Cultural practices in exclusive breastfeeding (Part 2: The Analysis)

My previous blog post discussed cultural practices and beliefs that have been identified as barriers to exclusive breastfeeding in the Faluni women of the Ndu area of North West Province of Cameroon. The barriers identified were:

1) Mixed feeding is a traditional practice encouraged by village elders. This is an issue because NOT supplementing breastfeeding could lead to issues with husbands, mothers-in-law, or women village elders.

2) Breastfeed is though to be an incomplete food source that only serves to satisfies a baby's thirst but does not help with the babies weight. A babies cry is a demand for MORE than breast milk

3) Mother's work to produce enough food to feed their family. If the food is for the family, it should go toward the family.

4) Sexual contact is prohibited during the breastfeeding period-- sexual intercourse is believed to spoil both the milk and child.

Other barriers include the need to return to working in the fields, which may be a long distance away and where they cannot bring the infant. Without pumping or a way to keep the breastmilk, exclusive breastfeeding may be close to impossible.

The point of this case or blog post is not to criticize these cultural beliefs or practices, but to illustrate where we face extreme difficulties in encouraging exclusive breastfeeding for the first 6 months of the child's life. It also illustrates some limits to introducing Western best practices into indigenous populations. The authors did find a difference in compliance when comparing the rate exclusive breastfeeding between the educate and illiterate. While not significant, it did appear that those with at least a primary school education more frequently attempted to comply with medical advice than illiterate women.

In class, Dr. Acharya discussed how we can begin to do work in populations where we are outsiders. It probably requires dropping our expert status, being vulnerable, and really listening. BUT! I am not certain that this population would identify any issues with how feeding is conducted in their society. Where I see a loss of agency in decision making (mixed feeding is an "old" practice encouraged by elders and group processes are in effect which may shame or ostracize women that do not comply), how is this any different than Western norms? We eat and shake with our left hands-- this would be inappropriate in other populations. What practices do we perpetuate through group pressures?

Cultural practices in exclusive breastfeeding (Part 1: A case study?)

Hi.

Source:

Kakute, P. N., Ngum, J., Mitchell, P., Kroll, K. A., Forgwei, G. W., Ngwang, L. K., & Meyer, D. J. (2005). Cultural barriers to exclusive breastfeeding by mothers in a rural area of Cameroon, Africa. Journal of Midwifery & Women’s Health, 50(4), 324-328.

A previous blog of mine served as an introduction to exclusive breastfeeding. While doing further research on the topic, I found quite a few article that discuss barriers to exclusive breastfeeding in very specific cultures (read: not U.K. or U.S. populations). In more remote areas, we can expect to see different expectations for breastfeeding and baby raising. One article, the citation provided above, interviewed women in tribal groups living in the Nde area of North West Province of Cameroon. The women identified several cultural beliefs that served as barriers to exclusive breastfeeding. These barriers persist in the face of Knowledge provided by local medical providers. Remember that the WHO and UNICEF recommend exclusive breastfeeding for the first 6 months of the babies life, with supplementary food being added alongside breastfeeding for the 6 months to 2 years period. They also recommend breastfeeding within the first hour of the child's life. The mothers interviewed practiced mixed feeding where they would combine breastfeeding with water, tea, or other foods.


The cultural beliefs listed are (with discussion to follow):

1) Mixed feeding is a traditional practice encouraged by village elders. This is an issue because NOT supplementing breastfeeding could lead to issues with husbands, mothers-in-law, or women village elders.

2) Breastfeed is though to be an incomplete food source that only serves to satisfies a baby's thirst but does not help with the babies weight. A babies cry is a demand for MORE than breast milk

3) Mother's work to produce enough food to feed their family. If the food is for the family, it should go toward the family.

4) Sexual contact is prohibited during the breastfeeding period-- sexual intercourse is believed to spoil both the milk and child. 

The initiation of breastfeeding, including the provision of the colostrum, is also influenced by cultural beliefs. Colostrum is:

the milky fluid that comes from the breasts of humans, cows, and other mammals the first few days after giving birth, before true milk appears. It contains proteins, carbohydrates, fats, vitamins, minerals, and proteins (antibodies) that fight disease-causing agents such as bacteria and viruses. Antibody levels in colostrums can be 100 times higher than levels in regular cow’s milk.

Colostrum also helps encourage a babies first stool. Colostrum, as discussed in class, would be extremely lucrative if able to be produced on mass. The Fulani women prefer giving cow's milk and viindi (local substance) rather than colostrum, which they believe to have no nutrients. Other issues with colostrum include the color being seen as "bad". The Fulani women also waited more than 2 days to breastfeed their babies. Again, the WHO recommendation is breastfeed within the first hour of life.

Their are other considerations at play with the Fulani women-- they work in the field and on farms. They may have to travel long distances to the field, which necessitates leaving the baby with grandparents or other caregivers. Without pumping or refrigeration, it is close to impossible to provide enough daily milk to take care of the baby through exclusive breastfeeding. The women also are aware of the relationship between supplemental feeding and diarrhea, but recognize that they have to return to the fields for work. Analysis to begin in Part 2! The adventure continues...

Encouraging Progress for Sanitation Workers

The following post is about the YouTube video entitled, "Can a Toilet Help Lift India's Untouchables out of Poverty?" posted by Journeyman Pictures and produced in 2008.

Lack of access to sanitation clearly causes  health problems. Pathogens transmitted through contacts with human waste or through consumption of contaminated food and water can cause a myriad of diseases that claim the lives of so many children and adults worldwide, each year. A World Health Organization estimate of the disease burden of lack of access to sanitation to be 4.0% of all deaths and 5.7% of the total DALY's, each year (Pruss et al., 2004).

