A Big Fat Crisis - Worldwide

Hello Everyone,

After Van's lecture on global nutrition and obesity, we viewed four clips by major news outlets and University of California TV describing the obesity epidemic in America and around the world.  First, take a look at this site which nicely displays data on the World Obesity crisis.

• ABC News and CBS News reports on the US obesity epidemic,
• Link TV provides news reports from Once Noticias, Mexico; RT, Russia; France 24, France; Al Jazeera English, Qatar; and KBS, South Korea, on the growing obesity epidemic in these countries, and
• "The Skinny on Obesity" by Dr. Lustig, Univ of California.  We watched Episode 3: "Hunger and Hormones - A Vicious Cycle."  All 7 episodes are found here.   

We did not watch, but I highly recommend, the HBO documentary series "The Weight of the Nation," made in collaboration with the Institute of Medicine, Centers for Disease Control and Prevention, and the National Institutes of Health.    For a historical perspective on sweets, this BBC documentary is both fascinating and depressing, as sugar or "white gold" was brought to the commoner's table through the sweat and blood of African slaves. 

1 M&M = 1 football field (100 yards) to walk off the 3.4 calories in each piece

Some of you asked about dietary supplements.  The mind is a powerful thing, of which the dietary supplement industry ($28 billion in annual revenues) knows and takes advantage through the "placebo effect."  Essentially, you think you feel better having taken that supplement, even though it is actually inert or ineffective. Dietary supplements are not "medicines" and hence not subject to FDA regulation.  Rather, dietary supplement manufacturers are only required to label their products, not prove they are actually effective, produce a health benefit, or that the ingredients on the label are what is actually contained in the product.   And some manufacturers take advantage of this lack of regulation AND the "placebo effect," selling products that are indeed harmful.  See this investigative series by NBC Dateline, Part 1, Part 2, and Part 3.  Basically, we know more about what is contained in a loaf of bread (which is regulated) than what's in a dietary supplement product.  

Lastly, bariatric surgery (from the Greek bár(os) meaning weight and iatric meaning treatment) is becoming increasingly popular as a method for preventing serious health outcomes in the extremely obese individual.  This type of surgery alters the stomach and/or intestines through permanent removal of tissue or temporary placement of inflatable restrictive devices or "lapbands."  This type of intervention is intended to help a person with extreme obesity lose weight by reducing the number of calories consumed and are typically recommended for people who have a body mass index (BMI) above 40, e.g., 5'8" male weighing more than 250 lbs.  As noted below, there have been problems with the success of these devices.

 ABC News describes the case of a Baltimore woman who was poised to get a "lapband" but took up running and diet control instead, because her BMI was less than 40.  Essentially, as Van emphasized, maintaining a healthy weight is a long term activity, not a short term fix addressed through dieting.  It is, indeed, a lifestyle.

So, what research questions should one ask to determine the factors that inhibit or encourage individual behavior vis-á-vis a healthy weight and subsequent increased/reduced risk for cardiovascular disease, stroke, diabetes, cancer, and the other complications from being overweight?  Should dietary supplements be regulated?  What about taxing sugar, like tobacco, to drive up costs and drive down use?

Finally, should the point-of-sale of sugar products, like candy bars, be restricted to food stores and not allowed in your local hardware store?  This is what Debra Cohen recommends in her new book "A Big Fat Crisis - The Hidden Forces Behind the Obesity Epidemic and How End It." 

Take care, Jim

Mothers Make the World Go Round

Hello Folks,

In this week's lecture on maternal and child health we learned from Andy that moms indeed carry the burden of the world's population through pregnancy, birth, and child care.  We wouldn't be who we are without the help of some mom somewhere during our lives.  So why is it that while the maternal mortality ratio (expressed as the proportion of women of who die from a pregnancy/birth-related complication per 100,000 live births) is declining globally, the MMR continues to remain very high in low-middle income countries when compared with developed economies, according to WHO and UNICEF?  For example, WHO reports that the MMR in Sierra Leone in 2010 was 890 deaths per 100,000 live births (down almost 31% from 1,300 in 2000) compared with the US which had 21 deaths per 100,000 live births in 2010 (up about 50% from 14 in 2000).   In 2012, the CDC reported that of the 3,952,937 births in the US, 32% were delivered by Cesarian section, 11.5% were preterm (< 37 weeks gestation), and 8% were low-birth weight (< 2,500 grams or 5 lbs).  As shown during Andy's lecture and this 2012 study of surgical activity in rural Ethiopia, many LMICs are not equipped to provide C-section services, even at the regional hospital level where this is a routine service offered in higher income countries, due to a lack of trained personnel, i.e., they report "only 76 health workers ... are providing a surgical service [including C-sections] to this sample population of 12.9 million people."   Consider we saw last week that local technicians can be successfully trained to perform trichiasis repair (when the eyelashes abnormally turn inward due to Chlamydia trachomatis infection and result in scarring of the cornea lens and blindness). 

So is the main barrier to the provision of C-sections at rural regional hospitals in sub-Saharan Africa (SSA) a function mainly of human resources? 

On the prevention side of the MCH equation, a woman's level of education is a strong predictor of severe maternal outcome, as shown in this 29 country, cross-sectional survey published two days ago in the British Journal of Obstetrics and Gynaecology, which presents data that indicate, when controlling for confounding variables, women with the least education are 5.6 times more likely to have a severe maternal outcome, including maternal death, when compared with women who have higher levels of education.


Clearly,  Millennium Development Goal (MDG) 2, which calls for universal primary education, will address this problem of MMR while also supporting MDG 5 (Target 5A), which calls for the reduction of the maternal mortality ratio by three quarters between 1990 and 2015. These are mutually reinforcing goals.

However, neither can succeed without the other.  Page 14 of the MDG 2013 Report shows that SSA has made significant progress in MDG 2, with an adjusted net enrollment rate in primary education of 77%, but still lags behind other regions.  Page 28 shows that maternal mortality has declined by nearly half since 1990, but still falls far short of a 75% reduction of maternal deaths, as called for by MDG 5A.  Access to modern contraceptives is hugely important to the economic viability of a family and reducing MMR.  Here is a listing by CDC of the effectiveness of contraceptives for the prevention of pregnancy.  Surveys of women and couples in LMICs indicate a desire to plan or space births, if modern contraceptives were available, as shown in this study in Burkina Faso.

Community Empowerment Meeting

Finally, I promised some information on female genital cutting (FGC), an ancient practice in many countries in SSA, not unlike footbinding was in China (which ended in the 20th century), both considered violent practices against women.

Here is an inspirational story posted yesterday in the Huffington Post by my longtime friend and colleague Molly Melching who has been instrumental in helping Senegal and other countries in SSA abandon the practice of FGC, through her organization Tostan (which means "breakthrough" in Wolof, the local language of Senegal).  Here is a short clip on how Tostan approaches the problem of FGC through education.  And this is longer clip by Tostan which shows how changing attitudes and behavior towards a traditional practice like FGC is indeed possible, if probably approached.  I think you'll find the cinematography and content of both these clips beautifully done.   

Qs for thought:  What is the Tostan approach?  Can it be replicated in other cultures?  What should be the post-2015 MDGs?  With wireless access greatly expanding in SSA, could nurses, at a regional hospital without a surgeon or trained physician, be "virtually supervised" to perform a C-section, assuming they have received requisite basic training and have the necessary equipment (recall the 76 number per 12.9 million people noted above)?

See you next week,

Jim 

Clean Water, Dirty Sewage, and "Hey, Check Out My New Smartphone!"

