WINTER 2016
THE YALE
VOL. 3, NO. 2
GLOBAL HEALTH REVIEW
THE POWER OF
CONDITIONAL CASH TRANSFER PROGRAMS BY CINDY ALVAREZ P. 24 Australia Dep. of Foreign Affairs and Trade
LETTER FROM THE EDITORS WINTER 2016
VOL. 3, NO. 2
Dear Readers, We are very excited to release the winter edition of the Yale Global Health Review! This new edition is the cumulative effort of our tireless writers, editors, production and design team, and business team; thank you for your hard work and passion. As the field of global health continues to garner interest on campus and gain prominence worldwide, our hope is that the Yale Global Health Review can serve as a platform for discussion. Through an interdisciplinary approach that draws on the experiences of a diverse group of students with unique backgrounds and interests, our articles strive to capture the nuances of health in the US and abroad. In this issue, our feature article explains the simple and effective strategy of utilizing conditional cash transfers to promote educational success and health improvements. This issue also includes a range of topics such as maternal health in Brazil, homelessness and mental health in the US, and one student’s reflections after a summer working with HIV/AIDS patients and organizations in Swaziland. These articles represent only a subsection of the interconnected and contentious issues that currently dominate the field of global health. Our generation is at the forefront of innovation and creative strategies required to empower communities. For first time readers, we hope you enjoy this publication and it serves as a launching point for your further interest in global health and related fields. To our long term readers, thank you for sticking with us and enabling this publication to thrive through your continued support. For more global health, visit our blog at yaleglobalhealthreview.com. Or, send us an email at yaleglobalhealthreview@gmail.com. All the best, Amber Tang and Sophia Kecskes OUR TEAM Editors-in-Chief Amber Tang Sophia Kecskes Senior Editors Hannah Krystal Kai DeBus Neha Anand Rachel Arnesen Associate Editors Cassandra Lignelli Claire Chang Elizabeth Zhang Lauren McNeel Production & Design Team Holly Zhou Jessica Schmerler Jilly Horowitz Maheen Zakaria Marc-André Alexandre Web Master Katerra Logan
Online Editors Al Nurani Caroline Tangoren Devyani Aggarwal Elizabeth Kitt Seojin Park Staff Writers Akhil Upneja, Anabel Starosta, Brenda Calderon, Grace Yi, Holly Robinson Business Team Christina Huang, Dan Bozik, Eli Lininger, Erica Kocher, Harland Dahl, Jennifer Peng, Kelsang Dolma, Mary Chandler Gwin, Paul Won, Ruiyi Gao, Sam Sussman & Sara Lee Copy Editors Dhikshitha Balaji Hannah Krystal Katerra Logan Social Media Director Sarah Barreto Ornellas
YALE GLOBAL HEALTH REVIEW: VOLUME 3, NO. 2
ABOUT US The Yale Global Health Review is the premiere undergraduate-run publication at Yale University covering topics in health. We feature original research, thoughtful commentary, and balanced reporting with a global health focus. Our goal is to bridge scholarship and practice, connect students and faculty, and bring together voices from across a spectrum of disciplines and sectors. The YGHR is a hub for discussion and engagement on all issues relevant to global health – in print and online, at Yale and beyond. SPONSORS We would like to thank the Yale Global Health Leadership Institute, Yale Global Mental Health Program, Yale China, the Yale School of Public Health Admissions Department & the Yale Undergraduate Organizations Committee for their support.
CONTENTS HEALTH POLICY
FEATURE ARTICLE
INNOVATIONS IN GLOBAL HEALTH 6
The Power of CONDITIONAL CASH TRANSFER Programs 24
Bridging the Gap Between Research and Practice by Sang Won (John) Lee
by Cindy Alvarez
ALTERNATIVE MEDICINE 14
Integrating Modern and Ancient Healing Practices by Dan Kluger
GROWING PAINS 30 Yale's Initiatives in Early Childhood Development Australia Dep. of Foreign Affairs and Trade
by Amanda Corcoran
GLOBAL HEALTH TODAY
BRAZIL 16
The Challenge of Maternal Healthcare by Rebecca Slutsky
UNITED STATES 44
Health, Homelessness & Conditional Morality
FIELD WORK
SWAZILAND 4
Looking Past the Data
by Erika Lynn-Green
by Diksha Brahmbhatt
CHINA 9
Listen to Your Heart: Insights from a Chinese Cardiology Hospital by Anson Wang
ECUADOR 22
Job and Food Insecurity Around the Country's Coast by Emma Ryan
Anson Wang
PHOTOGRAPHY
SAMOA 34 by Akeilly Hu
MOROCCO 40 Jake Stimpson
by Grace Yi
NUTRITION
UNITED STATES 20
SAMOA 32
GENDER EQUITY 42
by Carlin Sheridan
by Akeilly Hu
by Pavane Gorrepati
Advertising and Child Obesity
Eating Tinned Fish on a Tropical Island
A Path Towards Food Security
Akeilly Hu
SWAZILAND: Looking Past the Data
“So, where exactly is Swaziland?” is a question I became all too familiar with as I shared stories of my experiences during a Yale Summer Session class, “Visual Approaches to Global Health.” Honestly, I was poorly equipped to answer that question before I decided to fly to South Africa and Swaziland, a neighboring landlocked monarchy of just over 1.4 million people.1 During our two weeks in Johannesburg and four weeks in Swaziland, we witnessed the striking aftermath of the Apartheid, still alive and well, even outside of the Apartheid museum. In the coal mines that dot the landscape just outside of Johannesburg, the oppression of black people continues. Men from all over southern Africa flock to the mines with hopes of earning a living for their families back home. In doing so, they assume a life dominated by over-crowded quarters, a high risk of HIV, and a lack of health care. Mr. Mkoko, a friend of our professor, lives in rural Swaziland but moved away to work in a South African coal mine. When he returned, he brought home both HIV/AIDS and multidrug-resistant tuberculosis. We traveled to his village of Kashoba, where he is now an HIV community educator and an empowering figure promoting treatment awareness. Over a quarter of Swazis live with HIV, and the resulting high death rate has lowered the life ex-
4
FIELD WORK
By Diksha Brahmbhatt
pectancy to 49 years, with a third of the population currently below age 14.2 My global health courses only vaguely familiarized me with these statistics. While they are crucial for assessing the need for resources and action, they only paint half of the picture. I did not realize just how meager my understanding of the complexity of global health issues was until I took this course, which allowed me to study abroad with Professor Jonathan Smith, a filmmaker and lecturer in Epidemiology of Microbial Diseases and Global Health at the Yale University School of Public Health. When I see the number 3,500, which approximates the annual deaths attributed to HIV/AIDS in Swaziland, I now force myself to look beyond the number to the meaning that lies within.3 That number does not just describe the quantity of people killed by a vicious viral disease. That number represents a host of social, political, health, and economic issues that plague Swaziland. Although AIDS is a preventable, treatable disease, it burdens one’s life for a lifetime. That number hides the fact that antiretroviral therapy only became accessible in Swazilandwww in 2003, even though the therapy became available the United States as early as 1996.4 That number hides the loss of productivity caused by the disproportionate prevalence among those aged 15-24, particularly women. That number hides gender-based violence and a deep-running current of stigma associated with AIDS that has debilitated efforts to create change. MY STORY My interest in global health issues flourished after taking an introductory course with Professor Richard Skolnik. This course helped me realize the power of prevention, education, and treat-
ment beyond the offices of physicians. With the encouragement and advice of mentors and peers, I made my way to southern Africa. I expected to go on adventures and visit “cool” places, all while enhancing my understanding of health policy, data, and social welfare. By the end of six weeks, I realized that I had severely underestimated the learning curve that came with staying in a foreign country, especially one suffering from such a significant lack of medical care. Our professor lectured and gave us assignments, but he emphasized that these were only supplementary to what the local people taught us: the local hotel staff, the people we interviewed for the documentary we made as a class, and the Swazis with whom we formed friendships. They all taught me that behind the data lie stories that need to be heard. THEIR STORIES Meet Mr. Vusi Matsebula. He was the second person in Swaziland to publicly declare his HIV status in 1996, after three years of feeling like he was alone in his fight. His HIV counselor, who was assigned to him at the onset of his diagnosis in the early 90s, provided him with tremendous support and introduced him to others who were experiencing the same feelings of isolation, confusion and shame. Yet, he found it most difficult to convey his status to his mother. Though, when she found out through Vusi’s sister, his mom immediately opened up her arms to him.
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Data can never tell the full story, but human lives and personal interactions with those whom it represents can help fill in the gaps between data and narrative.
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YALE GLOBAL HEALTH REVIEW
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solidarity Although Her and affection gave him the AIDS is a to bepreventable, strength come an activtreatable dis- ist and create the Swaziland ease, some- AIDS Support how it has Organization, a national organizamanaged tion that provides and counselto make ingeducation to families affected life a by HIV in even the most rural areas. He truly bebur- lieves that his group provides den. a welcoming community and
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teaches families to be sympathetic and supportive. It gives people the motivation to not only get tested, but also to seek treatment, even in the face of possible social repercussions. Meet Sibonginkhosi Mawela. He is 20 years old and volunteers at an NGO-funded HIV clinic in the heart of the capital city of Mbabane. His mother works at the hotel we stayed at, and encourages his volunteer work even though he is not remunerated. He is HIV-negative. We asked him why he is forgoing the more traditional paths to a secure income, instead offering his youth, energy and time to educating his peers about protected sex and younger children about health and loving their bodies. For Sibonginkhosi, his activism started when he witnessed his HIV-positive friend refuse to go to a clinic for medication out of fear of being publicly recognized. Sibongink-
hosi realized that this stigma caused more damage than the virus itself. As a young person, he feels an obligation to work to ameliorate an issue that directly impacts his life. He distributes condoms discreetly at bars because he knows these alcohol-fueled environments are breeding grounds for high-risk behavior. Even though he does not currently have the funds to pursue higher education, he is a valuable asset in the struggle toward a better understanding of HIV prevention and treatment as it pertains to his own community. OUR STORY Data can never tell the full story; I have found that human lives and personal interactions with those whom data represent can help contextualize numbers on a page. My global health courses meant more to me after I became friends with families like the Matsebulas and the Mawelas. I saw how the burden of disease trickled into all aspects of their lives. Vusi thought he would never be a father because he was afraid of passing HIV to his child, though ultimately his daughter was born HIV-negative. Sibonginkhosi fears that stigma from others seeing him as HIV-positive will limit his future marriage prospects. Our class actively sought compelling narratives and learned to piece together casual conversations, information from class, discussions from a multinational conference on Mine Workers’ Compensations and TB, and the informal and formal interviews we conducted. As Professor Jonathan
Smith explains, we used film to translate an epidemic to an emotion. We hoped to produce a tangible product that would convey not only the severity of HIV prevalence and stigma, but also to depict hope and inspiration for our primary target audience, Swazi youth. Our documentary, a product of hours upon hours of story-chasing, filming, and editing, portrayed a story of social and institutional discrimination against those living with HIV, as well as current local and national efforts to combat it. More importantly, however, we tried to portray the strength of the human spirit within people who persevered despite daunting statistics. We wanted our work to be a call-toaction for Swazi youth, and an inspiration for them to change the dialogue, or lack thereof, surrounding the stigma that affects someone they know, if not themselves. If you would like to read the blog our class produced, visit http://yss2015.epidemictoemotion.org/. For more information on Jonathan Smith’s projects, visit http://epidemictoemotion.org/.
www Diksha Brahmbhatt is a sophomore in Berkeley College. Diksha is an Anthropology major from Florida. She can be contacted at diksha.brahmbhatt@ yale.edu.
Diksha Brahmbhatt Five of the seven students working on the documentary visit Mr. Vusi Matsebula’s home to film B-roll footage.
VOLUME 3, NO.2
5
HEALTH POLICY
INNOVATIONS
IN GLOBAL HEALTH: Bridging the Gap Between Research and Practice
By Sang Won (John) Lee
T
he gap between health research and practice in certain fields purportedly spans 17 years.1 While experts argue about the extent of this lag, they agree that it does exist and must be eliminated. Both the public and private sectors have increasingly pushed for research into the mechanisms that translate knowledge into application. The Black Dog Institute in Australia focuses on this issue by conducting research on the diagnosis, treatment, and prevention of mood disorders, with the aim of “rapid translation of quality research into improved clinical practice.”3 The institute has recognized that this lag, perpetuated by the whims and preferences of health practitioners, could deny people access to the best methods of care available. One project run by the institute, called We Feel, seeks to measure the relationship between social, economic, and environmental factors on the emotions in order to monitor and educate people about mental health.4 The project collects public tweets, country by country, then analyzes emotions such as love, joy, surprise, anger, sadness, and fear. The project attempts to bridge the gap between research and practical application, starting with the simple act of placing its research and practice wings in the same location. The gap between research and practice does not solely exist in the area of mental health. One significant example of the lag between research and practice is the introduction of new drugs onto the market, and their prescription rate by doctors thereafter.
