Clean Water & Sanitation

            Access to water is one of the biggest global health issues to date, but an even bigger issue is access to CLEAN water. Over 783 million people around the world do not have access to clean water. This leaves these 783 million people open to a wide array of problems, such as having to walk miles to find clean water, having consistent issues with diarrheal diseases, and choosing whether or not to put their money towards water or medications. Around the world and within the past century, the rate of water use growth is more than twice that of population growth.

            Yesterday we had discussed the issue of clean water during class. We talked about how there were issues with filtering things out of the water, and that is another important issue that these people around the world have. Not only do they not have access to clean water, but they don't even have toilets to use. This opens up a whole new can of worms, especially if the reason that the water is dirty is because people do not have toilets to use.  Sanitation doesn't only refer to clean water, but it also refers to the establishment of facilities for the safe disposal of human waste. Sanitation issues are one of the leading causes of disease and death, and human waste is a huge contributor to dirty water.

            The Millennium Villages Project that is working in Rwanda is currently trying to design sanitation programs that will increase access to safe and reliable water sources. At the same time, this project has worked to grow local capacity to maintain and manage the facilities. Since the project began numerous years ago, they have been able to implement over 300 miles of new pipes that will bring safe water to areas all throughout the villages. They have also built multiple boreholes and water pumps to help with the water shortage. This is just one of the many initiatives that has been taken to try to help with the water sanitation issue. Although this has helped these villages greatly, it will not be enough to reduce the disease burden that comes along with not having clean water.

            Another program that is working towards the same goal of clean water is the Water, Sanitation and Hygiene program or WASH. This program is actually working in collaboration with the Millennium Villages Project to achieve maximum results. By working in tandem with each other, other goals can be reached at the same time. For instance, one of the examples that was given in the article talked about how improved access to clean water can reduce the barriers and increase the number of girls that are attending school. This would get the world closer to our goal of achieving universal primary education.

            I think that this is a great goal of these organizations and it would be extremely helpful if other organizations could adopt the same concepts. Although it is beneficial for an organization to be focused in one area, it would be advantageous for organizations to team up and work together towards their long-term goals.  Many challenges still exist when trying to fix these global health issues, but improvements are slowly being made. 

Prior, T. (2014, September 3). Finding safe water in Rwanda. Retrieved September 9, 2014.

Introduction to the crisis of clean water & sanitation. (2012, October 11). Retrieved September 9, 2014.

Crazy About Food Deserts

Food deserts are super trendy right now. For those who aren’t yet hip to the trend, urban food deserts are qualified by the USDA as low-income communities where at least 33% of the population live more than one mile from a large grocery store (2014). Food deserts describe communities where theoretically there is little access to fresh fruits and vegetables; where the only foods that can easily be purchased are those from fast food restaurants and convenience stores. It is assumed that if residents of these areas have access to fresh fruits and vegetables, their health will improve.

Bodegas are a main source of groceries in food deserts

Well, a new study by Steven Cummins and his colleagues (2014) offers some evidence that supermarkets may not be the panacea that academics and local food activists (including me!) might have hoped. The study compared two Philadelphia communities, comparable in size (3 mi²⁾ and demographics, in which one community - the intervention community - got a shiny new 41,000 ft² supermarket. Data was collected from both communities for BMI, fruit and vegetable intake, and perceived access to fruits and vegetables. 

The mother ship of all grocery stores, Whole Foods headquarters in Austin, TX

Four years after the initial data collection, and one year after the introduction of the supermarket into the intervention community, only 27% of residents had adopted the new store as their primary grocery, and only 51% had used it for any food shopping at all. Surveys showed no significant change in BMI or fruit and vegetable intake. There was, however, a measurable difference in the way access to fresh food was perceived by residents of the intervention community: respondents reported greater choice and quality of food in general, greater choice and quality of fruits and vegetables, and a perception of lower cost for these foods. 

Cummins and his colleagues acknowledge limitations in their study; namely that the follow-up surveys were taken only a year after the introduction of the supermarket, and that BMI and other  food-related habits might be slower to change than the study allowed. But the low adoption rate points to other, more endemic challenges in getting people to change their relationships to food in the interest of positive health outcomes. Little attention was given to the economics of converting to grocery store shopping. I have lived in a food desert, in a low-income area of Indianapolis where my nearest grocery store required a trip on the freeway. But I was a young professional with access to a car and a budget that allowed for a plant-based diet. Also, my food habits were already set long before I moved to the area. If I had been raised on Cheetos and Ramen Noodles, the introduction of a grocery store into my immediate area would not have inspired a change in diet, just as when I moved to my current residence, down the street from a really good donut shop, I did not suddenly start eating donuts.

