Showing posts from category global health.
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Evidence, Links, and Solutions
Maternal Undernutrition
›“Maternal undernutrition is often overlooked as a strategy for reducing poverty and as a key intervention to reduce maternal mortality and morbidity,” said Mary Ellen Stanton, senior maternal health advisor at the U.S. Agency for International Development. Stanton was joined by Dr. Doyin Oluwole, director of the Africa’s Health in 2010 program, and Amy Webb Girard, assistant professor at the Emory University School of Public Health, in the final meeting of the Advancing Policy Dialogue on Maternal Health series on December 15 where they addressed the linkages between poverty, undernutrition, and poor maternal health outcomes.
The Cycle of Malnutrition and Poverty
Many factors contribute to a woman’s nutritional status, including lack of capital, access to land, and poverty; thus, said Oluwole, “we must adopt a multi-pronged and multi-sectoral response.”“General malnutrition is usually associated with iron-deficiency anemia, which leads to poor cognitive function and educational achievement, poor health, and fatigue.” Oluwole said. “These three factors lead to low worker productivity, and low worker productivity leads to income poverty.”
“All of these aggravate malnutrition and so the vicious cycle of malnutrition and poverty continues,” said Oluwole. To break this cycle, she pointed out that countries like Malawi and Mexico have implemented various multi-sectoral interventions that have “stimulated economic growth; implemented targeted social, health, and nutrition programs; and put in place safety nets.”
“In the window of opportunity during pregnancy and the first two years of life, we can make a big difference,” Oluwole said. She advocated for an “integrated anemia package” that provides anti-malarials, de-worming medicine, iron folic acid tablets, and extra food during pregnancy. She also noted the importance of family planning and targeted high-coverage interventions, such as salt iodization, vitamin A supplementation, and breastfeeding promotion.
In conclusion, Oluwole provided several recommendations for the development community to improve maternal mortality rates and undernutrition of women:
Maternal Undernutrition: Our Global Disgrace- Promote universal primary and secondary education, especially for girls
- Stimulate economic growth with a focus on gender and equity
- Invest in infrastructure to reduce transportation time to hospitals
- Postpone age of marriage and of first pregnancy
- Provide targeted and effective nutrition and health interventions
- Encourage private sector participation and government leadership
- Integrate the maternal health and nutrition communities and services
“We don’t tend to look at maternal nutrition and its impacts on the woman herself,” said Girard. The lack of data on the relationship between nutrition and maternal health outcomes “hampers our ability to move maternal nutrition onto the health and development agenda,” she added.“Anemia is widespread; worldwide, it is a significant public health burden, both in women of reproductive age as well as in pregnant women,” said Girard. Studies have shown that moderate anemia increases risk of hemorrhage and may also increase the risk of sepsis, while severe anemia has been shown to directly contribute to maternal mortality. Targeted interventions can help reduce these risks greatly. “For every one gram per deciliter increase in hemoglobin level, you can reduce maternal mortality by approximately 25 percent, but the mechanisms by which this occurs are not well elucidated,” noted Girard.
“We need to include women not as just targets of nutritional interventions, but as beneficiaries in their own health,” said Girard. Key nutritional interventions such as micronutrient supplementation, fortification, and behavior change communication can help to improve not only fetal, infant, and child health, but can also reduce maternal morbidity and mortality. In addition, Girard recommended the following strategies to achieve greater impact:
Together, these strategies can help improve access to nutrition and health services, as well as adequate food for women throughout their lives. “We need to integrate health and nutrition – they are actually the same pillar, complementing each other,” Girard concluded.- Improve nutrition throughout the life cycle, not just during pregnancy
- Look for alternate strategies for micronutrient delivery
- Integrate maternal nutrition into food security and agricultural strategies
- Collect indicators specific to women’s health impacts
- Recognize and address gender bias
Photo Credit: “Bangladesh mothers, kids,” courtesy of flickr user Bread for the World. -
The Role of Population Dynamics in Climate Adaptation
›December 21, 2010 // By Wilson Center StaffThis post is a synthesis of a panel discussion at the UNFPA Population Dynamics and Climate Change conference in Mexico City with Marcia Castro, of the Harvard School of Public Health; Heather D’Agnes, of USAID; and Lori Hunter, of the University of Colorado at Boulder.