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Another exists in the use of social networks as a method of health care intervention due to a lack of knowledge required to utilize these networks. The cost of inaction is high both in social and economic terms. A child may be denied access to the best-known medicine, or even a cure, for his or her illness, due to the gap between knowledge and practice. A government may not apply the most cost-effective approach to the promotion of health awareness, wasting resources that would have been better spent on other projects. Fortunately, there have been efforts to address the gap by integrating research into practice – the so-called Knowledge Translation. Going forward, we must infuse a drive for innovation into this domain and constantly rethink the concept and methods of Knowledge Translation. The fields of global health, social sciences, development economics, and medicine have already experienced the push for innovative, multi-disciplinary approaches to traditional problems. We can learn much by their example. In order to diminish the gap between knowledge and practice in the field of global health, we should direct our attention toward three specific areas. First, we must shift the model of global health and development from the intervention of foreign aid workers to the sustainable integration of local stakeholders into the processes of development. Second, the government and other structural agencies should more actively foster the development of innovative approaches that improve upon or complete-
ly replace traditional practices. Third, we must build platforms that encourage both the development of multi-disciplinary solutions and the spread of those ideas across disciplines. RETHINKING GLOBAL HEALTH AND DEVELOPMENT FROM LOCAL PERSPECTIVE Adam is a top pediatrician who works at a world-renowned hospital in the United States. With a grant from UNICEF, he buys a set of fetal incubators to send to a low-income country, where Ruth works as a midwife. Ruth receives the devices and attempts to use them, but she struggles to learn exactly how the machines function, how they should be repaired when they malfunction, and how to transport the heavy devices, which were made for hospitals with elevators, up and down the stairs in her clinic. Ruth now finds herself facing a “Choose, Use, and Pay the Dues“ problem. This concept describes the failure of good intentions to surmount the fact that the people who choose the medical devices (doctors in high income countries), the people who use the devices (midwives, community health workers) and the people and organizations that fund the technology transfer (UNICEF or other multilateral aid organizations) fail to properly meet the needs on-the-ground health systems operating in low and middle income countries (LMIC). In this case, Adam may not have realized the importance of Ruth’s needs
YALE GLOBAL HEALTH REVIEW
and specific circumstances, but Ruth paid the price for his ignorance. In order to solve this problem, we need to shift away from the current model, a failing one-way transfer between high-income and low-income settings. We need to further involve all stakeholders, such as local doctors and midwives, into the transfer of goods and ideas. We need to empower them to help us learn about the problems they face, to fully take advantage of the tools at their disposal, and to address these issues themselves. One creative solution exists in India: CAMTech attempts to accelerate the innovation of medical technology by building the entrepreneurial capacity to improve health outcomes in LMIC.5 CAMTech runs hackathons in India that encourage locals to develop solutions to the issues they face by providing them with the support and resources to do so, often publicizing promising solutions and establishing connections with interested aid organizations. Most recently, the hackathon focused on the problem of diabetes.
The CAMTech model has adapted to the circumstances of the region, and it avoids the problem of “Choose, Use, and Pay the Dues” by integrating the people who develop, use, and pay for the new products into the same environment. The products that come out of such hackathons include an infrared device that measures blood glucose through the earlobe, a tool more appropriate for LMIC field use than past devices because it was developed with readily available tools and resources in India. Technoserve, another organization that empowers locals to improve global health and development, provides support for local entrepreneurs to develop, for example, their business marketing.6 This model challenges the one-way dissemination of knowledge by making local people an important source of ideas. A third group, Little Devices Lab, builds easily usable and accessible tools for locals, such as simple design kits/platforms for diagnostic tests.7 Jose Gomez-Marquez, an MIT researcher, builds such DIY health technologies with the goal of empowering locals to develop
the kits further. All of these organizations emphasize the need to involve the people directly affected by these issues in order to formulate more comprehensive, sensible solutions to meet local needs. STRUCTURAL APPROACH TO INNVOATION Imagine that you were told to get over a bar that was hanging slightly above the ground. How would you do it? The natural instinct would be to step over the bar. Now imagine that the same bar was raised to the height of your knee. How would you do it this time? It might cost you more effort to do so, but you could still jump over the bar. What is the difference between these two situations, and what does that difference tell us? At the individual level, it shows that we have the untapped capacity to surpass our own expectations. Even when we do not expect to take the leap, the potential to do so lies within us. On the structural lev-
A traveling exhibition organized by the Smithsonian’s Cooper-Hewitt National Design Museum, hosted at venues such as the Centers for Disease Control and Prevention (CDC) and the United Nations (UN). It illustrates the movement to find low-cost solutions for problems in low- and middle-income countries, specifically how design can play a transformative role around the world.
James Emery
VOLUME 3, NO.2
7
el, it tells us that different circumstances elicit different responses. The high bar precipitates the act of jumping, while the low bar requires a single step. This insight suggests that greater involvement of governmental and external institutions would provide a structure that incentivizes people to take the leap, and to reach for a higher goal. We can apply this concept to knowledge translation. In particular, the government can foster innovation and streamline the implementation of necessary knowledge. One example of such a program is the Smart and Connected Health Program in the United States.8 The National Science Foundation program funds projects working to develop innovative approaches that would support “the much needed transformation of healthcare from reactive and hospital-centered to preventive, proactive, evidence-based, person-centered and focused on well-being rather than disease.” Programs such as this one encourage innovation, in particular the innovation of knowledge translation, by incentivizing individuals to leap rather than step. We need more, similarly structured programs in the realm of global health and development in order to drive large-scale structural changes.
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When people come together, they form a think tank capable of producing creative new solutions for existing problems.
PLATFORMS FOR SHARING ACROSS DISCIPLINES
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IDEAS
The scientific community has used journals in order to disseminate knowledge and ideas for centuries. Journals such as Science cover a range of general topics, while journals such as the Journal of Neuroscience focus on smaller areas of interest. By compiling advances relevant to the field in one location, journals keep those interested in the field up to date on the latest findings. Recently, this traditional model has been used more and more in a multi-disciplinary approach to innovation. When people come together, they form a think tank capable of producing creative new solutions for existing problems that have defied conventional interventions. The compilation of people from different disciplines can magnify the effect.
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Julien Harneis
A child in New Guinea with measles, a particular problem facing the country due to weak health infrastructure and lack of resources.
The Human Nature Lab at Yale is at the forefront of studying the spread of knowledge and behavior. Under Master of Silliman Nicholas Christakis, the lab works at the intersection of the social and biological sciences, studying social networks in order to determine how they facilitate the spread of knowledge, ideas, and behaviors. One project that the lab runs, which is based in Honduras, looks at the method by which insights in network science, such as centrality to the network, can improve the implementation of health interventions by determining the proper target for these interventions, which range from educational measures to health care. For example, offering lessons to the proper target community about the importance of giving liquids to children with diarrhea would save many sick children from dying of dehydration.9 Stanford Social Innovation Review publishes a magazine and website that cover cross-sector solutions to global problems.10 These media outlets allow the sharing of ideas across disciplines, then facilitate the dissemination of the resulting solutions. Another example of cross-disciplinary contact is the global design firm IDEO, which employs people from various areas of research ranging from behavioral science to healthcare services to digital design.11 The firm brings together diverse groups of talented people in order to help organizations in the public and private sectors innovate and grow. Both organizations represent a sign of hope for continual innovation in the context of global health and development. CONCLUSION Shrinking the gap between research and practice and increasing the amount of
cross-disciplinary research represent two important goals for global health and development. Both contain profound implications for both society as a whole and our daily lives. The focus on Knowledge Translation brings the best practices to those who can benefit the most from them. Knowledge Translation reveals important trends in our conception of global health and development, as well. We have focused on a one-way transfer of knowledge and goods, a simple interpretation of evidence into action that neglects so many possibilities. The application Knowledge Translation to the global health field is currently shifting communications from a one-sided flow of information into a pathway that integrates the local population as per Goal 17 of the Sustainable Development Goals set up by the United Nations. In the future, we need to continue to foster the spread of knowledge and innovation through partnerships between the public and private sector, as well as between various fields of scientific research. We need to address the many needs, often caused by the gap between research and action, around us. By working together, we can help each other fulfill a common goal: to bring our world a step closer to the world in which we wish to live. www
Sang Won (John) Lee is a junior in Calhoun College. Sang Won is a Molecular, Cellular and Developmental Biology major from South Korea. Contact him at sangwon.lee@yale.edu.
YALE GLOBAL HEALTH REVIEW
FIELD WORK
CHINA
Listen to Your Heart: Insights from a Chinese Cardiology Hospital
By Anson Wang
VOLUME 3, NO.2
9 Anson Wang
I
brushed open the long plastic curtains that covered the main entrance to the emergency room of Fuwai Cardiology Hospital. It was another warm and humid day in Beijing in the middle of June, or what the residents called, “sauna weather.” The waiting area of the emergency room was even hotter, and the walls of the hospital offered no solace from the noises of the crowded intersection of the two main roads outside. Families were crowded into the waiting room, occupying all the seating and floor space that the hospital provided. The buzz of noise and conversation made it difficult to decipher any single voice. As I passed through the emergency room, the first thing I was struck by were the beds; more than 50 mobile cots and stretchers crowded the emergency room and an additional area behind the main waiting room. Nurses dressed in pale-pink scrubs ran back and forth attending to these patients, administering IVs, or plugging in wires to EKG machines. As I snaked my way in between patients and their families, I imagined the austere waiting rooms of hospitals back in my hometown in New York, silent except for the corner television playing reruns of daytime television. My path through the labyrinthine hallways of the hospital was constantly interrupted by a frenzied family or a blur of white or pink as doctors and nurses rushed by on their way to see another patient. Like looking into the windows of a passing train, I caught fleeting glimpses into some of the patient rooms. Without exception, the rooms were packed with families and beds, with some crammed against the walls and separated only by a few chairs and a white metal nightstand filled with medical equipment. In the outpatient lobby, scores of people crowded in front of check-in and pick-up windows in lines that were vaguely defined only by the direction that each person was facing. If signs were not present to label each room, one would think he or she might have just walked straight into the middle of the New York Stock Exchange. I was in the hospital for two specific reasons. The first was that my grandfather was experiencing complications due to heart failure, and was being evaluated by the doctors of Fuwai for a few days. The second was that this was my first day – and my first time to shadow – a clinical physician. I was extremely curious about how China had adapted its medical system to accommodate its massive population and eager to witness this firsthand.
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(Just for perspective, China’s population currently exceeds 1.3 billion, and the city of Beijing alone contains roughly 21.5 million residents, which is almost twice the size of New York City and Los Angeles combined.)1 Fuwai Cardiology Hospital sits on the west side of Beijing within the Second Ring Road, the innermost of a set of concentric highways that define the cityscape. Founded in 1957 as a hospital specializing in cardiovascular disease, it stands as a symbol of China’s relatively recent modernity. Currently, its mix of concrete Soviet-style and modern industrial buildings make up a 570,000 square foot facility that employs roughly 3,000 medical workers and supporting staff. For the citizens of China, Fuwai stands as a beacon of hope for those suffering from the rarest and most serious cases of cardiovascular disease. Due to its reputation as one of the leading institutions for cardiovascular care in Asia, patients fly in from all over China to be seen by China’s most qualified cardiologists and surgeons. In 2014, Fuwai treated a total of 470,658 patients, an average of about 1,300 patients per day, according to its cardiovascular medicine outcomes report.2 Despite having familiarized myself with these figures, and having visited Beijing on multiple occasions, nothing prepared me for the overwhelming patient per square foot phenomenon that confronted me as soon as I
stepped foot into the hospital. Yet, the number of patients treated at Fuwai hospital has increased by 174% since 2007 and this number continues to rise. Despite this steady increase in hospital bed occupancy, which reached as high as 105% in 2014, and an increase in the number of interventional therapeutic procedures performed per year, inpatient mortality and average hospitalization days have steadily declined over the last 6 years, and have reached lows of 0.18% and 5.1 days respectively in 2014. How does Fuwai accommodate its increasing patient volume, yet continue to maximize treatment outcomes? It involves addressing social as well as medical factors of heart disease. Overall health in China is continuously affected by three dominant social factors: the growth of cities, the rising socioeconomic status of its residents, and its massive, aging population. These factors all have profound effects on cardiovascular health. Currently, heart disease is identified as the second leading cause of death behind cancer, accounting for 21% of all mortalities. As more of China’s citizens live longer, improve their standard of living, and grow older, the incidence of cardiovascular disease is likely to continue to grow. As the pinnacle of cardiovascular care, Fuwai Cardiology Hospital
Anson Wang
Surgeons and nurses perform a heart transplant on a 30 year-old woman. The team includes Dr. Huang and her colleagues.
