Who is still dying?

Sometimes the only thing standing between clarity and confusion is asking the right questions.  In the introduction to the book Dying for Growth, Millen, Irwin, and Kim do just that in the context of globalization and its impact on the world’s most marginalized populations.  Challenging the notion that economic growth trickles down to improve global health, they have profoundly asked the right questions: what is growing, and who is dying?  

The opening story of the young Guatemalan girl literally living off of the trash of others all too clearly illustrates the problem with assuming that growth will benefit all with any sense of equity.  To this girl, it does not matter that worldwide average life expectancy has gone up nearly 20 years since the 1950’s, or that half as many children die before the age of five than did half a century ago.  Her daily life is still a struggle through an unhygienic and dangerous environment.  

In the Ted talk that we watched the first day of class by Hans and Ola Rosling, they used the improvement of global health statistics to claim that, in general, things always improve.  But what if we always judged global health improvements from the perspective of the least common denominator, those who see little benefit from the system of global health policies in place now?  The statistics would tell a very different story.  When we learn basic statistical measures such as mean, median, and mode in middle school algebra, we are taught that no one measure can accurately describe a data set.  So what is growing?  Average life expectancy. The number of children that make it to age 5. But what about the low end of the spectrum? How is that data changing in the face of globalization and economic “growth”?  And the more important question: who is dying? Who is still dying? And why?  If economic growth isn’t the answer, what will be?      

The Importance of Sleep

Sleep is a vital part of health.  Along with steady amount of exercise and a good diet, it is part of the trinity for a healthy lifestyle.  The National Heart, Lung, and Blood Institute recommends 7-8 hours of sleep per night.  People are not getting Too often I hear complaints over people’s lack of sleep.  People seem to be consistently worn out.  This is true even of the people I know outside of college.  My friends who are in the workforce talk about not getting enough sleep.  I wonder if people are tired because they do not have good sleeping habits.  Another possible explanation could be the constant demand of life.  At least in the United States, we are always supposed to be going and going.  We are meant to be the proverbial Energizer Bunny(s) of life.

One study I found on what affects sleep gave some enlightening information on the topic.  This Irish et al. article found caffeine to be the most common factor among the study participants.  The study dubbed caffeine a “waking health behavior” or WHB.  The participants kept a diary of their daily habits and the researchers looked at the commonalities.  The people of the study also did not engage in hardly any physical exercise.  The 303 people under study also reported getting less than 6 hours of sleep a night.

Another article on sleep looked at how social relationships affect sleep patterns.  I found this article by Ailshire and Burgard to particularly interesting because it is such an understudied factor on sleep.  The authors looked at not only how romantic relationships have an effect on sleep, but additionally familial relationships.  What can be done to make sleep a more important factor of health?  Will it have to be a complete overhaul of the U.S. society’s get-it-done personality?  Will we address the less common factors affecting sleep?  All questions to hopefully be answered in the future.

Ailshire, J. A., & Burgard, S. A. (2012). Family relationships and troubled sleep among U.S. adults: Examining the influences of contact frequency and relationship quality. Journal of Health and Social Behavior, 53(2), 248-62. Retrieved from http://search.proquest.com.ezproxy.lib.purdue.edu/docview/1021197255?accountid=13360

Irish, L. A., Kline, C. E., Rothenberger, S. D., Krafty, R. T., Buysse, D. J., Kravitz, H. M., . . . Hall, M. H. (2014). A 24-hour approach to the study of health behaviors: Temporal relationships between waking health behaviors and sleep. Annals of Behavioral Medicine, 47(2), 189-97. doi:http://dx.doi.org.ezproxy.lib.purdue.edu/10.1007/s12160-013-9533-3

Hungry

This semester I have been working with a project in the nutrition science lab at Purdue.  The project is called Voices for Food, and is currently being run in five other states.  The main goal of the project is to study the nutrients found in food pantries and how these affect the food pantry user’s diet.  A second goal is to help food pantry owners make their food and pantry healthier for their clients.  Most of my responsibilities include recruiting new participants into the study.  This involves going to several food pantries throughout the state, observing the pantry, and telling the users about our study.  They take a survey about their background and their household’s food insecurity, and then do a 24-hour diet recall.

