Can the census help us reach our global goals?

On September 25, 2015, the UN General Assembly adopted the Sustainable Development Goals (SDGs) to be completed by 2030.  Seventeen goals with 169 targets fall neatly within a framework of People, Planet, Prosperity, Peace, and Partnership.


To estimate the likelihood of reaching these goals in the next 14-odd years, it is helpful to evaluate the shortcomings of the SDGs’ predecessor.  Established in 2000, the Millennium Development Goals (MDGs) consisted of 8 goals to be achieved by 2015.  Called the “most successful anti-poverty movement in history,” the MDGs made inroads in reducing global poverty, but there is still much to do.

A literature review finds that the MDGs were more favorable to wealthy countries, which for all intents and purposes had met or exceeded the 8 goals prior to inception.  In the development stage, only 22% of member parliaments were involved. Others argue that the MDGs ignored local and governmental capacity in poorer countries and limited policy growth by narrowing focus.  Rather than setting goals realistic for each country’s individual baseline and capacities, the MDGs ‘ghettoize the problem of development and locates it firmly in the third world.’  The final limitation of the MDGs speaks to issues of data collection and surveillance in developing countries.  Reliance on national averages and aggregated data ignored the world’s poorest, meaning they would be the last to benefit.

A video recently released by WHO’s YouTube page culminates with the sentiment “The world needs better health data and ICD is delivering it.”

The ICD or International Classification of Diseases allows global users to share health information about mortality and morbidity.  ICD counts deaths as well as diseases, injuries, symptoms, reasons for encounter, factors that influence health status, and external causes of disease.

ICD is less useful and utilized in developing countries.  In the least developed countries, health records, including birth and death records, are not well recorded and may be based on second-hand information or less scientific means such as verbal autopsies.  Is the ICD accessible to developing countries, ostensibly the same countries who share the largest burden of poverty and disease?  What are the fundamental gaps in data collection and utilization that must be ratified before progress is observed?

One of the first steps to usable data is the census.  A timely, accurate census is the foundation for public health policy and development:

Census data can, for example, highlight sex-ratio imbalance, identify trends in migration, fertility, nuptiality and population ageing. Such information is the bedrock of almost all aspects of human, social and economic development. It helps governments determine the number of schools, hospitals or highways to be constructed, or the kind of programs that should target young and older people, as well as women. Censuses thus contribute to reducing poverty, ensuring sustainable development and supporting reproductive rights and gender equality.

The United Nations Population Fund provides technical and financial support to assist developing countries with census efforts.  When a developing country conducts a census, the results can be unexpected.  Afghanistan’s 2010 census – its first since 1979 – found lower fertility rates and higher contraceptive use than anticipated.  In very remote areas, there is limited data to base projections on, such as in areas of Myanmar where there was no reliable data even on total population.

The 2030 Agenda is built on the assumption that every country will be able to identify and locate the most vulnerable groups, but over 109 countries in the world today don’t have vital statistics and registration. We still need to develop better ways to reach those who have historically gone uncounted.

– Dr. Babatunde Osotimehin, UNFPA Executive Director

Without accurate census information, are we putting the proverbial cart before the horse?

Finally, a #humanrights win for #HIV in Korea

Note: This was cross-posted to my own blog.

Seven years after it dismissed initial complaints against the South Korean Ministry of Justice’s (MOJ) policy of mandatory HIV and drug tests for foreign English teachers, the National Human Rights Commission of Korea (NHRCK) has (finally!) recommended that the MOJ remove the testing requirement. NHRCK’s recommendation follows the decision of the UN’s Committee on the Elimination of Racial Discrimination (CERD) in May 2015, which stated that the MOJ’s policy requiring a health check which includes HIV and drug tests for native-speaking English teachers (those on the E-2 visa) constitutes racial discrimination.

The complaint which led to the ruling, filed by a teacher from New Zealand against the Ulsan Metropolitan Office of Education, was initially submitted to the NHRCK in 2009 when the testing policy was first implemented. Unfortunately, the commission dismissed it, along with 50 others protesting the policy, and cancelled its initial plans for a public hearing on the grounds that they were not willing to hear cases on individual complaints. (You can read more about the NHRCK’s decision and the events leading up to it in a paper (PDF) by Ben Wagner, the human rights attorney who filed the case on the New Zealand teacher’s behalf.) In dismissing the complaints, however, the commission allowed the case to be taken to the CERD, where it was accepted in 2012.