YALE GLOBAL HEALTH REVIEW
In 2014, Fuwai treated
70%
The number of patients treated at Fuwai has increased by
470,658
of Chinese physicians have suffered verbal/physical violence from a patient
patients,
174%
an average of 1,300 patients per day
since 2007
FAST FACTS not only offered me an opportunity to see a multitude of patients and the afflictions that ailed them, but it also served as an insightful window into China’s most crucial issues in health in its most extreme cases. With each day that I spent observing the physicians carry on their duties, I learned more about the Chinese health system, its culture, and insights into how medicine adapted to one of the world’s most populous nations.
DAY 1 Dr. Huang was sitting in the transplant office when I entered. The room was cluttered with patient files, eating utensils, and file cabinets. Medical cabinets against the walls housed everything from gauze to IV needles. In the corner of the room was a bunk bed, most likely for anyone working a late night shift in the ward. The office was used by three other physicians as it was the center of all operations that took place on the floor. Dr. Huang was an old colleague of my dad’s back when he used to work in Fuwai as a researcher. She greeted me with a smile and led me to her private office as we chatted about how busy the hospital seemed today and how tall I had grown since the last time we met. Her office was a cozy space, located between the surgical and intensive care wards. Shelves against the wall displayed extensive collections of manuals and journals. Dr. Huang was an internal medicine physician specializing in cardiac transplants. She was in charge of prescreening patients for transplants and recommending
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The lack of privacy surrounding patient care was apparent.
and preparing procedures. She was a very tall woman, around my own height of 5 foot 11 inches, with short curly black hair and a face that radiated with excitement whenever she smiled or joked about her work. She also loved to chat, and could easily carry a conversation by herself. “Let’s go check up on your grandpa first of all, how about that?” she said, before leading me back downstairs. With only five patients sharing his room, my grandfather’s room on the first floor was considered one of the more spacious available. Before he was admitted, he had put up a huge fuss about staying overnight in a hospital, but reluctantly gave in to the pleas of my grandmother and father. After spending no more than half a day in the crowded halls, I could understand his complaints. Even in his room, the lack of privacy surrounding patient care was apparent. Dr. Huang conducted her physical examinations and interview of my grandpa in the open view of other patients and their families. In the United States, patient confidentiality is as sacred to medical care as Sunday mass is to the Catholic faith. However, in China, no one seemed to mind the lack of privacy, as recovery and treatment were everyone’s number one priority. After all, how could you afford privacy in such crowded conditions?
DAY 3
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By the third day I had grown accustomed to the crowded conditions. It was easy to see why there were so many patients. In China, diagnostic and therapeutic care – even in an area as specialized as cardiology – do not require referrals from a primary physician. As a result, any family can walk up to a check-in window in the outpatient lobby and queue for consultation by a cardiologist. If unable to obtain a consultation here, many families turn to emergency services since, by law, the emergency room is required to see every patient that requests care.
Today, I followed Dr. Huang into the emergency room as she made her rounds with her patients. The case we investigated seemed strange, an adult in his mid-twenties reporting symptoms of heart failure and fatigue. He was a portly man, lying sideways on bed number 6 in the corner of the room while playing games on his Samsung Galaxy. His mother and aunt stood nearby, clearly more concerned with the situation than the patient himself. Dr. Huang wasted no time in gathering a comprehensive medical history. “Does he drink?” she asked the mom. “Only in moderation, he drinks a few times a month,” replied the mother, look-
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ing at her son with a grave face. Her accent gave away that we was from the southern region of China, and her expression betrayed a hint of shame. “How much do you consume when you drink?” asked Dr. Huang to the man, still lying sideways. “Maybe a beer…or half a bottle of Er Guo Tou,” he admitted. Er Guo Tou is China’s famous white rice wine, which can sometimes contain up to 60% alcohol. Dr. Huang addressed the mother sternly for concealing the truth. The man revealed that he drank several times a week and consumed more than the average human should to maintain a healthy living. Dr. Huang threatened that if things were to continue, he would need a heart transplant. I was stunned; how could she be so harsh to a patient? “They don’t listen! Patients think they always know what’s best for themselves, or they think they can get better on their own. They’re stubborn folk, and they sometimes don’t trust what you tell them. You need to be stern and confident to communicate to a
patient successfully,” explained Dr. Huang. It certainly came across in her rapid-fire manner of speaking. “But fortunately, they are usually pretty cooperative. They understand that their life is in your hands, and they will do anything to ensure the best of care.” As I learned later from conversations with patients and other physicians in Fuwai, clear communication of the role of patient responsibility is invaluable, sometimes as a recusal of the doctor’s role in the case of poor outcomes. Chinese families
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You need to be stern and confident to communicate to a patient successfully.
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will accept nothing less than the best when the health of their loved ones is concerned, and this sentiment can sometimes take a deadly turn. Reports of doctors being beaten, sometimes to death, by dissatisfied fam-
ilies are far too frequent in Chinese media. According to a report by the Chinese Medical Doctors’ Association, more than 70 percent of physicians surveyed have suffered verbal abuse or physical violence from patients, and 13 percent of doctors and nurses have reported physical injuries. Some say this “patient-doctor conflict” is the result of a broken health system, one that overworks and underpays its doctors, and leaves hospitals and families struggling to pay for care. Others blame social prejudice of doctors that often paints them as civil servants rather than specialists in a highly trained and professional field.3 Prejudice about physicians also involved traditional gender roles. I had many conversations with family members regarding my desire to be a physician. It’s a tiring path, they would say, but rewarding and fitting for a man. Not for a girl though, it’s too stressful; girls should grow up to be teachers.
DAY 5 Families were already lined up in front of the door leading to a small examination
Anson Wang
The main gate of Fuwai Hospital the leads to the emergency room and the main hospital wards.
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YALE GLOBAL HEALTH REVIEW
Anson Wang
Families and patients crowd in the outpatient lobby waiting in line to receive a number for consultation, collect medication, or pay for treatment.
room by the time Dr. Huang and I arrived for work at 7AM. We were seated behind a large metal desk as patients filtered oneby-one into the room to consult Dr. Huang concerning the symptoms that discomforted them. One family I spoke to flew in all the way from Xinjiang, a province located in the westernmost area of China. The complaints frequently were related to symptoms of heart failure or coronary artery disease. Occasionally, a patient’s condition had deteriorated so severely that combination drug therapy provided no further relief. “There really are no other options that can help you. Have you considered changing a heart?” Dr. Huang dropped the news like a cannon ball falling through air. In the United States, the news of a heart transplant would have been handled more delicately. It was surprising how calmly the patient and his family received the news, as if they were already expecting to hear it.
DAY 10 During my second week, I was allowed to observe Dr. Huang and her team perform a heart transplant surgery. I was informed that the hospital performed two or three heart transplant surgeries a day, depending on the rate of delivery of donor hearts. The surgery was performed late at night. I dressed up in scrubs and disinfected myself before entering the operating room. Machines and monitors were laid out neatly, all connected by tubes to a
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figure on a table covered by a green sheet, which I presumed was the patient. The donor heart had already been placed in the chest cavity, and the surgeon was busy connecting all the necessary arteries and veins. I stepped up on the viewing platform which was right next to the patient. The surgeon made conversation with me, but I only dared reply in short phrases. I feared that one wrong word could lead to a slip of the hand, and before I knew it I would have a medical malpractice lawsuit before even reaching medical school. The surgery was fascinating to witness, yet I was the only anxious person in the room. After returning to Dr. Huang’s office, I took the stairwell where I found the patient’s family sitting on foam mats and plastic stools. They immediately stood up upon seeing me, as they’d seen me walk around the hospital with Dr. Huang. “How is she doing?” her mother asked me, her eyes filled with hope and fatigue. I replied that she was doing fine, and that they had just finished the transplant. I reassured her mother that the patient’s new heart was beating fine on its own. The mother and her sister breathed a great sigh of relief and thanked me for my help. I sheepishly said it was no trouble at all, and continued down the stairs. I believe that moments like this are common to all physicians across the world, regardless of their medical systems. It was a moment that reaffirmed my desire to enter the medical profession.
As a leading institution in the diagnosis and treatment of cardiovascular diseases, Fuwai offered a unique perspective into the effects of the Chinese health system, one that relies very crucially on efficiency in order to treat the sheer volume of patients requiring care per day. In an age where health care in the United States faces criticism as a business and calls for better efficiency, lower costs, and shorter hospital wait times, it may be best to turn to other nations to observe how they do it differently. In a nation that is increasingly business driven, it seems only natural to turn back to the numbers. Perhaps health is simply about maximizing the number of patients that are seen and treated by medical professionals, and insuring that these patients recover. As the most populous nation on Earth, China demonstrates that even at extraneous numbers, health care is still possible. We must reflect on the efficiency of our own health care, both from the perspective of individual doctors, to the system as a whole. www
Anson Wang is a junior in Davenport College. He is a Molecular Biophysics & Biochemistry major from New York. Contact him at anson.wang@yale.edu.
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ALTERNATIVE MEDICINE:
HEALTH POLICY
Integrating Modern and Ancient Healing Practices
By Dan Kluger
F
or millions of years, humans have healed themselves using the flora and fauna around them, guided by their own intuitive sense about health. In recent years, humans have vastly increased their survival rates, using Western medicine (also known as allopathic medicine) to treat and cure disease while sometimes dismissing the natural flora and fauna that had aided them for so long. For example, vaccinations, antibiotics, and technologies that decrease infant mortality are incredible advances that have dramatically increased life expectancy worldwide. Although this technological and scientific approach to healing has been incredibly successful, the scientific community should not dismiss the wisdom about the healing process that humans have gained over millions of years.
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used this common vine to treat headaches, the common cold, and joint pain.1 Because the medical establishment has turned away from natural cures such as sarsaparilla or willow tea, it has missed an opportunity to create a medical practice that focuses more on preventative or mild curatives. Instead, people often turn to the most concentrated alternative. For example, many chose to expose their bodies to drugs such as aspirin – which is actually derived from willow – which, according to a study performed by H. Sørensen et al. and published in Nature, can increase one’s risk of major gastrointestinal (GI) bleeding in the esophagus, stomach, and intestines, and in rare cases can have other severe side effects.2 In some cases, researchers find new cures or treatments for diseases when
Tu's story shows the true potential of a combined approach to medicine that merges practices of alternative medicine with those of Western medicine.
Although many of these centuries-old healing practices based their ideas upon an unscientific understanding of the human body, the flora and fauna that were used to heal people in the past could potentially revolutionize medicine today. For example, healers began to treat the sick with a vine known as sarsaparilla centuries before society had the tools to scientifically evaluate its utility. According to L. Taylor, Peruvian indigenous peoples have long
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they re-evaluate herbal remedies discovered by older cultures. For example, researcher Youyou Tu from the China Academy of Chinese Medical Sciences in Beijing will be awarded the 2015 Nobel Prize in Medicine for her discovery of an extremely effective treatment for malaria. In 1969, Tu was appointed to lead a project to combat chloroquine-resistant malaria. She began her research by collecting approximately 2000 candidate recipes from ancient texts and medicinal traditions.
Flickr
Sarsaparilla leaves are commonly cited as an example of an effective natural medicine solution to many diseases.