The problem of sanitation in this video is portrayed as a public health problem, technological problem, an economic problem, and a social problem. A solution to the problem of sanitation cannot come only from the discipline of public health, or engineering, or economics, or social science. A solution with a chance for success must address all parts of the problem of sanitation.

The video demonstrates some of the technologically-innovated alternatives to open defection that the Sulabh International Social Service Organization has implemented. Solar composting, and dry composting toilets can be installed in urban areas as public toilets that don't contaminate groundwater and recycle the human waste into fertilizer for crops. It also demonstrates how these facilities can charge a small user fee and collect enough revenues to sustain their own operation. This is important to Dr. Phatak, because it frees him from relying upon government support and conditional grants. SISSO can freely choose what programs they would like to start, where they would like to start them and who they would like to employ and support. Perhaps the most important part of the sanitation work that SISSO does is addressing the strict socio-economic stratification that exists within the caste system that exists in the urban areas they serve. By providing more formal employment for the sanitation workers, members of the lowest caste, they are no longer forced to work in a manner that does not relfect their human dignity. Their work in the streets is discussed in detail at 13:45 in the video.

SISSO may not be able to directly address the stigma the workers face, but they are able to offer housing and improved wages. The housing provision would, in my opinion, provide some stability and security in the lives of sanitation workers. A tour of one of the living quarters can be seen at the 11:45 video mark, and it appears that these living conditions are much improved from the tents in the streets shown in early portions of the video. The increase in stability and safety will allow them to use their increased wages to gain access to better health services and food.

The central mission of the SISSO is to improve the lives of the "untouchables". They recognize that improved sanitation is a means to improved wages, food security and social conditions as well as improved health. They also recognize that the caste system places limitations on how much social progress can be made, unless the employment conditions forced onto "untouchables" can be addressed.

Citation:
Prüss, Annette, David Kay, Lorna Fewtrell, and Jamie Bartram. "Estimating the Burden of Disease from Water, Sanitation, and Hygiene at a Global Level." Environmental Health Perspectives 110.5 (2002): 537-42. Web.

Obesity Epidemic

The FDA has now made a rule requiring calorie labeling on foods, including popcorn at the movie theaters and pizza at restaurants:

http://www.nbcnews.com/health/diet-fitness/new-fda-calorie-label-rules-include-pizza-popcorn-n255291

This is certainly important information that the public should have access to. However, as we have learned, education on health does not always influence behavior changes. For example, in the article from this week on hygiene, sanitation, and water, it was stated “It has only recently become clear to health professionals that emotional levers (‘Clean hands feel good’) change people’s health behaviours more effectively than cognitive statements (‘Dirty hands cause disease’)” (Bartram & Cairncross, 2010, p. 1).

The American Cancer Society lobbied for the labels, of course. The new article used a quote from a member of the American Cancer society: “‘Between one-fourth and one-third of all cancers are caused by poor nutrition, physical inactivity and excess weight,’ said Chris Hansen, president of the American Cancer Society Cancer Action Network, the group’s lobbying arm.” While this may be true, few people are motivated by the threat of a disease developing over time. The health behavior model would show that people perceive this risk as a low threat. Often, people do not consider their risk of cancer until they know people like them who develop it. Jill mentioned this as a comment in Ola’s cancer post.

The news article also mentioned “The group said FDA also needs to launch an education campaign so people know how to read and use the labeling.” Simply educating the public will yield few results if people do not perceive their threat of developing diseases related to poor nutrition as high. This will be largely inadequate in fighting the obesity epidemic. More emphasis needs to be placed on things like educational entertainment to motivate people to change their behavior.

People may not be able to make informed decisions if this health information was not available to them, but I think that government should be more focused on advertising that reflects emotional levers to influence the obesity epidemic. This, however, would have to be done in a way as to not make obese people feel bad about how unhealthy they are. Our society covets thin women over obese women, but recently, in media and songs such as Meghan Trainor’s “All About That Bass,” obese people have been shown as beautiful too.

What if a campaign were done to promote healthy eating as something that makes you feel good? It does not have to be related to beauty, as that would likely offend many people and cause them to ignore the message. Maybe some sort of campaign that shows that if you eat too much popcorn with too much salt and butter, you will have a stomach ache and headache and feel fatigued. This would be in contrast to if you ate a well-balanced meal with fruits and vegetables, which would make you feel energized.

The problem is that the government only has so many tax dollars to spend on advertising. They are up against large corporations with huge advertising budgets. Some of the numbers I learned in my Health Policy class are riveting. For example, on advertising alone, Reese’s spends $383 million each year, M&M’s spends $500 million each year, and McDonald’s spends $665 million each year. This is in comparison to the USDA, which spends $3.5 million each year on healthy food programs. No wonder why we have such an obesity epidemic.

Bartram, J., & Cairncross, S. (2010). Hygiene, sanitation, and water: forgotten foundations of health. PLoS Medicine, 7(11), e1000367.

Food Insecurity and Obesity in Brazil

Last week’s topic of household food insecurity (HFI) and obesity, and Secretary Vilsack’s veritable avoidance of the topic got me thinking about the HFI-obesity paradox and the way it functions in lower income countries in addition to in the United States. As this is also my final paper topic, I found it timely to take a look at an article from another part of the world where the paradox has been examined. 

