem existed and searched for affordable, simple solutions within that area. It just so happens that what they found in Mexico can also be applied elsewhere in the world. One downfall, however, is that cilantro only treats heavy metals in the water. This solution does not address other causes of contamination, such as bacteria, viruses and parasites, which are major sources of disease and illness around the world. However, perhaps a combination of solutions such as cilantro treatment, cloth filtering and boiling of water could resolve many of these health issues. Although these solutions seem simple, and they are compared to some other solutions, they would still require a good amount of education and resources to get people to understand and be able to effectively use some of these methods.

Sources:

http://www.acs.org/content/acs/en/pressroom/newsreleases/2013/september/cilantro-that-favorite-salsa-ingredient-purifies-drinking-water.html

http://www.nrdc.org/water/drinking/gfilters.asp

Colombo, Hayleigh. Cleaner water, thanks to cilantro? Journal & Courier. Wednesday September 25, 2013.

Impact of Syrian Crisis on Public Health

Turn on any news channel or open any paper and you will find stories of war-torn Syria. For most of these stories, the focus is on the political uproar and civil unrest among the people. Most of these stories overlook the public health impact from the months and months of fighting. In the future, research will unravel the long-term health impacts from the war. However, the health of the Syrian people is at risk as we speak.

Currently, over 1.5 million Syrians refugees are camped in the countries surrounding Syria including Lebanon, Turkey, Jordan, Iraq and Egypt. Though these camps are a safe haven from the violence of Syria, the healthcare can be a threat to the safety of these people. The World Health Organization has created health targets for each of these countries serving Syrian refugees because of the high risk for communicable disease outbreak and lack of quality services. These countries have requested millions of dollars of aid from WHO. WHO has been able to provide a very large portion of the funding but there is still a gap between what was requested and what has been received. Without adequate funding, the natives of each country and Syrian refugees will not receive adequate care.

Many of the WHO activities and achievements within these countries focus on immunization and prevention. Vaccinating the at risk population, children, is crucial to stopping the spread of disease such as measles and rubella. This will also cut down on the health services needed and the health problems that can occur following infection. Implementing stronger surveillance systems has been vital to preventing epidemics. For instance, in Lebanon, Syrian refugees account for over 20% of the total population. If Lebanon did not upgrade and expand the surveillance system to include the refugee population, disease would spread among refugees and the Lebanese population without knowledge of the source and how to stop it. Though risk within the countries providing aid for refugees is high, it is not the primary concern. Within Syria, the entire population is in danger both in terms of violence and health. 

While many people have fled to “safer” areas, this displacement has caused overcrowding and unsanitary conditions. These conditions have caused endless problems in terms of disease transmission. Lack of access to clean water has resulted in a 172% increase in acute watery diarrhea between January and May of 2013. 35% of the public hospitals are closed and 70% of trained healthcare workers have fled the country. This has resulted in a significant drop in vaccination rates- from 95% in 2010 to 45% in 2013. As these people flee to neighboring countries, they bring with them measles, TB and many other diseases prevented through vaccination. Also, without healthcare workers, Syrians do not have access to medicines or care.

                 
 The World Health Organization has cited areas of focus including safe drinking water and sanitation, early warning systems for detection of disease, distribution of bed nets and mass vaccination campaigns. However, it becomes more and more difficult to reach this country and these people with the war raging on. The impact of war can be deadly for the health of the affected population. If disease takes over your body before any weapon can cause harm, then public health needs to become the priority rather than an after-thought.   

Sources:

http://www.emro.who.int/press-releases/2013/disease-epidemics-syria.html

http://www.who.int/hac/emro_region_dashboard_6june2013_final_small.pdf

Publication Bias

Publication Bias

Something really struck me this past week after reading the article by Fewtrell et al. (2005) which analyzed different health interventions with use of meta-analysis: the mention of possible publication bias and the possibility that health interventions that produced negative or non-significant results weren’t submitted or published.

 When a researcher is conducting research or writing an article that involves analysis of data, or testing effectiveness of interventions, we are usually looking for significant evidence to support our alternative hypothesis, or for a positive outcome resulting from the intervention. Not only do we want to be correct in our assumptions, but we know that the likelihood of our research being published, or received well at a conference, is highly dependent on the significant/nonsignificant findings. This isn’t an irrational fear. It has been demonstrated by numerous studies that the likelihood of being published is higher with statistically significant results (Dirnagl & Lauritzen 2010; Hopewell et al. 2009; Dwan et al. 2008; Rothstein et al. 2005; Weber et al. 1998). Further, for clinical trials, negative results take longer to get published (8-9 years) as opposed to positive results (4-5 years) (Hopewell et al. 2009).

 Not only is this an issue for the studies conducting meta-analysis of interventions on a certain topic, such as the one we read in class last week (citation), but what about the important information that could be passed on to other researchers about null, or even negative, results? Altman and Bland (1995) stated “Absence of evidence is not evidence of absence”, and I think that is absolutely true.

 I came across an article that was specifically addressing the shortcomings, theoretical and specific reasons for the failure of a performance based contract pilot study implemented in in Uganda (Ssengooba et al. 2012). Why do we not see more articles like this? In the discussion section of the article, the author addresses the amount of successful case studies on PBC (performance-based contracting) that is found in the literature, but the lack of the popularity of this Uganda case. The author mentions how long it took to be considered for publication, and also attributes the lack of popularity in this unsuccessful case to the differing results from other countries, such as Rwanda and Cambodia, who showed successful results from PBC (Ssengooba et al. 2012).

How can we contribute to real progress in academic fields if negative results are deemed unworthy (or less worthy) of publication? This not only discourages researchers and scientists from trying to publish finished studies that showed non-significance or an ineffective intervention, but it also doesn’t present information to fellow researchers that could inform them about possible different outcomes. I think this is especially important to international/global health researchers, as we have learned that different countries face different structural and cultural issues that may cause an intervention to be ineffective.

Failures or varying levels of success in health interventions should be known and taken into account when creating an intervention, but that is nearly impossible when we aren’t able to access that information. I believe there should be an effort made on not only the editors and reviewers of journals’ parts, but also authors and researchers, to reconsider the value of mixed or negative findings, and find the courage to submit and publish that work anyway.

What do you guys think?

 

References

Altman D, Bland M. 1995. “Absence of evidence is not evidence of absence.” Br Med J 311:485.

Dirnagl U,  Lauritzen M. 2010. “Fighting publication bias: introducing the Negative Results section” Journal of Cerebral Blood Flow & Metabolism 30: 1263–1264.

Dwan K, Altman DG, Arnaiz JA, Bloom J, Chan AW, Cronin E, Decullier E, Easterbrook PJ, Von Elm E, Gamble C, Ghersi D, Ioannidis JP, Simes J, Williamson PR. 2008. “Systematic review of the empirical evidence of study publication bias and outcome reporting bias.” PLoS One 3:e3081

Fewtrell L, Kaufmann R, Kay D, Enanoria W, Haller L, Colford Jr, J. 2005. “Water, Sanitation, and Hygiene interventions to reduce Diarrhoea in less developed countries: a systematic review and meta-analysis.” Lancet Infect Dis 5:42-52.

Hopewell S, Loudon K, Clarke MJ, Oxman AD, Dickersin K. 2009. “Publication bias in clinical trials due to statistical significance or direction of trial results”. Cochrane Database of Systematic Reviews 2009, Issue 1.

Rothstein H.R., A.J. Sutton, M. Borenstein (Eds.).2005.” Publication bias in meta-analysis: Prevention, assessment and adjustments” Wiley, Chichester, England .

Ssengooba, Freddie, Barbara McPake, and Natashe Primer. 2012. “Why Performance –based contracting failed in Uganda- An “open-box” evaluation of a complex health system intervention.” Social Science & Medicine 75: 377-383.

Weber EJ, Callaham ML, Wears RL, Barton C, Young G. 1998. “Unpublished research from a medical specialty meeting: why investigators fail to publish”. JAMA 280:257–9.

Sex Workers and Safety

Making Prostitution Safer?

After reading and listening to last week’s case study about the 100% Condom Program in Thailand sex workers, I began to think about an article I read recently in the news. Prostitution is legal in Switzerland and has been since 1942; however, it was not until recently that the city officials in Zurich, Switzerland have taken action in an attempt to make prostitution safer.  The city has now forbidden women to solicit in the streets and expects them to use newly constructed facilities known as “sex boxes”. 

Zurich’s hope is that these sex boxes will make prostitution not only safer for the women but also for their clients. The facility is located in the suburbs of Zurich and is surrounded by security gates manned by guards. Men (clients) will be able to drive around in their cars, select a woman and continue business in that woman’s designated drive-in sex box. In each box there is an alarm button and an emergency escape, as well as safe sex reminders (such as condom use to prevent STIs and HIV). Also onsite are social workers, full bathrooms and a kitchen for the women to use and get assistance if necessary. Regulations also require all prostitutes to buy a daily sex workers license and have health insurance. The project was paid for using tax dollars and was approved by citizens who wanted the prostitution off their streets and out of the main city.

Although the main goal of this initiative is not HIV/AIDS prevention, I can’t help but wonder if it will not only successfully make prostitution safer but also lower rates of STIs and HIV/AIDS? This may be hard to determine, since Switzerland already has a low prevalence rate (0.4%) of HIV/AIDS. However statistics show that men ages 15-24 and women ages 20-24 have the highest risk for sexual transmission, so perhaps if this is the population predominantly using the sex boxes, it very well could lower the incidence of HIV/AIDS in these age groups. 

I realize a program similar to this is not feasible for many other countries, especially if prostitution was not legal and the citizens were not willing to have their tax dollars pay for such a program. However, I think it will be interesting to see the outcomes of this project in Zurich and to look for anything that can be learned and applied elsewhere.

I drew comparisons between the case study from last week and this article for several reasons. First both countries are trying to make prostitution safer, although it is legal in Switzerland and not in Thailand; both initiatives addressed a marginalized group of people (prostitutes). Second, although the initiatives had different objectives, the overarching goal was to make prostitution safer for both the women and their clients (and therefore the general population). Thailand was successful and the verdict is still out for Switzerland. Is it time that other countries began to address issues that are typically overlooked and frowned upon in order to improve the health of many? Switzerland did it in the past by battling drug addiction and unsafe usage in the streets with needle exchanges, injection rooms and even prescriptions for the drugs with success. If Switzerland and Thailand can do it, can other countries?

References:

http://www.bbc.co.uk/news/world-europe-23839358

http://www.unaids.org/en/regionscountries/countries/switzerland/

Culture, Spiritual belief, and Marginalized Populations

What is culture? I still remember clearly this was the first question I encountered when I came to the field of health. Basically a group of people tends to think, believe, and behave in a shared way and pattern, which is distinct with other group. This integrated system of behavior patterns is culture (Hoebel, 1966). Culture controls, oppresses and forms traditional ways of knowing and meaning making, being an important impact on human health status, hope and expectation. In the world of health, I think, culture is like a seed, which provides individuals, a group, a population original power of living, developing, and achieving goals. At the same time, the environment and context around it bring sunshine or storm, illuminating or restricting health behaviors. Also, culture is like embrace of a mother, emotionally and cognitively upholding patients.

As we approach more knowledge about culture from the global perspective, it is interesting to find out that a normal phenomenon in one culture may be considered as unusual thing. There are different even opposite cultures everywhere in the world. Dutta-Bergman (2004) implied in the paper “Poverty, Structural Barriers, and Health” that the Ojha, a spiritual healer, played a strong role in the Santali people’s health. Why people there believed in a spiritual healer. I was impressed by the point that the Ojha was trusted by the Santal, because he understood the pain of the patients, as a member of the community. In addition, it was associated with the poverty of the Santali people. They had no access to food and health care. How can they survive? Who knows their struggles? The Ojha was here to help them. I think spiritual concern is an alternative way of knowing that requires notice. Patients who have spiritual beliefs tend to contribute healing to God or spiritual power’s will. Spiritual values create power for them to resist the violence. Various ways of healing and knowing bring complication to health professionals’ work. What can we do? Without doubt we need to obtain deeper understand of people’s religious beliefs and cultural beliefs. Then, how to be more sensitive to the spiritual beliefs? I think we should learn appropriate ways to be perceptive of patients’ cues; learn how to identify patients’ agenda and underlying motivation and expectation.

When Dutta-Bergman (2004) came to the issue of “marginalized”, I was thinking there may be a wall between the “central populations” and the “marginalized populations”. The central populations enjoy most of the basic resources, such as food, money, and materials, but in the meantime, marginalized populations endure pain of inadequacy of resources. Why? It is because they are in the other side of the thick wall, no one sees their situation, and no one hears their voices as well. The wall is built by the structure, the culture, and these lead to inequality in race, gender, and socio-economic status. It seems like a vicious circle. Culture is a constructor of meanings, values, and roles within which the community exists, and it also can become a barrier of the existence of the community. The web of violence that is knitted by the structure is covering over the head of the “marginalized populations”. They are suffering, struggling, striving, and hovering. They need support and direction, and their nature of suffering requires to be understood. As mentioned earlier, there is a circle. Cultural difference is a start of meaning making process, and one of the causes of inequality. To jump out of the circle, we need to put culture in the center, recognize the differences the structure leads to, identify potential methodology for resistance the structural violence and make efforts to achieve social change.

Reference:

Dutta-Bergman, MJ. (2004). Poverty, structural barriers, and health: a Santali narrative of health communication. Qual Health Res, 14(8), 1107-22.

Hoebel, Adamson (1966). Anthropology: Study of Man.

The Idea of Empowerment

I found this week’s reading very insightful regarding the topic of empowerment and how culture affects this concept. There is currently a huge emphasis in the healthcare community on transitioning from handing health information down a professional chain to the layman to the practice of “empowering the patient” and facilitating “self-management.” Increasing patient engagement in their care and protecting their autonomy is lauded as a top priority. The following quote from the article is a very accurate expression of what I’ve been taught so far in my nursing education: “It is assumed that improved knowledge and a change in attitude are the twin engines that generate expected outcomes in behavior” (Airhihenbuwa, 1999). This idea has gone virtually unchallenged, but Airhihenbuwa provides an differing perspective. He brings to light the underlying basis of the western push for empowerment as (perhaps misguidedly) an effort of the highly educated to change the behavior of the “disenfranchised” on an individual level. He contends that effective empowerment must rely on manipulating environmental, cultural and political contexts rather than just personal choices within those infrastructures.  

This is a welcome perspective in my mind as I have witnessed firsthand the frustration of trying to instill change in people and feeling as though you’re talking to a brick wall. Even if you can get as far as helping people actually understand their health (not to mention the all-important task of figuring out what will make them want to change), if they lack resources or community support or financial stability, it will not come to fruition. Even in accomplishing the first two points, we are slowly realizing that imparting knowledge is not enough to incentivize behavior change (hence the focus on giving patients a collaborative role in their healthcare).  However perhaps what we are not realizing is that improving outcomes may have less to do with personal motivation and education and more to do with home environment, cultural values access to outside support, etc.

Culture indeed has a significant role to play. Although culture is talked about much more today than in years past, differing cultures are often presented as a factor to be aware of and acknowledged, but not necessarily to be embraced and integrated into care. One tends gets a sense of how various cultures clash with our western methods and how our “normal” care must be altered. Rarely do we see specific aspects of cultures exemplified as beneficial and helpful. 

What do you think? Do you see culture as an important factor in healthcare? What about the most important factor? Do you there is a place for individual patient empowerment or should our focus really be on collective empowerment of populations?

HIV/AIDS Prevention Programs

The case study discussed last night focused on preventing HIV/AIDS and STI’s in Thailand. HIV/AIDS cases in Thailand increased dramatically in the late 1980’s among injecting drug users and sex workers. The young military population was also seeing an increase in cases. When investigated further, a connection between young military men and the frequent use of sex establishments was found. The intervention was first pioneered in the province of Ratchaburi and then expanded throughout the entire country. After watching the TEDX event featuring Mr. Condom, I questioned how effective this program could be if used in other countries.

Mechai Viravaidya, also know as Mr. Condom, has been the leader of the family planning movement in Thailand since the 1970’s. He founded the Population and Community Development Association, aimed at slowing Thailand’s rapid population growth. As a public health advocate, Viravaidya did not just plan interventions strictly by the books, theory and research. Humor was one of the most essential parts of his effort.  In one interview, Viravaidya said “You cannot win people with embarrassment and shame.” Viravaidya has reached the Thai population through school campaigns, restaurants, markets and other popular public arenas. The Thai people do not need to search for condoms or information related to HIV, STI’s and family planning. Instead, they can simply walk out their doors and down the street to the local market or restaurant to find condoms.

My first reaction to this public health campaign was astonishment. In America, where sex is talked about or alluded to on almost every single television station, we are still very “conservative” in our sex education. During my practicum this past summer, I worked in the STD clinic of a health department. After many, many years of fighting to get into the school system, the health department’s STD staff had finally been able to break through the school board and will begin a sexual education course this fall. After watching the TEDX video, I had wondered how many setbacks Viravaidya had to endure during the implementation of this campaign. My search online did not come back with much information on the setbacks, only on the successes.

I question how many other countries would be able to adopt a program such as this one? With many countries deeply rooted in spirituality and/or religion, it would seem nearly impossible for the government and gatekeepers to allow such open discussion about sex and condom use. It is evident the Thailand campaign was extremely successful, as seen by the 90% reduction in new HIV/AIDS cases. However, this may not be enough evidence for other countries to accept.

I believe one of the next steps in this war against HIV/AIDS in Thailand would be the implementation of a surveillance system. The pioneer program briefly mentioned the use of contact tracing, by identifying the partners of infected men and women. From what I learned during my practicum, this is an essential part in breaking the chain. The case study mentioned the lack of focus on noncommercial sex. Implementing a surveillance system and hiring Disease Intervention Specialists to interview and track down partners, especially those taking part in noncommercial sex would be extremely beneficial.

Privilege or Right?

Is healthcare a right or a privilege? What should healthcare be? Can healthcare truly be one or the other?

These questions keep coming up in my classes, and although I have been pondering on them for some time, I cannot come to a clear conclusion. Obviously, healthcare in some countries is more of a right than in other countries and vice versa, but is healthcare ever truly a right OR a privilege? For example, in the countries that offer universal care, almost everyone may be able to receive care at low costs, but is it always the care they need, when they need it? Or do the people get put onto waiting lists and receive the minimal amount of care needed for the time being? If so, is this what is considered a right? Even in countries that offer universal care, access to healthcare may still be a huge problem. The healthcare may be available but if the people cannot access it, then what good is it? If you can only use the universal healthcare if you have access, then wouldn’t it be considered more of a privilege?

In countries such as the United States that do not offer universal healthcare, almost everyone can still get care if they can get to an emergency room.  Granted this may not be the best care and may be expensive, but  they can still receive care (although access could still be a problem).  So in a way, could healthcare in this situation also be considered a right?  Also in countries such as the U.S., if you have insurance then you can receive excellent care, albeit expensive, whenever and wherever you need it. So although this may seem like a privilege to many, do Americans view it as a right to have the choice to purchase or not to purchase healthcare and insurance?

In this way, I believe whether healthcare is considered a right or privilege is influenced by cultural, historical, social and even personal factors.  A country may state that they offer universal healthcare and that they believe healthcare is a right, which I believe to be a wonderful goal, but will it ever be truly attainable? There will probably always be a portion of the population for which healthcare is more of a privilege than a right. And even in countries that have great universal healthcare, people can still purchase supplemental health insurance which gives them a wider range of options when it comes to healthcare. So within a system that healthcare is viewed as a right, there are still people with healthcare privileges.

I guess what I am trying to get at is that it seems no healthcare system is perfect and can treat everyone within the system as complete equals. I think this is a great goal to work towards, and some countries have come closer to achieving it than others, but there is still progress to be made in all countries. I know there is a lot of debate surrounding this issue occurring right now in the United States, and as long as this issue is being discussed I believe there is hope for change.