This week on Translational Global Health – we’re experimenting with something new! The first of our PodCast interviews with leading health thinkers. Leading us off, is the inspiring Siri Tellier – of the University of Copenhagen, Denmark, and Renmin University, China.
Talking about life, interests and her incredible work in North Korea, Afghanistan and more…
Siri Tellier holds an Master’s from Harvard School of Public Health, 1970, with a specialization in public health demography.
She has 40 years of experience in international health, including as Director of International Department of Red Cross in Denmark (1992-2001), as well as long term field postings as representative of UNFPA in Afghanistan, China, and the Democratic People’s Republic of Korea, Programme Director for Community Participation in Water and Sanitation with the UNDP, and Chair of the UN Theme Group on HIV/AIDS in China.
Last week in Stockholm, Sweden, I was asked to present an insight into the links between food and global health to the Swedish Medical Society Conference; a brief outline on the parallels and overlap between what we eat, the systems that produce and support that consumption, and the health of our populations.
Now this is no easy task – and not because the overlaps are limited – quite the opposite – but because I had only 10 minutes to do it in!
With this in mind, I proposed just 5 of the reasons why food is, and must be, a Global Health Issue.
Reason number one, we are what we eat.
Put simply, globally, locally and individually – we are what we eat. Improvements in nutrition may have given us enormous health benefits this last century, but food-related disease, including obesity, has now become our greatest health challenge for the current century.
In addition to half a billion people still undernourished worldwide – today diabetes, heart disease, cancers and lung disease, are the leading cause of global deaths. In China, a nation rapidly undergoing nutritional and epidemiological transition, one in two or 500 million people are thought to be prediabetic or diabetic.
Diseases which are both caused and solved, in part, by food.
In Europe, the USA and Australia, obesity rates range from the low teens to mid thirty percent, and obesity-related disease is already crippling populations, health systems and national budgets – concurrently under strain from the economic crisis.
Now this is not to suggest that it is simply a question of calories in versus calories out, but the food we eat, can afford and have access to – and how this is marketed, packaged and served – is a large dictator of our health.
Reason number two: Poverty is not a protector from food-related disease, but a risk factor for it.
In the 20th century, the global health scourges were more likely resulting from under-nutrition. This is no longer. Today – our leading global health challenge results from over-nutrition related malnutrition, with 80% of this disease burden occurring in the world’s low and middle income nations.
The commonly spouted theory that malnutrition resulting from overconsumption is a rich-person’s problem is a dangerous myth.
Risk factors such as obesity and poor diet – as well as diseases such as diabetes, heart disease, lung diseases, cancers and mental illness – are linked with poverty, not affluence. Diseases deeply linked with the quality and quantity of our diets, these are all linked with social and economic derivation.
Reason three: Dietary risks represent profound health opportunities.
The 2010 Global Burden of Disease Study ranked the top causes of global disability and deaths. It is no surprise to many of us, that diet-related diseases topped the charts. But what can surprise some, is that diet itself was named the number one risk factor for morbidity and mortality globally.
The good news though, is that this is a risk factor. This is a disease modifier and amplifier, but if addressed, it is also a disease minimiser and an opportunity for prevention. The quality and quantity of our diets may be an enormous threat to current global health, but inversely it can also become an enormous opportunity for creating a healthier future – if managed appropriately.
The fourth reason: Big Food is a complex, heterogenous and prickly beast.
In 2013, top food companies have more power than some governments, but are unelected and have very different incentives – we must understand this.
The world’s biggest food company alone employs 330,000 people and has an annual revenue of almost 100 billion US dollars – two-thirds the GDP of New Zealand and twice the GDP of Croatia. This company also produces 1 billion products each and every day.
In short, some of these companies have more economic power than some national governments and probably more global political influence than many national governments. Yet, the leaders of these companies are unelected and their driving incentives are market-based and focused on profit, not development, environmental sustainability, social justice or health.
This is a challenge – a huge challenge – and currently there is no clear consensus on how to manage this risk.
Do we work with them? Do we shut the door? Do we regulate or let them regulate? Can they really be trusted to fund governments and elections?
These companies exert an enormous influence on population health and I categorise their behaviours into three groups. The good, the bad and the ugly.
The good companies – those which supply food staples, share the need to create healthy populations and sustainable practices – must be engaged and led by government, but in an independent, mature, arms-length and transparent way.
The bad must be recognised, called out, improved and, when necessary, regulated.