Well in Mauritania

Hi Folks,

In this week's presentation, John Borrazzo gave a really nice comprehensive view of two issues we essentially take for granted in the US:  clean and accessible water, and a clean and accessible place to poo, with the operative terms being "clean" and "accessible."  Regarding water, it is the stuff of life and essential to our well being.  But nearly 800 million people do not have access to improved drinking water.

Roman Latrine

Even though proper and organized disposal of human waste was present in the Roman era, the flush toilet, or "WC" for water closet, was only invented in the 16th century by John Harington (no relation to yours truly), though Thomas Crapper is often given credit.

John spoke about exposure to indoor smoke from cooking fires as a significant cause of respiratory illness and death around the globe, particularly among women living in low-income countries.  The Global Alliance for Clean Cookstoves is making an effort to address this problem by supporting funding for the development of low-cost, sustainable, and scalable cookstoves.  While a new device may be necessary, it is not sufficient to address the problem of exposure to indoor smoke.  Sometimes the "new" cookstove ends up being unused, in favor of the traditional three-stone method, as in this photo.

The "new" cookstove stands idle

Why is that?  Why wouldn't a woman in Senegal, for example, jump at the chance to have a ''new and energy efficient" cookstove?  Cooking is a behavior that is passed down from generation-to-generation and adoption of changes to this behavior can be difficult.

Recognizing the importance of understanding human behavior and the adoption of new ideas is both necessary and sufficient for behavior change.  Here is an example of a human-centered approach to cookstoves that attempts to understand and address behaviors to adopt a new cookstove. 

Finally, after the lecture this week, we watched four films on electronic waste, or e-waste, which is the dirty underside of electronics disposal and how the developed world's lovefest with new smartphones, computers, and other e-gadgets is becoming a major threat to human health in low-income countries.  See this example of the problem of e-waste in India from Greenpeace, in Nigeria from the Basel Action Network, and in this CBS 60 Minutes exposé entitled Wasteland.  The New York Times published a lengthy article and slide show on e-waste last year.  And there are indeed consequences for violators of recycling laws.  Fortunately, there are companies that recycle e-waste in a safe and efficient manner, including SIMS Recycling Solutions, but at a cost that is unaffordable in most low-income countries.

Boy disassembling e-waste in Ghana

Research questions to consider regarding e-waste:

• What types of incentives are necessary to promote environmentally safe disposal of e-waste? By and for whom?
• Can electronics be made more safe for the environment using biodegradable materials?
• What are the health hazards and associated costs (monetary, developmental, societal, etc.) to the environment and populations living, working, attending school, etc., near unsanctioned e-waste sites?

See you next week.

Jim

Global Health, Inc. - Role of the Private Sector

Hi Everybody,

This week John spoke about the role of the private sector in global health, drawing upon his >20 yrs of experience working for the pharmaceutical giant Pfizer.  In this context, it would be helpful here to define our terms, so I've tapped these Wikipedia resources to describe the private for-profit sector, private not-for-profit sector (also called non-governmental organizations (NGOs)), the philanthropies, and the public/government sector, which seem accurate from my perspective, though your mileage may vary.

The fundamental distinction between the private sector and the nonprofit sector is the former has shareholders who have invested their money in a company and expect a return on that investment or ROI.  An example of a for-profit company is Pfizer, which has publicly traded stocks which were selling for $32.34 per share, as I write this, and had annual revenues of $59 billion in 2012.

Examples of nonprofits include the International Committee of the Red Cross (annual budget $1.3 billion) and Médecins Sans Frontières (annual budget $400 million). The nonprofit entity may have one or more benefactors or donors who fuel the entity's bank account so it can do business, and/or it may generate revenue from the sale of its products.  Indeed, any surplus revenue the nonprofit earns from its business is returned to the entity to further the mission of the nonprofit, as it has no shareholders.

