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.

unmetneedandunintendedpregnancy

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.

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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.

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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.”

IISC_EqualityVsEquityCartoon
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).

Global News Round Up

Politics & Policies

A new study that examines some major health care proposals from presidential candidates finds that Donald Trump would cause about 20 million to lose coverage while Hillary Clinton would provide coverage for an additional 9 million people.

The government isn’t regulating how highly dangerous viruses and bacteria are rendered safe for shipment, posing risks to the public, auditors say.

At this year’s United Nations General Assembly, policymakers and elected officials should increase their political commitment for breast- feeding as they work to tackle issues of critical importance related to the health, wellbeing and economic success of their 193 states. It’s directly related to our collective goals.

The United States unveiled plans on Thursday to ramp up efforts to end female genital mutilation (FGM) after figures showed more than half of million women and girls were living at risk.

On September 21st in New York all 193 UN member states agreed to tackle the growing resistance of microbes to antibiotics.  Drug-resistant infections now kill more than 700,000 people a year. On current trends, that number may reach 10 million by 2050.

Senate Republicans on Thursday released the latest draft of a $1.1 billion funding package to fight the Zika virus, and it contains some of the controversial funding offsets that Democrats have long opposed.

The World Health Organization (WHO) is preparing to select a new director general.  It needs someone dynamic and politically astute to drive strategic reforms, say global health experts.

A study funded by the Bill and Melinda Gates Foundation, measured how countries, including Australia, China, India, the US and UK, performed over the last 15 years with Iceland taking the top spot for its health related Sustainable Development Goal (SDG) performance.

New Zealand falls way behind our neighbours across the Tasman as a healthy country to live in, a major global study has found.

Programs, Grants & Awards

The Center for Global Health in the Perelman School of Medicine at the University of Pennsylvania is pleased to honor Ernest Madu, MD, chairman and CEO of the Heart Institute of the Caribbean with its first annual Global Health Champion Award. Madu was presented with the award on Thursday, Sept. 15 as part of a celebration for Penn’s newly launched Center for Global Health.

Bill Gates, Bono among big names at Montreal conference to replenish fund to fight HIV/AIDS, TB and malaria.

Glaxo-Smith Kline (GSK) has plans to address emerging global health issues, the company said in a Sept. 19, 2016 press release. The company put forth a series of steps it will take in order to combat several global health challenges, including access to vaccines, antimicrobial resistance, and preparation for future pandemics.

University of Iowa students now will be able to expand their knowledge of health around the world, thanks to a new major in Global Health Studies.

Research

Since December 2013, an armed conflict in South Sudan has resulted in the displacement of over 2.2 million people, more than 270,000 of whom are presently in refugee settlements located throughout Uganda. Existing literature suggests that refugees are at increased risk for a range of mental health and psychosocial problems.

Molecular surveillance identifies multiple transmissions of typhoid in West Africa.

Experimental treatment of Ebola virus disease with brincidofovir.

During 2004–2013 in Mozambique, 455,600 HIV-positive adults (≥15 years old) initiated antiretroviral therapy (ART). We evaluated trends in patient characteristics and outcomes during 2004–2013, outcomes of universal treatment for pregnant women (Option B+) implemented since 2013, and effect on outcomes of distributing ART to stable patients through Community ART Support Groups (CASG) since 2010.

Informed risk assessment and decision making for an emerging infectious disease in the Asia-Pacific Region.

For the first time, abnormal brain development following a Zika infection during pregnancy has been documented experimentally in the offspring of a non-human primate.

By 2050, 75% of the world’s population is expected to live in cities, making city planning key for addressing disease prevention and global health challenges, according to a series published in The Lancet.

Diseases & Disasters

Hookworm is a parasite that is behind millions of infections worldwide. This intestinal parasite can cause a host of complications in people of all ages.

More than a third of the burden of disease experienced by Indigenous Australians could be prevented, with tobacco and alcohol use, high body mass, physical inactivity, high blood pressure and diet contributing to their illnesses, data released by the Australian Institute and Health and Welfare shows.