Now the commission has formally backed the CERD’s ruling, which – despite the fact that it took seven years to get there – is a big win on the topic. HIV is a forgotten disease (PDF) in South Korea and is incredibly stigmatized, which makes it easy for government agencies like the MOJ to codify this kind of direct discrimination without any public outrage or pushback from within the country. In this sense, the challenge to this ongoing affront to human rights from an authoritative domestic institution is crucial. In particular, the commission’s decision calls out the MOJ’s policy as blatant racial discrimination, specifically citing the fact (also noted in the CERD’s decision) that the tests have no basis in the protection of public health because both Korean nationals and non-citizen ethnic Koreans are exempt from the testing requirement:

[T]he Ministry of Justice takes a stand that an independent state is bestowed with wide discretion in its immigration control and, in particular, such tests are indispensable as the instructors are supposed to protect young students and facilitate a safe environment and public health.

However, as noted by the CERD, even the vast discretion embedded in immigration control hardly renders it reasonable that while Korean teachers and ethnically Korean foreign language instructors are exempted from the testing, only foreign E-2 visa holders are under an obligation to test for HIV. Likewise, the concerns about a safe public health environment offer little ground for different treatment between ethnically Korean teachers and foreign instructors with E-2 visas.

Second, it points out that the policy has the potential to stigmatize foreigners as being high-risk for HIV and thus lead the general public to believe that they are not at risk for infection. This is important, as the country’s HIV infection rate continues to climb.

The MOJ never responded to, or changed its testing policies in response to, the UN CERD’s ruling. Hopefully the Korean government will be more responsive to a ruling from a domestic institution, but there is no way to know for sure. However, foreign English teachers now have a resource to challenge the testing if they wish. The NHRCK decision explicitly states that the UN CERD decision carries the same authority as domestic Korean law:

Article 6 (1) of the [Korean] Constitution states, “Treaties duly concluded and promulgated under the Constitution and the generally recognized rules of international law shall have the same effect as the domestic laws of the Republic of Korea,” indicating that the country has a legally binding obligation to facilitate the rights prescribed by the treaty to which it agrees by means of accession, ratification or succession. Article 26 of the Vienna Convention on the Law of Treaties stipulates, “Every treaty in force is binding upon the parties to it and must be performed by them in good faith,” while Article 27 states, “A party may not invoke the provisions of its internal law as justification for its failure to perform a treaty.”

English teachers may be able to use the CERD decision to persuade their employers not to require the HIV test; alternatively, they have the option to file a complaint with the NHRCK (either named or anonymous) and/or the UN CERD Secretariat. The full decision has been made available by Matt von Volkenburg on Gusts of Popular Feeling.

Shameless plug: I will be presenting on this topic, including successes and ongoing advocacy initiatives, at this year’s APHA Annual Meeting in Denver.

A Trump presidency would be a catastrophe for global health and human rights

With less than a month till the U.S. Presidential election, UN High Commissioner for Human Rights Zeid Radd al Hussein has taken a stand against Donald Trump, calling him a threat to international affairs:

If Donald Trump is elected on the basis of what he has said already – and unless that changes – I think it is without any doubt that he would be dangerous from an international point of view.

The High Commissioner isn’t alone. The Economist‘s Intelligence Unit ranked a Trump presidency sixth on their list of global threats, just after jihadi terrorism destabilizing the global economy.

The Economist might have a point. Trump has made numerous comments that indicate that neither health nor human rights will be prioritized in his administration’s foreign policy:

I would bring back waterboarding and I’d bring back a hell of a lot worse than waterboarding. (Republican Presidential Debate, ABC News 2016 )

What I won’t do is take in two hundred thousand Syrians who could be ISIS. (Face the Nation, CBS – 2015)

This is reinforced by the unusual cadre of suspect world leaders (read: perpetrators of human rights abuses) that he has singled out for praise, including Kim Jong-eun, Saddam Hussein, and Vladimir Putin.