This study shows that “poor access to food retail environments may not always be associated with poor diet and obesity in children or adults.” Habits are identified as such because of their seeming obduracy in the face of change. If the course of obesity trends in the US and other countries is to be diverted or even reversed through changes in eating, the introduction of supermarkets appears to be a false panacea based on Cummins’ findings. We can find hope, however, in the change in perception amongst residents of the intervention community. Even though habits did not change, the change in perception could be the first step to a more systematic change in food habits. More research must be done to establish connections between food habits and obesity, obesity and geography, and geography and behavior change.  

Cummins, S., Flint, E., & Matthews, S. A. (2014). New neighborhood grocery store increased awareness of food access but did not alter dietary habits or obesity. Health Affairs, 3(2), 283-291. Retrieved March 14, 2014, from http://content.healthaffairs.org/content/33/2/283.full.html

Food Deserts. (n.d.). United States Department of Agriculture Marketing Service. Retrieved September 8, 2014, from https://apps.ams.usda.gov/fooddeserts/foodDeserts.aspx

MDG 8: Realistic Goals or Set-Up for Failure?

The Millennium Development Goals (MDGs), established in 2000 at the Millennium Summit, are the world’s largest time-bound and quantified targets for addressing the eight major global issues listed below.

1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower women
4. Reduce child mortality
5.  Improve maternal health
6.  Combat HIV/AIDS, Malaria, and other diseases
7. Ensure Environmental Sustainability
8. Develop a global partnership for development

While the world has made some significant progress, this progress has failed to be uniform across nations and the determined goals. It is this lack of uniformity and streamlined focus that has lead me to question whether it is realistic to think we have the possibility of reaching the established goals, as a world, by 2015.

Let’s take a look at MDG 1: Eradicate Extreme Hunger andPoverty. This goal contains three objectives: halve, between 1990 and 2015, the proportion of people whose income is less than $1.25 a day; achieve full and productive employment for all, including young people and women; and halve, between 1990 and 2015, the proportion of people suffering from hunger. 

The picture above indicates the progress of MDG 1, as of 2013. The green tiles indicate that the goal has been met or will be met by 2015. The yellow tiles indicate that progress made is insufficient to reach the established goals if trends persist. The red tiles indicate no progress or deterioration in goal. It is easy to see that, as of 2013, we were spilt even between meeting goals and insufficient progress/no progress. With this even spilt is it realistic to believe that these objectives can be met by 2015? Additionally, this image demonstrates the uniform progress between different countries, even different geographically areas within these countries. It is easy to see that Eastern and Central Asia are expected to meet their goals, while Sub-Saharan Africa is struggling to make progress in the same goals.  Is lack or funding/resources promoting these objectives the only thing limiting the progress in struggling countries or is the cycle of poverty harder to overcome than originally expected?

Poverty is cyclical; usually when born into poverty it is extremely difficult to raise out of poverty.  Extreme poverty, I believe would follow this trend even more, which is why I am left wondering how do we, as a world, help the extremely impoverished and met the goals established in MDG 1? We could give the impoverished food and jobs, but giving them these things won’t increase their ability to get food and jobs themselves. While I believe the MDG goals are a good beginning and much needed focus on the problems our world, I am considered about helping vulnerable populations without hurting their ability to achieve for themselves.  Additionally, any political uprising local or global could reverse any progress made within these vulnerable populations. Without infrastructure and stable governmental system these countries are vulnerable to numerous factors, all outside of their control, which will affect their ability to rise out of poverty.

Global Health Security in the Time of Ebola

The recent Ebola virus outbreak in West Africa is currently the most likely global health concern to be in the headlines of major media outlets. A quick Google News search for "ebola outbreak" yields 865,000 results. The world's preeminent health organizations are on the ground in Guinea, Liberia, Nigeria and Sierra Leone as well as on the phone with world leaders and health officials, in an attempt to contain the virus from neighboring countries.

To quickly summarize the state of affairs, the 2014 Ebola outbreak not only the first in western Africa but one of the largest in history. The virus is transmitted through direct contact with a sick person's blood or bodily fluids, contaminated objects or infected animals. This leaves healthcare works and other caregivers, such as family members, at the highest risk of infection because they are the most likely to come into contact with bodily fluids (1). While the number of known cases has yet to match that of another recent viral outbreak, SARS, the known number of Ebola deaths has already more than tripled those caused by SARS (2).