It is well-known that environmental change — including climate change — has important impacts on human health. However, it is less well understood how health systems shape the responses of individuals and households to environmental change. Population dynamics — such as fertility, migration, and mortality and morbidity — influence community health and greatly affect community resilience in the face of environmental changes, including the capacity to adapt to climate change.
Mortality and Morbidity
Morbidity and mortality dramatically shape a household’s ability to adapt its livelihood strategies to a changing climate. For example, in areas of high HIV prevalence, such as sub-Saharan Africa, adult mortality seriously undermines livelihood options. In the face of such loss, the household’s reliance on local natural resources intensifies. If environmental change reduces the amount of available resources, the household has fewer options for energy and sustenance.
Morbidity also affects adaptive capacity, and morbidity itself can be shaped by environmental change. For example, environmental scarcity can increase poverty, which can lead to an increase in risky transactional sex, further fueling the HIV pandemic. Malnutrition resulting from drought and environmental shocks can suppress the immune systems of HIV-positive people, making them more vulnerable to illness and less able to adapt to other external changes.
Fertility and Family Planning
Healthier households are more resilient households, so increasing access to health services, including reproductive health services, is essential for building adaptive capacity. High fertility poses challenges to a family’s livelihood and has negative health effects on women and children. Providing reproductive health services is an effective way to improve the capacity of these vulnerable groups to adapt to climate change. For example, a recent study argues that lowering fertility rates in the Himalayan region could increase community resilience to the predicted fluctuations in water quantity.
However, there is a high level of unmet demand for contraception across the globe. How can community adaptation programs help meet this need? Importantly, research from the Philippines suggests that integrating population, health, and environment programs in a package approach to community development is more effective than single-sector interventions. Including family planning and reproductive health services in community-based climate adaptation programs could not only more effectively meet the community’s needs, but could also improve its adaptive capacity better than health or climate programs alone.
Migration
Another population process, migration, can both impact health and affect the capacity for adaptation. For example, internal migration in the Brazilian Amazon appears associated with the spread of malaria, which negatively impacts the adaptive capacity of households. To mitigate climate change’s health impacts, states should more effectively plan settlements and health systems, including health impact assessments for infrastructure and development projects. (Editor’s Note – northern Nigeria and Niger present another example of similar climate-related migratory patterns that significantly impact health and economic resilience.)
In summary, the scientific evidence is clear that population dynamics — such as mortality, fertility, and migration — and environmental trends are linked. Projects intended to improve a community’s ability to adapt to a changing climate should consider and address these linkages in their design and implementation.
Sources: Foundation for Environmental Conservation, UNFPA, USAID.
Photo Credit: “Toureg family in Niger,” courtesy of flickr user ILRI. -
Judith Bruce on Empowering Adolescent Girls in Post-Earthquake Haiti
›“The most striking thing about post-conflict and post-disaster environments is that what lurks there is also this extraordinary opportunity,” said Judith Bruce, a senior associate and policy analyst with the Population Council’s Poverty, Gender, and Youth program. Bruce has spent time this year working with the Haiti Adolescent Girls Network (HAGN), a coalition of humanitarian groups conducting workshops focused on the educational, health, and security needs of the country’s vulnerable female youth population.
Gender-based violence has long been an issue in Haiti, but the problem became even more pronounced in the wake of the January earthquake. HAGN has sought to address the problem by concentrating its community-based programming on “high priority” groups, including girls who are disabled, serve as de facto heads of households, or are aged 10-14.
Bruce asserted that protecting and empowering young girls is critical because upon reaching puberty, “their access to a safe world shrinks dramatically.” With the post-disaster environment adding another layer of challenge, she said “there could be no ambiguity in anyone’s mind that we have to create dedicated spaces for girls who, at least for a few hours a week, feel secure to be themselves and to plan for their long-term safety as well as their development.”
The “Pop Audio” series is also available as podcasts on iTunes. -
The World’s Toilet Crisis
›Forty percent of the world’s population – 2.6 billion people – do not have access to toilets, and some in the international aid community are finally dispensing with the euphemisms and calling this sanitation crisis what it is: “shit.”
In “The World’s Toilet Crisis” (trailer above), Adam Yamaguchi sets off in an episode of Current TV’s Vanguard program to tell the story of “the deadliest killer in the world…something no one wants to talk about.” All around the developing world, thanks in part to rapid population growth and poor development and environmental standards, “people are literally eating their own shit,” he said.
His journey takes him to India, where more people own cell phones, than toilets. The 55 percent of Indians who practice open defecation have contributed to another grim statistic: an estimated 840,000 children under the age of five die in India each year from diarrheal diseases.
India’s water quality is especially affected by lack of sanitation. In the documentary, Yamaguchi visits the Yamuna River, which is Delhi’s primary source of drinking water, and has become a “giant toilet” literally bubbling with methane gas. This phenomenon is not unique to India. Approximately 80 percent of sewage in developing countries goes untreated, polluting local water resources.
But it is women who feel the effects of lack of access to clean water and toilets most keenly. In 72 percent of households around the world, women are the primary water collectors, often travelling long distances for drinkable water. They face shame and harassment when going to the bathroom, causing them to suppress their need until dark, causing negative health effects. Waiting until nightfall also means that when women openly defecate, they often face molestation, violence, and rape. Teenage girls also often drop out of school once they begin to menstruate because toilets are not private, unsafe, or are simply nonexistent.
Reflecting on his motivations for making the documentary, Yamaguchi said that in order to expose this “global public health crisis,” he needed to be as graphic, shocking, and disgusting as possible.If you’re not grossed out by, or incensed by the fact that there is shit everywhere, you’re not really moved to act or change your ways. And that’s ultimately what’s happened in many places in the world. It’s a normal fact of life. You see it everywhere, and you think nothing of it. There are causes out there that are deep sexy causes or marketable causes. Shit or toilets – not the most marketable thing in the world.
“The World’s Toilet Crisis” forms part of a broader trend among sanitation advocates to use crude language to address a problem the international health and development community has traditionally shied away from talking about directly.
Tales of shit: Community-Led Total Sanitation in Africa, published shortly before World Toilet Day by the International Institute for Environment and Development, takes an equally direct approach to sanitation.
Community-Led Total Sanitation (CLTS) is an approach begun with great success by Dr. Kamal Kar in Bangladesh that relies on “triggering” to change community behavior. The report, which is prefaced by a three-page “International Glossary of Shit” listing the words for shit in other languages, emphasizes the need to “explicitly [talk] about and [make] visible the shit that is normally hidden beneath taboos and polite language.” By almost literally thrusting people’s shit right under their noses, communities learn what they have been ignoring: that they are “eating each others’ shit.”
Traditional sanitation programs often fail because “a high proportion of latrines constructed with subsidies are never used as toilets, but as storage space, animal shelters, or prayer rooms – the buildings are too high quality to be wasted on toilets!” says the report. CLTS, on the other hand, focuses on changing behavior at the community, rather than the individual level to create sustainable change that responds and adapts to a community’s distinct culture and needs.
“The World’s Toilet Crisis” shows the promise CLTS has of meeting the needs of the billions without toilets. In East Java, Yamaguchi joins a community leader to collect a “specimen” from a well-traveled river bank near the town, which he proceeds to show to a group of women in the town who are, predictably, revolted. The community then takes collective action to become “open-defecation free” and invest in toilets.
“The World’s Toilet Crisis” is not easy to watch, nor was it easy to film – seven minutes in, Yamaguchi vomits on the banks of the polluted Yamuna River. Disgust, however, is central to raising awareness and affecting change on both the community and global levels. As Yamaguchi explains, “You’re going to get grossed out by seeing this piece, and that’s part of the point.”
Sources: Community-Led Total Sanitation, Current TV, Earth Times, IIED, Water.org, World Toilet Organization, WHO, United Nations University.
Video Credit: “The World’s Toilet Crisis – Vanguard Trailer,” courtesy of Current TV’s Vanguard. -
Watch: Joel E. Cohen on Solving the Resource-Population Equation in the Developing World
›December 14, 2010 // By Wilson Center Staff“It’s very hard to put a number on a quantity that depends on future events, processes we don’t understand, and values that may change over time,” said Joel E. Cohenof the Rockefeller University in this interview with ECSP. “That doesn’t mean we have no problems and it doesn’t mean there’s nothing we can do.”
There are three schools of thought or proposed “panaceas,” when it comes to balancing natural resources and population, said Cohen: a bigger pie (new technology to increase productivity), fewer forks (reduced consumption), and better manners (reduced irrational market inequities and better governance).