At the moment, Trump is all talk. However, should he be elected and even one of his portentous assertions be made manifest, both health and human rights – which in many cases are inextricably linked – will be imperiled. Here is a look at how Trump might influence health at home and abroad.

Sexual assault
In 2013, Trump dismissed the U.S. military’s atrocious sexual assault record on Twitter in his usual style:

26,000 unreported sexual assaults in the military-only 238 convictions. What did these geniuses expect when they put men & women together?

What Trump’s tweet fails to grasp is that more than half of reported military sexual assault victims are men.


Like the perpetrators of these assaults, Trump struggles with issues of consent. Even if we ignore recently surfaced audio of Trump boasting about inappropriately grabbing women or comments made about women consciously and unconsciously flirting with him, Trump has a history of hiring men with dubious ideologies and records. His own private council and a top executive at The Trump Organization, Michael Cohen, recently stated that women cannot be raped by their husbands, in response to decades-old allegations by Trump’s first wife. Ahead of his September 26th presidential debate, Trump was advised by Roger Ailes, former Fox News chairman who was fired by the network amid sexual harassment allegations. As President, Trump would appoint more than 6,000 federal positions, including top officials for all federal agencies.

Reproductive rights
Abortion in the US was legalized in 1973, in part to reduce the public health toll of illegal abortions especially as they impacted low-income women. Shortly after legalization, deaths and hospitalizations due to unsafe abortion practices significantly decreased. However, access to abortion is constantly challenged in the States, through measures such as Texas’s recently-defeated HB2 and legislation that puts restrictions on the administration of medication abortion. Thirty-seven states require prescription of the dual dose by a licensed physician, while 19 others require that a licensed physician be physically present when the medications are taken. As the scope of reproductive rights grow slimmer, what American women need is a champion, not a leader whose basic understanding of female anatomy is that they bleed out of their “wherever.”


Trump (despite describing himself as “very pro-choice” when he flirted with a presidential run in 1999) appears to be prepared to encourage the erosion of this ever-embattled constitutional right: in a town hall meeting in March, he voiced his support for the criminalization of abortion and stated that women who seek them should face “some sort of punishment.” He quickly backed down from this extreme position in response to public backlash (even from those within his own party), but his potential ability to appoint up to four Supreme Court justices creates the specter of encroachment on women’s rights. At a time when reproductive choice is finally beginning to see some forward movement around the globe in countries such as Poland and the Philippines. If US law heads in that direction, it could embolden other countries to go the way of Northern Ireland.

Religious discrimination
Trump has taken a hard line on his views of the world’s Muslim population. Besides proposing a ban on Muslims entering the U.S., Trump suggested that all Muslim-Americans be tracked through a surveillance system. Many drew comparisons to Nazi Germany, but in an interview with George Stephanopoulos, Trump justified his proposal by saying it was no worse than the internment of Japanese-Americans under the purview of Franklin D. Roosevelt . A report by the Commission on Wartime Relocation and Internment of Civilians found the internment camps “were motivated largely by racial prejudice, wartime hysteria, and a failure of political leadership.”

War and war crimes in the Middle East
War is a guaranteed human rights catastrophe, and the devastation that armed conflict wreaks on public health infrastructure and health systems is myriad and far-reaching. In addition to the direct destruction of hospitals and killing, often directly and intentionally, of health workers, war and conflict can reverse decades of progress toward eradicating diseases – as evidenced by the recent reemergence of polio in conflict zones. US military activity has been responsible for much of this kind of damage in the Middle East. Iraq’s healthcare infrastructure may never fully recover from the first Gulf War in 1991 and the subsequent 2003 invasion. As it stands, nearly 97% of Iraqi families have no health insurance, and even if they do there are only 7.8 doctors per 10,000 patients, a rate miniscule in comparison to neighbors such as Jordan and Lebanon. Personal safety and security are the top reason physician recruitment and retention in this country is so difficult, according to Médecins sans Frontières (MSF). Additionally, Syria and Yemen are humanitarian tragedies due to ongoing American coalition-funded proxy wars.

Adding nuclear weapons to the mix hardly seems imaginable, but Trump seems to have a bit of a trigger finger when it comes to nuclear weapons. On a morning news show, Trump said that he would never rule out the use of nuclear weapons against ISIS, citing “unpredictability” as a central theme of his foreign policy agenda.