The ugly are the most dangerous. We must recognise that selfish and deliberate decisions by food multi-nationals have caused enormous public health costs in the past decades. These Big Food corporations and their practices must be controlled, even limited – this is essential for global health.
The final reason, there is a growing disconnect between food, cooking and people.
Food is essential to global health, right down to the individual level. As food systems become more processed, supply-chains become longer, and our diets are characterised by a long list of chemicals rather than ingredients – we are losing our personal connection to food. Our understanding of how to choose it, cook it and consume it. And this is occurring almost ubiquitously.
Understanding food and where it comes from, is an essential knowledge nugget for a healthy society – and crucial for those working in health. As the Journal of the American Medical Association recently published, the old medical adage of “see one, do one, teach one” must also become “see one, taste one, cook one, teach one”.
Engaging with the education and political sectors to ensure this is understood, would be time and energy well spent for any global health enthusiast or doctor. Food must become a more accepted part of the clinical mandate.
To conclude, Food is an essential part of health and wellbeing – chosen, prepared, cooked and consumed correctly, food is medicine – it can and has been an enormous catalyst to gains in life expectancy and quality of life to populations around the globe.
But – and this is an important ‘but’ – mismanaged, unregulated, recklessly advertised, poorly produced and over consumed, food can have dire public health consequences. And those consequences are currently playing out around the world.
Food companies, governments, the medical community, the food supply, what we eat, how we eat, food policies and what we subsidise, how much we eat and what we waste will all dictate whether, in the next century, food can once again be a catalyst of health – or continues as a risk to it.
One thing is clear – food is, and must be, a Global Health Issue.
Since typhoon Haiyan ravaged the Philippines last month, some predictable patterns of disaster news coverage have begun to emerge – including evidence of a sometimes contentious relationship between the press and aid organizations. This week on PLOS TGH, Columbia University’s Chris Tedeschi explores.
Stories about the acute phase of the disaster—sudden chaos and unprecedented destruction—have given way to a secondary wave of intermittent criticism, stories of corruption, and even debate about why we still can’t get it right when the international aid machine groans into action.
On time.com, John Crowley argued that a disproportionate number of stories ask why disaster responders have not yet repaired a system rife with inefficiency. He notes that reports from the field indicate that the problems are not as pronounced as news reports make them out to be.
Crowley argues that some of the overblown coverage reflects the moment when journalists witness the inevitable chaos before roads are cleared and medicines are delivered. He blames the media for exaggerating this disparity of supply and demand in the early phase of a crisis, and for “scaremongering” security issues, ultimately delaying aid.
But even the scaremongering is part of an awkward symbiotic relationship between aid groups and the press. Reporters depend on NGOs for access, and in turn, aid organizations survive on dollars donated by individuals and groups moved by dramatic news reports.
The secondary wave of reporting usually focuses on something gone awry—fuel line brawls after Sandy, cholera in Haiti, everything in Katrina—and helps to maintain viewership while postponing crisis fatigue, thus generating more support for agencies on the ground. Oftentimes, financial contributions from this phase can pad the budget of NGOs for months to come.
In Linda Polman’s The Crisis Caravan: What’s Wrong with Humanitarian Aid, journalist Richard Dowden describes the relationship between NGOs and the media in Goma following the 1994 Rwandan genocide: “Each [NGO representative] would give a higher death toll, because each one would know that the man with the highest death toll would get on the nine o’clock news that night. And being on the nine o’clock news meant you got money….”
To some degree, the media does focus disproportionately on what’s gone wrong, partly because journalists fall into a trap of propagating classic disaster myths: all aid comes from far away, countless people and resources are required, and locals often can’t help themselves.
Few reporters cover humanitarian crisis full time. A 2004 study by the Fritz Institute and Reuters Foundation found that of 265 reporters surveyed, only 27 said that crisis stories were more than half their output. Reporters who do specialize in humanitarian emergencies often lack resources or the specialist knowledge to understand complex issues, and make poor use of available resources such as the UN OCHA website and reliefweb.
Ultimately, Crowley’s conclusion is on target. Information is aid. Stories should focus on building capacity and empowering responders, and describing the experiences of those impacted by the disaster. Less congratulatory stories should focus not on the unalterable realities of disaster response, but on the need for organizations to operate efficiently and transparently.
“It is time to look at how effectively international organizations are supporting a normally well-oiled (but now struggling) domestic response capacity,” Crowley argues, “not how international aid shipments are arriving late.” Sadly, it’s not that simple. Stories about how everything is going well would fail to paint the real picture, and would deny a critical role of the press: to expose injustice, highlight inefficiency, and serve the public.