            Although I have been doing this for about a month now, yesterday it really hit me.  We talk about these “vulnerable populations” and “malnutrition” and so on and so forth in classes, but yesterday I saw it right in front of me.  I was talking with a woman who participated in our study about her food insecurity.  The survey is set up on a laptop, but this woman preferred I read it to her.  Some of the questions ask things like, Do you ever have to go a whole day without eating because you didn’t have enough money for food? and Have you ever skipped meals because there wasn’t enough money for food?  and the responses ranged from very often – never.  For most of these questions, the woman shook her head vigorously, “Very often, every day.  There’s never enough food. There’s never enough money.”  I talked to several people throughout the day with similar answers.  Some were better off than others.  Some described sharing food with neighbors/friends to get more of a variety.  Some shared that they visit several food pantries a month, EVERY month (most pantries only allow households to visit once a month, however, there usually isn’t one big system to monitor this, so “food pantry hopping” is acceptable, and necessary).  Near the end of the food pantry hours, actually after the pantry had officially closed for the day, a woman came bursting through the door: “My friend needs help.  She doesn’t have anything.  She thought your pantry was open till four, but she’s too late now.  Can you help her please?”  The woman at the front desk responded without even the slightest regard to the hours “Of course, what does she need? Food? Toilet paper? Follow me.”  And they scurried into the pantry, about the size of a small bedroom. 

            I talked to even more people and could probably talk about my day even more, but I’ll try to keep it short for the sake of this blog post.  As I was driving home, I was exhausted, and thinking about what I was going to make for dinner.  I thought about my refrigerator, my stove, my sink with running water, my leftovers from the chili I made the other night, the cookout my friends were having tomorrow.  I am not vulnerable.  But I was sad and frustrated at how vulnerable the people I interacted with were.  I hoped that they had enough food to last them, although I knew it wouldn’t keep most of them and their family comfortable (let alone “healthy”).  I thought about this blog, and worldwide food insecurity.  You always see those cute little kids on TV for those NGOs, etc. that will donate food to them, but the same thing is happening literally right here in Indiana…  I thought “Man, at least the States have food pantries,” and was sad at how some/most developing countries don’t have this sort of system set up for them. 

I hope that the project I am involved in can make a difference someday.  Food insecurity is such a heart breaking issue, and I am really thankful that we have systems like food pantries in our country.  I was wondering how all of you reflect on this issue?  In the States and globally?

Indigenous Participation in Public Health Interventions

I start by saying that this thought has been brewing for many years and ultimately sparked my interest in public health.

We have been talking a lot these past few weeks, as well as my exposure to literature on various concepts about applying programs, services, and tools across regions and communities that would essentially increase the amount of information accessible to people around the world. For example, the HINTS survey and its abilities and mission to carry it forward to multiple countries; an AMAZING outcome the more countries come on board! Imagine the knowledge gain, the ability to move forward with have identified knowledge on what needs to be done and where. Another example being mobile applications and their use in public health around regions in India etc. are also becoming increasingly used and have shown tremendous results in improving healthcare access.  All of such initiatives ultimately seek to decrease the health disparities in the communities in which they serve and the very reason why we, I am sure, are all wanting to continue to work in this field. However, in also being exposed to the “strain”, as the video put it a few weeks back, that might be caused, it got me thinking about “the other side”. What strains are we causing by using technology for example in these populations that are increasingly becoming saturated by the Western world?

So in my search found numerous news articles on public health interventions with aboriginal and indigenous communities and advocacy groups wanting to be protected and heard on the impact that such modern takes are having on their culture. With such push back, how can we also motivate such communities to take part in the public health interventions that are created in their benefit and not having them see it as a threat to their cultural practices?

“There must be a model in place!”, I said to myself.  

So I actively searched for one with little success on a model that has been proven to be successful. I make it my mission (along with graduating) that in my time as a researcher in public health that I create one that is able to be measured and applied with success and transferable to indigenous populations around the world.

found this article for example, a long with others in my search that gave me the motivation I needed to get going! The work, “Overall Approach to Health Care for Indigenous Peoples”, (King, 2009) discusses the importance of approaching health care for indigenous communities as complex systems that need to be a collective effort with researchers and practitioners with multiple dimensions to consider. But where do we start?! How can we assure we are not influencing acculturation in a manner that is detrimental to these cultures and at the same time motivate them to participate? How can we measure the impact and their likelihood to participate?  Here is what I have as factors that I would like to include and be able to measure in some way:

•          Understand their attitudes towards the intervention
•      Motivations to participate (behavioral intentions
•      Culture/ ethnic identity (including subjective norm, perceived risk)

What would you change?!!