The candidate has also advocated the murder of terrorists’ families, which, as John Oliver helpfully reminds us, is a war crime:

The other thing with the terrorists is you have to take out their families, when you get these terrorists, you have to take out their families. They care about their lives, don’t kid yourself. When they say they don’t care about their lives, you have to take out their families.

Trump has indicated that he is willing to compel servicemen and women to do this and commit other war crimes, such as torture detainees:

They won’t refuse. They’re not going to refuse me. If I say do it, they’re going to do it.

These statements (and many more) have been made – in public fora and broadcasts – since Trump announced his presidential bid 485 days ago. The American voter can only speculate what other dubious position statements will emerge in the scant weeks leading up to election day. Is Trump a threat to global health and human rights? That is a personal call each voter will have to make on November 8th.

Global News Round Up

Politics & Policies

Until last week, Congress had appropriated exactly zero dollars in emergency funding to support Zika prevention, public education, and reproductive health services, leaving women to bear the burden.

Thai authorities have decided that pregnant women infected with Zika virus can undergo abortion without legal consequences.

Venezuela has become dangerous for the healthy, it is now deadly for those who fall ill.
One in three people admitted to public hospitals last year died, the government reports.

The Census Bureau released a report last week showing continued improvements in the uninsured rate between 2014 and 2015 following the implementation of the major coverage provisions of the Affordable Care Act (ACA).

Boosting developing nations’ access to medical advances is top of the agenda at Berlin’s World Health Summit, but will it improve healthcare for the poorest?

Valentin Fuster, MD, PhD, director of Mount Sinai Heart and physician-in-chief of The Mount Sinai Hospital, has been appointed co-chair of the consensus committee on global health that will advise the next presidential administration.

It’s gratifying when global health research affects policy. This was the case when Peru’s federal government declared a state of emergency after the publication of a report by DGHI researchers showing the distressing impact of gold mining on the health of people living downriver from mines in the Peruvian Amazon.

Programs, Grants and Awards

The Health Scholars Program  provides outstanding Princeton students with funding for travel and research to pursue global health-related internships and senior thesis research, both in the US and abroad. This competitive program, administered by the Center for Health and Wellbeing, is open to students from all departments.

World Mental Health Day is observed on 10 October every year, with the overall objective of raising awareness of mental health issues around the world and mobilizing efforts in support of mental health.


Researchers have completed the most up-to-date analysis on the state of the world’s health to equip governments and donors with evidence to identify national health challenges and priorities for intervention.

In this pilot study, we found that a colorimetric system using AuNPs and MSP10 DNA detection in urine can provide fast, easy, and inexpensive identification of P. Vivax.

Cutaneous anthrax, a disease associated with biological terrorism in western countries, is common and underreported in the rural areas of Africa .It can be lethal in some cases, especially when the oropharyngeal area is affected after ingesting meat from contaminated sources.

The most up-to-date analysis of the world’s health shows that while life expectancy has increased, about 7 in 10 deaths are due to non-communicable diseases. You can access these articles here.

Researchers have sequenced the full-length genome of a Zika virus taken from a patient in Brazil and identified a virus-derived molecule that inhibits part of the infected person’s immune system.

We use national population-based survey data to quantify diabetes prevalence and met and unmet need for diabetes diagnosis and care in 12 countries in sub-Saharan Africa. We further estimate demographic and economic gradients of met need for diabetes diagnosis and care.

Diseases & Disasters

Zika infections are expected to continue rising in the Asia-Pacific region, where authorities are increasing surveillance, preparing responses to complications and collaborating on information about the disease, the World Health Organization said Monday.

Every few years, a group of federal agencies publishes a raft of data on every conceivable subject affecting older people.  At every age, the report shows, older men are far more likely to be married than older women.

It’s dangerous to be a doctor in Afghanistan.  This is what the staff deal with most days at a hospital in the country’s north-west: physical attacks by patients’ relatives; gun-wielding soldiers inside the wards; and verbal assaults and threats of bodily harm against doctors and nurses who are only trying to help.

Myanmar’s largest city, Yangon is capturing some of its tens of thousands of stray dogs, using blowpipes to sedate them for neutering and vaccinations to combat a rabies epidemic.