Historically, NGOs and humanitarian organizations have been largely immune from critical coverage, despite an enormous diversity in the quality of the services they provide. In a rare exception after the 2010 Haiti earthquake, a Lancet editorial described the aid machine as “polluted by the internal power politics and unsavoury characteristics seen in many big corporations.”
So maybe the press should be even more critical of what’s going on in the field. What about missed benchmarks and overspending? And why are those aid shipments arriving late after all? We should encourage coverage – for the benefit of donors, readers and affected populations – of poorly coordinated efforts, of groups who cannot provide their own volunteers with basic necessities, of money and resources spent on aid which never reaches its goal, of disaster tourists who take more than they give.
NGOs and reporters alike ought to avoid the trap of addressing inputs rather than outputs, describing how many dollars have been donated or tons of medicine have been shipped, rather than what those dollars purchased or who received the medications.
Several authors have argued for standardization in the practice of humanitarian assistance, but a formal system has yet to emerge. In any emergency, most NGOs and aid groups will demonstrate excellence. But sometimes, there will be confusion, wastefulness, and corruption. And when the dollars at stake have come from governments, private donors, church groups and bake sales, the folks spending the money deserve to know what happens on the ground.
NGOs should take the lead in understanding their role in preventing disaster “catastrophization.” In the Fritz/Reuters study, when journalists were asked, “what do you consider the most difficult barrier to crisis reporting?” the most common answers included “lack of response from groups at the scene,” and “lack of coordination between groups at the scene and their own parent organizations.”
So how can NGOs avoid coverage that makes their skin crawl? Offer press training to field workers. Develop strategies for press relations. Share (don’t hide) information regarding peer organizations, and avoid duplicated effort. Understand that reporters are under pressure to tell dramatic stories that include conflict. And most of all, prepare for greater scrutiny: humanitarian aid workers are professionals spending millions of dollars of other people’s money, and ought to be accountable for it.
Christopher Tedeschi, MD, MA, is Assistant Professor of Medicine at Columbia University and a practicing emergency physician. He is past-chair of the disaster and humanitarian medicine committee of the Wilderness Medical Society and a Fellow of the Academy of Wilderness Medicine. He has worked in disaster preparedness in India, Sri Lanka, the US and elsewhere with an interest in media coverage and communications during emergencies. He is visiting faculty at the Global Emergency Medicine program at Weill Cornell Medical College. Prior to medical school, he received his master’s from the writing seminars at Johns Hopkins and worked for HBO Documentaries. He lives in NYC.
In time for International Day of People with Disability this week, London School of Economics and Yale graduate Pooja Yerramilli returns to discuss the importance of disability inclusive development and innovative partnerships to empower persons with disabilities worldwide.
“I am very happy. I stand on my own feet – but it was not always this way,” twenty-six year old Mohammad Rafiuddin told me. Rafiuddin is a Hindi language trainer at Tata Business Support Services Ltd (TBSS) in Andhra Pradesh, India. As his family’s sole wage earner, he uses his annual salary of Rs. 180,000 (US$ 3280) to support his elderly parents. Few would guess that only three years ago, this confident young man was unemployed, depressed, and frustrated with a society that defined him not by his personality or skills but by his crutches.
Rafiuddin was only ten months old when he was diagnosed with polio. His family lived below the poverty line and relied on the sole income of his now retired father, an agricultural worker. They could not afford special equipment or assistance to ease Rafiuddin’s physical struggles. Neither did their village have the infrastructure and transportation services to help persons with disabilities (PwDs). So when Rafiuddin reached childhood, he had no option but to crawl one kilometer to and from school. Against all odds, Rafiuddin earned a B.A. and a B.Ed.
Yet, Rafiuddin soon faced a harsh realization that so many other PwDs share – that he was more crippled by society’s attitudes than by the impairment of his legs. He applied for jobs at ninety schools in his district. Even with his academic qualifications, he was turned away from every single one. “They looked at my disability, not my skills,” Rafiuddin says.
Rafiuddin’s story of struggle is not unique; however, his story of ultimate success is. According to the World Bank, India has between 40 and 90 million PwDs. The 2002 National Sample Survey Office estimates that the majority of India’s PwDs are illiterate, and only one in four are employed. Further, the UN Development Programme estimates that 80% of PwDs reside in low and middle-income countries. These statistics reflect the cycle between disability and poverty. Namely, poverty increases susceptibility to such disabling conditions as malnutrition, while the stigma associated with disability precludes access to education and employment.