It's plain to see that the containment of the outbreak is not going as well as the world would hope. In a recent Newsweek article, an official from the National Institute of Health described the outbreak as "completely out of control" (3). As the projections of the outbreak spread, Ebola will continue to be a global health security concern. Global health security focuses on outbreaks haven't occurred yet as a way to prevent the spread of a deadly pathogen from threatening wealthy counties. The pathogens of concern, such as SARS, originate in developing regions of the world and have the potential to travel to the rest of the world. To stay a step ahead of potential outbreaks, large health organizations, disease control institutes and laboratories use cutting edge technology to track occurrences of disease around the world (4). 

While resources are being spent to monitor and control the  further movement of Ebola, there is a desperate need for medical treatment and care for people already infected with the disease. Some of those who are sick now are members of the global humanitarian biomedicine networks. Professionals who's primary global health concerns are the alleviation and mitigation of suffering in afflicted populations often work in apolitical settings. They work for and coordinate with non-governmental organizations, activists, and other health-related parties to bring health interventions to individuals and communities in need (4).

With hundreds of millions of dollars pouring in from international organizations, governments and private charity, the question of who will, and should, be the primary benefactor of those financial resources. Ethically, that decision is tricky and can one's view can depend greatly on what they regard to be the primary focus of global health which, when greatly generalized, boils down to protection of the wealthy or assistance to the poor. The issue of ethical funding distribution is not so simple, of course.

The protection of global health security, by way of improving disease surveillance and global health crisis response, stands to serve some of the world's poorest citizens. A significant issue facing respondents to this year's Ebola outbreak has been coordination of local and state governments to disseminate information and maintain a civil and cooperative society. Expending resources to streamline outbreak response and international coordination policies could, in the long run, save lives through the prevention of outbreak growth. Issues with inter-organizational communication plight humanitarian efforts as well. In their efforts to provide basic care and alleviate acute suffering, health professionals face problems of transaction costs related to management and coordination when new actors are introduced, and many are (5).

When deciding where international aid money should be spent, the question does not have to be framed as, "save the rich, or save the poor". There are merits to both views of and approaches to global health. I believe some prominent global health practitioners like Paul Farmer would argue for a strong centralized public authority over small, disconnected, health service providers, based on the grounds of improved efficiency and power to accomplish complex, long-term health goals. In this instance, I would have to side more with those who favor global health security. Perhaps the best way to stop future viral outbreaks is to increase international response efficiency and provide support for country-level health authorities.

1."Ebola Hemorrhagic Fever." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 29 Aug. 2014. Web. 4 Sept. 2014.

2. "What You Need to Know About the Ebola Outbreak." The New York Times. The New York Times, 30 July 2014. Web. 5 Sept. 2014.

3. Kloc, Joe. "NIH: Ebola Outbreak Is 'Completely Out of Control'" Newsweek 4 Sept. 2014. Print.

4. Lakoff, Andrew. "Two Regimes of Global Health." Humanity: An International Journal of Human Rights, Humanitariansim, and Development 1.1 (2010): 59-79. Web. 5 Sept. 2014. <http://muse.jhu.edu/journals/humanity/v001/1.1.lakoff.pdf>.
5. Schieber, George. "Financing Global Health: Mission Unaccomlished." Health Affiars 26.4 (2007): 921-34. Print.

Surgery: The Neglected Stepchild of Global Health

            In the article that I read called Surgery and Global Health: A view beyond the OR, surgical services seem to be sidelined from the global health scale. The article referred to surgery as the "neglected stepchild of global public health". This is an issue because a large amount of the diseases that are killing the poverty stricken areas of the world are treatable by some type of surgery. As stated by Dr. Doruk Ozgediz, "Recent evidence shows that surgical conditions account for up to half of the global burden of disease". The even bigger issue is that surgery is still not seen as a priority in these areas. It was mentioned that even the smallest illnesses or diseases that can be treated by a simple surgery could easily turn into a deadly issue in areas that don't have access to surgical services.