After Hurricane Matthew slashed through the impoverished nation of Haiti on Tuesday, leaving death and destruction its wake, the country may be facing another deadly crisis:  a surge in cholera.

Life expectancy has increased by 10 years across the globe in the past 35 years, thanks in part to efforts to treat infectious diseases such as AIDS and malaria, but diet, obesity and drug use are now major causes of death and disability while too many women still die in childbirth, data reveals.

In 2007, a World Health Organization committee said shift work “probably” had a link to breast cancer, based on studies of animals and people.  But this new work by leading UK cancer experts looked at data on 1.4 million women and found there was no association with night shift work.

The Region of the Americas is the first in the world to have eliminated measles, a viral disease that can cause severe health problems, including pneumonia, blindness, brain swelling and even death. This achievement culminates a 22-year effort involving mass vaccination against measles, mumps and rubella throughout the Americas.

A 10th of children have a “monkey-like” immune system that stops them developing AIDS, a study suggests.

Hypertension (high blood pressure) is the leading risk factor for heart disease and stroke and is responsible for 9.4 million largely preventable deaths worldwide – more than tobacco. Thirty three percent of adults in Barbados have high blood pressure, and they develop it for largely the same reasons as people in other developing countries: not getting enough exercise and eating an unhealthy diet.

Those who are malnourished are set to be, by far, the biggest casualties of Yemen’s war. More than 6,000 people have been killed in the bombing and fighting.

International aid agencies have called for millions of dollars of funding for an urgent relief effort in North Korea after floods in the country’s remote north-east in August left 70,000 people homeless and 600,000 others in need of humanitarian assistance, including tens of thousands of children.

With more than 65 million people displaced globally – the most there have been since World War II – the global refugee crisis has captured the attention of aid groups and political leaders worldwide.


As drones quickly pick up momentum around the world in everything from military strikes to pizza delivery, Africa, the continent with some of the most entrenched humanitarian crises, hopes the technology will bring progress.

Researchers at McMaster University and two American universities have taken another step closer to developing a much more effective, “one-punch” universal flu vaccine.

The Microsoft co-founder and philanthropic leader sets out an agenda of global issues that he thinks whoever wins the presidential election should address.

In 2014, the Senegal Ministry of Health and Social Action (MOHSA) began the development of a national eHealth strategy.

The U.S. Department of Health and Human Services (HHS) has announced progress on several fronts to develop vaccines that protect against Zika and yellow fever viruses.

Environmental Health

According a new interactive air quality map released by the WHO, nearly 92% of the world’s population lives in areas where outdoor air quality do not meet WHO standards.

While members from the least developed countries applauded the ratification of the Paris deal, they have urged that financial support be made available swiftly in order to start implementing their plans to curb emissions.

The Quest CCS (carbon capture and storage) project near Edmonton announced last week that it successfully stored one million tonnes of carbon dioxide deep underground in its first year of operation. That’s equal to the emissions from about 250,000 cars.

Equity & Disparities

A new measure of development from the Global Burden of Disease study, called the Socio-demographic Index (SDI) aims to use a finer yardstick of development to accurately reflect the reality among disenfranchised populations.

A quarter of a billion children across the globe may not achieve their full potential because of extreme poverty and stunting, says a series of papers published in The Lancet.

New research published in the journal Urology reveals that African-American and Hispanic men in the US were less likely to receive treatment for prostate cancer. The study was based on 327,641 men diagnosed with localized prostate cancers reported to the SEER program between 2004 and 2011.

In order to achieve the education goals put forth in the SDGs by 2030, the international community needs to recruit and train 69 million teachers. South Africa and South Asia are most affected by the shortage of well trained teachers.

When it comes to health, there are many factors that influence how long and how well people will live, from the quality of their education to the cleanliness of their environment. But of all social determinants of health, research shows there is one that is perhaps the most influential: income.

Dr. Jim Kim, the president of the World Bank and one of the founders of Partners in Health, recently gave a talk about changing the focus of the World Bank, and cited two leading principles: “A preferential option for the poor and evidence-based medicine.” I could not agree more, and I suspect many in global health are guided by a similar set of values.

The 2016 Lancet Advancing Early Childhood Development series updates the science on various aspects of early childhood including epigenetic effects of adverse childhood experiences on brain development and cognition. The series also focuses on strategies for implementation of early childhood programs at scale.

The global news round up was prepared by the communications team.

Food for thought: can Meatless Monday save the planet?

World-renowned researchers, physicians, government officials, and industry leaders are meeting today in Berlin to discuss the state of global health.  Amidst presentations and discussions about non-communicable diseases, global health security, and priority issues in conflict zones, the attendees of the World Health Summit will gather together to break bread.  The menu might look a little different this year, as the Summit will jump on the Meatless Monday bandwagon.

The brainchild of Sid Learner, in partnership with Johns Hopkins Bloomberg School of Public Health, Meatless Monday was established in 2003 to reduce reliance on red meat, improve chronic disease, and protect the environment.  Meatless Monday is now active in 44 countries – from Bhutan to Togo.

Could wider adoption of Meatless Monday or less reliance on meat as a diet staple prove a boon for food scarcity, health, and reduction of green house gases?  When so much of the world suffers from malnutrition, is this fad a luxury or a necessity?

The ills of large-scale factory farming are well established.  These facilities, known in the US as concentrated animal feeding operations (CAFO), can each produce up to 1.6 million tons of manure a year, more waste than a U.S. city.  Unlike human waste infrastructure, there is no mandated system for the storage or sanitization of animal waste which can be rife with E. coli, antibiotics and other hormones, animal blood, and organic and inorganic compounds dangerous to human health.  Improper or overextended systems for storing untreated manure can cause run off or leaching into ground water.  Degrading animal waste can also affect local air quality and attract insects.

It isn’t just the immediate health effects of factory farming – such as increased incidence of childhood asthma in communities near CAFOs – but the cumulative effects that contribute to global warming.  A 2006 report of the Food and Agricultural Organization of the United Nations found that CAFOs deleterious outputs could account for 18% of global emissions.  The list is literally and figuratively exhaustive: from the methane gas emitted from the aforementioned manure, the oil used to transport carcasses to processing plants and on to stores, the electricity used to keep the meat cool, and the emissions and energy needed to harvest the crops that feed the livestock and pumps for water.  Dig a little deeper and consider, as suggested by two World Bank Scientists, the following:

Should you include all the knock-on emissions from clearing forests? What about the fertiliser used to grow the crops to feed to the animals, or the emissions from the steel needed to build the boats that transport the cattle; or the “default” emissions – the greenhouse gases that would be released by substitute activities to grow food if we were to give up meat? And is it fair to count animals used for multiple purposes, as they mostly are in developing countries, from providing draught power to shoe leather or transport, and which only become meat once they reach the end of their economic lives?

All told, these activities add up to 32.6 billion tons of carbon dioxide annually, or 51% of global greenhouse gas emissions.  Even at its lowest estimate of 15%, greenhouse gas emissions from livestock are equal to exhaust emissions from every vehicle – plane, train, and automobile – in operation today.

How much less meat would we need to eat to keep rising temperatures below the 2-degree Celsius mark that could spell big trouble for life as we know it?  Industrialized countries currently consume more than twice the amount of meat considered healthy.  Americans eat three times as much.  While meat consumption in developing countries is a fraction of those listed above, an increased call for meat has been seen as countries become more urban.   Meat consumption in developing countries has tripled compared to developed nations in recent decades.

While the simple solution is to eat less meat, the type of meat might also be important.  Raising beef requires nearly 30 times more land and 11 times more water than pork, chicken, dairy or eggs.  Three staple crops – potatoes, wheat, and rice – require up to six times fewer resources than pork, chicken, dairy or eggs.

If industrialized countries were to consume less red meat, global malnutrition could be addressed. Only 55% of the world’s crops feed people, the rest are reserved to feed livestock or to make biofuel.  The conversion of calories from grain to meat leaves much to be desired.  One hundred calories of grain produce a mere 3 calories of beef.  Just switching from grain-fed beef to pasture-raised beef, chicken, pork, eggs, and dairy products could free up much more food to feed the world.