Ban Ki-Moon, Secretary-General of the United Nations, addresses the General Assembly’s high-level meeting on “The way forward: a disability inclusive development agenda towards 2015 and beyond.”
According to the UN, PwDs constitute the “largest and most disadvantaged group” in the world. Yet the rights and empowerment of PwDs have long been neglected. The Millennium Development Goals make no mention of disability. As a result, according to the International Disability and Development Consortium, PwDs are often left out of development initiatives. Programs to increase school attendance do not accommodate the needs of disabled children, and projects to improve access to water do not consider the physical barriers that PwDs encounter. These challenges are the focus of this year’s International Day of Persons with Disabilities. On December 3, the UN will promote the theme of “Break Barriers, Open Doors: for an inclusive society and development for all.” As Secretary General Ban Ki-moon stressed at the UN High-Level Meeting on Disability and Development in September, “we must not only lift the physical barriers, but also the barriers in attitudes that fuel stigma and discrimination.”
But how exactly can we go about this complex task? Meera Shenoy, founder of the Center for Persons with Disabilities Livelihoods (CPDL) in Andhra Pradesh, believes that in order to break the poverty cycle, society’s conception of disability must change. “Many disability NGOs,” she argues, “focus on the rehabilitation of persons with disabilities, but do not address the fundamental socioeconomic challenges that persons with disabilities face.” To address this need, Shenoy established the CPDL, a public-private partnership with private companies, a private sector foundation (Youth4Jobs), and the government of Andhra Pradesh.
The generic education that many PwDs receive in school does not adequately prepare them for the realities of a competitive job market. CPDL takes an innovative multisectoral approach and unites NGOs, companies, and the government on a single platform – the education and empowerment of young disabled adults. The organization teaches these youth practical skills to prepare them for specific jobs in service and manufacturing. Such partner companies as McDonalds and TBSS recruit from this pool of workers. In this manner, CPDL secured employment for approximately 70% of the 2800 youth trained through its programs.
Shenoy submits that “these youth transform themselves and their societies when they begin sending money to the same families that previously saw them as burdens. They show their peers that they are not disabled, but merely differently abled.” CPDL’s work has also helped improve perceptions of PwDs among employers. “There are many companies that cannot employ PwDs because the jobs require physical labor,” a partner company’s HR manager concedes. “But where we can take them, where they can work, we should employ them. We have a responsibility to put them in jobs where they can use their skills.”
Disability Rights Advocates rally in Washington DC to urge Senators to ratify the UN’s Convention On The Rights Of Persons With Disabilities
CPDL’s success shows that the world’s “most disadvantaged group” can indeed participate in the global economy. Thus, it is crucial that we prioritize the needs of the disabled particularly in developing countries, both in rhetoric and in action. As a first step, the United States Senate must ratify the UN’s Convention on the Rights of Persons with Disabilities. The treaty does not, as opponents believe, curtail national sovereignty, but merely promotes the international re-conceptualization of PwDs from individuals who require charity to productive members of society entitled to fundamental human rights. The impact that such a revised framework has already made is evident in the hopes and dreams instilled in CPDL’s students. “My ambition is to establish an NGO for the people who are affected by disabilities,” Rafiuddin says. “I want to collect those people and train them – and give them better opportunities, like me.”
Pooja Yerramilli is a Yale graduate and completed the MSc. Health Policy, Planning, and Financing degree at the London School of Hygiene and Tropical Medicine and the London School of Economics. She has been involved in cancer advocacy efforts for several years, and was an active participant in policy discussions regarding smoking behaviors and insurance coverage of smoking cessation treatments at Yale. She recently worked with the Indian Institute of Public Health and is collaborating with the Harvard Global Equity Initiative on research on the Financing of Cancer Care and Control in Low and Middle Income Countries.
This week, Director of Global Health Communications with the American Cancer Society, Rennie Sloan, provides an update and insights from the UICC’s World Cancer Leader’s Summit in Cape Town, South Africa.
This week, more than 175 health leaders and UN and government officials convened at the World Cancer Leader’s Summit in Cape Town, South Africa. This important annual Summit, organized by the Union for International Cancer Control (UICC), focuses on addressing the glaring disparities in cancer control.
Cancer, a leading global killer, takes the lives of more than 7.6 million people per year. Together with diabetes and heart and lung disease, these noncommunicable diseases (NCDs) account for about 65% of global deaths. Roughly two out of three deaths worldwide are from NCDs and 80% of these fatalities occur in low- and middle-income countries.