In the 15 years since his book How Many People Can the Earth Support? was published, Cohen’s approach has changed. While the 1996 book lacked a definitive policy recommendation, he is now analyzing options. “The evolution of my thought has moved from ‘how many people can the Earth support?’ to ‘what do we need to solve problems?’” he said.
You need adequate child and maternal nutrition to produce potential problem solvers and you need education to give them the tools to do it with, said Cohen, who studied the impact of universal primary and secondary education with colleagues at the American Academy of Arts and Sciences.
“If you look at a map of stunting in the world, there are parts of South Asia and sub-Saharan Africa where more than half the children are stunted – that means two standard deviations [of] height below normal for their age,” said Cohen. “Those populations are handicapped at the starting gate because they don’t have the problem solvers.” -
Expanding Access to Maternal Health Commodities
›“This is not just about getting quantities of drugs out, this is about saving women’s lives with really simple products that work,” said Julia Bunting, team leader of AIDS and reproductive health at the UK Department for International Development and coalition chair of the Reproductive Health Supplies Coalition, at the ninth meeting of the Global Health Initiative’s 2009-2010 Advancing Policy Dialogue on Maternal Health series. Joined by panelists Melodie Holden, president of Venture Strategies Innovations (VSI), and Elizabeth Leahy Madsen, senior research associate at Population Action International (PAI), the panel discussed the challenges and strategies for expanding access to maternal health commodities.
Integrating Maternal Health and Family Planning Supply Chains“It is often said that the family planning and the maternal health communities have very different views of supplies… but actually [both communities] recognize that we need to explore the continuum,” said Bunting, addressing the need to integrate maternal health commodities into existing reproductive health supply chains. “I really think the stars are aligned right now for advancing this agenda,” added Bunting.
“Many of the commodities that we talk about in terms of reproductive and maternal health cost tiny amounts to deliver, but actually save lives and are some of the most cost-effective interventions we have both in public health and in broader development,” said Bunting.
No Product, No Program
“Supplies are a key element in programs to improve maternal health and they are also a tangible and visible hook to increase awareness and commitment,” said Madsen. “Policymakers whose eyes glaze over when they hear the term ‘health systems strengthening’ can grasp… much better when they learn that supply shelves in clinics are bare and that women are making great efforts to reach facilities, only to leave empty- handed,” said Madsen.
Presenting research conducted by PAI, Madsen discussed the availability of four key maternal health medicines and products in Bangladesh and Uganda including:
By focusing on supplies that target the three leading causes of maternal mortality, Madsen and her colleagues identified factors that inhibit access to these commodities and developed recommendations for strengthening maternal health supply chains.- Oxytocin: used to prevent post-partum hemorrhage
- Misoprostol: used to prevent post-partum hemorrhage
- Magnesium Sulfate: used to treat pre-eclampsia
- Vacuum Aspirators: used for treatment of early and incomplete abortion
Madsen identified several strategies to strengthen supply chains for maternal health commodities including forecasting and preparing for growing demand, advocating for government and donor support, encouraging scaling-up of community-based approaches, promoting family planning, and focusing on human resource training.
“In maternal health, if a supply to prevent or treat a life-threatening complication is in stock, there must also be a way for a woman to reach it in time… and in most cases a provider who knows how to administer it,” said Madsen.
“This research is intended to lay the groundwork for future advocacy and policy initiatives by providing an evidence base that is informed by local expertise,” said Madsen. “We hope that this information will inform program implementation, funding decisions, and awareness raising.”
Getting the Product to People: The Case of Misoprostol
“The story of Misoprostol is still being written. The goal is to invest in creating access to interventions that are low-cost and relatively simple to use,” said Holden. By sharing lessons learned, Holden described VSI’s experience registering and procuring Misoprostol and demonstrated how community mobilization is imperative to overcoming major challenges for large-scale implementation.“Making products available is not without challenges,” said Holden. To increase access to Misoprostol in rural communities, maternal health experts must work to “engage communities, educate and mobilize women, train providers at all levels of the health care system, and provide support to distributors to jump start sales,” said Holden. “By looking holistically across entire health systems, bringing in great interventions, addressing the components of supply and demand, and working with local partners, we can have lasting impact.”