Miami district which saw the first locally transmitted Zika cases in the US has been declared free of the virus.

Health organizations have all the right weapons to eradicate polio, but can’t deploy them because of wartime conflict in Nigeria, Pakistan and Afghanistan – the last three countries affected by the disease.

The World Health Organization (WHO) has recently initiated a global health strategy, which will run between 2016 and 2021, to eliminate hepatitis C as a global health threat by 2030.

With all four strains of the dengue virus now circulating in Pakistan and outbreaks of the viral disease being reported in new areas, this South Asian country now faces a serious health problem from the mosquito-borne pestilence, researchers say.

In the five years since the civil war between President Bashar Assad’s government and rebel groups began, more than 250,000 Syrians have died in the conflict. But thanks to the White Helmets, over 60,000 lives have been saved.

Traditional strategies for delivering health services to refugees and migrants will not meet the needs of today’s 65 million displaced people, according to refugee, development and global health experts who met Thursday at a UN General Assembly side event.

Technology

A new technique may democratise vaccine production.  James Collins of the Massachusetts Institute of Technology (MIT) thinks that he may have developed one.

Healthcare, the USD 18-billion healthcare technology unit of GE, has announced USD 59-million funding aimed at improving services of healthcare startups in developing countries.

Facebook founder Mark Zuckerberg and his wife Priscilla Chan have pledged $3 billion (£2.3bn) to fund medical research over the next decade. At a press conference in San Francisco, they said their ultimate goal was to “cure, prevent or manage all diseases by the end of the century.”

Environmental Health

Volkswagen (VW) emissions cheat may lead to 50 premature deaths, $423 million in economic costs, study shows.

Australia’s offshore petroleum industry regulator is set to rule next week whether to grant oil giant BP’s application to drill in the Great Australian Bight.

While July was busy becoming the hottest month in 136 years of record-keeping, Donald Trump made no reference at all to climate change in his nomination-acceptance speech, and Hillary Clinton made only two passing references in hers.

A week before Russia’s Daldykan river was turned red by a leak from a metals plant, the UN issued a warning as chilling as it was overlooked: 323 million people are at risk from life-threatening diseases caused by the pollution of rivers and lakes.

Equity & Disparities

Gender equality remains the greatest human rights challenge of our time, and one way to achieve the goal is by empowering women to have greater choices economically and control over their lives, United Nations Secretary-General Ban Ki-moon declared today, urging the international community to spearhead efforts that provide opportunities for women and girls.

A new analysis shows that the life expectancy of people living with HIV is very different between Europe, North America and African countries.  The analysis pools the results of eight previously published studies on life expectancy, with over 150,000 people included.

Increasing evidence from scientists the world over indicates that many health outcomes — everything from life expectancy to infant mortality and obesity — can be linked to the level of economic inequality within a given population. Greater economic inequality appears to lead to worse health outcomes.

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

Our response to @NASEM_health’s request for comments for their #globalhealth consensus study

Last week, a researcher from the NAS’s Board on Global Health reached out to us to request public comments from the IH Section in order to inform its recommendations for the next U.S. presidential administration on global health:

A project that we are currently conducting aims to provide recommendations to the new administration on what the next phase of U.S. commitment to global health should look like. This project is a consensus study, meaning that we will be convening with a committee of experts in the field to negotiate a set of evidence based recommendations. However, as we progress through this project we are seeking public comments from interested in parties that we will then present to the committee. Given APHA’s work in International Health, we would be interested in receiving public comments from your organization.