Yet, you would never know the enormous toll chronic diseases take from the current global health and development resources and policies. As of 2009, NCDs received less than 1% of health and development assistance. While NCDs received historic and critical attention at the 2011 UN High-level Meeting on NCDs, there is still an urgent need for NCDs to be adequately resourced and integrated into UN and national government priorities.
Bold action from top global leaders is needed to change the landscape of global public health. Equally important, grassroots activities need to be more strategically coordinated. The youth community could help with bolster grassroots efforts by amplifying the message for greater NCD resources.
It is significant that this cancer Summit takes place – for the first time – in Africa, where a newly released American Cancer Society report cites tobacco as a growing threat to the continent. Tobacco is a common risk factor to all four primary chronic diseases, accounting for 1 out of 6 NCD deaths.
The tobacco industry sees youth as one of the last frontiers of marketing, and has their sights set on Africa and many developing regions.. Big tobacco spends hundreds of millions of dollars trying to ensnare new users with clever campaigns designed to entice young people. If their deplorable tactics were better understood, the same demographic they hope to addict to deadly tobacco could become its most powerful foes.
While NCD advocacy among youth is sorely needed, governments and donors still need to fully realize what’s at stake with the projected rise of these diseases. They should take note that prevention of NCDs is cost-effective, not prohibitive. Pooja Yerramilli at the Harvard Global Equity Initiative offers this perspective.
“Many assume that the control of NCDs and chronic illnesses in low to middle-income countries is a Herculean task, as financial protection against such conditions is simply unaffordable in resource-constrained settings. However, gross inequities in incidence of preventable chronic illnesses and survival rates within and across countries can be mitigated in many cost-effective ways. In fact, countries such as Mexico, India, China, etc. have begun incorporating such diseases into national or state-level insurance schemes and implementing innovative prevention and screening programs.”
Without interventions, the World Economic Forum projects $47 trillion in lost productivity over the next two decades from NCDs. This means that Ministers of both Health and Finance should be participants at key meetings to discuss cancer, tobacco, and NCDs. Left unchecked, these diseases will perpetuate the cycle of poverty in addition to causing unnecessary and preventable deaths.
The NCD response seems painfully slow given their human and economic toll. But according to Ambassador Sally Cowal, Sr. VP of Global Health at the American Cancer Society, it was the same decades ago for the HIV/AIDS response.
“It’s like turning around the Queen Mary. It took a long time for the HIV/AIDS tide to turn and resources to catch up with the epidemic.”
And the NCD advocacy community today has at least one advantage the HIV community did not enjoy decades ago. Youth are better empowered now with social media to inform and unite them to demand action for significant change. Passion and knowledge, combined with innovative technology tools, can put a face on these chronic diseases, a critical component in turning the tide in a global health crisis.
The young leaders of global health should take note of what Summit speakers and African leaders have reminded us – cancer and NCDs are becoming a human rights issue because they are projected to hit the most vulnerable populations the hardest. Tools such as the UICC new World Cancer Declaration released this week can be used to disseminate advocacy messages that will allow the cancer community to reach out to the development, disability, education, employment and many other sectors for innovative partnership. The refreshed Declaration can also be used to align with the emerging global NCD framework and the dialogue on the post-2015 development agenda.
But first, there is a clear need to define and widely share the NCD message. What are NCDs? Sadly, most people don’t know the ominous data on the diseases, much less the lexicon to define them. The current and future generation of youth are poised to loudly sound the alarm and to make sure the world hears it.
In her role as Director of Global Health Communications with the American Cancer Society, Rennie Sloan works to put cancer on the global health agenda at the UN and with the US Global Health Initiative. She has worked with U.S. and global NGO partners, governments, health leaders, the United Nations, the UN Foundation, the private sector, and WHO to promote awareness and advocacy for policy change to place cancer, heart disease, diabetes and respiratory diseases on the U.S. and UN agendas.
Translational Global Health – from #COP19, Warsaw. An article from the team at the IFMSA Think Global Initiative, attending the nineteenth session of the Conference of the Parties in Warsaw - Claudel P-Desrosiers, Chalotte Holm-Hansen, Yassen Tcholakov and Nick Watts. These inspiring young MD-trainees are leading the charge on climate and health at this week’s UN meeting.