One of the recipes utilized an extract from the artemesia annua plant called artemisinim, which she discovered was very effective. She then used various Western technologies to reduce the toxicity of the extract while boosting its potency. Tu’s story shows the true potential of a combined approach to medicine that merges knowledge of alternative medicine with the advanced scientific understanding that underpins allopathic medicine.3 Along with traditional herbal medicine, other branches of alternative medicine such as Reiki (sound healing) and acupuncture can also benefit modern medicine. The placebo effect is well documented in Western medicine and has even been shown to stimulate changes in blood pressure, heart rate, and brain activity. A recent Harvard study concluded that different placebos have varying ef-
YALE GLOBAL HEALTH REVIEW
Wikimedia
Acupuncture, either sham or authentic, can have a profound impact on one’s well-being.
fects. Ted Kaptchuk, a Harvard researcher, collaborated with a nearby hospital on a study in which 262 patients with Irritable Bowel Syndrome (IBS) were either given no treatment, sham acupuncture (placebo acupuncture) with minimal interaction from the practitioner, or sham acupuncture with warm care from the practitioner. Warm care consisted of at least 20 minutes of communication, as well as physical contact with the hand or shoulder of the patient. The
group that received warm care experienced the greatest relief of symptoms.4 While this study does not compare the effectiveness of Western and alternative treatments for IBS, it is noteworthy because it indicates that the emotional aspects of treatment impact the healing process. If the scientific community utilizes the wisdom of natural healing
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If we tap into the wisdom garnered during the millions of years in which humans have been trying to heal each other, as alternative medicine does, we will most likely find even more effective methods for optimizing the emotional and mental states of our patients.
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David Goehring
this can be seen in how for cancer patients, alternative medicine utilized early in the treatment process may work as an efficacious supplement to chemotherapeutic treatments, but should not replace modern treatments unless the patient opts solely for a palliative care. While many of the healing procedures used in alternative medicine today alleviate certain ailments by utilizing the placebo effect, it would be difficult to prove their efficacy through the double-blind gold standard used in the scientific community. This is because double-blind experiments seek to prove that a treatment works better than the placebo effect, instead of studying the benefits of the placebo effect itself. Considering the difficulty thus far in proving its efficacy, ideas about the placebo effect beg further research if scientists aim to comprehensively understand the benefits and harms of this form of alternative medicine.
www
Garlic is one of the most powerful healing foods, and can help fight cancer and boost immunity.
methods garnered over millions of years, it will likely find additional methods for optimizing the emotional and mental states of patients. One example of
Dan Kluger is a sophomore in Morse College. Dan is an undeclared major from Connecticut. He can be contacted at dan.kluger@yale.edu.
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GLOBAL HEALTH TODAY
BRAZIL:
The Challenge of Maternal Healthcare
By Rebecca Slutsky
B
razil has the largest economy of all Latin American nations. Despite its economic status and its efforts to improve the health of its citizens, morbidity and mortality statistics remain shockingly high. Nearly 50% of babies are delivered by caesarean section, leading to C-section related complications. Furthermore, over a million illegal abortions are performed each year, suggesting that one in four pregnancies are terminated. Maternal mortality rates (MMRs) are also five to ten times higher in Brazil than in countries of similar economic status.1 These distressing statistics display the deficiencies of the health care system created by the sociopolitical environment of Brazil. Significant regional disparities within Brazil’s poor northern and relatively wealthy southern regions result in socioeconomic differences and unequal access to quality health care. As a result, improving the health system to reduce the high frequency of caesarean sections and illegal abortions represents a major challenge for maternal healthcare in Brazil. If Brazil succeeds, it would reduce MMRs to an acceptable level and measurably improve the health of mothers throughout Brazil. With its tremendously large and ethnically diverse population, Brazil is the fifth largest landmass and eighth largest economy in the world.2 Historically, its size and diversity have contributed to its substantial health and wealth inequities. The population is heavily concentrated in the south and southeast regions, which hold 115 million inhabitants and 56.5% of the population. The northeast also contains 53.5 million inhabitants and 28.2% of the population.3 The two regions with the largest land area, the center-west and north regions, together make up 64% of the landmass of Brazil, yet they contain only 15.2% of the
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population, or 29.1 million people.4 The poorest regions of Brazil are found in the north and northeast. In the past five decades, Brazil has evolved from a predominantly rural society to one in which 84% of the population lives in urban centers. Many of these cities, such as Sao Paulo, Rio de Janeiro, and Belo Horizonte, are located in the Southeastern region.4 The Brazilian population identifies itself as approximately 48% White, 44% Pardo (brown), 7% Black, and 0.3% indigenous.2 The majority of Whites live in the southeastern region, while the majority of Blacks live in the northeastern region. The indigenous people form the majority of the population in the north, northeastern, and center-western regions. The huge disparity of wealth in Brazil, a product of its sheer size and diversity, has greatly affected access to health care in the poorer and more remote regions of the country. The maternal mortality rates in the poorest, northeastern part of the country, for example, are significantly higher than those in the south and southeast.5 As a country with a Catholic majority, Brazil has strict anti-abortion laws. Only women who have been raped or who might die from their pregnancy may induce abortions. Brazil even requires judicial permission for severe fetal malformations such as anencephaly.4 In order to prevent illegal abortions, Brazil has set the sentence for illicit abortion at one to ten years in prison.6 The illegality of abortion has not slowed the rate of abortions in Brazil, however, but has instead contributed to unsafe practices and limited the reliability of abortion statistics. In 2010, a national survey of urban cities concluded that 22% of women between the ages of 35-39 reported inducing an abortion.1 In 2008, abortion related com-
plications accounted for 215,000 hospital admissions, of which only 3,230 were from legal abortions.6 Estimates suggest that 22% of abortions, or roughly one in five, result in hospitalization. This statistic suggests that more than one million induced abortions were performed in 2008. In that same year, three million babies were born in Brazil.1 Though not all illegal abortions result in death, or even abortion-related complications, women of lower classes face the greatest danger. Poor women do not have access to the same quality of health care as members of the upper class, lacking access to basic clean facilities and trained medical professionals. Some women may even decide to induce abortions by themselves. Due to socioeconomic inequality, poor black women in Brazil are also three times more likely to die from unsafe abortions than white women.1
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The illegality of abortion has not stopped the rate of abortions in Brazil, but it has contributed to unsafe practices.
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In an attempt to ensure better access to quality maternal care and lower MMRs from abortion, the Brazilian government passed Provisional Measure 557 in 2012.6 This law created a registry of pregnant women and allowed them to access funding for prenatal care. Some worry, however, that the provision will potentially prevent women from getting abortions, leading to more unsafe abortions and
YALE GLOBAL HEALTH REVIEW
increased rates of maternal mortality.6 Other Catholic Latin American countries, such a Mexico and Argentina, have made substantial progress in reducing abortion-related MMRs. These countries have refocused the debate upon medical statistics that study the social and health effects of illegal abortions in order to advocate for the sexual, reproductive, and basic health rights of women.3 In addition to the high rates of abortion related morbidity and mortality, the number of caesarian sections performed each year is dangerously high. Nearly 50% of babies are delivered by c-section.18 As access to better prenatal care and the likelihood of giving birth in a health facility have increased over the past 20 years, so has the use of caesarean sections and episiotomies. Brazil has the highest C-section rate in the world, with an average of 35% of patients in public hospitals and 80% of patients in private hospitals undergoing the procedure over the past 20 years.1 Yet the World Health Organization requires that the rate of medically necessary caesarean sections in any given population never reach higher than 15%, because the possibility of excessive bleeding, blood clots, infections, and complications from anesthesia makes C-sections much riskier than vaginal births.2 The unnecessarily high rate of caesarian sections in Brazil contributes dangerously to the high rate of maternal morbidity and mortality. Is the high rate of caesarean section due to medical preference or to women’s demand? Some argue that the culture in Brazil promotes the procedure, increasing the rate to abnormal levels. Women schedule caesarean sections to avoid the pain and physical changes that accompany vaginal delivery. In addition, Brazilian doctors have been accused of pressuring women into this otherwise unnecessary procedure merely for their own convenience. In the 1970s, as the procedure was gaining fame, doctors and hospitals earned more for the procedure than they did for vaginal delivery.7 This pay gap contributed to the increasing frequency of caesarean sections. To counteract that trend, Brazil instituted equal pay for all types of deliveries in 1980, but the change only temporarily halted the growth of the C-section rates.8 The government implemented other policies in 1998, 2000, and 2005, but again, they only temporarily slowed the increasing
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trend.1 The upward trend still does not seem to show any signs of reversing, and it continues to contribute significantly to Brazil’s high mortality rates. In contrast, a decrease in income also comes with a decrease in the number of C-sections, as low income hinders access to health services. The small beach town of Itacare, for example, has limited healthcare, because its location in the north of Brazil is over 1.5 hours from the nearest city. Itacare has a hospital with a maternity ward, but that ward is not equipped to perform C-sections. Pregnant women who are able will most likely travel to Ileus, the nearest city, to give birth, because they do not want to risk finding themselves without the option of an emergency caesarean section. Traveling and waiting to give birth in Ileus is expensive, so mothers often ask for or accept C-sections instead of waiting for vaginal births. Unfortunately, because regional public hospitals in the north have higher C-section related mortality rates than private hospitals in the south, undergoing this procedure in Ileus is relatively risky. In addition, many women who cannot afford the travel expenses will simply stay in Itacare, where they cannot access a potentially life-saving medical procedure. As a result, both the high caesarean section rate and the lack of access to necessary caesarean sections contribute to Brazil’s high MMRs.1 The Millennium Summit of the United Nations addressed the high rates of MMRs in Brazil and throughout the
world in 2000 by establishing Millennium Development Goal 5 (MDG 5).7 MDG 5 required that Brazil reach maternal mortality rates of no more than 35 deaths per 100,000 live births.6 Estimating MMRs in Brazil, however, is a tricky process. First, the only recent data on MMRs are limited or inaccurate. In addition, estimates of maternal mortality vary widely because they rely upon a number of different methods for calcution.5 Under-registration of deaths, especially in rural areas and small towns where mortality ratios tend to be highest, as well as the underreporting of maternal causes of death, have decreased only slightly because of new auditing procedures.6 A maternal mortality survey taken in all state capitals in 2010 estimated the MMR in Brazil to be an average of 54.3 deaths per 100,000 live births, a number that ranged from 42 in the south to 73 in the northeast.2 This rate of progress fails to satisfy the requirements of MDG 5, and the goal of 35 deaths per 100,000 live births remains out of reach. Significant regional disparities worsen the unequal access to health care that exists between the north and northeast regions and the south and the southeast regions. Although Brazil’s MMR is still too high, especially when compared with those of neighboring countries like Chile, Argentina, and Uruguay, Brazil has achieved advances in maternal healthcare in the past two decades. Improved socioeconomic conditions and the reform of the health sector have created positive changes. Since the 1990s, government
CDC Global
A mother and her two young child in rural Brazil being interviewed by Field Epidemiology Training Program (FETP) staff.
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policies have focused on social protection mechanisms that include the promotion of social inclusion in all sectors of society. The establishment of the Unified Health System (SUS), the Community Health Worker Programme, and the Programme of Integrated Care for Women’s Health (PAISM) have helped improve women’s sexual and reproductive health.2 Women’s movements have also initiated the creation of new policies, such as the 2000 National Programme for the Humanization of Antenatal, Delivery, and Post-Partum Care. Furthermore, a 2005 ruling encourages the presence of an assistant during labor in public hospitals to provide independent support for mothers.1 In addition, several initiatives have improved surveillance and reporting of maternal deaths. Maternal mortality committees now exist in all municipalities of Brazil. Many Non-Governmental Organizations (NGOs) also focus on improving maternal health and education. A key health reform measure has been
the decentralization of healthcare. An ecological analysis of 2,700 municipalities accounting for 89% of the Brazilian population showed that the municipalities with the greatest decentralization and primary health care expansion also exhibited the largest decrease in mortality rates from 1998 to 2006.9 These health programs turned their focus on the unique sociopolitical climates of the particular regions they served, resulting in improved patient care. The use of contraceptives and the level of antenatal care coverage have both increased, as well as the presence of skilled attendants at deliveries of every socioeconomic group. These changes all indicate Brazil’s efforts to improve equitable access to essential reproductive health services.6 Even as Brazil attempts to reduce socioeconomic differentials in health care, the magnitude of the poor-rich gap in maternal health is still larger than that of other countries of similar economic status. Illegal abortions and unnecessary caesarean sections represent only two
examples of the challenges Brazil must address in order to improve its health care system and deal with fundamental sociopolitical issues. The most pressing challenge now is providing access to the most remote regions of Brazil; for example, the rural populations in the Amazon rainforest and northeast regions where up to 10% of Brazilian municipalities do not even have access to a physician.1 Brazil must increase its efforts to strengthen its health care systems and reduce socioeconomic disparity in order to achieve measurable improvements in maternal health. www
Rebecca Slutsky is a sophomore in Silliman College. Rebecca is an undeclared major from New York. Contact her at rebecca.slutsky@yale.edu.