While the price of Misoprostol has decreased significantly, Holden stressed the need to identify creative ways along the supply chain that reduce costs to the end user. Additionally, “establishing policies around this new intervention not only establishes its reach, but also makes its use institutionalized, which means it will be part of the system even if governments or individuals change,” said Holden.
“If there is a gap between what could be achieved with Misoprostol and what is being achieved, we need to go back to the model and figure out what pieces aren’t working,” concluded Holden. “The work is complex and takes time, but it’s worth it.”
Photo Credit: “Rapid HIV testing,” courtesy of flickr user DFID – UK Department for International Development. -
Hans Rosling Double Feature: ‘The Joy of Stats’ on BBC and Population Growth at TED
›Hans Rosling, creator of Gapminder and professor of international health at Sweden’s Karolinska Institute, hosts a new documentary on the BBC called The Joy of Stats that takes a look at the breadth and depth of data available today to analysts and private citizens alike.
In the clip above, Rosling demonstrates his primary interest in world health, tracking life expectancy and income over the last 200 years to show both the remarkable progress that has been made but also the tremendous gap that remains between those at the top (the very rich and healthy) and those at the bottom (the very poor and sick).
Rosling has been a vocal (and visual) advocate for expanding people’s knowledge of the world by presenting statistics in innovative ways. “Statistics should be the intellectual sidewalks of a society, and people should be able to build businesses and operate on the side of them,” he said at a discussion at the Wilson Center in May 2009.
In particular, Rosling’s focus has been on health, poverty, and the developing world, where he’s advocated for increased focus on child and maternal health and education. “The role of the old West in the new world is to become the foundation of the modern world – nothing more, nothing less,” he said during a TED talk on population growth (see below) where he broke from his more flashy visuals and went analog – using IKEA boxes to illustrate population and consumption growth. “But it’s a very important role. Do it well and get used to it.”
Rosling’s Gapminder software has been incorporated into Google’s Public Data Explorer, where many development indicators from the World Bank, World Health Organization, and others can now be easily tracked by anyone. For more on Google Data and to see an example set of indicators (agriculture as a percentage of GDP vs. fertility rates over the last 50 years), check out this previous Eye On, on The New Security Beat.
Video Credit: “Hans Rosling’s 200 Countries, 200 Years, 4 Minutes – The Joy of Stats – BBC Four,” courtesy of BBC, via YouTube, and “Hans Rosling on global population growth,” courtesy of TED. -
International Responses to Pakistan’s Water Crisis
›December 6, 2010 // By Michael KugelmanExcerpt from the executive summary of the NOREF Policy Brief, via the Norwegian Peacebuilding Centre:
Pakistan faces a multidimensional water crisis that claims hundreds of thousands of lives every year. The root causes of the crisis are twofold:- Circumstantial, which are linked to poor water-resource management policies (including water-wasting flood irrigation);
- Structural, tied to factors deeply ingrained in politics and society such as the obsession with India, inequitable rural land-ownership and endemic water misgovernance (for example, exploitation of the rotational irrigation system to the detriment of the poor).
However, international responses must be measured. They should actively target the circumstantial causes but, at the same time, recognize that their ability to take on the structural ones is limited. While the international community can help mitigate the effects of the underlying structural drivers, Pakistan itself must take the ultimate steps to eliminate them.
Circumstantial causes can be addressed through international aid provision and international exchanges. Aid provision must be generous enough to meet Pakistan’s prodigious needs but modest enough to respect the country’s limited absorptive capacities. It should emphasize the restoration of infrastructure and distribution systems, be more responsive to the needs of Sindh and Baluchistan provinces, and be channeled through both government agencies and civil society.
Despite the challenges the international community faces in addressing the structural causes, opportunities do abound. These include embarking on back-channel diplomacy to bring Pakistan and India closer together and cooperative projects with Pakistanis to make water distribution more equitable. To be effective, international responses must target all affected parties and be sensitive to ground realities. They should also be mindful of indigenous success stories and the factors that bring about that success.
The full report, “International Responses to Pakistan’s Water Crisis: Opportunities and Challenges,” is available through the Norwegian Peacebuilding Centre.
Michael Kugelman is program associate with the Asia Program at the Woodrow Wilson International Center for Scholars.
Image Credit: Adapted from “USG Humanitarian Assistance to Pakistan for Floods in FY 2010 and FY 2011 (as of 30 Nov 2010),” courtesy of USAID and ReliefWeb.