Flickr / net_efekt
Climate change has important health impacts and given the inequitable distribution of its consequences, it is contributing to increasing health disparities between developing and developed countries. (1,2) Quantitatively, climate change is estimated to be responsible for “154 000 (0.3%) deaths and the attributable burden was 5.5 million (0.4%) DALYs” in 2000.(3) If we continue along the current path, health impacts of climate change will not only increase, but do so faster than ever before. One of the most terrifying things about climate change is that those it affects most are also the most vulnerable people, those living in the poorest countries. They, who are the least responsible for climate change, will bear the largest burden of impact. Inequalities in social and economic development, education, accessibility and quality of basic health care, infrastructures and public policy, will play a crucial part in determining the national consequences climate change impacts. Once again, the poorest populations will be hit the hardest. The World Bank estimates, in a recent report, that a 4 oC warmer world is so different from the current one that it comes with high uncertainty and new risks that threaten our ability to anticipate and plan for future adaptation needs.(4) Isn’t that scary?
Climate change will affect health in many ways:
Increased frequency and severity of extreme weather events (heatwaves, hurricanes, cyclones, massive floods), affecting health care delivery and weakening health systems;
Famine, drought threatening food supply of millions, causing malnutrition, mortality and damaging child growth and development;
Mass migration, with recent estimations indicating over 200 millions climate change refugees by 2050, posing a threat to social security;
Infectious diseases, especially diseases transmitted by mosquitoes (malaria, dengue, yellow fever, West Nile Virus, etc) spreading to new territories;
Air pollution, increasing the incidence of lung cancers, asthma and chronic obstructive pulmonary diseases.
As we speak, thousands are gathering in Warsaw (Poland) for the 19th meeting of the Conferences of Parties (COP19) for the UN Framework Convention on Climate Change (UNFCCC). This intergovernmental process has been operating since 1994, and serves as the international forum for negotiations and discussions on global action to combat climate change. The conference will see over 10,000 experts in climate change, sustainability, and development come together for two weeks from November 11 – 22 to piece together the initial building blocks of a new global agreement, to be delivered in 2015 at COP21 in Paris. You can find all information about #COP19 on the official website: http://www.cop19.gov.pl/.
In the past years, the International Federation of Medical Students’ Associations (IFMSA) has been one of the leading NGOs, delivering powerful interventions, organizing massive mobilization, leading youth efforts, and above all, advocating for a bigger health consideration in the COPs negotiations. It also works together as part of the Global Climate and Health Alliance (GCHA) to advocate for policies which promote human health and protect the planet. The Alliance is managed by a number of leading, international environment and health organisations, coordinating their international policy and communications strategy at the UNFCCC. On the 16th of November (in parallel with COP19), the GCHA is holding the second Global Climate and Health Summit, which will develop a road-map for the international health community to mobilize around in the lead up to COP21 in 2015. If you’re in Poland at the time, you can register for the Summit here.
“We need to bring the two agendas of health equity and climate change together” - WHO Commission on Social Determinants of Health
At this years climate talks, IFMSA has a delegation consisting of five people from all over the world, led by Charlotte Holm-Hansen from Denmark. The delegation will mainly focus on promotion of the second Global Climate and Health Summit, youth participation and how health should not be seen in isolation but as coming with many the co-benefits which can strengthen other issues. The delegation will be blogging daily, and can be followed on twitter using the hashtag #IFMSACOP19.
IFMSA believes that we, as young professionals and as medical students, have no choice but to act. As the WHO Commission on Social Determinants of Health states, “we need to bring the two agendas of health equity and climate change together”. We need to act as responsible members and leaders of our communities. We must pressure our politicians to implement sustainable and climate-sensitive strategies that go beyond a 4-year political mandate.
Whether you like it or not, climate change is linked to health. Climate equals health. And it’s not too late to stand up for a healthy environment for all. We are now more than 7 billion living on Earth and we need balance and sustainability. We have the potential to improve the life of millions by taking action right now. As Yeb Sano, the delegate from the Philippines, said on Monday during the opening plenary of COP19, we must “stop the madness”.
For health professionals and medical students interested in getting more involved in the climate health efforts, here are a few ideas:
1. Climate Change 2007: Impacts, Adaptation and Vulnerability. United Kingdom and New York, NY, USA: Intergovernmental Panel on Climate Change, 2007 4.
2.Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet. 2009 May 16;373(9676):1693-733.
3. World Health Organization. The World health report : 2002 : Reducing the risks, promoting healthy life. Geneva: World Health Organization; 2002. 248 p.
4. World Bank. Turn Down The Heat: Why a 4°C Warmer World Must be Avoided. