The CDC Looks Ahead: 13 Public Health Issues in 2013

With the semester ending and the new year approaching I thought it would be interesting to review the CDC's list of 13 things that they were planning to work on for the year 2013. I found that a majority of the issues listed below were not only covered in our readings, but also in our class discussions this semester! In my opinion, I think that the CDC hit the nail on the head with the issues to tackle for 2013, but I think they missed out on a large one: childhood obesity, and obesity in general. What do you think? 

First, Healthcare associated infections. More than 1 million Americans are exposed to health care infections while receiving medical treatment. The CDC is working towards the elimination of healthcare related infections. 
Second, HIV. Let's Stop HIV Together was launched to help overcome stigma and complacency. It is a national communication campaign that gave voice to the estimated 1.1million Americans living with HIV. 
Third, CDC Vital Signs: Public Health Calls to Action. Vital signs reports data and calls to action on important public health issues. The CDC believes that by focusing on individual problems and using multimedia to promote them they can have success in getting the message out to Americans. 
Fourth, Public Health Grand Rounds: Exploring PH Issues. Grand Rounds attempts to close the gap between science and communication. The main focus of these are HPV, teen pregnancy, and immunization. 

Fifth, Million Hearts: Preventing Heart Attacks and Strokes. Nearly 800,000 people die each year due to CVD, accounting for 1/3 deaths and $300 billion in direct medical costs. CDC is working to prevent 1 million heart attacks and strokes by 2017. 

Sixth, TIPS: Helping Smokers Quit. Tips from former smokers is a national ad campaign that will be released. 

Seventh, Newborn Screening: Saving Babies Lives. Nearly 6,000 babies are born in the US with severe disorders, most of which are treatable. The CDC will be working with the Association of Public Health Laboratories to promote the benefits of newborn screening. 

Eighth, Food Safety. The CDC data collection will better help to track where food borne outbreaks start, travel and and why the outbreak occurred. 

Ninth, Heads Up to Parents. This program helps parents, coaches, and athletes to identify concussions caused by sport injuries. Currently, 800,00 copies have been distributed with more on the way. 

Tenth, Children's Mental Health. Approximately 1/5 children in the US will be diagnosed with a mental, emotional or behavioral disorder this year (blogs.cdc.gov).  The economic cost is $247 billion/year. 

Eleventh, Clinical Preventable Services for Children and Adolescents. Screening for things such as developmental delays, vision screenings, tobaccos use counseling and more will be achieved through this initiative. 

Twelfth, Preventable Parasitic Diseases. 1 million people are killed, disabled, or disfigured by parasitic diseases worldwide and millions in the US are infected (blogs.cdc.gov). The CDC is launching high quality screening that will help to screen and diagnose 15,000+ cases. 

Thirteenth, Global Efforts to Prevent Violence Against Children. More than 1 billion children (half of the children in the world) are victims of violence each year. The CDC will expand and work with global partnerships to measure the amount of violence towards children that exists as well as develop ideas to combat this horrible issue. 

Sources:

(1) http://blogs.cdc.gov/cdcworksforyou24-7/2013/01/cdc-looks-ahead-13-public-health-issues-in-2013/

(2) http://www.cdc.gov/nchhstp/newsroom/LetsStopHIVTogether2012-IndividualStories.html

(3) http://www.cdc.gov/about/grand-rounds/index.htm

(4) http://www.cdc.gov/tobacco/campaign/tips/

Health Programs for Children and HIV/AIDS

Despite increased access to treatment and testing facilities, the number of orphans due to HIV/AIDS will continue to increase, particularly in regions such as Sub-Saharan Africa. Children living without one or both parents are at greater risk of dropping out of school and have higher rates of emotional /physical abuse and sexual exploitation (1). In many countries, the infrastructure to care for orphaned children is not sufficient and puts additional stress on extended families if they are able to care for the child at all. This additional stress affects children’s health, nutrition, mental health, and education. In some cases, children have to do difficult or exploitative work to help meet basic needs. Children may also experience HIV-related stigma and discrimination, keeping them out of school and away from groups of friends and health services (2). Though all income levels can experience the loss of a parent due to AIDS, the poorest households are typically the least resilient to HIV’s economic consequences and least able to manage the lost household income. Special attention needs to be given to children who do not live with one or both parents as they are more likely to be out of school and experience early marriage, which has its own negative outcomes (3).

Recently, UNICEF has led a review into how programs can better impact children living with HIV/AIDS or are suffering the consequences from the disease (ex. The loss of a parent due to AIDS).  Health programs were often too “goal-focused” and did not address factors that were so influential and crucial to their program.  Programs for children affected by AIDS have typically targeted individual children, bypassing their families and similarly many HIV programs for adults have bypassed children (1).  Finally, a family centered program addresses the needs of a whole family and not just an individual has been proposed. Family-centered approaches can be facilitated through community-based care workers who are well-positioned to support HIV-affected families by linking adults and children to antiretroviral treatment, legal support, food and nutrition assistance, and social protection entitlements (2). It is theorized that this link will also improve child and family outcomes by reducing barriers to HIV-related services (2).

Though less feasible due to unstable governments and a lack of funding, social protection would be able to greatly impact HIV transmission and consequences. Social protection is defined as a set of public and private initiatives that provide income or consumption transfers to the poor, protect the vulnerable against livelihood risks, and enhance the social status and rights of the marginalized (4). In small scale studies, it has been shown to promote access to healthcare, education, and nutrition.  These social protection programs would need to be short term in order to not create dependency and allow people to use the skills and education learned through the program.

Overall, children are at the greatest risk of suffering the consequences of HIV/AIDS. It is important that health campaign programs are somewhat flexible in order to address the needs of the community instead of forcing the predetermined plan. It seems that UNICEF realizes this and plans to implement programs with more leeway, but not many “flexible programs” are running now. The greatest issue with this is the inability to prove impact.  Protection, care and support programs often fail to attract funding due to this inability. Monitoring systems should include baseline measures, comparison groups, and quantifiable targets to ensure progress can be measured and impact attributed to the campaign (1). Context-appropriate indicators should be developed to establish a universal standard of measurement. Flexibility does not mean impact cannot be measured, only that health workers and program designers must be especially conscious of added variables and confounders.

(1)    Cluver, L. Orkin, M. et al. (2011) Transactional sex amongst AIDS orphaned and AIDS affected adolescents predicted by abuse and extreme poverty, Journal of Acquired Immune Defincieny Syndromes.

(2)    Range of 14.4 – 18.8 million. UNICEF (2010), Children and AIDS: Fifth stocktaking report, New York

(3)    EveryChild, Maestral and UNICEF (2012), Children living with and affected by HIV and AIDS in residential care

(4)    Devereux, S. & R. Sabates-Wheeler, Transformative Social Protection‟, Institute ofDevelopment Studies Working Paper 232, Brighton, 2004

Protecting Mother Earth

In another class, I was assigned to read Erle C. Ellis’ New York Times article “Overpopulation Is Not the Problem” (1) as part of our discussion of environmental health and the ever-present concern that our planet will not be able to sustain an ever-growing population.  I was first taken aback by Ellis’ bluntness when he wrote, “Disaster looms as humans exceed the earth’s natural carrying capacity.  Clearly, this could not be sustainable.  This is nonsense” (1).  He goes on to write that with the development of technology, the planet has been able to go from a carrying capacity of ~100 million prehistoric hunter-gatherers to ~3 billion farmers “in poverty or near-vegetarian diets” (1).  Today, the world’s population is estimated to be just shy of 7.2 billion people and counting (2), thanks to the technological advances we as the human race have developed (1). 

I agree with his argument that “humans are niche creators [and that we] transform ecosystems to sustain ourselves,” however, one aspect I feel he fails to address is our use/depletion of natural resources at a rate that is exponentially faster than the rate of replenishment of those resources.  Natural gas and oil were not created in a day (and I will add a girl’s best friend(s), diamonds, although they are more a luxury than a source of energy).  Although we know the process of how Mother Nature has created these, we do not have control over time.  As we tap into more and more wells, digging further and deeper in to the Earth, we are not only depleting the stores we had, but we are also changing the ecosystem that originally created those resources.  Of course, there are some areas of Earth that have not been “disturbed,” but in our capitalist world, where materialistic possessions are becoming greater and greater, the demand for gasoline and coal is increasing as we observe developing countries try to adopt developed countries’ habits (take for example the smog cloud in Beijing, China, which is visible from outer space (3)).  Developed countries are making efforts to develop alternative energy sources (through tax breaks mainly) but I don't believe that our progress is meeting the demand, partly due to the slow progress of research or the cost ineffectiveness of the new methods.  I remember when I was looking at buying a car, a hybrid seemed like a great choice, and although they would save gasoline costs over the years, hybrid vehicles were at least $5000 more expensive than “gas guzzlers.”  Additionally, replacing and recycling of the batteries in those vehicles is costly and in recent news, there is a risk of fires in the over $75000 Tesla vehicles (4).  Costs involved in being “green” are extensive and it would require everyone to switch to hybrid vehicles, to bring costs down.  Until then, those who cannot afford it (i.e. developed countries, people of lower socio-economic status) will still drive their high-emission vehicles, so as a planet, we need to address these issues together because we share the air and our environment – country borders are completely irrelevant which calls for global attention.

(1)  http://www.nytimes.com/2013/09/14/opinion/overpopulation-is-not-the-problem.html?_r=0

(2)  http://www.worldometers.info/world-population/

(3)  http://www.businessinsider.com/satellite-images-of-chinas-smog-2013-10

(4)  http://money.cnn.com/2013/11/08/autos/tesla-fire-details/

When Disasters Hit

Disasters can strike anytime and anywhere. Whether it be man-made or the result of the forces of nature, a disaster occurs anytime destruction overwhelms a region’s ability to cope and recover from it. However, it has been estimated that although only 11% of disasters affect the populations of the least-developed countries, they sustain 53% of all casualties (1). In other words, vulnerable populations are unequally affected by global hazards. Many of the factors that play into this are consistent with the themes we’ve discussed in class such as poor infrastructure for healthcare delivery, disparities in access to resources, low levels of education and other factors like climate change. 

A U.N. human development report on climate change cited that in the four years between 2000 and 2004, 1 in 1,500 people living in an OECD country were affected by a climate disaster. In contrast, 1 in 19 people living in the developing world were affected (2). When natural disasters strike, the effects are widespread and long-lasting. In the short-term there is often chaos, confusion and tragedy as people try to save their families from fire, floods and hurricanes. The focus for responders is usually to evacuate people to safety and treat critical injuries. However, even if we could do that effectively, prompt rescue and treatment does not mitigate the long-term effects on health and economy. Not only could houses, businesses, hospitals and government buildings be destroyed in a disaster, but the neighboring communities of a disaster area must find ways to support a rapid influx of people and their resources are often overwhelmed. 

This affects people for years as they struggle to find housing, jobs and security. 

We must think broadly about cultural and social issues that all play a role, even among factors that aren’t obviously related. For example, the report cited a study that found gender bias affected the ability of women to recover from a disaster. When a cyclone and flood hit Bangladesh in 1991, the death rate among women was five times higher and for those who did survive, legal restrictions on land and property ownership limited their capacity to rebuild their lives without a husband or father to provide for them (2). 

The coordination and efficacy of the global response to disasters is often painfully unhelpful. The Social Issue Report found two main barriers exist: insufficient coordination among actors (including local governments, aid governments, military, U.N. forces, NGOs) and limited involvement of the affected government in response. Although technology has allowed us to better predict when and where some types of disasters will occur, for the most part this has not yet led to prevention of destruction. Until we are able to control external factors like wind and rain (which may never happen), we must work to mitigate vulnerability and advocate for the rights of those at most risk of being affected. 

1. Jauregui, C., Sholk, J., Radday, A., & Stanzler, C. (2011). International disaster response. Social Issue Report, Boston: MA. 
2. United Nations Development Programme. (2007). Fighting climate change: Human solidarity in a divided world. Human Development Report 2007/2008. New York: NY

Female Genital Mutilation

Female genital mutilation (FGM) is an often misunderstood and highly controversial practice. Though those in Western societies view FGM as purely negative, the practice is held in high regards and considered an essential “rite of passage” for young women in many societies. According to the World Health Organization, FGM includes any procedure that intentionally alters or causes injury to the female genital organs for non-medical reasons. When the practice is done varies by culture and community, but the typical age range is between infancy and 15 years old. The practice is mostly carried out by traditional medicine women, who often play other vital roles in their communities. The procedures can cause life-threatening infections, bleeding, urination problems, infertility, and complications during childbirth. (1)

Female genital mutilation is classified into three main forms;  

1. Clitoridectomy: Partial or total removal of the clitoris and, in very rare cases, only the prepuce. This is consider the least harmful version of FGM. (2)

2. Excision: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora .  (2)

3. Infibulation: Narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris. This form of FGM is the most harmful and is what people typically think of when referring to FGM. (2)

 

FGM is recognized internationally as a violation of the human rights of girls and women. It reflects intense inequality between genders, and is considered an extreme form of discrimination against women. Since it is almost always performed on minors, it is a violation of the rights of children. The practice also violates a person's rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death. About 140 million girls and women worldwide are living with the consequences of FGM. In Africa alone, about 101 million girls (aged 10+) are estimated to have had the FGM procedure. (1)(3)

The causes of female genital mutilation include a mix of cultural, religious and social factors. In many communities that practice FGM, it is a social convention that is considered necessary in order to properly raise a respectable girl. This is traditionally motivated by the culture’s beliefs about the importance of premarital virginity and marital fidelity (3).  By completing type 3 FGM (Infibulation), it is believed that women will fear the pain of opening the covering seal and refrain from taboo sexual activities. Though there is no religious script that supports the practice, many religious practitioners and followers believe FGM is a fundamental aspect of a girl’s modesty and devoutness.

The international response to FGM has been large, but not effective. Many organizations publish strategies and declare resolutions against FGM, but do not address the fundamental cause of the practice. In order to create change within a community, you must address their leaders and cause a community-based movement against the practice. Simply stating that it is unhealthy will not motivate individuals to abandon an old, established tradition. It is extremely important to reach out specifically to religious leaders and elders who are respected leaders in the community and to the medicine women who carry out the FGM procedure. If FGM cannot be completed stopped, medicine women can at the very least be educated on proper sterilization, motivate them to perform type 1 and 2 forms instead of type 3, and given the proper resources to make sure her “patients” are properly cared for to the best of her ability.

(1) Department of Reproductive Health and Research, (2012). Annual technical report 2012 (WHO/RHR/13.05). Retrieved from World Health Organization website: http://www.who.int/reproductivehealth/publications/reports/rhr_1305/en/index.html

(2) Rymer, J. (2003). Female genital mutilation. Current Obstetrics & Gynaecology, 13(3), 185-190. Retrieved from http://www.sciencedirect.com/science/article/pii/S0957584703000040

(3) Boyle, E. (2005). Female Genital Cutting: Cultural Conflict in th Global Community (pp. 1-181). Baltimore, Maryland: Johns Hopkins Univerity Press

The Hidden Cost of Building the Olympic Stage

The 2014 Winter Olympics might still be a few months away, but they are already having an impact.  For the most part, the only piece of the Olympics that the majority of people will see is the two weeks of televised sports between the Opening and Closing ceremonies.  We see the triumphant athletic successes and emotional stories as narrated by Bob Costas.  What we do not see is the exploitation of over 16,000 migrant workers who were brought in to build the stadiums and arenas and the families who have been displaced (without compensation) so these facilities could be built on their land. 

Human Rights Watch interviewed workers employed on Sochi construction sites working in low-wage and low-skill jobs like carpentry and welding.  They discovered that they their typical wages were between the U.S. equivalent of $1.80-$2.60 per hour, that is, if they got paid at all.  The workers consistently reported that their employers failed to pay their wages in full, if they were even paid at all.  As expected, the contractors who hired these workers denied these claims, which means that it’s the workers’ words versus the contractors’. One might ask why the workers continued to do their jobs if they were not being adequately compensated. During the interviews, workers stated that their employers claimed they would pay them “tomorrow,” so they kept coming back. 

Unfortunately, the workers cannot afford to take legal action.  Migrant workers who did complain about the lack of wages and other abuses (12 hour shifts, 7 days a week, one day off every two weeks) were reported to the Russian authorities by their employers and subsequently deported.  Additionally, part of the lure of coming to Sochi for work was that part of their compensation was that food and housing would be provided.  However, the housing is typically overcrowded and the meals are insufficient to adequately provide the nutrition necessary to sustain the long hours of manual labor the workers perform.  Human Rights workers looked at the housing supplied to the workers and found that “in some cases, over 200 workers lived in very cramped conditions in a single family home” (Human Rights Watch, 2013).

The abuse is not just limited to migrant workers.  Russian citizens have found themselves displaced and without basic necessities like water.  One village relied on five wells as a water source since it does not have running water.  However, once Olympic construction started, four of the wells were paved over to build a road and the fifth has since been contaminated by runoff containing pollution related to the construction.  It took several months, but there is now a water truck that services the village once a week; each resident is allowed 200 liters of water.  Additionally, cement factories have been constructed near residential areas and operate day and night, creating environmental and noise pollution.  Complaints to local authorities have gone unanswered (Gill, 2009).

I find it ironic that an event that is supposed to promote world unity is being built on the violations of the rights of those who are not in a position to defend themselves.  When we watch the athletes take the stage this February, we should be aware of what it cost to build that stage.

Gill, Allison. (2009). “Letter to the International Olympic Committee: Human Rights Concerns   Related to the Sochi Games.” Retrieved from:http://www.hrw.org/news/2009/10/01/letter-international-olympic-committee-human-rights-concerns-related-sochi-games

Human Rights Watch. (2013). Russia: Migrant Olympic Workers Cheated, Exploited. Retrieved    from http://www.hrw.org/news/2013/02/06/russia-migrant-olympic-workers-cheated-exploited

Tuberculosis Concerns today

A few weeks ago, we talked about the effects of globalization, one of which is an increase in traveling and ultimately, the spread of infectious disease worldwide.  TB has recently been in the news and is the second leading cause of infectious diseases after HIV/AIDS, claiming 1.3 million deaths in 2012 (1).  TB is caused by the bacterium Mycobacterium tuberculosis (2); however, one of the major challenges with TB today is the rise of Multidrug-Resistant strains (MDR-TB) (2) due to the overuse of antibiotics, improper dosage, not following the prescribed regimen, and the slow progress of antibiotic discovery compared to the rate of adaptation of the bacterium to our current drugs (3).  Another cause for alarm with TB is that it exists in active and latent forms, where individuals with either form are still able to spread the disease (2).

I stumbled upon this interview of Dr. Mario Raviglione, the Director of the World Health Organization’s Global Tuberculosis Programme where he talks about the much higher prevalence of TB in India (4).  India currently has a quarter of all TB cases worldwide (4) and has not really made progress towards reaching the 2015 Millenium Development Goal #6 (5) due to a high number of missing reported cases and lack of political will and commitment (4).  India’s neighbor, China, on the other hand, has been able to make progress because of a national effort in tackling TB, whereas India, as Dr. Raviglione is quoted, “has yet to initiate survey at the national level to document drug resistance and TB disease prevalence. A drug resistant TB survey is about to start in early 2014. India has conducted surveys in some states but not on a national base” (4).  Incomplete reports of cases have led to inaccurate numbers as far as estimating need as well as the unknowing spread of disease since individuals are unaware that they themselves are infected.  Related to the drug resistance issue, Dr. Raviglione mentions the lack of regulation of TB drugs in India as chemists sell medication without a doctor’s prescription (4).  He recommends Brazil’s example, where TB drugs are unavailable in pharmacies and instead, individuals with TB are referred to public TB clinic where drugs are administered and free (4).  I view this as drug quality are ensured (no counterfeiting) and patients will participate in Direct Observation Therapy (DOT) where they are ensured they are taking the right dose at the right time (6) as well as providing staff support and encouragement to return for the next dose.  As Dr. Raviglione admits, every culture is different, and with India being that much more different than Brazil, the Brazilian model may not work elsewhere in the world (4).  It is up to us, the next generation of public/international health advocates to spread knowledge as well as address concerns in terms of how the culture views TB in order to design and implement an intervention that will hopefully eventually eradicate tuberculosis once and for all.  But similarly to what we see with polio today, these efforts cannot and should not stop as soon as the disease is under control for fear of outbreak.  There needs to be constant checks and balances for a few years after eradication to ensure the disease is gone (as in smallpox).

(1)          http://www.rawstory.com/rs/2013/10/23/tuberculosis-killed-1-3-million-in-2012-world-health-organization-says/

(2)          http://www.cdc.gov/tb/

(3)          http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095086/

(4)          http://www.dnaindia.com/health/interview-put-in-more-money-to-tackle-tuberculosis-dr-mario-raviglione-the-director-of-world-health-organization-s-global-tuberculosis-programme-1920747

(5)          http://www.un.org/millenniumgoals/aids.shtml

(6)          http://www.cdc.gov/tb/education/ssmodules/module9/ss9reading2.htm

Obesity in children and gender disparity

Obesity is increasingly a health issue in the United States, and many other countries as well. It was interesting to find the association of socioeconomic status and obesity varies across different societies (Hossain et al., 2007). Low SES is related to less time of doing physical activity, less nutritious food, and some psychosocial factors such as stress (Gearhart et al., 2008). In addition, lower SES people may have less health consciousness and lower capacity to think about the ways to keep healthy. These factors partly contribute to unhealthy behavior and can lead to obesity in developed countries. However, the case is different in developing countries. In China, for example, the obesity rates in large cities is higher, where is influenced by globalization and eating pattern is changing to high intake of high fat and sweetened food – Western style. The reasons why people in higher SES groups are at risk of obesity in China may include cultural norms that view round body shapes as prosperity - in particular for middle-age women, the greater capacity to obtain rich nutrition, and lack of physical activity (Gearhart et al., 2008). Although the relationship of SES and obesity is different between countries, what the same is that unhealthy eating diet, less physical activity, and poor self-management could cause obesity (Zimmet et al., 2001). 

In this sense, I was wondering how SES affects obesity and physical activity among children. I think it is related to parental education levels, and peer influence. For example, parents in low SES whose work schedule is tight may have no time to educate the children or involve in recreational physical activity with children. Besides, the eating diet that parents prepare for the children can form children’s future habit in adulthood. Fast food, which is cheap, available and convenient, usually is primary choice in low SES family. But can we make a change? I recall that the food items of McDonald’s in China is actually different with those in the US. There are more fresh vegetables in the hamburger, and more options such as fish hamburger, red bean pie, vegetable soup, and even rise and beef package. I think it is because the company attempts to cater to the preference of Chinese. Although fast food is still not a healthy choice, it is possible to make it healthier. Apart from family education, I think the peers of children also play a role. If the peers pay less time on physical activity, then the children would have less motivation and interest on engagement, since there are little peers ganging out with.

I am also curious about the role of gender in obesity. For example, boys in China have much higher obesity rates than girls in all age-specific subgroups (Wu, 2006). Is it just because of genetic factors, or because Chinese parents tend to have a tolerance for obesity among boys, and girls are assumed to keep a thin body image? Is there any gender inequality, such as preference for boys and thus over rich nutrition is offered to boys, rather than girls? I didn't find evidence for these questions, but I think it might be also related to socioeconomic and behavioral factors. For example, the rapid economic development of China makes parents are able to and willing to provide rich nutrition to children. It is normally assumed that boys need more foods than girls physiologically. Also, I read a report which proposed that many boys drink soft drinks more frequently than girls, and many boys adopt sedentary behavior such as playing computer games. By contrast, in many Western countries, the prevalence of obesity is higher in girls than boys (Song, 2013). It would be interesting to look at the comparison. I just find some assumption saying genetic factors play a significant role on the gender differences in Western countries (DeLany et al., 2004).

Therefore, what can we do to deal with the problem of obesity and improve physical activity? It is consistently a big challenge. We can easily suggest dietary modification and encourage physical activity, but it is difficult to accomplish. I think children obesity should receive much more attention, no matter from parents, family, community, or nation. Early life experience and habit in childhood would determine preference and decision-making in adulthood. Children establish eating and behavioral patterns since childhood, sometimes following parents without consciousness. Family involvement and parents’ model are very important (McLennan, 2004).

Reference:

Gearhart, R. F., Gruber, D. M., & Vanata, D. F. (2008). Obesity in the lower socio-economic status segments of American society. Forum on Public Policy. Retrieved from: http://forumonpublicpolicy.com/archivespring08/gearhart.pdf

John McLennan (2004). Obesity in children. Retrieved from:  http://softballone.com/rfe/obesity.pdf

Yangfeng Wu. (2006). Overweight and obesity in China. BMJ. 2006 August 19; 333(7564): 362–363.

Yi Song et al. (2013). Secular Trends of Obesity Prevalence in Urban Chinese Children from 1985 to 2010: Gender Disparity. Retrieved from:  http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0053069

DeLany JP, Bray GA, Harsha DW, Volaufova J (2004) Energy expenditure in African–American and white boys and girls in a 2-year follow-up of the Baton Rouge Children's Study. Am J Clin Nutr 79: 268–273.

Cultural Differences in Medicine

            We have talked a lot about culture and health in this class. I mean we have practically beaten it to death with a big, critical, scholarly stick. However, I have been reading this book called “Medicine and Culture”, which discusses the differences between the ways medicine is practiced in four developed countries: the U.S., Germany, France, and Great Britain.  It is so fascinating. We often talk about the different diseases that plague countries, and how social standing and geographical location affects the types of diseases and social problems you encounter, but this book looks at it from a different angle, and illuminates the differences in medical diagnosis, treatment, and care provided to patients. One World Health Organization report found that doctors from different countries diagnosed different causes of death when given identical information on the patient and death report.

            For example, if the same patient were to go to a physician in each of the four countries with the same ailment, such as fatigue, the diagnosis and treatment would differ due to each culturally acceptable medical response. In the U.S., a physician would tell the patient that he/she had a virus, mostly for the patient’s comfort of having a diagnosis; in France, a physician would attribute it to the liver and suggest a natural remedy; in Germany, a physician would consider the patient to have a cardiac insufficiency, but that is a casual term that doesn’t warrant worry from the German patient like it would in the U.S.

          Not only are the diagnoses different, but the treatments vary as well. A coronary by-pass in the U.S. is an extremely popular procedure for patients with heart problems, but the American rate of coronary bypasses is 28 times higher than European countries, and has been shown that they rarely need to be done immediately. One of the most common procedures in the U.S. for breast cancer is a mastectomy; however, in France and Great Britain, they consider this barbaric, and rarely an option, usually opting for the “tylectomy” (British term for lumpectomy) (Payer1996). Causing even more room for confusion, what we consider common medical terms for illness don’t necessarily mean the same things in other countries: peptic ulcer and bronchitis don’t mean the same thing in Britain as they do in the U.S. These discrepancies lead to a somewhat alienated profession, whose members barely read medical journals outside of their own country (Payer 2006), and prevent true collaboration.

            All four of these countries have a certain amount of cultural bias that creates this notion that their country is doing it the “right way” and is the most scientific, but really each country just has a different definition of what illness is, what the symptoms looks like, and a different preference for the way they want to treat it. I really like this book because we often times lump all developed, westernized countries together as being very similar, but really, there are a lot of subtle cultural dissimilarities that create different ideas of what makes up the term “scientific”. 