A mother recovering after delivery. Adequate postnatal care is vital for ensuring the health of mothers and avoiding complications that can result from labor.
Pixabay
VOLUME 3, NO.2
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NUTRITION
UNITED STATES: By Carlin Sheridan
I
n 2013, the American Medical Association formally recognized obesity as a disease for the first time. This designation attempted to combat the widely held misconception that obesity results from simply eating too much or exercising too little.1 Over the past four decades, obesity rates among U.S. teenagers have quadrupled, and today one out of three teens is either overweight or obese.2 Food corporations have significantly influenced the rising obesity epidemic. Their marketing strategies have played a decisive role in the development of this health crisis. It is impossible to avoid marketing in the modern world because of the bombardment of advertisements that society, especially children, face each day. If public health officials and the medical community hope to quell the rise of obesity, they will need to fundamentally change the interactions between the general public and food corporations. David Barboza, a journalist for The New York Times, describes how “the McDonald’s Corporation wants to be everywhere that children are. So besides operating 14,350 restaurants in the United States, it has
plastered its golden arches on dolls, video games, book jackets and even theme parks”.3 Without increased government regulation of food advertising and a shift in public views on all of this marketing, the obesity epidemic will continue to expand.
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There is food and beverage advertising in 70% of American elementary schools and middle schools and 90% of high schools.
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Research has demonstrated the powerful effect of marketing upon the type and quantity of food that people eat. In one study, elementary school children watched a cartoon that contained either a food-related or a nonfood related ad. The children who watched the food advertisement consumed 45% more
Waferboard
Advertising and Child Obesity
of the snack they were given afterward.4 Subtle messages about food, often specifically designed to trigger the body’s hunger response, have become an integral part of the typical television viewing experience. A review of advertising techniques done by the Yale Rudd Center for Food Policy and Obesity, now the UConn Rudd Center for Food Policy and Obesity, found that fast food commercials directly aimed at children have increased by 28% and adolescents today see 40% more restaurant ads than 2002.5 This increase contributes significantly to the obesity epidemic because the malleable minds of children make them easy prey for advertisements. A study of 92 children studied the effect of food-related or non-food related content in a video game on eating habits. The kids exposed to food advertisements within the game chose snacks with greater caloric density and ate significantly more.6 Americans expose themselves to extremely high quantities of advertising, in part due to their tendency to watch excessive amounts of television. Parents often use television as a
U.S. Department of Agriculture
An elementary school in Silver Spring, Maryland implements reforms to improve healthy eating and physical activity habits among students. The USDA’s Food and Nutrition Service runs several programs to combat obesity by providing healthy meals to school children.
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cheap and reliable babysitter. A recent study looked at 207,672 adolescents and children, and found that 89% of adolescents and 79% of children reported one hour or more of daily television exposure.7 This increase in exposure corresponds to the growing overlap of popular culture and food marketing. Children interact with food in a context that references familiar, popular trends; they may receive free toys with their happy meals or watch celebrities and movie characters endorse the products they soon begin to use thereafter. These advertisements have spread beyond the confines of televisions or computers into our off-screen communities. A study published in BioMed Central found that for every 10% increase in food advertising in urban neighborhoods, the odds of high obesity levels increased significantly.8 In 2009, the fast food industry spent over $4.2 billion on TV advertisements, radio, magazines, outdoor advertising, and other forms of media.9 This terrifyingly huge sum includes the smaller, but no less terrifying, $150 million budget for campaigns that took place directly in elementary, middle, and high schools, demonstrating the corporate value of the school-age demographic. Food and beverage advertising exists in 70% of elementary and middle schools and 90% of high schools.10 Companies integrate themselves in students’ social lives, as they claim advertisement space in cafeterias, sponsor school dances, and fund athletic programs.11 An article in The New York Times put it this way: “We’re talking about children being bombarded by propaganda so clever and sophisticated that it amounts to brainwashing, for products that can and do make them sick.”
Gender, race, socioeconomic status, and cultural traditions all play a vital role in shaping an individual’s relationship with food. Companies are aware of this and take advantage of these factors when creating their advertisements. According to a report about digital food marketing, “the goal of contemporary marketing is not simply to expose young people to ads, but rather to foster ongoing engagement- by encouraging them to interact with, befriend, and integrate brands into their personal identities and social worlds.”2 By connecting food products to pop culture, corporations generate enthusiasm among their young targets, who then influence their parents’ choices. A 2010 study by the Yale University Rudd Center for Food Policy and Obesity found that 40% of parents reported that their child asked to eat at McDonald’s at least once a week.11 Recently, the government has attempted to change the way companies market. Under the Obama administration, the White House and the Department of Agriculture have laid out new restrictions to limit advertisements for unhealthy foods on school grounds.13 However, restrictions can be hard to implement because food companies are wealthy, well connected, and accustomed to self-regulation. In 2014, the food and beverage industry spent over $32 million lobbying against governmental attempts to rein in their advertisement campaigns.14 They argue that the right to free speech extends to corporations,
which justifies their right to advertise free from governmental oversight. The attempt to regulate school-based advertisements, although it springs from good intentions, lacks the power to spur real progress. It is time to hold corporations accountable for their role in the obesity crisis. We will struggle to change the way in which the public interacts with food companies, as well as food itself. We will need to win over not only corporate boardrooms, but also classrooms and homes. Government officials must oversee food marketing and product placement, especially in schools. States need to incorporate nutrition courses into their curricula, mixing the importance of vegetables and the dangers of advertising into classes that will create savvy consumers. As new advertising techniques develop, we will need to empower the public to recognize manipulation in all of its forms. The best course of action lies in public education and the regulation of fast food and advertising corporations. Food companies are making America’s children sick, so we as a nation must begin to fight back.
www Carlin Sheridan is a sophomore in Trumbull College. Carlin is a History major from New York. She can be contacted at carlin. sheridan@yale.edu.
Michael Vaca
VOLUME 3, NO.2
21
ECUADOR:
FIELD WORK
By Emma Ryan
Job and Food Insecurity Around the Country’s Coast
O
Over the past decade, rates of diet-related illnesses such as diabetes and hypertension have risen noticeably in coastal Ecuador.1 In this region, essentially every meal consists of a plate that is half filled with rice and half filled with fried fish, with maybe a few slices of cucumber and tomato on the side. Half a plate of rice, multiplied by three meals a day, adds up quickly. As this illustrates, dietary diversity and food insecurity are a challenge for many households in coastal Ecuador. This brings one to question the true root of this problem, is it a lack of knowledge about what constitutes a balanced diet, or lack of access to the necessary food?
hope that the research we collected would prove useful to the clinic’s team. Our research indicated that an average six-person household in the area has a monthly income of $466, a generous estimate given the sporadic nature of employment in the region. The average BMI of the study population was 25.9, which falls in the category of “overweight,” with a large percentage of the population falling in the “obese” category. Diabetes was the principal cause of mortality in Ecuador in 2008, causing more deaths than either cerebrovascular disease or hypertensive heart disease, and the Santa Elena province has the highest diabetes-related mortality per 100,000 people in the entire country.2,3
This past summer, I worked a part of a student-research team that examined the links between dietary diversity, food insecurity, and Body Mass Index (BMI) in coastal towns in the province of Santa Elena, Ecuador. We collaborated with the Futuro Valdivia clinic to conduct research in
What is causing this rise in diabetes and other diet-related illnesses? Over the course of our study, we found that lack of information and nutritional knowledge certainly plays a role in the rise of diet-related illnesses. For example, one woman we spoke with told us that putting lemon
on fried food reduced the amount of fat in the cooking. Beliefs such as this one suggest that certain knowledge barriers should be addressed. For the most part, however, the population had a fairly accurate idea of what constituted an ideal balanced diet. According to many people with whom we spoke, the problem lies principally in the dearth of available, steady employment, rather than a lack of knowledge about a healthy diet. The lack of resources to buy enough fruits and vegetables to maintain a balanced diet constituted the main obstacle to healthy eating, hence the enormous quantities of rice that characterize most Ecuadorean plates. It makes intuitive sense that food insecurity and job insecurity go hand in hand, a relationship that has been demonstrated in studies worldwide.4 After all, in the simplest terms, people need money in order to buy food, unless they are among the small minority who can exist entirely upon subsistence farming. In the coastal region of
Emma Ryan
A meeting with the members of the Casas Viejas community in coastal Ecuador.
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YALE GLOBAL HEALTH REVIEW
Data presenting the household dietary diversity score (HDDS) and body mass index (BMI) among those surveyed in coastal Santa Elena. Data courtesy of Etna Tiburcio, Yale School of Public Health MPH 2017 Candidate.
the Santa Elena province of Ecuador, subsistence farming is a rarity. Most people do contract work on construction projects or work as part-time agricultural laborers. Almost no one in coastal Santa Elena has a steady source of income. According to the World Health Organization, 35.5% of the rural Ecuadorian population lives below the national poverty line.1 Given the almost uniform lack of job security in coastal Ecuador, the high prevalence of food insecurity is unsurprising. We surveyed approximately 250 people to gather information on household dietary diversity scores (HDDS) and food insecurity among the study population. We asked people questions about how often they worried about not having enough food in the house, and if they had to reduce the quantities of food in meals due to lack of money. Our survey found that only 5% of the households were food secure, whereas 32% were mildly food insecure, 31% were moderately food insecure, and 31% were severely food insecure. The level of food insecurity in this region is substantially worse than the overall food insecurity levels in Ecuador, where 33% of households are reported to be food secure, 21% mildly food insecure, 25% moderately food insecure, and 21% of households severely food insecure. Unsurprisingly, people with higher levels of food insecurity also tended to have lower dietary diversity. Overall, approximately 35% of people had dietary diversity scores in the lowest category, but that number climbed closer to 55% for people who were severely food insecure. Conversely, 13% of all participants had dietary diver-
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sity scores in the highest category, while only around 6% of severely food insecure people had high dietary diversity scores. These numbers highlight the fact that a lack of money inhibits both the quantity and diversity of food that people are able to buy. We also conducted multiple focus groups and in each one, participants linked the lack of steady employment with unbalanced diets and their related illnesses. They mentioned the rising price of food, citing the fact that chicken used to cost $1.25 and now sells for $2.00. As a result, people tend to eat large quantities of fish and rice, because “la pobreza no da para comprar otra clase de comida,” (poverty doesn’t allow for buying other types of food). Many focus group participants stressed the difficulty of allocating income to food and other necessities such as clean water and school supplies. They told us that, when faced with long lists of school books to buy for their children, they were often forced to reduce both the quantity and diversity of food that they bought. Parents will often forgo a meal or eat a very small quantity so their children can have something a bit more substantial to eat. In addition to the focus groups and surveys we performed in the coastal towns, we spent two days in the town of Casas Viejas collecting socio-demographic data at the request of Futuro Valdivia. Casas Viejas is a small town in the mountains near the coast that is very challenging to access. The road to get there crosses the river at least 20 times, which meant that the pickup truck we rode in drove down a couple of precariously steep riverbanks and jolted along the rocky riverbed multiple times. We asked people what they considered to be the most
pressing issues facing their community, and 79% stated that a lack of steady employment was the largest problem because it made buying food and medicine difficult and stressful. The second most mentioned problem was the lack of an easily accessible health clinic – the closest one is a three-hour walk away in the town of Jipijapa. These remarks echoed those made by people we spoke with in the coastal focus groups, highlighting again the link between employment and health issues related to poor nutrition. It is tempting to assume that a lack of education drives diet-related illnesses, in part because increasing access to education has proven to be a somewhat concrete and manageable goal. The reality, however, is much more complicated. The people with whom we spoke often knew that diabetes resulted from a poor diet, but the constant job insecurity made it impossible for them to eat a diet healthy enough to prevent the onset of diabetes and other diet-related illnesses. As much as we would like to believe the contrary, even when we enter Ecuador with the best of intentions to educate people about the importance of a balanced diet, we will unfortunately have a limited impact unless a substantial overhaul of the local economy occurs that enables people to maintain a steady income.
www Emma Ryan is a junior in Ezra Stiles College. Emma is an Environmental Studies major and is from Vermont. She can be contacted at emma.ryan@yale.edu.
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FEATURE ARTICLE
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YALE GLOBAL HEALTH REVIEW
THE POWER OF
CONDITIONAL CASH TRANSFER PROGRAMS
by Cindy Alvarez
VOLUME 3, NO.2
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Flickr
Flickr
A
lthough classified as a middle income country, Mexico is characterized by vast inequality that divides the population into the frivolously wealthy and the extremely poor. In 2000, approximately a quarter of Mexico’s population was living in extreme poverty. In other words, a quarter of Mexico’s population did not have enough income to cover basic food needs, much less vital health needs.¹ In fact, in 2000, an estimated 3 to 4 million families incurred catastrophic or impoverishing health expenditures.² In recent years, however, efforts to reduce the inequality gap have begun to pay off. Through a focus on progressive spending on education, health, and nutrition, Mexico has seen the income of the bottom 10 percent grow twice as fast as the income of the top 10 percent.³ The relationship between access to proper education and the overall health and wellbeing of an individual has been studied as a point of interest and utilized by countries to improve their economic state and the health of their population. In 1997, Mexico introduced a program called Progresa, later renamed Oportunidades, based on this relationship. The program’s benefits continue to be significant today, covering roughly 5.8 million poor households or around 19% of households in 2012.3 Why should it matter to a government whether or not its population is healthy? Besides important ethical reasons, there are great economic implications associated with an unhealthy population. When people are unhealthy, they do not go to work or they do not perform as well as their healthier counterparts, resulting in a loss in productivity that is ultimately detrimental to the economy.
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Countries such as Brazil, the Philippines, and Bangladesh are choosing to decrease the burden of the direct and indrect costs of education by sharing these costs and 'helping families invest in human capital...through conditonal cash transfer programs.'
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YALE GLOBAL HEALTH REVIEW
Many African countries, for example, continue to grapple with the effects of malaria on their economies, and it is postulated that their GDPs are actually 37% lower than it would be in the absence of malaria.4 Similar effects on the GDPs of other countries can be caused by other communicable and non-communicable diseases that could perhaps be partly prevented through improved education. Governments are aware of this and are working to find ways to help low income families overcome the barriers they face when enrolling their kids in school. The greatest of these barriers is cost, which grows with the child. For many low income families, not only do the direct costs of keeping a child enrolled in school increase with age through the demand for books, uniforms, and other materials, but the opportunity cost of going to school also increases. As kids get older, they also have the option to work and contribute to the
In 2000, approximately
25%
of Mexico's population was living in extreme poverty.
economic wellbeing of their family. Children who choose to work sacrifice their education and are inadvertently trapped within a cycle of poverty. So how can governments help low income families overcome this barrier and encourage the enrollment of children in school at all ages? Countries such as Brazil, the Philippines, and Bangladesh are choosing to decrease the burden of the direct and indirect costs of education by sharing these costs and “helping families invest in human capital.”1 They accomplish this through conditional cash transfer programs (CCTs). These programs are an opportunity for governments to incentivize specific behaviors in exchange for money. Conditions can range from up-to-date vaccinations to children’s school attendance. CCTs are seen as a cost effective investment on the government’s part, as they will yield
In 2012, Oportunidades' benefits covered approximately
19%
of Mexican households.
better long-term effects and work to break the transmission of poverty from one generation to the next.5 One of the most well-known cases of the use of conditional cash transfer programs is Mexico’s Oportunidades. Oportunidades, originally called Progresa, is a CCT program that was established in 1997, designed to improve the overall health, education, and nutrition of Mexico’s children. At its inception, it primarily targeted rural villages as these were home to the most at-risk populations. Within the education sector, the government incentivized child attendance in school by providing grants from primary school to high school.1 In order to address the increasing opportunity cost that comes with age, the grants increased as the children got older. They ranged from about “$10.50 in the third grade of primary to about $58 for boys and $66 for girls in the
The Pantawid Pamilya conditional cash transfer program has helped bring about near uiversal primary school enrollment of
98%.
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third year of high school.”1 The program yielded positive results; specifically, there was a 30 to 60% increase in regular health visits by children under 5, the proportion of malnourished children decreased by 17.2%, disease incidence decreased by 12% among children under two years of age, and enrollment in secondary school increased by 11% among girls and 7.5% among boys.6 Because of the success brought upon by Oportunidades in Mexico and other conditional cash transfer programs in countries such as Brazil (Bolsa Familia) and Bangladesh, many other nations have begun to consider these programs to tackle issues of poverty, lack of education, and poor health. One example is the Philippines. Although the Philippines underwent economic growth between 2003 and 2006, poverty increased from 24.9% in 2003 to 26.5% in 2009 and the number of poor increased from 22.2 million to 23.1 million from 2006 to 2009.7 Its program, Pantawid Pamilya, was designed to target these issues and includes conditions that require pregnant women to attain pre- and post- natal care and have a trained professional present during childbirth. Children under 5 years of age are also required to receive vaccinations and preventative health checkups.8 Education is an important part of the program, as children aged 3 to 18 must not only enroll in school, but also maintain at least an 85% attendance rate each month.8 A recent assessment of the Philippines’ Pantawid Pamilya conditional cash transfer program found that it has been instrumental in boosting the enrollment of children in primary school and has helped bring about near universal enrollment of this age group.9 The same study also noted a 10% increase in the number of poor mothers receiving antenatal care in areas where the program had been established and a reduction in the rate of severe stunting among poor children aged 6 to 36 months by 10.1%.9 After witnessing the great success of these programs, it may be tempting to suggest that conditional cash transfer programs should become a standard in many, if not all, low income countries. After all, if education promotes health and health is viewed as a human right, governments must do all that they can to ensure equitable access to proper education. However, as stated by Nicholas Rowe in his essay, Mexico’s Oportunidades: Conditional Cash
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Transfers as the Solution to Global Poverty, it is important to acknowledge that in order for a conditional cash transfer program to be successful, we assume that the program will have certain, specific outcomes: “first, that the supply of publicly provided educational and health infrastructure is adequate or an increase in services will follow the increase in demand; second, that the use of educational and health services will result in human capital accumulation; and third, that labor markets will respond to increased human capital with gainful, productive employment opportunities that match demand.”10 Of course, because the economic situation, as well as the cultural and political climate varies dramatically across countries, these assumptions cannot always be justified and success cannot be guaranteed. Critics of CCT programs argue that although they provide an adequate temporary solution for poverty in some countries, they should be seen as no more than that, temporary solutions. Countries should not depend solely on conditional cash transfer programs to solve economic issues and they should not view them as substitutes for proper structural reform.¹1 Indeed, many lower income countries can only afford to maintain families enrolled in the conditional cash transfer program for a couple of years because of a lack of financial and institutional support for the programs.¹2 Even countries, like the Philippines, that have already implemented successful conditional cash transfer programs must continue to face issues that are not completely resolved by the CCTs, such as unsatisfied school enrollment goals at all ages and persistent low vaccination levels among the poor. Thus, although the importance of conditional cash transfer programs in alleviating poverty in the short run cannot be understated, low income countries should continue to pursue efforts to bring about more permanent structural change. However, conditional cash transfer programs’ emphasis on education, health, and nutrition has proved to be predominantly effective, as seen in Mexico and Brazil, and could serve as a paradigm for long-term solutions. These positive effects of CCT programs have been documented, acknowledged, and endorsed by major global institutions such as the World Bank and UNICEF. In the race to meet the Mil-
lennium Development Goals, conditional cash transfer programs were instrumental and now, as we work towards meeting the Sustainable Development Goals, CCTs will continue to have the potential to play a vital role in the fight to end poverty and ensure prosperity for all. www
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After all, if education is a promoter of health and health is to be viewed as a human right, governments must do all that they can to ensure equitable access to proper education.
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Cindy Alvarez is a sophomore in Calhoun College. Cindy is a History of Science, Medicine, and Public Health major from Texas. She can be contacted at cindy.alvarez@yale.edu.
VOLUME 3, NO.2
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HEALTH POLICY
GROWING PAINS: Yale’s Initiatives in Early Childhood Development By Amanda Corcoran
Venkataramesh Kommoju
Young children from a school in Hyderabad, India walking at a zoo.
A
s the correlation between a child’s first few years of life and future well being is becoming increasingly clear, Yale University and the field of global health broadly are responding to the importance of early childhood development. Research from myriad fields supports that a stable and healthy developmental experience has a positive effect on health and social wellbeing for the remainder of one’s life. The effects of childhood experiences are not only limited to the child themself, but also extend to their environment. Societies in which children have negative life experiences at young
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ages are prone to violence and systemic problems that will continue to worsen if the root the children’s early experiences are not improved. It is imperative, both for child health and for societal advancement, that global health players prioritize improving the lives of children and protecting them in their formative years from harmful influences that will hinder their development and future. A child’s development, especially during the “1000 day” window (the time between pregnancy and the child’s second birthday) is crucial to their ability to thrive
in the world. A child’s status during these first 1000 days not only greatly determines how well the child will do in school, but also how they will interact with others, cope with stress, be able to survive diseases, and engage in many other behaviors. For example, children who are poorly cared for or grow up amid violence are likely to later exhibit similar behaviors. Similarly, if a young child repeatedly has challenges in social interactions, they are likely to have social challenges later in life, which further serves to hinder their development. Children and adults without a supportive social network are more
YALE GLOBAL HEALTH REVIEW
likely to become violent, unhealthy, or depressed. Malnutrition also negatively affects cognitive development, as do other factors such as stress or violence. Research from various fields – neurological, social, economic – supports the aforementioned findings.1,2,3,4 Unfortunately, children in many countries face major barriers to a healthy and safe life. According to UNICEF, over 7.6 million children under five die every year, and of those that survive, over 25% do not reach their full potential.5 Lack of access to quality nutrition, poor education about how to care for children, exposure to societal violence, and gender discrimination are just some factors that pose significant challenges to children and exacerbate violence and chronic poverty. Countries that are trapped in cycles of poverty and poor education, cannot escape without a commitment to improve the lives of their next generation.5
tries to develop more effective ECD policies. For example, in fall 2015 Yale worked with the governments of Rwanda and Timor-Leste to implement national ECD programs. The university is also collaborating with two Colombian organizations to strengthen and evaluate programs that help children who are negatively affected by the unstable political situation and extreme poverty. A final Yale-related project is a research project in Lebanon with the Arab Resource Collective to understand the effectiveness of a school readiness and parenting program.
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often see in countries is that sectors (such as health, education, and child protection) tend to work in silos. What this means for children, particularly in vulnerable contexts, is that they may not effectively receive the support in every dimension and as continuously as it is necessary. Increasing sector coordination is difficult, especially in countries where the sectors themselves face significant operational challenges” (A. Ponguta, personal communication, October 20, 2015). In chronically poor countries where ECD services are perhaps most needed, ECD services often do not exist at all. The implementation of strategies is a significant challenge for poor nations. A top-down approach tends to be ineffective, so many conclude that communities need to have a central role in any initiative. Ponguta explains, “articulation and mobilization happens at the grassroots level, and the value-systems of communities with regards to the aspirations for their children are crucial in effectively ensuring holistic development opportunities are granted” (A. Ponguta, personal communication, October 20, 2015). She also notes that there is not a single “best” ECD program; to maximize efficacy, countries must research their own distinct needs and create a unique, nation-specific evidence-based program.
A child’s status during these first 1000 days (time between pregnancy and the child’s second birthday) not only greatly determines how well the child will do in school, but also how they will interact with others, cope with stress, be able to survive diseases, and engage in many other behaviors.
As more people understand the importance of early childhood development (ECD), organizations such as UNICEF are collaborating more in efforts to address this key health issue. To improve early development, cost-effective interventions such as nutritional aid, community educational programs, and violence reduction initiatives are employed.
Yale adopts a multifaceted approach to promote early child development. For example, the Yale Child Study Center, led by Program Director Dr. James Leckman, collaborates with various organizations to research and develop policy initiatives to address this international issue. One of Yale’s partners is the ACEV Foundation (The Mother Child Education Foundation), an organization based in Turkey aiming to empower poor children and families by implementing a mother and child education program in Palestinian refugee camps in Beirut. Another organization with whom Yale collaborates is Empowerment and Resilience in Children Everywhere (ERICE), an Italian non-governmental organization that facilitates cooperation between Israeli and Palestinian health professionals. Yale’s commitment to strengthening ECD systems includes aiding other coun-
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Although many people recognize the importance of ECD, creating effective strategies to address issues is not always easy. Some opponents do not see programs such as parenting education or preparation for schooling as addressing pressing issues, especially in times of extreme stress or crisis. The multidimensionality of ECD can also impede progress. Dr. Angelica Ponguta, Associate Research Scientist at the Yale Child Study Center, has been involved in drafting and implementing ECD policies, and she notes some of the logistical barriers to the issue: “Early childhood development is, by definition, multidimensional. This means that sectors must, to an extent, coordinate their services to ensure all the needs of children are met during the entirety of their developmental trajectory. What we
As the conversation worldwide shifts from simply prioritizing child survival to more broad discussions about strategies to maximize quality of life, ECD assumes a central role in solutions. Every child has the right to a healthy, happy life; strong ECD initiatives will not only improve individual children’s lives, but will also strengthen communities and nations. www
Amanda Corcoran is a sophomore in Branford College majoring in Molecular Biophysics and Biochemistry and Italian. She can be contacted at amanda.corcoran@yale. edu.
