US opposition to UN breastfeeding resolution defies evidence and public health practice

Statement from Georges Benjamin, MD, Executive Director, American Public Health Association

Washington, D.C., July 9, 2018 – “We are stunned by reports of U.S. opposition to a resolution at the World Health Assembly this spring aimed at promoting breastfeeding. According to news stories, U.S. officials attempted to block a resolution encouraging breastfeeding and warning against misleading marketing by infant formula manufacturers.

“Fortunately, the resolution was adopted with few changes, but it is unconscionable for the U.S. or other government to oppose efforts that promote breastfeeding. The consequences of low rates of breastfeeding are even greater for the health of children in resource-poor countries.

“Breastfeeding is one of the most cost-effective interventions for improving maternal and child health. Breastfeeding provides the best source of infant nutrition and immunologic protection. Babies who are breastfed are less likely to become overweight and obese, and have fewer infections and improved survival during their first year of life. Breastfed infants often need fewer sick care visits, prescriptions and hospitalizations. In addition maternal bonding is increased, a benefit to both mother and child.

“The scientific evidence overwhelmingly supports breastfeeding and its many health benefits for both child and mother. The American Public Health Association has long supported exclusive breastfeeding for the first six months and continued breastfeeding through at least the first year of life. APHA also strongly supports policies that encourage breastfeeding at home, maternity hospitals and birth centers and the workplace, and help identify women most in need of support of breastfeeding practices.

“In cases where mothers are unable to breastfeed, there are evidence-based solutions to protect the mom and ensure the baby thrives. The solution to malnutrition and poverty is not infant formula, but improved economic development and access to domestic and international nutrition and food programs.”

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APHA champions the health of all people and all communities. We strengthen the public health profession. We speak out for public health issues and policies backed by science. We are the only organization that influences federal policy, has a nearly 150-year perspective and brings together members from all fields of public health. Learn more at www.apha.org.

The G20 Makes Early Childhood Development a Priority

World wide roughly 200 million children under the age of five, in low and middle income countries, will fail to meet basic developmental milestones. Such deficits affect health across the lifespan, the ability to contribute to the national economy, and the ability to stop the cycle of poverty. With this knowledge in mind the United Nations made a point of linking their sustainable development goals to children’s issues, specifically early childhood development (ECD). Recently the G20, with Argentina as the new chair, have placed an emphasis on ECD in the international community by adding it to their own sustainability goals. The G20 has recognized that ECD must be incorporated into all programs, not just within child centric programs and that an emphasis must be placed on children under five years of age.

Programmatic areas have remained siloed focusing on nutrition and ensuring school aged children receive an education. While these initiatives play a role in ECD they only focus on topical areas and do not formally integrate ECD, newborn to age five, into programmatic work. The G20 has created a case for cross collaboration within programmatic and policy level work, even laying out funding streams for such work. This puts the G20 in line with World Health Organization guidelines, including guidelines around integration of ECD in emergency situations. When you are already servicing families and their children, especially in low income programmatic settings, it is easy to add in basic ECD education. For example, when providing breastfeeding support to mothers this is a wonderful opportunity to briefly discuss the need to talk and sing to the child in order to develop language acquisition. Another example is to provide pamphlets, that match the health literacy level of the community, around positive parenting and age appropriate milestones at an immunization drive.  

ECD doesn’t just apply to children – it applies directly to the child’s environment: families, caregivers, and national leadership. ECD focuses a lot on positive parenting to encourage positive brain development and language acquisition. The World Health Organization just released a guideline that discusses nurturing care within ECD, highlighting strategies and policies focusing on the environment that impacts ECD. A really interesting piece that the G20 highlights is the need for better trained child care providers. The G20 ties it back to economics – if a family, mothers in particular, feels comfortable leaving their child in the care of someone else they are able to contribute to their local and national economy in a greater way. There is also the money saving aspect for countries who invest in programs that promote ECD in children under the age of five. As discussed in the literature, children’s brains are rapidly developing arguably from in the womb through the first 1,000 days of life, and programs that focus on this age group provide a larger cost saving than programs that focus on children over five. This is because potential developmental delays are prevented, thus not as much money is needed to get a child back on their developmental track. Also, at such a young age with the focus predominantly being on environmental factors the cost is solely around training and educating front line staff, not actual school aged interventions.

Again – it is great news to have a group like G20 make ECD a priority, especially for children under five. It brings the topic back to the front of the global health stage and proves that it can be easily incorporated into programmatic work.

Achieving health equity in global health through workforce diversity

This International Women’s Day we honor the achievements of women leaders working to advance the health and well-being of people all over the world. Their path to success was certainly not easy. It was fraught with numerous challenges; challenges that are not only experienced by those of us working in global health but by women across all industries.