Payer, Lynn. 2006. Medicine & Culture.  New York: Henry Holt and Company, Inc.

The Invisibility of Mental Health

            A few weeks ago, we discussed mental health.  According to The World Health Organization, more than 450 million people worldwide suffer from mental disorders (WHO, 2010).  Unfortunately, this is a topic that does not get as much attention in comparison to other global issues such as HIV/AIDS and malaria.  Part of this problem is the stigma associated with mental disorders; in the United Kingdom, 70% of people affected by mental illness experience discrimination (Chambers, 2010).  Another problem is that it is difficult to generate empathy given that the external symptoms aren’t as obvious as those from physical illnesses.  Market research shows that people will donate about twice as much if they can emphasize with a picture as opposed to statistics; therefore just stating how many people suffer from a mental illness is not as effective in raising funds as showing a photo of an individual suffering from starvation (Heath, 2007).  This makes it difficult for organizations to raise funds to help raise awareness for treatment.  An additional barrier to treatment is that many cultures still regard mental illness as a punishment from whichever religious deity they believe in.  Therefore, when people do seek treatment, it is delivered by a local healer and is interpreted as a misfortune or a curse (Chambers, 2010).  This lack of treatment and misinterpretation opens those with mental illnesses up to abuse and human rights violations.

            While it seems that raising awareness and funds to combat this global issue is a daunting uphill battle, there is hope.  Vikram Patel, the co-director of the Centre for Global Mental Health and co-founder of an NGO dedicated to mental health (Sangath), describes a different approach to treating mental health illnesses.  He suggests training those who are available, such as local nurses or even family members, to provide mental health interventions.  He outlines his idea in a TED talk (link at the bottom of the page).  If you think about it, training community members to assist other community members is a great idea.  For one thing, it is sustainable provided that the resources (training guides, etc.) were readily available and the training done properly in the first place.  Also, if more people understand mental health issues, it might decrease the stigma and misconceptions that surround them.  People will not be as fearful to seek treatment, and when that treatment is provided, it will be effective.  Programs that utilize this idea support these notions.  In rural Uganda, villagers were taught to deliver psychotherapy to treat depression.  It was found that 90% of those who received the treatment recovered.  Patel himself did a study comparing those treated by lay counselors for anxiety and depression had a 70% recovery rate compared to only a 50% recovery rate of those who were treated at a primary healthcare center.  Perhaps one reason that the community based interventions are so effective is that patients already know the person treating them, which helps them trust and better engage in therapy sessions. 

            This new approach is definitely something to consider, and raising awareness for this type of intervention is one way that we can help reduce the problem of mental illness.

TED talk: http://blog.ted.com/2012/09/11/some-stats-on-the-devastating-impact-of-mental-illness-worldwide-followed-by-some-reasons-for-hope/

Chambers, Andrew. (2010). “Mental Illness and the Developing World”. The Guardian.    Retrieved 

November 17, 2013, from http://www.theguardian.com/commentisfree/2010/may/10/mental-illness-developing-world

Heath, C., & Heath, D. (2007). Made to stick: Why some ideas survive and others die. New          York: Random House.

The World Health Organization. (2010). “Mental Health: Strengthening Our Response.”   Retrieved November 17, 2013, from http://www.who.int/mediacentre/factsheets/fs220/en/.

Vulnerable Children

Earlier this week I stumbled upon a blog (1) that questioned if building orphanages could actually be enabling the impoverished to give up their children, i.e. “child abandonment.” Many orphans today are “poverty orphans,” that is one or both parents may still be living, but they cannot afford to care for their child/children. For many people, I think the idea of donating money or supplies to orphanages is an appealing way to help others. While I don’t doubt generally good intentions, it seems as though few people have stopped to rigorously assess how and by what means the very real issue of orphans and vulnerable children should be addressed. 

Sub-Saharan Africa is often a focus in discussions about orphans due to the myriad of ways HIV/AIDS contributes to vulnerability. Contributors to a book called “A Generation At Risk (2)” pointed out that although institutional care is still found to a large degree in these countries (and often supported by Western NGO donors), the Western world generally does not favor congregate care. Instead, family and/or community-based alternatives are promoted. Now, family-based solutions such as foster care are not perfect and can open doors for abuse or exploitation; however institutions like orphanages are not immune to such problems either and have the added stress of caring for great numbers of children at once. Many times orphanages in developing countries are overwhelmed by demand and struggle to provide food, safe water and sanitary conditions to their residents. 