In “Severe food insecurity is associated with obesity among Brazilian adolescent females” from 2012, researchers looked at the issue of the HFI-obesity paradox with special focus on Brazilian adolescent girls. There is inconclusive research linking moderate but not mild or severe food insecurity to obesity, but the authors hypothesized that the outcomes for adolescent girls would be different based on health data from the Brazil Demographic and Health Survey. This is one of the first studies examining the HFI-obesity relationship in less-developed countries. 

As BMI data was taken from the Demographic and Health Survey, and food insecurity data was taken from the Brazilian Food Security Scale, the study found that “food insecurity is significantly and independently associated with excessive weight” in adolescent girls, differing from the study of grown women showing a moderate food insecurity and excessive weight relationship. Adolescent girls in Brazil were almost two times more likely to have excess weight if they were food insecure than their food secure counterparts. 

The authors posit myriad reasons for this outcome, including:

• Do parents shield children from food insecurity by giving them the food they have?
• Is eating a coping mechanism for the stress of being hungry?
• Do families purchase more nutrient-dense foods if they are cheaper?
• How do the strong body image concerns of Brazilian adolescents contribute to adolescents eating more or grown women eating less?
• What role do social assistance programs play in the types of foods that families purchase?

Notable here is that all but one of the questions commonly asked to unpack the paradox are questions that US-based researchers ask as well. The uncommon question is the one about body image. Brazil has an intense female aesthetic culture, including a high participation in plastic surgery amongst Brazilian women. This would be an interesting dynamic to explore when considering contributing factors. 

The authors’ conclusion is: "It is possible that the hunger-obesity paradox may be directly related with the way different countries experience nutrition transition. It seems that only when the nutrition transition reaches a stage at which energy-dense foods become available at affordable prices does food insecurity become a risk factor for overweight and obesity” (p. 1857) They seem to suggest that price points play a major role in determining calorie consumption. 

I think this study is interesting on many fronts. Like nutrition itself, research around the HFI-obesity paradox is inconclusive and few solid statements can be made about why people who are food insecure seem to show a greater tendency to be overweight. As we know that poorer countries are not immune to obesity nor to the paradox, it’s encouraging that similar (although not identical) results are being found across cultures. I’m hoping in my future work to start to unpack some of the questions/considerations listed above in both the United States and abroad. 

Kac, G., Velásquez-Melendez, G., Schlüssel, M. M., Segall-Côrrea, A. M., Silva, A. A., & Pérez-Escamilla, R. (2012). Severe food insecurity is associated with obesity among Brazilian adolescent females. Public Health Nutrition, 15(10), 1854–1860. doi:10.1017/S1368980011003582

Policies of public health, and the difference between health care systems

In Prof Boling Lecture, she gave us a different prospective in global health, it is about health policies across the different countries and its effect on health of population and mortality and morbidity rates.

She talked about social determinant and infrastructure and its effect on health. Social determinants of health are conditions in which people are born, grow, live, work and age. These circumstances are shaped by distribution of money, power and resources at global national and local level. It can lead to health  inequities, there is an important role played by social determinants of health in global health, one of the Who preamble constitution is that "the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition". health inequities within and between countries are politically, socially and economically unacceptable, Reducing health inequities through action on the social determinants of health could be a very effective way, These include early years' experiences, education, economic status, employment and decent work, housing and environment, and effective systems of preventing and treating ill health. Infrastructure is the basic structure needed for the operation of the society, an example of that is the water system as a basic infrastructure and how some low income countries did not have access to clean water which affects the population health dramatically. This interesting site of the World Bank where we can search data about health across the whole world and compare different countries, shows how health policies in the different countries affect the distribution of the health of the people.

One of the nice examples of some data that has been shown in this site is the record of immunization across different countries, how this in high income countries compared to low income countries also the distribution of life expectancy which found to be highest in Canada and eastern Europe compared to lowest ay south Africa  countries and other low income countries, the same regarding infant mortality rate , all these  health issues and other public health systems was affected mainly by the socioeconomic status  which affect the health policies in the lower income countries.

Health care system differ greatly from one countries to another. Some countries depends mainly on out of pocket expenditure and most of those are the lower income countries the more developed countries like Canada depend on governmental insurance others like USA depends mainly on private insurance. I think that the governmental insurance is the best of those three systems. It ensures the equality of health distribution in the nation and decrease the individual disparities between the different socio-economic levels. It also remove this burden from the shoulder of poor people and achieve the health access right for everyone. Despite that, it has some disadvantages like long waiting line to get the service.

Reference:

Prof Boling lecture on politics of public health, a global and comparative perspective.

Genetic contributions to the obesity epidemic - focus on marriage

I thought I would go ahead and post about the article I referenced during Dr. Saviano’s visit to our class last week. He asked what some of the causes of obesity are, and I answered that marriage was a major culprit in contributing to the evolutionary development of obesity as a phenotype in the US and other countries. 

In an article by David Allison and colleagues, they examined the health records of individuals’ BMIs at age 13 using the national health registry in the Netherlands, and compared this data via personal identification numbers to marriage and health registries during traditional marrying decades later in life. Using various statistical analyses that I won’t go into here, the study showed that for individuals who were in the 90th to 95th percentiles for BMI at age 13, their BMIs increased steadily during decades when people traditionally get married. In other words, folks with a high BMI at age 13 continue to get fatter over time, as is reflected in most of the obesity literature. 

When it came to marriage, folks in the 90th and 95th percentiles for BMI at age 13 were highly likely to marry someone who also had a correspondingly high BMI at age 13. This is regardless of weight loss or change in body type in the interim years between age 13 and marrying age. In short, the study showed that if a person was overweight as a 13-year-old, that person would have a high chance of marrying someone who was also overweight as a 13-year old, regardless of either partner’s weight on their wedding day. 