It may be that time is running out to make smarter food choice before climate change makes the decision for us.  Currently, 4% of global croplands experience drought each year but could reach as high as 18% by the year 2100.  Even at the current rate, droughts have the capacity to devastate regions and industries.  A recent study found that an extra 500,000 deaths will be attributable to a decrease in nutrient-rich food in 155 world regions by the year 2050.  Rather than malnutrition related to caloric intake, these deaths will be due to lack of vitamins from fruit and vegetables. The majority of these deaths will likely occur in already impoverished countries of Asia and Africa.

If you are reading this blog, you can probably afford to have some lentils or a nice vegetarian burrito for dinner.  While you sup, feel free to check out these great articles by Maryn McKenna.  The first imagines a world without antibiotics – a huge issue especially as it pertains to the food industries over-use. The second examines a Dutch company that is mass producing antibiotic-free boiler hens.

Female sterilization not an answer to global contraception

The last week of September marks two days dedicated to improving reproductive health: World Contraception Day  (September 26) and Global Day of Action for Access to Safe and Legal Abortions  (September 28).  Both days are committed to improving the reproductive health and choices of women worldwide. With the vision of making every pregnancy a wanted pregnancy, World Contraception Day aims to help the estimated 225 million women in developing countries who have an unmet need for contraception.

Reports such as the UN’s 2015 Trends in Contraceptive Use Worldwide include somewhat promising data, such as 64% of married or in-union women use a modern contraceptive method. This figure is lower in developing countries, including 17 countries in Africa where modern contraceptive use is below 20%.

Sterilization is the most widely used form of birth control, accounting for a third of modern contraceptive use. Sterilization is heavily weighted toward female sterilization, 18.9% versus 2.4% male sterilization globally.  In certain countries, the prevalence of female sterilization as modern contraception is much higher.  Female sterilization of sexually active women aged 15 to 49 is most prevalent in Latin America.  The Dominican Republic leads the pack at 47%  followed closely by Colombia, Costa Rica, El Salvador, and Puerto Rico.  China (29%) and India (36%) are also front runners.


Sterilization is a popular choice in the developed countries of Europe and North America, though male sterilization tends to be more prevalent than in the developing world. When practiced safely, sterilization offers many benefits because it is a one-time procedure with no follow-up or maintenance.  While sterilization might be the best choice for some individuals or couples, unsafe, involuntary, or otherwise coercive female sterilizations are altogether too common and an affront to human rights.

China’s “one child” policy  – perhaps one of the more infamous anecdotes in mandated family planning – has relied on sterilization to meet its goals.  In the heyday of the 1980s, neighbors became informants on so-called “out-of-plan” pregnancies.  Offending families were fined and possessions stolen, and local bureaucrats oversaw countless forced abortions and sterilization. 1983 alone saw over 20 million sterilizations. China’s Communist Party has recently relaxed its one-child policy  to allow each couple two children, but many in China, including activist Chen Guangcheng don’t see the difference as stated in this tweet:

This is nothing to be happy about. First the #CCP would kill any baby after one. Now they will kill any baby after two. #ChinaOneChildPolicy

Lesser known is an Uzbekistan policy that assigns gynecologists a sterilization quota of up to 4 per month.  In a report by the BBC, rural women who have had two or more children are the main target of this campaign.  It is estimated in 2011 alone that 70,000 Uzbek women were sterilized, some voluntarily and some involuntarily.  Unlike China’s policy to slow population growth, Uzbekistan’s goal is to manipulate its once abysmal infant mortality ratings.  Fewer infants means fewer infant deaths, and Uzbekistan’s infant mortality rate in 2012 is half of what it was in 1990.

India has received much attention for its sterilization camps.  The name alone conjures images of the Nazi eugenics movement.  In 1951, with Malthusian ideology in mind, an Indian demographer set out across rural India to complete a census.  His prediction – that India’s population would reach 520 million people by 1981 – was both incorrect (India’s population in 1981 was 683 million ) and the catalyst for a mass sterilization program.  This led to compulsory sterilization in 1976  that lasted for 21 months and effectively sterilized 12 million men and women, often rural, poor, and of low caste.  Employment, wages, and even running water were withheld from individuals and whole villages until 100% compliance was met.

Today, while technically voluntary, sterilization in India is incentivized. In the past, men were promised transistor radios in exchange for a vasectomy.   Male sterilization is now considered culturally unacceptable.  Women are the target of sterilization campaigns and can receive up to $23 US – a month’s income – to submit to a tubal ligation.