Even if facilities are adequate,  researchers are finding out more and more about how profoundly parental attachment impacts child development. In 2012, Time magazine wrote an article discussing the results of several studies researching this issue (3). One study conducted in Romania found that compared to children placed in an orphanage, children placed in foster care had less distress, increased attentional skills and less incidence of mental illness (4). The article also cited a study that suggests not only do emotional problems arise in children without parental involvement, but lack of attachment may actually alter hormones in the body and impair development.

This being said, there are situations where institutionally-based care is the best option based on the circumstances. But as public health professionals, we should be looking to remedy the root cause of the problem, which is invariably more complex and involves system-wide changes to promote economic development, access to education and health care, food security, etc. I personally support the model of child sponsorship as an “in-between” step towards full community mobilization. Many organizations (such as World Vision (5)) match donors with specific children to continue their education, provide meals and develop a network of support. Children who are supported in this way remain with their families and the aid goes to help them utilize community resources. I think more of these types of systemic approaches are needed to prevent the underlying circumstances that ultimately lead to vulnerable children. What do you think?

(1) http://www.theveryworstmissionary.com/2013/10/would-jesus-be-cool-with-keeping-poor.html 

(2) Foster, G., Levine, C. & Williamson, J. (2005). A Generation At Risk: The Global Impact of HIV/AIDS on Orphans and Vulnerable Children. Cambridge University Press

(3) http://healthland.time.com/2012/05/24/the-measure-of-a-mothers-love-how-early-deprivation-derails-child-development/#ixzz1w4pqbIKw

(4) Ghera, M., Marshall, P., Fox, N., Zeanah, C., Nelson, C., Smyke, A. & Guthrie, D. (2009).

The effects of foster care intervention on socially deprived institutionalized children's attention and positive affect: results from the BEIP study. Journal of Child Psychology and Psychiatry, 50(3).

(5) http://www.worldvision.org/about-us/how-we-work

Drought, Famine and Conflict in Somalia

Drought, Famine and Conflict in Somalia

People in Somalia are facing a trio of challenges that are exacerbating each other and putting Somalis in very a precarious and dangerous situation. The crisis in Somalia consists of severe drought, famine and civil conflict. There has been no rain in the area for almost two years, prices of food have risen dramatically and the civil war has been raging off and on since 1991, which makes it too dangerous for aid workers to reach those who need help the most. The nearest refugee camp is over fifty miles away in Kenya, called the Dadaab complex it is the largest refugee camp in the world. Somalis hoping to stay alive and reach safety travel the fifty miles by foot across treacherous terrain, often risking death on the walk. There are almost 400,000 Somalis living in the Dadaab complex and over 1,000 new refugees arrive every day. Many of the refugees, if not most, arrive at the complex extremely malnourished and sometimes on the edge of death. Some don’t even survive the long journey to the complex. Once refugees reach the complex, although the conditions are better than what they were facing in Somalia they are a far cry from being healthy, sanitary or safe.  Recently, security in Dadaab has become high-risk after aid workers were abducted and refugee leaders and Kenyan security workers were attacked and killed. This led to a tightening of security, which makes it more difficult for aid to reach the camp. Currently the Kenyan government, The UN Refugee Agency (UNHRC), their partners, and refugee leaders are looking for innovative ways to improve the delivery of assistance and the protection of all people within the camp. They hope to increase physical security, improve living standards, increase social services and infrastructure, and improve school enrollment among many other goals. Although there are many health and humanitarian issues occurring in this situation, I am going to focus on the famine and hunger.

According to Sheeran’s (2008) article in the Lancet, the WHO declares hunger and malnutrition to be the greatest threat to public health, especially when combined with climate change (which could be a factor in the 2 year drought in Somalia). It is difficult enough trying to eliminate hunger, without trying to work in a war torn country such as Somalia. According to the same article, hunger is a threat to safety and stability and can be extremely detrimental to a country’s social and economic development. Many countries is Africa, such as Somalia, already have food insecurity issues without the added effect of drought, inflated prices, limited supplies, little food aid and war (Sheeran, 2008). Looking at this evidence the aid effort in Somalia is facing huge challenges and if hunger cannot be reduced, Somalia may continue in this cycle of war, famine and hunger.

I understand that the basic needs of these refugees are the first priority and that they must be established before moving forward. However, I believe that a plan for the future of these people must also be established. If the conflict in Somalia does not end soon, the Dadaab complex is not built to sustain the refugees for long term. These people, who came do the complex with almost nothing but the clothes on their backs will need assistance getting back on their feet and establishing themselves anew. So my question is, will these people, who left everything behind, who are living in a foreign country in near destitution, ever be able to regain their livelihoods and well-being?

Sheeran, J. (2008). The challenge of hunger. Lancet 371, 180-181.

http://abcnews.go.com/International/somalia-drought-largest-humanitarian-crises-decades/story?id=14088488

http://www.unhcr.org/pages/49e483a16.html