We are considered either too soft and feminine or too bossy and pushy to be seen as competent leaders. Our work culture lacks family-oriented, work-life balance policies which enable us to contribute to our field in significant ways. We lack female mentors to encourage us to grow and push us to overcome any obstacles we encounter in our career. We work for organizations where the people who make the big decisions on what policies and programmatic areas to focus on are men. The struggles we face trying to advance in our careers are reflected in the lack of gender equality in the global health workforce. While women make up 70% of the global health workforce, only 25% of leadership positions in global health are held by women.

We have known for a long time that when women are given equal opportunities for leadership at all levels of decision-making in economic, political, and public life, everyone in society does better. Female leaders in health “promote access to contraceptives, empowerment programs for girls, women’s rights to family planning and maternity care, safe abortions, and protecting environmental assaults on children’s health.” In addition, women leaders at all levels of governance have shown to be the primary driver toward financing public goods such as health, education, hospitals, clean water, and sanitation. Women’s participation and leadership in economic, political, and public life is so critical to advancing societies that it is even written into one of the sustainable development goals. When women have a voice at all levels of decision-making, we are closer to eliminating the inequities that lead to disparities in health.

More global health organizations are recognizing the need for women leaders and organizations such as Women in Global Health are working toward achieving gender equality in global health leadership. Last year the World Health Organization’s newest Director-General, Dr Tedros Adhanom, appointed eight women to senior leadership, effectively outnumbering the men. In doing so, he took one big leap toward achieving gender equity at the WHO – a goal that was first set in 1997 and that took two decades to realize.

Gender equality is not the only type of diversity we need to strive toward in our global health leadership however. Diversity in global health leadership must also focus on inclusion of people from different ages, race and ethnicity, sexual orientation, social class, geography, religion, and other characteristics of personal identity.  As a woman and a first-generation Filipino-American working in global health in the United States, I often find myself at global health and public health conferences and meetings wondering why there are very few leaders that encompass the diversity that I represent on stage (and occasionally even in the audience). The people who make the decisions with the biggest impact in global health must reflect the diversity of the people we serve.  

Learning from, understanding, and seeing the world through another person’s point of view is at the heart of working in global health and a driving reason for why I chose to work in this field. In order to truly reflect the diversity of this field though, the definition of diversity itself needs to go far and beyond the characteristics of one’s personal identity. To fully be inclusive, we must also be open to learning from, understanding, and seeing the world through the perspectives of individuals in the global health workforce with diverse backgrounds, life experiences, and competencies. Our field could benefit from the ideas of diverse individuals in solving some of the world’s most pressing global health problems. These ideas cannot always come out of our own echo chambers. 

Achieving diversity in the global health workforce is everyone’s job. It requires each one of us to recognize and overcome the personal biases (whether they are subconscious or not) which prevent us from hiring and working with more diverse talent. For those of us responsible for making decisions, we must work to create policies at all levels which not only promote but require inclusion. It’s only then that we can achieve true diversity in our workforce and our leadership. It’s only then that we can progress further in achieving health equity.

Stay tuned for part two of my series on Achieving health equity in global health through workforce diversity in which I will discuss different ideas for how we can achieve diversity in the global health workforce.

New paper released on the global burden of severe neonatal jaundice

While severe neonatal jaundice (SNJ) that is not successfully treated is rare in the U.S. and Western Europe, and thus often ignored as a global health problem, there is  evidence that SNJ is still a problem globally. In a paper co-authored by IH Section Councilor Dr. Mark Strand on the global burden of severe neonatal jaundice in newborns, the incidence of SNJ was found to be at 667.8 per 10 000 live births in the African region, where it is the highest, followed by Southeast Asia (251.3), Eastern Mediterranean (165.7), and the Western Pacific (9.4). This condition is easily diagnosed and inexpensive to treat and can save lives of children.

Read the rest of the research article here: http://bmjpaedsopen.bmj.com/content/1/1/e000105

International Group B Strep Awareness Month: What Should I Know About GBS Disease?

July is International Group B Strep Month. This blog post gives an overview of the illness and its impact on pregnant women around the globe.

Group B Streptococcus bacteria (GBS), also known as Streptococcus agalactiae, typically colonize the gastrointestinal and genitourinary tracts, the throat, and the skin. GBS disease is caused when bacteria enter a normally sterile site such as the blood, bone, or spinal fluid. Both children and adults can develop GBS disease. The disease usually develops in infants that are 0-90 days old and adults that are 60 years of age and older with underlying chronic illnesses. There is currently no vaccine for GBS disease.