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SAMOA:
NUTRITION
Eating Tinned Fish on a Tropical Island By Akielly Hu Akielly Hu
O
n my second day of living with a host family in Samoa, my host siblings and I rode a bus into the capitol city of Apia. I vividly remember peering over the railing at the top of the Apia government building, wide-eyed at the novelty of the view: stark white buildings with bright orange, green, and blue rooftops dotted the mountainous green landscape beyond the crowded city center. The straight, wide roads were fringed with palm trees and bustling with cars – so unlike the empty, winding paved roads of our host village, Satapuala. The winter of my junior year, I stayed in Satapuala for three weeks with the American Youth Leadership Program with Samoa. The purpose of the trip was to study the factors that contribute to obesity and food insecurity in Samoa and reflect upon the similarities and differences with our own country’s nutritional issues.
According to the World Health Organization, over 80% of adults in Samoa are overweight (classified as having a bodymass index or BMI of 25 or greater) and 41.6% of adults in Samoa are obese (having a BMI of 30 or greater).1 As a result, Samoa also has high rates of obesity-related diseases, with 23% of adults affected by diabetes and 21% by hypertension.2 As startling as these figures might seem, the United States’ own statistics don’t trail too far behind -United States’ adult obesity rate is 34.9%, with about 68.8% considered overweight and 9.3% diagnosed with diabetes.3 With such similar statistics, I assumed before visiting Samoa that, like the United States, the prevalence of cheap fast food
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chains like McDonald’s must play a significant role in this high rate of obesity. Yet squinting at the vivid colors against the sunny blue sky on top of the government building, I only spotted one set of tiny golden arches in Apia. In fact, throughout my five or six trips into the small capital city, Samoa’s only urban, commercialized area, I only ever saw that one lone McDonald’s. According to a doctor we met in Apia, barely anyone in Samoa was obese fifty years ago. While Samoa has only recently faced obesity issues, my experience in Samoa revealed that clearly, the abundance of globalized fast food chains was not the reason for this drastic change. PHYSICAL ISOLATION AND AGRICULTURE In order to understand Samoa’s public health issues, one might begin by describing its geographical context. With an area of about 2,800 square kilometers, Samoa is a bit smaller than the state of Rhode Island.4 There are two main islands, Upolu and Sacaii, but most people live on Upolu. While about 37,000 people live in Samoa’s only city (the capital, Apia), the rest of Samoa’s population of about 200,000 lives in villages.4 Samoa is also very isolated; it is located in the chain of Pacific islands that includes Fiji, Tonga, and American Samoa, and lies over 2,000 miles away from New Zealand and over 3,500 miles away from Australia.4 This physical isolation means that imports are both costly and inconvenient. While not entirely inaccessible, buying imported produce requires a substantial trip away from rural villages to a slightly more
populated area with a grocery store. During the three weeks I lived with my host family in the village of Satapuala, the only non-native produce I remember eating are carrots, bok choy (perhaps once or twice), and the occasional apple. By and large, the most affordable and therefore most-eaten foods are locally grown starches: ulu (or breadfruit – a starchy fruit grown on abundant, large-leafed trees that reminded me of both potatoes and plantains), talo (taro – a large export of Samoa), niu (coconut), and fa’i (bananas), along with tropical fruits like fala (pineapple) and esi (papaya). Poor soil quality contributes to the lack of food diversity. “In the United States, you might have 15 feet of top soil. In Samoa, we only have about 8 inches”, a government employee informed us at the Ministry of Agriculture and Fisheries. Because Samoa’s soil is scarce and rocky, people grow local crops on subsistence-level family farms rather than mass-producing a variety of produce on the mechanized, industrial farms we have in the United States. This resulting lack of crop variety, in addition to the country’s lower middle income economic status, leads to less consumption of expensive produce like leafy greens and vegetables and a higher demand for cheaper, imported processed foods. DIET, INCOME, AND CULTURE This recent increase in consumption of processed, imported foods is perhaps the largest contributing factor to Samoa’s obesity rate – and yet another aspect of Samoan life I didn’t anticipate. Having only seen idyllic pictures of a tropical paradise before traveling to Samoa, I expected to eat nothing
YALE GLOBAL HEALTH REVIEW
but fresh fruits and locally caught fish. In reality, the foods I most often ate included corned beef, ramen, white bread, crackers, and “Spaghetti-o’s”. While Samoa’s physical isolation and low crop diversity makes purchasing imported foods a necessity, most imported fresh produce are too expensive to purchase regularly. These barriers result in high consumption of processed canned and packaged foods including Spam, chips, and soda. “All over the world, poor quality and highly energy-dense food is the cheapest,” says Jonathan Shaw, associate director of Baker IDI Heart and Diabetes Institute of Australia.5 These canned or packaged goods are non-perishable and cheaper than expensive imported fruits and vegetables, so
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panied by treats like sweetened milky black tea and homemade cake.4 Samoans still frequently prepare food using their traditional method of cooking with an umu – a fire pit that’s prepared with hot coals, with banana leaves layered over the food to help it cook. For example, an umu is used to create palusami, a coconut cream dipping sauce baked inside taro leaves, freshly baked breadfruit and taro, and pulini, a warm and fluffy banana-based cake steamed inside a banana leaf. Each week, we helped prepare these traditional foods for the to’onai – a large meal for village residents and church leaders held every Sunday after church. Interestingly, Samoan livestock is relatively healthy and most families raise their own chickens and pigs. These free-range Samoan chickens provide both lean meat and fresh eggs.
This physical isolation causes imports to be both costly and rather inconvenient. the Samoan families we encountered overwhelmingly bought these as staples of their diet. Temo Waqanivalu, program officer with the WHO’s Prevention of Non-communicable Diseases department, notes that in many Pacific Island countries, the price of imported processed foods is lower than even native foods, with “fishermen often selling the fish they catch to in turn purchase canned tuna.”5 Ironically (as the ocean was a mere five-minute walk away), I only ate fish once with my host family – and it was tinned. According to Aliioaiga Feturi Elisaia, Samoa’s ambassador to the US and the United Nations, before the arrival of cheap foreign foods, few people in Samoa were obese.6 Now, as a result of this demand for cheap imports, regular consumption of high-energy, processed foods has contributed to Samoa’s poor nutrition and alarmingly high obesity rate. Despite this recent shift towards unhealthy imported foods, traditional food is still a culturally significant part of Samoan life. Evening prayer every night (as 99.1% of Samoans are Christian) was usually accom-
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It is shocking to note how the advent of global trade has transformed Samoan diets and the nation’s economic fabric – family-run kiosks selling imported candy, chips, cookies, and soda, frequented almost daily by my host siblings, were ubiquitous in every village I visited. Dr. Jan Pryor, the Director of Research at the Fiji School of Medicine notes: “Even if you go into a store in a remote village you’ll find shelves of Spam and corned beef.”7 A typical dinner prepared by my Samoan host mother combined both traditional food and Westernized imported food: for example, chicken soup made with ramen, baked breadfruit and taro, and a chop-suey made with corned beef. Almost everywhere I went I encountered a similar mix of traditional foods combined with or made with packaged imported foods and local starches, with few vegetables. This trend is common in the isolated, recently industrialized developing Pacific Island region. A World Health Organization study of eight different Pacific Island countries found that less than 20% of people surveyed reported eating the recommended five or more portions of fruit and vegetables a day.8 Address-
RESPONSES Although obesity remains a pressing issue, Samoa has made several efforts to lower obesity rates and improve food security. In our visit to the Ministry of Agriculture and Fisheries of Samoa, government officials informed us of several programs to overcome challenges of low crop variety, including promotion of the export economy and research into genetically modified crops and local farming methods. Delegates of the Pacific Food Summit in 2010 agreed to increase regulation on nutrition labeling on imports, which often vary in language and content. 8 Additionally, the Ministry of Health in Samoa has initiated physical activity programs in 173 of its primary and secondary schools.9 Continuing and increasing these efforts in agriculture, import regulation, and health education is crucial to further reducing Samoa’s obesity rate. THE COMPLEXITY HEALTH ISSUES
OF
PUBLIC
During my time in Samoa, I quickly learned that a single obesity statistic – 41.6% –encompasses a variety of economic, environmental, and cultural factors. Issues including the price of imports, lack of top soil, poor crop variety, and a food culture now dominated by processed imported foods all contribute to this nutritional imbalance. My observations in Samoa taught me that only by experiencing public health issues firsthand and considering them holistically can we avoid reducing people to mere statistics and begin to address these challenges.
www
<20%
41.6%
of Pacific Island adults eat 5+ servings of fruit and vegetables per day
of adults in Samoa are obese
Akielly Hu
VOLUME 3, NO.2
ing obesity in Samoa would therefore first and foremost require improving access to fruits and vegetables.
Akielly Hu
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T
hese pictures attempt to capture the lush, tropical, and vibrant Samoan way of life, or fa'a Samoa. Many depict the family farm lifestyle, as well as traditional cooking in the umu, or cooking pit. Samoa's culture is rich with traditional foods, church-related activities, art, dancing, and so much more. Above all, the fa'a Samoa is defined by a strong sense of family and community.
SAMOA By Akielly Hu 34
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PHOTOGRAPHY
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Akielly Hu is a freshman in Berkeley College. Akielly is an undeclared major from Washington. She can be contacted at akielly.hu@yale.edu.
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PHOTOGRAPHY
MOROCCO 40
By Grace Yi
YALE GLOBAL HEALTH REVIEW
W
hile Morocco boasts a rich culture and diverse landscape, significant health issues still plague a large proportion of their population. Illnesses resulting from poor sanitation are widespread, and tuberculosis is still an endemic health problem. Morocco is furthermore divided geographically; people living in rural areas experience greater poverty than those in urban areas. However, emerging international markets have contributed to growth in the Moroccan economy and tourism continues to bring in steady revenue.
Grace Yi is a junior in Berkeley College. Grace is a Cognitive Science major from Ohio. She can be contacted at grace.yi@yale.edu.
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NUTRITION
GENDER EQUITY:
DFID
A Path Towards Food Security
I
n a world where many live with plenty, millions still go to bed hungry every night. Women and girls are disproportionately affected by hunger, bearing approximately 60% of the undernourishment burden globally.1 The issue of food insecurity has historically been attributed to climate and weather, war and displacement, and unstable markets. However, one of the most important determinants of food security is gender equality. The lack of gender equality limits a woman’s potential to actively contribute to rural development and agriculture, thus weakening her chance of attaining food security.1 A cross-country study of developing nations found 43% of hunger reduction from 1970 to 1995 was directly attributed to gains in gender equality, almost equaling the reduction of hunger attributed to the combined efforts of increased food availability (26%) and improvements to the environment (19%). An additional 12% of hunger reduction was accredited to increased life
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By Pavane Gorrepati expectancy of women.2 Global comparisons show a strong correlation between hunger and gender inequalities as countries ranking highest on the global hunger index have the most severe gender inequalities.3 Rural men and women also perform different roles when it comes to attaining food security for their communities and households. In many communities, women are responsible for preparing and growing most of the food.4 Additionally, as women tend to spend more of their income on children’s needs and food, gender equality is associated with increased allocation of food to children.5 When the mother controls the household’s budget, a child’s chances of survival increases by 20%.6 Women play a crucial role in determining the household’s diet and the well-being of children, emphasizing the role of gender equity in food security. A key part of gender equity in low-income counties is a woman’s ability to own
land and property.7 Development economist Bina Agarwal, who works on women’s property rights has stated, “…the single most important factor affecting women’s situation is the gender gap in command over property.”1 In the Oxford Bulletin of Economics and Statistics, a positive association was found between a woman’s assets, including land at the time of marriage, and the “share of household expenditures devoted to food.”8 In many low-income countries, gender bias and discrimination manifest themselves in limiting women’s access to land.9 Empirical research in the Journal of Agrarian Change suggests that women are left in a more helpless position when they rely on indirect access to resources.10 A 1999 study showed that when designing and implementing agricultural programs, planners in low income countries lacked gender sensitivity. Additionally, women are often marginalized during negotiations of contracts and leases.11 In many countries, women are the primary users of land, but their rights to land are rarely recognized.