The authors argue that because BMI at age 13 suggests a genetic predisposition to overweight as an adult, and because assortative marriage (marrying based on similar phenotype or genotype) appears to occur within these populations (and the general population as well), assortative marriage could be a prominent factor contributing to the obesity epidemic. They say, “Genetic predisposition toward a high BMI in both spouses—apparent already in childhood—may predispose their offspring towards the same trait to a higher degree than by simply adding the effects. The offspring may inherit several interacting risk alleles from both parents, and, in addition, homozygosity at loci associated with obesity may allow recessive loci to be expressed” (p. 5). Essentially, two people who are predisposed to obesity because of their genetic profiles will create children who are also predisposed to obesity. 

I’m fascinated by this research because of its implications for communication activities aimed to change health behaviors. While the media and the public often attribute obesity to personal choice and individual behaviors, this research suggests other, less easily mitigated factors to consider. While we can’t tell people who to have children with, this research may demand new and different behavior change research to effect health outcomes. 

Ajslev, T. A., Ängquist, L., Silventoinen, K., Gamborg, M., Allison, D. B., Baker, J. L., & Sørensen, T. I. A. (2012). Assortative marriages by body mass index have increased simultaneously with the obesity epidemic. Frontiers in Genetics, 3. doi:10.3389/fgene.2012.00125

Conference Post 2: Traditional Health Practices in Nepal

My second conference blog is coming from a graduate student paper in health communication I heard presented this Friday. The idea may not be exceptionally new, but I thought it was exciting to know that others in my field are pursuing interesting work relevant to global health. It was called “Perception of Social Power and Compliance Based on Traditional Health Beliefs in Nepal” by Yerina S. Ranjit from the University of Connecticut.

The presentation began with a discussion on the social structure in Nepal relevant to young women. When a woman marries, she joins her husband’s family and relocates to live with them. In general, these women have very low social power. Ranjit did not find that this was as true when women were from wealthier families or had received a stronger education. But in general, the younger women had low social power. Mothers-in-law, however, had high social power. They made major decisions for the family.

This social structure became problematic for issues relevant to the health of these young women and their children when they became pregnant or were raising young children. Traditional health beliefs about pregnancy and child nutrition were not in-line with what was actually best for the mother’s and children’s health. And, the social structure did not always allow women to protest against these traditional health practices, causing them to comply whether they agreed with the practice or not.

This has a very relevant implication for health interventions that we have discussed previously. An intervention targeting the young mothers may be effective in changing their attitudes or beliefs about these health practices, but the mothers may not have the social power to enact behavior change. Therefore, interventions that solely target the mothers in this particular social environment would not result in the desired health behavior change.

What must be done instead is to have an intervention that does still target young mothers, but also targets mothers-in-law. These women are the gatekeepers to behavior change in their families and have the social power to promote these changes. I do not claim that this would be an easy task. These women are operating from strongly held beliefs that have been passed down in the past by their families. Changing their attitudes and beliefs would involve delicacy and the involvement of community members.

The main results from the paper were that women with greater wealth or education were less likely to comply with traditional health practices imposed by mothers-in-law, because they perceived the power distance between them to be smaller. This also points to the solution of increasing educational opportunities for young women to increase their perception of their own social power. This is also, however, not a simple solution.

Conference Post 1: Agenda Setting

I was at the National Communication Association’s annual convention this weekend and have two blog posts that will be coming out of this. The ideas I present here first came to me at the GIFTS session (where people present great ideas for teaching students). I was standing in for a friend presenting her teaching activity on Agenda Setting Theory. I was pleased at people’s responses to the theory and intrigued by one issue that kept coming up during the presentation. But first I will briefly explain the theory.

The idea of Agenda Setting Theory is that the media does not necessarily determine how we think about particular issues. Instead, news media “sets the agenda” or determines what we will be talking about. In the activity, students are put into groups and given a set of news values (like timeliness, uniqueness, number of audience members impacted, etc.). They pretend that they are in charge of selecting news stories for a television program and must select four out of ten stories they are given to run. The top three stories the students select are always the same. It demonstrates how using these news values causes viewers to perceive a few specific issues as more important to discuss and form opinions on than others.

Every time I presented this activity, one person would always say “like Ebola.” And I agree. The media has indeed set up Ebola as an issue that the public at large should be concerned about. And yes, people have different opinions about what should be done and how the situation should be handled, but the fact is that the media has placed Ebola firmly “on the agenda.”

This, as a result, has placed the actions of those responding to the epidemic under a microscope. I am torn about whether this is a good or a bad thing. On the one hand, this could result in policymakers’ actions being held to a higher standard because they will be highly publicized. But as we saw from the NPR article, the climate of fear about containment has in fact allowed human rights to be disregarded with limited public backlash. But, this story of hardship was stilled covered by someone. On the other hand, actions must then be taken in light of how it will look to the public, not necessarily what is best for those directly affected. There are both positives and negatives associated with an issue being put “on the agenda.”

But my question is, what stories are not making the cut? Are there other issues that would benefit from public attention and concern but that do not have enough news value? I am certain that there are, but I could not identify for sure which issues these would be. My greatest application for global health that has come out of this thought process is: how can workers in global health services manipulate these news values to get issues that need attention air time? I recognize that news coverage comes with unintended negative consequences, but the good could outweigh these effects for some issues.

Breastfeeding introduction (work in progress to answer my questions from weeks back!)

Goal 4 of the U.N. Millennium Development Goals and Beyond 2015 is a two-thirds reduction in the under-5 mortality rate. Suboptimum breastfeeding has been identified as a major factor in under-5 mortality rates 1.4 million deaths (12% of under-5 deaths) and 43.5 million DALYs (10% of the global under-5 DALYs (Black et al. 2008). Respectively, the percentage attributed to non-exclusive breastfeeding is 77% for mortality and 88% for DALYs. Exclusive breastfeeding is recommended for the first 6 months of the infant’s life, with complementary feeding recommended after 6 months and up to 2 years. Despite these recommendations, a sizable proportion of women worldwide do not exclusively breastfeed for the child’s first 6 months. For instance, the 2011 (most recent data) U.S. rate of exclusively breastfeeding for the full 6 months is about 19% (CDC, 2011). While this number has risen steadily in recent years, the vast majority of the U.S. population does not follow the recommendation on exclusive breastfeeding. Barriers vary by region and population, but some themes have emerged. Knowledge of best practices, concerns about milk production and suitability, support (spousal, family), and structural constraints are the primary culprits. The primacy of a barrier should change by population under consideration— structural barriers such as returning to work or need to work may be more or less critical depending on the role of women in a population. In Northern Vietnam, women may be expected to return to rice paddies as soon as possible after giving birth. If time and energy are at a premium, women may be less likely to exclusively breastfeed. 

Breastfeeding exclusively for 6 months is time consuming and requires constant forethought. Frequent stimulation is needed for milk production, and milk supply takes time to become established. In the beginning, the newborn should be fed “on demand”-- maybe 8-12 times per day. By 1-2 months, this number goes down to seven to nine times per day. While pumping (using a pump to extract milk for later use or to keep up your production at times when feeding is not recommended) is a viable option for mothers, this may not be available or feasible for certain populations. Pumping requires 1) equipment, and 2) refrigeration or freezing capability. If women must return to work, pumping may be the only option for providing the infant with mother’s milk. While you may lose some of the bonding associated with feeding on the nipple, the nutrient function is still in tact. Some countries have established laws to protect new mother’s ability to express milk. In the U.S., section 7 of the Fair Labor Standards Act of 1938 (29 U.S.C. 207) was amended in 2010 to offer some protections to nursing women:

Employers to provide break time and a place for hourly paid workers to express breast milk at work. The law states that employers must provide a "reasonable" amount of time and that they must provide a private space other than a bathroom. They are required to provide this until the employee's baby turns one year old.

Ebola Dolls?

Links:

http://www.herobuilders.com/pop+culture+action+figures.htm

http://jezebel.com/great-someone-made-an-ebola-nurse-doll-1659489805

http://jezebel.com/nurse-kaci-hickox-still-wont-take-no-quarantine-goes-f-1652787968


A custom action figurine/doll maker has designed a Case-E Ebola Nurse Action figurine. Jezebel, a well known website that I read and in equal amounts enjoy and hate, wrote an article criticizing the manufacture of action figurine and also linking to an article they wrote in support of nurse Kaci Hickox (bike riding Ebola free nurse from Maine). I found both articles fascinating-- on one hand, should we be disgusted or mildly amused with the figurine? Or, just ignore it? The figurine, which comes with a certificate stating that the doll is "100% EBOLA FREE DOLL"
, bears close resemblance to Ms. Hickox. Is this a case where any publicity is good publicity? Does it harm public perception of Ebola and the severity and need for intervention? The writer(s) at Jezebel would argue that it is just sleazy. The author remarks "so you see they just had to jump in and find a way to exploit the story to make some money. Their hands were tied, OK?". While this seems like an issue of low importance (which it is), I still find the whole thing interesting because we live in such strange times. Oh well, on to talking about Kaci Hickox.

Ms. Hickox is the nurse in Maine that came back from treating Ebola patients overseas and was asked to keep a quarantine in her home until the end of the 21 day symptom period. If you followed the news coverage (which I barely did), you know that at one point she decided to go for a bike ride with her significant other. This resulted in news media and police following her entire trip. In the comments section on a Jezebel article on the nurse, a commenter asks:

100s of nurses and doctors in the US have treated Ebola patients here, but we aren't quarantining them, right? I read that at least 70 health care providers will come in contact with Dr. Craig Spencer. They aren't being asked to stay in their homes for 21 days. Is ebola only scary when it comes directly from Africa? Or are we really worried that Africa itself is contagious?

 This is such a provocative question! Were these health care providers subject to the same scrutiny and the threat of quarantine? What is different about Ms. Hickox situation? I personally don't see the issue with being careful and respecting the quarantine-- it sounds like a good time to catch up on Netflix and sleep! Does it really add to public misconception of Ebola? Or, to put it another way, what does this add to any public misconception of the disease beyond any misunderstanding people would already have?  Other interesting comments on the same article:

YOU CANNOT LEGISLATE BASED ON WHAT YOU FEAR MIGHT HAPPEN, YOU NEED TO BASE POLICY ON ACTUAL FACTS

And, as a corollary, this:

Going against scientific evidence only perpetuates fear and makes it harder to actually work on curing the damn disease.

Do you agree with these sentiments? 

Dr. Bailey tries to get "healthy"

Last night on Grey’s Anatomy, one of the leads, Miranda Bailey, was performing surgery on a man with a stomach tumor that was caused by poor eating and lifestyle habits. Bailey, an obese (I’m pretty sure) woman, was so moved by seeing this tumor and hearing the stories from her patient of his reckless health behaviors that she immediately ran her own panel and found both of her cholesterols and blood sugar to be in dangerous ranges. 

As a result of the panels, she panicked and began making immediate changes: running, avoiding donuts, and discussing these changes with her husband, Ben. She says to Ben, a very fit-looking man, “I’m such a hypocrite. I spend so much time telling people every day to eat right. And exercise I have to make some changes. Starting now.”  Ben responds by laughing it off, but we are left wondering what lifestyle changes are in store for Dr. Bailey in the future. 

This episode elicited multiple questions for me. First, what was the motivation for Shonda Rimes, the producer, to create this storyline? Did the actress who plays Bailey, Chandra Wilson herself have a health scare and want to change her weight, and was that consequently written into the storyline to accommodate her impending weight loss? Do overweight characters like Bailey normalize overweight and could her weight loss and the weight loss of other characters in popular television normalize weight loss? Also, what will happen to Bailey as a character and to Wilson as an actress if she does achieve change? 

In light of our conversations about campaigns and the Sabido method last week, I’m interested in how eating and diet could be utilized in dramas such as Grey’s Anatomy to affect health behavior changes in the general public. The United States public might not be as enamored with serials whose sole purpose is social or behavior change, but could writers of these shows be convinced to change the way food is portrayed in their shows, or convinced to have characters who are not only “fat,” but also take steps to change their health behaviors and have eventual success? 

I believe that the normalizing of healthy eating, such as the normalizing of not smoking in television shows could happen and could affect public health changes. We rarely see smoking characters on television anymore; why can’t we see characters who generally eat healthy food, or at least have conversations about these behaviors as Bailey and Ben did last night? It seems odd that it could be radical to have a character lose weight, but I was completely sidelined by last night’s episode. Normally overweight characters just stay overweight, and their health status is only talked about in a humorous manner. I would like to spend more time in my final paper for this class exploring ways that healthy eating might become more normative in television, and envisioning how this might look in the context of a concrete action plan. 

Compassion International

Throughout my time in this course, I have been thinking a lot about the impact of various aid organizations. There are two that I have had a small level of involvement with that I have naturally been contemplating more. These are Compassion International and WAR international. I just wanted to take a couple of these blogs to discuss my thoughts on them and see if anyone else had opinions or information about them.

I’ll start with Compassion International. They are basically an organization that pairs sponsors with a specific child. The sponsor gives a sum of money each month, most of which goes to the child’s education and health. It is a faith-based organization, so resources also fund church-related activities, but the overall priority seems to be fighting poverty through education and health, including care for mothers. The sponsor and child also exchange letters. The thing that I had liked originally about the organization is that they have people staying in the locations of the children being sponsored on a long-term basis. They work with locals and the parents to find out what the actual needs of the child are. Additionally, when sponsors purchase birthday or Christmas presents for the child, they do not select the actual items. Those who are on-site in the child’s area select what is best suited for the child. These factors appealed to me, because I know that it is difficult, if at all possible, to determine the needs of someone whose culture and environment you do not understand. A lot of our readings have established that partnership with the community is essential for effectively delivering aid.

However, this organization is not perfect. I understand that people at times take issue with faith-based organizations, but I’m not going to discuss that here. My biggest concerns were with how sponsors are paired with children and how the situation is framed by the organization. Sponsors select the child or children they want to support by looking through pictures coupled with information about the children and their area. My worry is that people will be more likely to select children that they think look “cute,” leaving, for lack of a better term, less physically attractive children with a lowered chance of being paired with a sponsor. The organization does identify children that are “more in need of help” with the child’s information. Specifically, they label those who have been waiting for a sponsor for over six months and those are in areas with a higher prevalence of HIV.

My final concern was the manner in which they sometimes frame the sponsor-child relationship. The advertisements clearly use “hero” terminology. I feel like this is extremely common for aid organizations targeting the Western world. It is a persuasive technique playing on people’s desire to be a hero, make a difference, and feel good about themselves because of it. The concern is that this will perpetuate the inequality between the groups. Those providing aid will continue to view themselves as the powerful providing a service to those in need rather than equals facilitating the fulfillment of the human right to health. But, I suppose that framing the action as heroic rather than a duty is more persuasive. So what matters more, persuading people to donate money or promoting an ideology of equality?

Common cancers globally and statistics

Cancers account for 14.1 million morbidity and 8.2 million mortality rate /year, 7.4 million (53%) in males and 6.7 million (47%) in females. Cancer prevalence worldwide were 32.5 million as of 2012. The most common four cancers worldwide is Lung cancer, breast cancer, Bowel cancer, Liver and prostate cancer, those account for 46% of all cancers deaths.

 

 

About 30% of cancer deaths are due to the five leading behavioral and dietary risks: high body mass index, low fruit and vegetable intake, lack of physical activity, tobacco use, alcohol use.Tobacco accounts for 20% of the cancer deaths and Cancer causing viral infections such as HBV/HCV and HPV are responsible for 20% of cancer deaths in low- and middle-income countries.

 

Cancers has mainly a genetic cause, but it does not mean it is uncontrollable. Physical and environmental as well as behavioral factors plays an important role in either activation or suppression those genes by a process called epigenetic modification.

That mean that cancers to some extent could be preventable and modified. Primary prevention focus mainly on behavioral and dietary factors and secondary prevention depend on early detection and intervention as early as possible.  Increase avoidance of the risk factors, Vaccinate against human papilloma virus (HPV) and hepatitis B virus (HBV), Control occupational hazards, Reduce exposure to sunlight are all a primary preventive measures. Visual inspection with acetic acid (VIA) for cervical cancer, Pap test for cervical cancer, mammography screening for breast cancer are all examples of secondary preventive measures.