Women undergo sterilization operations at the Cheria Bariarpur Primary Health Centre in the Begusarai District of Bihar. A few dozen women were sterilized in one day. Although India officially abandoned sterilization targets years ago, unofficial targets remain in place, according to people working on the ground. One Primary Health Centre doctor says the targets in themselves are not necessarily the problem, arguing instead that itÕs the lack of a good healthcare infrastructure in some places that makes it difficult to safely meet those targets. SARAH WEISER

Indian women arrive at sterilization camps by the jeep load.  In makeshift operating theaters –  with no electricity and running water – neither gloves nor equipment are changed between the five-minute operations.  Expired antibiotics given to some women are found laced with rat poison.  In 2014, Dr. R.J. Gupta, self-described as performing 300 tubal ligation in one day, was arrested after women he and an assistant sterilized either died or were hospitalized.  The current government regulation is that no one doctor should perform more than 30 sterilizations a day.  On the day in question, Gupta’s six-hour spree resulted in 83 tubal ligation.  It is believed that Gupta was trying to reach a government-set target of 220,000 sterilizations in one year.

On September 14th of this year, India’s Supreme Court ordered a close of all sterilization camps within three years.  That is an unsettling time span in which over a half a million more women could be sterilized and many more deaths and hospitalizations could occur.  Even after the dissolution of government-sanctioned sterilizations camps, women will continue to be subject to this dangerous procedure.

What are low cost, accessible, and humane forms of birth control for the developing world?  A promising alternative might be Sayana® Press, a lower-dose presentation of the three-month injectable contraceptive Depo-Provera® in the Uniject™ injection system.


A village health worker counsels a client in family planning and administers Sayana Press. Phiona Nakabuye (left), village health worker trained by PATH’s Sayana Press pilot introduction program, with Carol Nabisere (right), age 18, who chose to receive Sayana Press after being counseled in the various forms of contraception, Kibyayi village, Mubende district.

Original trials of the injectable contraceptive were successful in Florida, New York, and Scotland, and the same seems to be holding true in Uganda.  Most women were able to self-administer the drug after just one training session and again at the next dose, three months later.  Designed for single use, Sayana® Press reduces reliance on needles and needle sharing  which is essential in the fight against HIV/AIDS and women only need to travel to a clinic once to get a year’s supply.

There is so much to consider when it comes to global family planning.  It would be remiss not to mention the impact that the HIV/AIDS epidemic has on sterilization rates in some regions of the world and you can read more here, here, and here.  Organizations such as USAID have been implicated  for funding so-called fertility reduction programs that include mass sterilization.  What can be done to ensure all women have access to contraception?

Social determinants of health

“When we try to pick out anything by itself, we find that it is hitched to everything else in the universe”, you can probably extrapolate this John Muir quote to health. For far too long, health has been a very specific, very individual-driven personal attribute. Although social inequalities and inequities are not new to any of us, we now have data that show how health is impacted by not just individual preferences/behaviors and biology but also by social, environmental and economic conditions that individuals live in. These are collectively known as social determinants of health (SDH or SDoH) and the WHO defines SDH as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.”

Recognizing the impact of social determinants on health, Dr. Frieden introduced the Health Impact Pyramid in 2010.

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Source: Health Impact Pyramid

What exactly are social determinants of health? Below is an easy-to-read table from a Policy Brief from Kaiser Family Foundation.

Figure 2: Social Determinants of Health
Health equity can be achieved by addressing the upstream root causes a.k.a the social, environmental and economic factors that negatively impact health. Health Equity, as so aptly described in the image below, is defined by the WHO as “the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically.”

Source: “Interaction Institute for Social Change | Artist: Angus Maguire.”

While there is plenty of evidence for how social determinants impact health, there have not been many solutions that have been tested and you can probably imagine why!

In the coming months, we will explore evidence for working upstream and programs and practices that are being tested to impact health by addressing social determinants of health. If you know of any implementation examples, please leave a comment.

Don’t forget to tune into and participate in APHA’s Social Determinants of Health Twitter chat #SDOHChat  on October 5th, 2016 between 1:00 PM – 2:00 PM (EST).