Reference:

King, M. (2009). An Overall Approach to Health Care for Indigenous Peoples. Pediatric Clinics of North America, 56(6), 1239–1242. http://doi.org/10.1016/j.pcl.2009.09.005

NCDs and Sequestered Disease

SARS and Ebola outbreak caused the world to wake up and become aware that disease is not sequestered within a geographical boundary.  However the poor and poorer countries bear the burden of these diseases. As money is being funnel into cures and interventions of these diseases, diabetes, CVD and other noncommunicable diseases (NCDs) are outpacing globalization of infectious disease because: (1) there is a weak compatibility with existing security frameworks (2) difficult to treat because of multiple determinants leading to difficulties in prevention, containment or treatment and (3) the threat is not immediate and may be deferred.

In the past frameworks were not developed to treat NCDs because they were considered prevalent cases and not new case (incidence) or recurring cases. Because the etiology of the disease and modifying factors were varied. Today WHO and others are taking a systematic look at frameworks and assessment of an integrated surveillance of NCD to address policy and strategy developments. So why were NCD overlooked and underestimated.

NCD’s were endemic to western and developed countries, however, with the increase in western lifestyle in developing countries the incidence of NCDs began to rise. Globalization, that supposed free flow of trade, resource etc., does not take into account the culture, norms or lifestyle of developing countries. While the model of globalization insist that we are all free and equal to trade, the burden of those trade deficits impacts the developing world at a greater rate.  Take for instance the fact that with globalization, countries with a population that depended on farming and producing fresh food and open markets are now relying on canned imports and fast food from global corporations like McDonalds, KFC. This is unsustainable because many in the developing world live a lifestyle that is slower than that of the developing world.  Dietary norms that were followed in developing countries are now being replaced by that of the western world. The act of farming and gardening and walking to an open market provided necessary exercise and community interaction. The added sugars, fats, and substrates to packaged food, without the necessary investment in energy expenditure creates risk factors for NCDs. 

While the developed world is worried about non NCDs crossing border we were systematically introducing the agents of NCD into to the developing world.  The developing world has now has to face the impact of NDs as well as other communicable diseases on an already impoverished economy and health care system. Globalization comes as a cost, and many times the developing world is the one left to pay the bill without the benefits.

Oral Health: Consequences and Challenges

Recent decades showed marked improvements in the field of oral health. However; the gap is still large. Oral health remains underestimated in many parts of the world. The concept of dealing with oral diseases as one of the preventable non-communicable ones needs more attention. Some people consider it as a welfare. Such a thought is supported with the high expenses of oral health care. Besides, even most of those who realized its importance, cannot have adequate access either regarding availability or financial support.

In fact, oral health is the mirror of general health. This theme should be taken into consideration when dealing with this global health issue. Hold on it is critical!

Oral cancers are lethal especially that they are kept hidden for long periods of time. Fatal conditions are not only restricted to cancers but also include other conditions that may seem simple although they are not! Do you know that you can have an oral infection and die from swelling and suffocation if not treated? Do you know that simple periodontal pocket which can progress to periodontal abscess, severe bone loss and disfigurement, may also lead to death of bacteremia?

From another perspective, oral diseases have a lot of social implications. For example, dental caries not only causes pain and eating difficulties, but also it affects speech, esthetics, social communication, in addition to significant reduction in productivity in adults and academic performance in schools for children.