Lastly, well known examples of philanthropies include the Bill and Melinda Gates Foundation, the United Nations Foundation (started by CNN mogul Ted Turner), the Hewlett Foundation and the Packard Foundation.  Each of these groups is funded initially by an individual who was passionate about a particular issue or cause, including global health, support for the United Nations, environmental issues, and advancing reproductive health, respectively for the foundations listed above.

Azithromycin molecule

John used the example of global eye diseases in his discussion. Trachoma is a disease of poverty, as you saw in the film clip from last week.  This bacterial infection can be treated successfully with the antibiotic azithromycin, which is made by Pfizer and one of the most widely prescribed antibiotics in the world.  Thus, the morbidity and mortality from this disease and others are reduced, sometimes even eradicated, e.g., smallpox, because of the genius of scientists, and the investors who fund them, at  Pfizer or the other major pharmaceutical manufacturers. They are absolutely essential to the success of any global health effort.

That being said, the question of fairness in pricing arises.  The Togolese suffering from trachoma cannot afford to buy azithromycin, so the Carter Center is making it available free.  Is this a sustainable approach?

What about HIV/AIDS treatment?   Recall in the early 1990s azidothymidine (AZT) was proven to successfully treat AIDS, but the cost per patient was an astronomical $10,000 per year.  ACT-Up protested in front of the NIH Director's Office against this discrimination.  Brazil stated it could not afford the high cost of AZT, so they broke the patent held by the Burroughs Wellcome drug company and made a generic version of AZT.

Finally, in the early 2000s, President Clinton, through the Clinton Health Access Initiative (CHAI) was able to negotiate with the pharmaceutical companies to lower the cost for life saving AIDS treatments to $365 per year ($1 per day) for first line drugs.   CHAI with others have also done the same for other drugs that low-income countries and individuals could not otherwise afford.

Ultimately, the private sector companies are necessary to produce the antibiotics, vaccines, diagnostics, etc., needed to reduce disease morbidity and mortality that afflict populations across the globe. Of concern though is the question of "fairness" in the costs of these drugs.  The Rx company will argue that R&D costs to develop a compound are costly, exceeding $20 billion, and the Rx company needs to deliver ROI for their shareholders.  Lower prices are not justifiable to the shareholders who essentially "own" the company.

What do you think should or could be done to address this conundrum?  What is fair in drug pricing and for whom?   Do subsidies make a difference and, if so, by whom, how, and for how long?

I hope you find that this discussion has been helpful.

Jim






 

Health Systems Strengthening - HSS

Hi Everyone,

In Joe's presentation this past week, he made reference to a couple of key resources on health systems published by the World Health Organization (WHO), including Systems Thinking and in the context of the Millennium Development Goals.  There are additional sources on health systems strengthening found here WHO HSS publications (WHO is  prolific at churning out paper), the USAID Health Systems 20/20 effort, and the Lancet series on child survival.

Joe made the side-by-side comparison of mechanical systems, like an airplane (see this time lapse clip of the interior of an Airbus A380 being assembled) and a biological system in describing the complexity of health systems.

Finally, here are the clips for those who were unable to stay for the optional film session:

1.  River Blindness in Togo (1:19) https://www.youtube.com/watch?v=Pze0EpGwDlE

2.  Carter Center trachoma in Ethiopia (3:59) https://www.youtube.com/watch?v=HgSaUCGzqT8

3.  Malaria and lymphatic filariasis elimination in Nigeria (3:21) https://www.youtube.com/watch?v=uviglebTV1M    

4.  USAID Smiling sun project in Bangladesh (5:01) https://www.youtube.com/watch?v=Vfy81ZwR_tU   

5.  Health Systems and Policies: Case Study of Urban Poor in Bangladesh (11:00) https://www.youtube.com/watch?v=LeVXIEp0Hto

What are the similarities and differences in health systems you see when you consider these cases from Togo, Ethiopia, Nigeria, and Bangladesh?  How is the health system being strengthened in each case?  What are the advantages and disadvantages of each approach?

Looking forward to seeing you next week.

Take care,

Jim