WHO and the International Agency for Research on Cancer (IARC), the specialized cancer research agency of WHO, collaborate with other United Nations organizations and partners to:

coordinate and conduct research on the causes of human cancer and the mechanisms of carcinogenesis; develop scientific strategies for cancer prevention and control; generate new knowledge, and disseminate existing knowledge to facilitate the delivery of evidence-based approaches to cancer control; develop standards and tools to guide the planning and implementation of interventions for prevention, early detection, treatment and care;facilitate broad networks of cancer control partners and experts at global, regional and national levels; strengthen health systems at national and local levels to deliver cure and care for cancer patients; and effective transfer of best practice interventions to developing countries.

References:

 

1.  Globocan 2012, IARC

 

2. de Martel C, Ferlay J, Franceschi S, et al. Global burden of cancers attributable to infections in 2008: a review and synthetic analysis. The Lancet Oncology 2012;13: 607-615.

When Scientific Consensus and Religious Doctrine Disagree

Partially evidenced in our assigned TEDx video about increased contraceptive distribution in Thailand to stall population growth and the spread of HIV/AIDS was the friction between religious doctrine and scientific consensus on the role of contraceptives in public health. In the TEDx video, the speaker presents a photograph of himself assisting a Buddhist monk in blessing birth-control pills. The photograph was distributed as a means of communicating that obtaining a prescription was an important and commendable step families could take to improve their health and maintain a more 'ideal' family size. The speakers noted that this communication strategy worked in Buddhist communities but would be ineffective in communities with a strong Catholic presence.

The Catholic Church has emphasized it's teaching that the use of contraceptives to prevent a human being to come into existence is intrinsically wrong since Pope Paul VI's encyclical letter on the subject of human life in 1968. This particular teaching of the Catholic Church has been in practice since the origins of the Church and its predecessor, Judaism. In opposition, many public health policies across the world support the use of condoms to control the size of families and prevent the spread of HIV/AIDS through sexual contact. Approximately two-thirds of people infected with HIV/AIDS across the globe live in sub-Saharan Africa, while the Catholic population in Africa, which accounts for 16% of the global Catholic population, grew nearly 21 percent between 2005 and 2010.

Since the rise of the HIV/AIDS epidemic in the 1980's both African public health groups and African bishops of the Catholic Church have argued for circumstantial acceptance of the use of condoms. The arguments center around a person's right to defend themselves for mortal danger, and that in a situation where one partner of a married couple has HIV it is morally defensible for the couple to utilize condoms. In 2010, Pope Benedict XVI wrote in Light of the World that condoms could present "a first step in the direction of a moralization, a first assumption of responsibility". The ambiguity of this statement did anything but satisfy the calls from HIV prevention groups and public health professionals. Although the current leader of the Catholic Church, Pope Francis, has been outspoken on the need for global changes to bring about social justice, there is still no strong indication of a change in the Church's stance on condoms as a means of preventing HIV transmission.

Currently, the Church only endorses two of the three measures of the ABC method for HIV prevention. Those two would be the A (abstinence) and B (being faithful to one's partner) but not the final measure, C (contraceptives), which non-Catholic healthcare workers would argue is the most important to the prevention of the spread of HIV. The odds are that the Catholic Church will never approve of the use of contraceptives or abortion for family planning purposes. Equally unlikely is that the Church will approve of condoms as a method for HIV control. In a region of the world where practice of Catholic doctrine is increasing simultaneously with HIV prevalence, what are global health professionals convinced of the need for condoms to do?

In a debate where the two sides in opposition are assured of their position based on separate principles, resolution and agreement is unlikely to occur. Arguments of policy that pit beliefs and values against scientific knowledge are difficult to reconcile. Issues of science and morality often intersect, but neither is fully capable of addressing the central concerns of the other. Programs like Thailand's free condom campaign of the 1990's can continue across the globe, it has certainly been replicated outside of Thai borders, however in the future the issue of HIV prevention in practicing Catholic communities will have to be settled. When the the time for compromise comes, will global health be willing to accept interventions designed around just an AB strategy?

Providing Essential Medicines While Encouraging Innovation

In class, we discussed the need for neoliberalism to incentivize innovation, especially of pharmaceutical products. We also discussed the problems with neoliberalism in allowing access to essential medication. They are seemingly conflicting in nature. After doing some research, I have discovered an article with two creative solutions to this problem. This is what Jayadev and Stiglitz suggest:

We here proffer two proposals that should be considered: (1) replacing existing price-regulatory structures with a value-based approach to pricing; and (2) moving toward public funding of clinical trials. The former can serve to realign national regulators’ budgetary allocations in a non-arbitrary fashion to maximize access to innovative drugs. The latter could simultaneously direct research into more productive areas and reduce the cost of drug development, while having a number of potential ancillary benefits.

I believe these are steps in the right direction. Many times, especially with cancer drugs, new drugs will come on the market that has been shown to increase survival by a month or two. These drugs, however, may cost upwards of hundreds of thousands of dollars and cause awful side effects. If we used value based purchasing, pharmaceutical companies would not invest in products that offer little benefit to the consumer and be able to charge so much for them.

Currently, the pharmaceutical industry creates a drug and then sets whatever price they want. When they set prices for drugs, they take into consideration how to maximize their profits. If we changed to a value-based pricing approach, pharmaceutical companies would no longer set their prices however they see fit. Rather, in countries which have a single payer model through the government, the government will decide how much a drug is worth. They would do so using measures such as the QALY or DALY. These measurements, as we discussed in class, are imperfect, as they do not consider social implications. They would, however, help focus pharmaceutical companies on products which would be of more benefit to society.