Although, I used to raise the theme that primary level of prevention is the key of success, I intend to talk here from a different perspective. After I handled the readings of the last two weeks, I realized that politics and health care systems share a great responsibility! How can we blame people for their behaviors without providing the MINIMUM essentials to maintain their oral health?! Although, the problem is over-presented in developing countries due to extreme lack of resources, it is also well established in developed ones which ensures the globality of this threat. Here, in US we see dental insurance being separated from health insurance, as if they are separate entities! Moreover, dental insurance is so expensive, that cannot be afforded by many people, and also with limited benefits! As I understand, this is one of the critical consequences of neoliberalism in health care. Privatization, free markets and focusing on the capital on the expense of patient benefit is a disaster. I know one of my colleagues, in the US, who is currently having pulp exposure and is in bad need of root canal treatment. However, she couldn’t afford the fees! She is suffering a terrible pain and is on extreme high doses of analgesics, which is destructive to her general health, to keep her life on till she arranges her financial situation. How sad the condition is! What makes me even more frustrated, that I am talking about one of the developed countries. What about developing ones? How can we manage and face this neoliberal monster that is attacking and destroying health equity and justice? What can we do, as public health professionals, for such an issue? How can we save our populations and improve their health conditions taking into consideration these global political and commercial considerations?

Getting Rid of the Mental Health Stigma

          Although mental health may not seem extremely prevalent in our society, in 2014, there were an estimated 43.6 million adults aged 18 or older in the United States with a mental illness in the past year. This number represented 18.1% of all U.S. adults. This number may seem shocking to some people as this indicates that almost 1 in every 5 people have a mental illness- this means you probably are around a number of people all day long that have a mental illness and you don’t even know it. Why don’t we know that our friends, co-workers, or peers have a mental illness? Because mental illnesses are unbelievably stigmatized. People feel embarrassed to talk about the mental health to health professionals, let alone their friends. How do we stop this? How do we help people feel open to talk about their mental health in a non-judgmental environment? I have talk about these issues in a number of my classes. A couple solutions that have arose are:

        1. Having more integrated care facilities- a one stop shop for all of your health needs. Instead of people “going to the psychiatrist” they are just “going to the doctor”. Although mental health and physical health are currently regarded as two separate things, they need to become more integrated. They both reflect and impact the other, so why not put them both under the general health term instead of distinguishing them so much?

        2. We need more advocacy for mental health. This may through social media, commercials with celebrities, or just more focus on this topic at your annual check-up.

        3. Last, I think workplaces and employers need to be more sensitive about this topic. In class yesterday a student spoke about an experience she had in Ireland. She met a man dressed in a suit walking around at a park. She spoke to the man to find out he was on his way to work that morning until he realized he was way too stressed, called his boss, and was advised to take the morning off to go for a walk and then report back about his encounters on his walk later that afternoon. I don’t think that is heard of here in the U.S. We then discussed how not only should we get sick days, but also mental health days.

Mental health must not be neglected due to the many effects in can have on one’s body. It can worsen physical problems as well as worsen as a mental health illness if it is not treated and discussed. How can we get rid of this stigma?

Stress in the College Student

As a resident assistant, I feel like I am better able to identify health trends on campus.  I am surrounded by the same 60 people all the time.  This makes it easy to notice when health is poor and stress is high.  One of the trends I see most frequently is the occurrence of the common cold.  My question is, “Why are Purdue students continuously getting sick?”  It is easy to assume that the illness is due to college students being focused on other things and not overly concerned about their health.  I think a greater influence on health is the stress associated with college.  This stress is academic, social, and psychology.  I wanted to analysis this idea by looking up any research done on the topic.  I found an excellent article proving that there is a correlation between stress and college student health.  This Misra and McKean article stated that once stress becomes negatively associated or excessive, both physical and psychological health will decline.  Unfortunately for this International Health class, women college students are shown to be more affected than men.   This is true even after the researchers found women to have better time management skills than men.  Not surprisingly, older college students are also shown to have more proficiency in time management.  Purdue students are lucky in that we have CAPS or the Counseling and Psychological Services center.  There are people at this center that are experts on dealing with stress.  The services are free to Purdue students.  If I notice one of my residents getting too stressed out, I explain the services at CAPS and recommend them to go.  Keeping up with assignments and the other aspects of college life is hard.  Only you know the amount of stress you can handle.  Don’t be afraid to say no in favor of something you need to do to thrive.   You have to take care of yourself, to have the best college experience.