Although GBS may come from unknown sources, one out of four pregnant women are carrying the bacteria in their vagina or rectum and can vertically transmit an infection to their newborns. Infections occur during labor (“early-onset disease” or EOD) or within the first week of life through three months of age (“late-onset disease” or LOD). Symptoms can be difficult to distinguish from other infections and range from fever, difficulty breathing, lethargy, and “blue” skin. Severe symptoms that can develop in newborns and infants include sepsis and pneumonia. Meningitis is more likely to occur in infants or newborns with LOD. Complications from GBS disease may result in preterm delivery and lead to developmental disabilities or death. According to the Centers for Disease Control and Prevention (CDC), risk factors for pregnant women include:

  • Testing positive for group B strep bacteria late in the current pregnancy (35-37 weeks pregnant)
  • Detecting group B strep bacteria in urine (pee) during the current pregnancy
  • Delivering early (before 37 weeks of pregnancy) 
  • Developing a fever during labor
  • Having a long time between water breaking and delivering (18 hours or more)
  • Having a previous baby who developed early-onset disease

Since 1970, GBS disease has been a topic of concern in health care, research, and public health circles. In 1989, the death of three newborns from GBS disease led to the development of public awareness campaigns that called for improved education, detection, and preventive resources in the U.S. Furthermore, around this time, data collected by the CDC revealed that GBS disease was the leading cause of death in newborns. Parents and advocacy groups actively demanded guidance that would allow for routine screening and the development of an effective vaccine for pregnant moms, globally. Below is a timeline of how advocacy efforts led to research, policy change, and the implementation of effective interventions:

Brief Timeline of GBS Disease Awareness, Education, and Prevention Efforts

  • 1990 Group B Strep Association US/International is created. Its primary goals are to:
    • Educate the public about GBS infections.
    • Promote prevention of neonatal GBS infections through routine prenatal screening.
    • Promote the development of a GBS vaccine.
  • 1991 GBS researchers awarded a 5-year grant to begin research on a vaccine for  GBD disease
  • 1992 American College of Obstetrics and Gynecology and American Academy of Pediatrics publish position papers for members
  • 1996 CDC Call for Content on GBS Prevention Protocol in (January MMWR)
  • 1996 CDC, ACOG, AAP published first consensus statement on GBS National Prevention Guideline in June
  • 1997 Group B Strep Association launches its first website
  • 2002 The National Consensus Guidelines recommending routine screening for all pregnant woman was published
  • 2008 The CDC Active Bacterial Surveillance Core published data that showed an 80% drop in GBS neonatal morbidity and mortality
  • 2014 WHO convened the first meeting of the Product Development for Vaccines Advisory Committee (PDVAC); GBS and RSV identified as pathogens that cause a large burden of disease

Globally, it is estimated that EOD makes up 60-90% of GBS disease cases. The mean incidence of GBS disease in infants 0-89 days old is estimated to be .53 cases of GBS infection/1000 live births. The highest incidence of cases is reported to be in the continent of Africa, however, additional studies need to be conducted in low-income countries to better assess the true burden of disease. Prevention methods worldwide include providing prophylactic treatment (antibiotics) to women that are either high-risk or have tested positive for GBS, during labor. With treatment, there is only a 1/4000 chance of the baby becoming infected compared to a 1/200 chance if no treatment is given. In order to identify those who qualify for treatment, a culture-based method can be used to screen all pregnant women between 35-37 weeks for vaginal or rectal colonization of GBS. On the other hand, a risk-based method identifies pregnant women with risk factors for EOD such as fever, preterm delivery, and being in labor for 18 or more hours.

Although the administration of antibiotics during labor reduced EOD from .75 cases of GBS infection/100 live births to .23 cases of GBS infection/100 live births, GBS disease morbidity in infants and mothers is still significant and likely underreported. Antibiotic treatment and GBS disease education are more accessible to pregnant women in high-income countries than those in low-middle income countries. It is likely that challenges related to access to care and health system deficiencies limit the use of antibiotic treatment in low-middle income countries. As a result, the development of a cost-effective vaccine may be able to help bridge an awareness gap.

According to the World Health Organization (WHO), developing a vaccine for maternal immunization is a priority when it comes to GBS disease. In 2016, the WHO Product Development for Vaccines Advisory Committee held a technical consultation to discuss vaccine development. Ultimately, the committee determined that the global burden of GBS disease cases that result in stillbirths needs to be assessed. In addition, standardized antibody assays need to be developed in order to find correlates of protection. Vaccine targets such as the type III capsular polysaccharide (CPS) and proteins on the GBS bacterial surface have also been identified. As new vaccine development ideas for GBS disease are being discussed, here are some foundational components that the Group B Strep Association (US/International) and Group B Strep Support (UK/EU) groups feel have an important role to play in the introduction of the vaccine to pregnant women across the globe:

  • Standardized definition of disease worldwide.
  • Standardized monitoring of disease worldwide.
  • Routine prenatal care widely available in which a vaccine can be delivered.
  • Education of health professionals and parents and expectant parents about group B Strep and the vaccine.

Check out these CDC podcasts, if you want to learn additional information about GBS disease during International GBS Awareness Month!