The next question is who will determine how much patients are willing to pay for a drug? The answer to this is not policymakers, as they may have limited clinical knowledge. It should be managed care pharmacists. These are pharmacists who understand how to evaluate clinical evidence for their clinical significance. They understand the use of DALYs and QALYs and have no stake in the profits of a drug. This would be flawed if managed care pharmacists are lobbied to by pharmaceutical companies or patients. Therefore, laws should be in place to prohibit such activity.

The next proposal suggests moving toward public funding of clinical trials. While this would certainly focus researchers on exactly what consumers want, it has many drawbacks. As discussed in the article we read by Kremer, there are two types of funding: push and pull. Push funding rewards outcomes, whereas pull funding pays in advance (Kremer, 2002). This proposal would be an example of pull funding. Pull funding is not always as efficient, as research is paid for regardless of results (Kremer, 2002). In addition, a research project may not receive funding, even if it is near completion (Kremer, 2002).

Certainly, there is need for the pharmaceutical industry to be incentivized to create drugs that will benefit society, while not over spending on products that are only marginally useful. These are steps in the right direction, but much more needs to be considered in assessing best solution.

Kremer, M. (2002). Pharmaceutical and the developing world. The Journal of Economic

                Perspectives,16(4), 67-90.

Jayadev, A., & Stiglitz, J. (2009). Two ideas to increase innovation and reduce pharmaceutical

                costs and prices. Health Affairs, 28(1), 165-168.

Who Knows better?

Who knows better? It’s not only an ethical issue; it is also social, economic, environmental, and cultural issue. The problem that prof Amber raise in his lecture about the sex workers and using condoms raise that issue to my mind, by asking them what they really need and try to understand the socio-economic back ground  for them he improve their risk behavior.

We assume as a health workers that we knows better than the community we are working with, we assume causes, precipitating factors, correlations and decide the best solutions. Since we are the experts in the science, we can decide the best for them. In fact, that is not usually the case. Studies and Science is about probability not certainty, we must know that well. We try our best but at the same time we should take in consideration that we still do not know a lot.

Dose the community knows best? Sometimes yes, but other times no. The communities over time developed their knowledge by try and error, as humans we gain the ability to survive and develop by experience. The natural selection keeps those who had the right choices. Cumulative experiences of the communities are as much important as the science probabilities.

We should consider ourselves as a part of the community not separate. We all know better. When we conduct a study or planning an intervention, we should consider the ethical issue, the cultural back ground, the socio-economic status, the demographic status or whatever, not only from our opinion but also from the opinion side of the community under the study. This will gives us a better chance to discover the salient and hidden factors that contribute in the problem.  Our collective experience can really merge together to produce a better choice. So, the right question is not who knows better? It is how we decide the best interest?

As a global health worker, I think we should not put assumptions or previous judgments on the communities that we are working with.  Previous assumption will hide the real causes and risk factors that may have  high impact on the problem. It also may hinder some simple solution that we can figure it out by just being more open minded and accepting to the community habits and background. People trust those who listen to them and work for their interest and distrust those who are deaf to their concerns.

Okinawans

            One topic that was recently discussed in one of my Anthropology classes was the differentiations among cultures and countries in life expectancy, disease prevalence and incidence, and diets. We talked specifically about Okinawa, Japan and their community differences between ours.

            To give you all a little bit of background, Okinawa, Japan is known as the area with the longest-living people (and some of the healthiest). Some quick facts about Okinawa compared to other places……

• ·      More people over 100 years old per 100,000 population than anywhere else in the world (known as centenarians)
• ·      The lowest death rates from cancer, heart disease and stroke (which are the top three causes of death in the US)
• ·      Highest life expectancy for both males and females over 65
• ·      Women have the highest life expectancy in all age groups

            Clearly they are doing something right! Their elder population is more active and healthy than any population seen around the world. There are people over the age of 90 that are still working and are just as active as they were in their 50s. The biggest question is why and HOW? This idea has been studied intensely since the 1960s to try to figure out what kinds of differences in their lifestyles cause these great results. Below are some of the key factors that have been discovered during these studies.

·      Genetics

o   Okinawans have certain genetics that have helped them to prevent inflammatory and autoimmune diseases.

·      Free radicals

o   Okinawans have lower levels of free radicals in their blood. This can be contributed to their diet and the fact that they do not consume nearly as many calories as other countries (due to cultural reasons).

·      Heart health

o   Okinawans have clean arteries with little to no plaque build-up. They also have low cholesterol levels, which can be contributed to the fact that they have a healthier diet, are very physically active even in their older years, non-smoking habits, and a less stressful life.

·      Low cancer risk

o   They have a much lower risk for certain cancers (specifically hormone-dependent cancers such as breast, prostate, colon and ovarian cancers). This is mainly due to their diet, which is rich in fiber, "good" fats and fewer calories.

·      Bone health

o   Okinawans have a better chance of stronger bones and less of a chance of hip fractures. Studies have shown that their bone density actually decreases at a slower rate than people that are their age living in other countries. Researchers contribute this to their high calcium intake, which is also involved with their diet.

            It is very interesting to evaluate other cultures and countries, and it is especially fascinating looking at their health history and habits. The Okinawans are successful for a reason, and it would be beneficial for other countries to look into the reasons for this success. We could all learn a lot about healthy living and maybe translate that information into our own communities. It might be easier than we think to figure this stuff out of we used the resources around us!

References:

http://www.okicent.org/study.html