Misra, R., & McKean, M. (2000). College students' academic stress and its relation to their anxiety, time management, and leisure satisfaction. American Journal of Health Studies, 16(1), 41-51. Retrieved from http://search.proquest.com/docview/210480531?accountid=13360

Diseases as Flowers

Which came first, the chicken or the egg?  Upon reading the assignments for this upcoming week, I was taken aback by just how complex a disease can be.  Not just biologically, but socially, economically, culturally…  Which came first, structural violence or AIDS?  While I do not mean to sound philosophical, I do want to point to just how many factors go into a disease.  Farmer discusses in many of his writing his work with HIV/AIDS.  Dependent on so many factors, a person’s chance of contracting this disease can vary.  And if a person with say, a 45% of contracting HIV (being “at risk” for the disease) moves to another country, then what?  One’s odds increase or decrease.  This concept is not new, it is social determinants of health, but it is interesting as always to look upon.  I want to take this blog post to reflect on the readings for this upcoming week.

            I have always enjoyed breaking large concepts into easy to understand concepts, I think it is crucially important for everyone, regardless of education level, to understand concepts like these.  Everyone including me, because some concepts are really hard to understand.  A disease, such as AIDS, can be more or less likely to affect a person based on many factors.  These factors are vast, but mainly include (in no particular order) socioeconomic status (money), race, ethnicity, geographical location, occupation, education, gender, hunger, social engagement, support, and safety.  Generally, there is a strong relationship between being disadvantaged in these factors and having a higher rate of disease or mortality (death).  So how do we address these factors?  Why does that relationship exist?  Farmer argues that health and human rights are inextricably connected (impossible to be separated).  If we wish to improve health of those that are “at risk,” we must look toward basic human rights and suffering.  If being less educated makes one more at risk of getting AIDS, then we need to first address the issue of the right to education than cost-effective medicines to treat AIDS.  People with AIDS do not want cost-effective treatments they want to not have AIDS to begin with.

In a strange (and hopefully not too hippy) way I think diseases could be looked at as flowers: if a flower gets sick and turns brown, why?  Was it because it wasn’t in enough sunlight?  Did it have a chance to be in the sun?  Did its owner not water it enough?  Was it the right type of water it needed?  Were its roots in enough soil?  What was the condition of the soil?  Did the genetic makeup of its seed doom it to an early death?  This is a lot of thought and effort to look into a dead flower, but the concept can easily be applied to a diseased human.  When we look at disease our first, third, tenth, hundredth question should be, why?  Maybe then we can begin to address and fix the issues behind diseases instead of just diseases themselves. 

Medicine vs. Public Health: An Unnecessary Debate

As an aspiring physician, I felt I had a lot to learn from Farmer and others in Structural Violence and Clinical Medicine. Doctors are often critiqued as being out of touch with patients and treating only their physical ailments, not the whole person or the root cause of their troubles.  While I definitely know doctors in multiple specialties who break this mold, spending long bouts of time with each patient to really get a grasp of their struggle, I have no doubt that many doctors have work to do in their understanding of structural violence and social determinants of health.

As Farmer himself points out, many doctors see social intervention as not part of their job, and rightly so. The discussion led me to wonder why public health and medicine are considered two separate and sometimes competing fields.  Farmer discusses the ongoing debate in international health of whether to seek proximal or distal solutions, essentially a debate of public health verses medicine, respectively, and questions why it need be an either/or approach.  I would agree, and it is part of the reason I am seeking both an MPH and an MD.  In just a few weeks of MPH classes I have already sensed that this degree is really getting me questioning the role of the physician and how to be an effective, conscientious, and inspirational doctor someday. 

While not all aspiring MD’s will seek an MPH degree, there are programs being implemented in medical school curriculums to increase student understanding of the conditions of their patients and the medical system through which they are navigating.  One article I found in particular discussed Penn State’s relatively new program for all first year medical students to spend time serving as patient navigators, which gives them a direct patient perspective to the challenges of daily life, health problems, and understanding the health care system.  The article (an interview with Terry Wolpaw, vice dean) is linked below, but I felt her closing comment really summed up the great potential this has for creating a new generation of public health physicians:

“We expect that our students will reflect on a patient’s journey through the health care system, identify barriers, propose plans to health systems leaders to change those barriers, and help implement the plans.  We believe in the power of our students and know that, given the opportunity, they will make a difference.”

References

Farmer, P., Nizeye, B., Stulac, S., and Keshavjee, S. 2006. Structural Violence in Clinical Medicine. PLoS Medicine; 3:1686-91.

http://www.commonwealthfund.org/publications/newsletters/quality-matters/2014/april-may/qa-wolpaw