YALE GLOBAL HEALTH REVIEW
If the gender gap is closed, or at a minimum, narrowed, in terms of access to resources such as land, credit, machinery, or chemicals, it helps reduce the global hunger burden and potentially leaves 100 million fewer people living in hunger. Hridoye Mati O Manush
Women farmers are responsible for 60-80% of food production in low income countries, but, globally, own less than 20% of agricultural land.3 When women have secure rights to land, they are better able to engage in household decision making, access credit, participate in off-farm entrepreneurial opportunities, and rent land.5 Land is a source of livelihood and a valued form of property. Owning land buffers against economic shocks and notably provides “almost complete insurance against malnutrition.”4 Women’s ownership of and control over assets affect what a household produces in addition to how the profits from production are distributed within the family.14 A study in Ghana showed that when women own a share of the household farmland, a larger portion of their household income is allocated to food.15 A 2006 study found that when women own land,
their children are less likely to be severely underweight.16 In many sub-Saharan African nations, women’s access to land is determined primarily by family. Local customs typically exclude women from ownership, and land is typically passed patrilineally and held in a man’s name.12 Even a widow’s right to her husband’s land is not secure. A study in Tanzania found the Bahaya, Chagga, and Sambaa peoples tend to keep land within the family, which has led to discrimination against women’s rights to control land.17 Typically daughters are allowed to cultivate land, but cannot exercise rights over it. For land to be used more effectively and have a greater effect in reducing food insecurity, women need more access to land, security of tenure, and control of resources.4 If women have secure rights to land, they will be better able to contribute to household decisions, including those regarding food and nutrition needs.16
Overall, women’s ownership and power over assets affect what households produce and how the profits from these productions are distributed within families. If the gender gap is decreased in terms of access to resources such as land, credit, or machinery, the global hunger burden will be significantly reduced. Thus interventions targeting gender equality have the potential to leave 100 million fewer people living in hunger.
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Pavane Gorrepati is a senior in Ezra Stiles College. Pavane is a History of Science, Medicine, and Public Health major from Iowa. She can be contacted at pavane.gorrepati@yale. edu.
Women farmers are responsible for
But, globally, own less than
While bearing approximately
of food production in low-income countries
of agricultural land
of the global burden of undernourisment
60-80%
20%
60%
SarahTz
VOLUME 3, NO.2
43
Monica Kelly
GLOBAL HEALTH TODAY
By Erika Lynn-Green
UNITED STATES I
Health, Homelessness & Conditional Morality
n 2005, LA Times columnist Steve Lopez met Nathaniel Ayers, a Julliard-educated musician whose diagnosed schizophrenia left him homeless on the streets of Los Angeles. The friendship between the two men grew into a book, as well as the high-profile movie The Soloist. In 2013, with the support of Lopez, a nonprofit organization named Housing Works, and other Los Angeles housing resources, Ayers moved into an apartment with a system of mental health professionals to assist him. His schizophrenia, however, continued to severely inhibit his ability to live on his own. After a conflict with his neighbors, Ayersâ&#x20AC;&#x2122; friends, including Steve Lopez, helped him into a mental health institution. The structured care he received at the mental health facility included talk therapy, monitoring, and anti-psychotic medication. Thanks to this care, Ayers still plays the upright bass, violin, cello, and trumpet. Unfortunately, Ayersâ&#x20AC;&#x2122; level of care and support lies beyond the reach of hundreds of thousands of people who struggle with both health problems and homelessness. Living without a home often exacerbates mental illnesses, substance use disorders, and other diseases such as tuberculosis and HIV/AIDS. Because health problems can make it difficult to avoid or escape homelessness, homelessness
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and poor health form a cycle that few can break without external support. While not all people experiencing homelessness are mentally ill, the factors that cause people to become homeless, such as the inability to pay rent, difficulty finding new housing, or living alone, particularly affect people with mental conditions. The strain of mental illness exacerbates the problems of finding and keeping stable work that pays rent, as well as finding and keeping suitable housing. Many people who suffer from mental illness struggle to find affordable housing that not only provides adequate care for their specific needs, but also does not discriminate against the mentally ill. Without a support network to help with this detailed and difficult search, people with mental illness are at a far greater risk of experiencing homelessness than people without mental illness. According to the 2014 Point-In-Time Count, a biannual nationwide count of those experiencing homelessness, 21% of the 578,000 homeless persons surveyed suffered from a serious mental health condition such as bipolar disorder or schizophrenia. Of those people, 40% lacked any form of shelter. In contrast, only a total of 6%
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of American adults live with a serious mental health condition.1 According to a study by the National Association of State Mental Health Program Directors, Americans living with serious mental health conditions, with or without housing, die on average 25 years younger than other Americans.2 Our interactions with people experiencing homelessness often bias our perceptions of mental illness. Oftentimes, we may brush past a homeless individual with a curt nod, or with no acknowledgment at all. Yet, the experience of homelessness itself greatly shapes mental illness, even if a person experiencing homelessness struggled with a mental health condition beforehand. The extreme stress of experiencing homelessness stems from the daily challenge of finding food and shelter while working, looking for jobs, taking care of children, or going to school. Many US cities also criminalize behaviors associated with homelessness, such as sleeping in public places or in cars; thus making survival even more difficult. The sensation of invisibility experienced even in America’s busiest cities also creates severe mental strain. Imagine crying out for help in a crowded room, and watching as everyone around you ignores your pain. From a neurological perspective, this stress alone can damage neurogenesis and create a feedback loop that increases one’s vulnerability to mental illness. Stress elevates glucocorticoid levels, which regulates white matter in the brain. White matter changes have been linked to schizophrenia, bipolar disorder, and PTSD, among other serious mental health conditions. Homelessness itself can act as a traumatic event, which further perpetuates this brain chemistry spiral. Many people experiencing homelessness also lack access to adequate health services. Utilizing a clinic or health care
21%
of homeless people suffer from a mental health condition
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center, even one specifically designed to serve people experiencing homelessness, becomes exponentially more difficult. While Federally Qualified Health Centers and Health Care for the Homeless Clinics provide crucial, basic health care for free, treating serious mental health conditions over time often requires health insurance.3 Even with Medicare and Medicaid, which cover over 27% of all mental health care in the US,4 parity in mental health insurance varies greatly depending on the state. Most insurance plans do not cover mental illnesses to the same extent as physical illnesses, in part because mental health treatment can be prohibitively expensive. Those without insurance do not have access to early visits or screenings, check-ups, or prescriptions. As a result, health conditions often worsen until they require hospitalization, which is one of the most expensive treatment options for individuals and for the US health system.
“
Homelessness and poor health form a cycle that few can break without external support.
”
Another common negative cultural association of Americans is the belief that people experiencing homelessness abuse alcohol and/or illicit drugs. Indeed, in the 2014 Point-In-Time Count, 20% of the surveyed people experiencing homelessness suffered from a chronic substance use disorder; 40% of that population, moreover, lived without any kind of shelter.1 These numbers correlate closely with the count of those suffering from mental health conditions on the street. Together, people with mental illness
Only
6%
of non-homeless adults suffer from a mental health condition
and with substance use disorders make up more than 40% of all persons experiencing homelessness in America, a total of over 240,000 people,5 even without looking at the overlap between these groups, chronic homelessness, and veteran homelessness. Homelessness and substance abuse disorders can create a self-reinforcing cycle similar to that of mental illness, albeit with several distinctions. Testable disqualification for various housing programs due to the illegality of many drugs and the instability of their users creates an additional problem for addicts, especially with the ease of modern drug testing. Many shelters, buildings, programs, and jobs require sobriety as a prerequisite for consideration. High arrest rates and mandatory sentences for the use of drugs like cocaine further compound this problem. Once he or she has a felony record, a person experiencing homelessness will find it nearly impossible to find good, affordable housing with supportive services. While civil rights laws that govern housing require an individualized assessment of each housing applicant, these assessments often require the applicant to first enroll in a recovery program, even though quality rehabilitation is very expensive.6 The application decision rests solely on the housing provider or landlord. As a result, people with mental illness, substance use disorders, or criminal records often cannot attain suitable accommodation. The current “three-quarter housing” problem in New York City represents one result of the national housing crisis – people struggling with addiction or mental illness cram into “sober,” or “transitional,” homes, which in reality are unregulated housing where stability and constancy depends entirely on the decision of the landlord. New York City Mayor Bill de Blasio recently criticized landlords for “exploiting addicts and homeless people by taking kickbacks on Medicaid fees for
20%
of homeless people suffer from a chronic substance abuse disorder
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drug treatment while forcing them to live in squalid, illegal conditions.”7 Even Public Housing Agencies (PHA) such as Section 8, a low-income voucher-based housing program, or public housing apartments, will not accept applicants unless their criminal conviction occurred “a reasonable time” in the past.8 Any “drug-related criminal activity” can also mean immediate disqualification from PHA. These policies affect whole families by evicting those who have been convicted of a drug-related crime. Traditional services like halfway houses, which work to support people with a history of mental illness, substance abuse disorders, or criminal onvictions, can effectively transition those in their care to permanent housing and help sustain that permanent change. If such a transition fails, then those who need longterm support are left at great risk. The lack of permanent supportive housing that provides rehabilitative, health, and job-related services creates an environment in which people with substance abuse disorders must stop using any drugs order to receive help, sometimes an unachievable request for those who have been struggling with their disorder for years.
“
Poor health and poverty are not moral failings, and housing should not be conditional.
”
People experiencing homelessness are also more susceptible to a variety of ailments, such as tuberculosis (TB), virulent influenza, pneumonia, and illnesses related to poor hygiene.9 High rates of HIV/AIDS also persist among people experiencing homelessness, especially in conjunction with substance abuse and intravenous drug use. These health problems stem from environmental exposure, lack of access to safe water and sanitation, and sexual violence.9 The latter particularly affects wom-
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Patrick Feller
A homeless man asleep with his belongings beneath the Highway 90 bridge in Richmond, TX.
en living on their own or with dependents. Living without a guarantee of personal safety, whether on the street, in shelters, or in precarious living situations, creates vulnerability to sexual violence from acquaintances, strangers, sex traffickers, or intimate partners. The fact that people experiencing homelessness often avoid the police also increases their risk of being victims of violence. Low vaccination rates related to poor health coverage also contribute to the prevalence of health conditions otherwise uncommon in the United States.9 Illnesses such as pneumonia and TB often spread in high-density shelters or shared apartments. Poor bedding, limited access to washing machines, and a lack of clean clothing can cause scabies and infectious diseases such as Bartonella quintana, the pathogen that caused trench fever during World War I.10 Health care and hospitalization do not suffice to permanently treat illnesses so closely tied to living conditions, especially since illnesses such as HIV/AIDS require extensive treatment and an elaborate prescription regimen that must be rigorously maintained. This treatment is not accessible or feasible without health insurance and daily stability. An overarching problem with the intersection of homelessness and public health is the sense of moral judgment with which our society views mental illness, substance use, sexually or intravenously transmitted diseases, poor hygiene, and homelessness itself. The unacceptable living conditions
of people experiencing homelessness repel society at large, which often leave the people who dwell in these conditions ignored. Through requirements of sobriety, discrimination towards the mentally ill, refusal to accommodate convicted offenders, low employment rates among populations vulnerable to homelessness, and rejection of those with different lifestyles, it is virtually impossible to recover from homelessness or poor health conditions without money and support, neither of which American society provides adequately. Poor health and poverty are not moral failings, and housing should not be conditional. Housing should take priority, without any prerequisites. If someone’s health condition causes her to lose the roof above her head, her support should not disappear. We need a comprehensive system of Permanent Supportive Housing, a movement that integrates systems of treatment into housing so that people can experience a combination of stability, sanitation, education services, job services, and health services. Lasting change for more than half a million homeless Americans comes from improving health care and ending homelessness. www Erika Lynn-Green is a sophomore in Calhoun College. Erika is an English major from California. Contact her at erika.lynn-green@yale.edu.
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Feans
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