            Going off of the example that was given in the article, over 500,000 women die each year during childbirth because medical workers cannot stop the post-partum hemorrhage. This wouldn't be as big of an issue if surgical services were available in these areas.  Not only are there not nearly enough physicians available in poorer countries to perform surgeries, but also some of the people that need it the most cannot afford it. This is still one of the biggest obstacles that is keeping surgical services from helping the people that need it the most. By having a fee-for-service system in place, the people who are in the most desperate need of a surgery are unable to receive it. The biggest advances that have been made in this area were seen in Haiti in 2007. The district health commissioner for Haiti revealed that all prenatal care and emergency obstetrical services would be free of charge to the patient. Yet another issue is that most of the surgical services that are found in poor countries are also mostly concentrated within the bigger cities.

            There are numerous reasons why surgery hasn't been big on the global scale. Most of the infectious diseases that would benefit from some type of surgery aren't readily passed from one person to another. This knocks it way down on a priority list of public problems and health issues. Another reason why surgery isn't all that popular is because of the lack of surgeons willing to show attention to these matters. There has been negligence to surgery on a global scale and that is hindering the progression of this "movement". There is minimal public support for the matter, and it will be very difficult for foundations to be willing to fund programs and implementations that aren't deemed important by the public. Surgery is also a very complex matter. Not only is there the actual surgical process, but numerous other things are required such as an operating room, blood banking, and post-operative care. In order to successfully complete a surgery they would also require a substantial amount of money, training, and infrastructure to carry out.

            The article offers some suggestions to bring surgery to the global health forefront. One of these suggestions is making these surgical services free of charge if money can be shown to be a barrier to the poor. One of the goals is to bring the importance of surgical services to the public's attention and to find organizations that would help fund the efforts. They also mention that it is crucial that all surgical services are readily available within the public sector. Hospitals are frequently neglected in developing countries, which obstructs the expansion of the surgical field.

            In order to make progress in the area of global surgical services, the issue must be addressed to the public. Before reading this article, I didn't really put much thought into the fact that global surgical services really aren't that common. Half of the problem with all of these global health issues is the fact that we aren't aware of them in the first place. Without awareness, no progress can be made.

Farmer, P., & Kim, J. (2008). Surgery and Global Health: A View from Beyond the OR. World Journal of Surgery, 32, 533-536. Retrieved September 3, 2014.

Ozgediz, D., & Wang, J. (2006). Surgery and Global Health. Bulletin of the American College of Surgeons, 91(5), 26-35. Retrieved September 3, 2014.

Food Security: A Global Issue

The World Health Organization (WHO) defined food security, as the World Health Summit in 1996, as existing “when all people at all times have access to sufficient, safe, nutritious food to maintain a healthy and active life.¹” The WHO also stat that food security is dependent upon three pillar: availability of food, access to that food, and knowledge on proper use of that food.¹ When one or more of these pillars are not achieved individuals are at risk of being food insecure. The United States Department of Agriculture (USDA) established varying degrees of food insecurity. The first, “low food security,” is characterized by having “reduced quality, variety, or desirability of diet with little to no indication of reduced intake.²” The second, more severe is “very low food security.” Which is characterized having multiple indications of disrupted eating patterns and reduced food intake.²”

Globally, 870 million, around 15% of the world’s population, is chronically undernourished and food insecure.³  This equates to roughly 1 in 8 people, the majority of which live in developing countries such as Southern Asia, Sub-Saharan Africa, and Eastern Asia. In the United States in 2012, 14.5% of all households were food insecure. This number can be further broken down by severity in that of the 14.5% of food insecure households 8.8% had low food insecure and 5.7% had very low food security.³ 

In the United States, like developing countries, food insecurity rates are comparable and trend with poverty rates in that specific country.  Tragically, in these developing countries the child mortality rate follows this trend as well. While food insecurity is still a problem in developed countries, children are for the most part shielded from food insecurity in households. However, this is not the case in developing countries. In 2012, 6.6 million children under five years of age died, nearly 18,000 everyday, due to health issues related to undernourishment such as failure to thrive, and infections.⁴

What can be done to reduce these rates of food insecurity globally? One economical approach, presented in the FAO: The State of Food Insecurity in the World 2012, highlights three specific steps for improvement. The first step would entail adding economic growth that will reach the poor and increase job opportunities.³ The second step would increase economic incentives aimed at improving diet quality and quantity.³ The final step would involve establishing governmental infrastructure, and public health services.³ 

Food is a basic need, required for proper growth and development, and sustained health of all people. This basic need must be address before any other issue can be solved in the developing world. While the solution I highlighted of introducing more economic infrastructure into needed areas, may not be the best way in solving the issue of food insecurity, but it is a beginning. It is my belief that all people should have access to healthy, safe foods. Food security is an issue we all should be aware and support endeavors to eradicate this problem People must get health before they can stay healthy.  

References:

1.  Food Security. (2014, January 1). Retrieved August 26, 2014, from http://www.who.int/trade/glossary/story028/en/

2.  USDA ERS - Food Security in the U.S.: Definitions of Food Security. (2014, April 14). Retrieved August 26, 2014, from http://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/definitions-of-food-security.aspx#.U_0Fz0u4lHg

3.   FAO, WFP and IFAD. (2012). The state of Food Insecurity in the World 2012. Economic growth is necessary but not sufficient to accelerate reduction of hunger and malnutrition. Rome, FAO.

4.   Under-five mortality. (2014, January 1). Retrieved August 27, 2014, from http://www.who.int/gho/child_health/mortality/mortality_under_five_text/en

Knowing and not Knowing

Lately I have been consumed with ideas around knowing and not knowing, particularly with regard to health issues such as obesity. I think I always assumed that someone knew if their child was overweight or obese. But research shows that knowing whether or not your child is overweight or obese is not that simple, in particular for immigrants to this country. In this article,  UCSF's Linda Rosas (2010) and her colleagues decided to assess the maternal weight perception of mothers in Mexican immigrant communities in California against those of mothers in high emigration areas of Mexico. Basically, the researchers wanted to see whether these mothers could identify the ideal size (not weight) of a child as well as whether they could identify the accurate size of their own child. And so the researchers showed them the Collins Scale . . .

. . . and asked the moms to identify an ideal size for a kid. On average,  Mexican mothers chose a larger-than-ideal body size. The mothers in California, mostly immigrants, generally chose the correct ideal body size. However, when asked to choose the Collins Scale figure that most closely resembled their own child, the Mexican women on average chose a figure that closely resembled their child's size, but the moms in California were staggeringly less likely to choose the right size. In fact, 57% of the the US-residing children were overweight or obese, but only 10% of the mothers chose a figure that corresponded with the size of their child. 

I had this study in mind when I read a short article by Katherine Hobson (2014) on WFYI's Sound Medicine website that synthesized data from a CDC report that came out in this summer. In the report, the CDC shows that 30% of kids in America misperceive their weight. 76% of the kids who were designated as overweight thought they were "about right" and 42% of those who were obese though they were "about right." Sound Medicine doesn't indicate which percentage of participants in the CDC study were Latino/a, but does mention that boys, younger children, and poor children were more likely to misperceive their weight. 

There's so much to unpack here. First, the model itself: 

• I realize that these figures are based on representations of BMI, but when looking at the scale, I wasn't sure where I fit, either. Female body image in the US is a tricky thing. The scale doesn't account for muscle definition, and some folks just aren't as well-balanced as the Collins figures. So I conducted my own little study using my partner (dangerous, I know). I chose my Collins image, and then asked him to as well, without sharing my answer. We were pretty much spot on, within .25 of each other. So knowing is possible, but it took a long time for me to decide on a figure. 

• There's something about moving to the United States that makes people think that they (or their children) are of a more ideal size than they actually are. In both Rosas and the CDC study we can see that even when kids are overweight, both kids and parents consistently rate kids as ideal- or average-sized. This is despite the fact that folks in the United States know what an ideal-sized person looks like. This has huge implications for my work in campaigns, as both articles recommend positively framed education as a way to change childhood eating and exercise behaviors as opposed to fat-shaming negative frames. 

These articles introduce some of the ways in which ideas of knowing and not knowing need to be navigated in order to create successful anti-obesity campaigns. Throughout this blog, I will continue to address issues of obesity, particularly amongst children and particularly in immigrant communities where issues of language and culture intersect with health practices.

Hobson, Katherine. "Many Kids Who Are Obese Or Overweight Don't Know It."Sound Medicine. N.p., 23 July 2014. Web. 29 Aug. 2014. <http://soundmedicine.org/post/many-kids-who-are-obese-or-overweight-dont-know-it>.

Rosas, Lisa G., Kim G. Harley, Sylvia Guendelman, Lia Ch Fernald, Fabiola Mejia, and Brenda Eskenazi. "Maternal perception of child weight among Mexicans in California and Mexico." Maternal and Child Health Journal 14.6 (2010): 886-894. Print.