We are interested to see if NAS will approach the new administration any differently than it approached the Obama administration in 2009, and whether it will keep politics in mind – or even better, reference specific political challenges – with their recommendations. Frankly, any new approach to U.S. global health policy will risk going the way of the failed Global Health Initiative without strategic and sustained effort to (1) harmonize it with our overall foreign policy approach and (2) overcome considerable political and legislative barriers. Laurie Garrett has a fantastic summary of the latter in the 2013 Existential Challenges to Global Health report:

The first two years of the Obama Administration were wasted with in-fighting and debate over the future of all foreign assistance, culminating in 2010 creation of the Global health Initiative, a State Department-run melding of programs operated by multiple American agencies. In late 2011 Secretary Hillary Clinton…signaled impatience with the GHI effort: it was abandoned entirely in the summer of 2012. In December 2012 Clinton shifted control over global health operations into the hands of US Ambassadors, creating the Office of Global health Diplomacy to oversee all HIV, malaria, TB, health systems, and other health-related programs. Polls show that Americans…are deeply confused about how much of the federal budget is dedicated to such foreign aid, imagining it devours as much as 25 percent of the budget, versus the actual less-than-1 percent. This combination of Administration shuffling of priorities and structure of global health operations, with public confusion regarding their cost to taxpayers, renders the entire mission highly vulnerable to budget slashes.

Section elected and committee leaders offered their thoughts on what should be in our response, which were compiled and integrated into a formal statement (below).

We urge that the new administration adopt a systems-centered approach to global health with a focus on equity. Historically, the global health field and professional community has been dominated by vertical (i.e., disease-centered) approaches to global health improvement. While these approaches may seem more glamorous and marketable, and the gains and progress made by these initiatives cannot be understated, the earthquake in Haiti, the reappearance of polio in conflict zones, and the recent Ebola outbreak in west Africa are cautionary tales of the devastation that an emerging disease or unforeseen catastrophe can have when health systems are poorly equipped to respond. To advance the health of the world’s population, U.S. global health efforts should contribute to elimination of poverty, advancement of education, and ensuring access to health care by the poor. Health systems strengthening, both technically and managerially, and increasing access by incorporating the participation of communities and civil society in systems for social accountability, is more important than battling each new disease as it erupts and will ensure that those systems are prepared to protect the health of their constituencies no matter the disease du jour. We question current strategies for blanket integration of health programs/services and decentralization of governance, and urge that these policies be carefully assessed in each country situation before promoting them. Countries should be empowered for improved decision-making to increase aid effectiveness.

A greater focus is needed on the health needs of mothers, newborns and children (MNCH), especially in first 1,000 days (conception to 2 years). Improving health and development in infants and young children can have impressive impact and have the greatest potential for better population health and productivity in the future. While substantial gains have been made in this area in the last 15 years, this population group remains underprioritized, as demonstrated by the MDGs 4 and 5 which had the lowest level of completion among the MDGs. MNCH is best helped by addressing social determinants of health with pro-poor and health in all-sectors policies and by strengthening primary health care systems to work better with communities, reducing cultural and economic barriers to improve access to preventive and curative care. Improving quality of obstetric and neonatal care in health services should be a priority to reduce mortality.

A serious commitment to a health systems approach must also include work to address the health effects of climate change, which disproportionately affect developing countries and children under five years of age, with both mitigation and adaptation.

If the NAS is committed to advocating for the administration to make global health a pillar of US foreign policy, then it must urge that administration to work to make sure that the rest of its foreign policy reinforce that commitment. That includes advocating for peace and reducing armed conflict wherever possible. We need to stop investing in war and weapons, particularly the catastrophic conflicts in Yemen and Syria (which the US has prolonged by engaging in a poorly organized proxy war with Russia) and the new planned $1 trillion nuclear weapons modernization act. Our country will have no standing as a global health leader if our military continues to engage in arms races, bomb hospitals, and kill civilians in drone strikes.

Finally, the administration needs to make sure that whatever global health policies or initiatives it decides to launch are sustainable in the long term. The White House’s original Global Health Initiative (which, ironically, appears to have been inspired by the last NAS report on global health to the incoming administration) fell on its face and failed embarrassingly, much to the chagrin and frustration of the development community at large. The problems that were intended to be addressed still remain: turf battles between agencies, competing priorities, lack of rigorous evaluations, and (most importantly) lack of overall strategic vision.

You can read more about the project here. The committee’s first meeting (September 29 from 1-5:30 p.m. EST) will be open to the public, and there will be a live webcast as well.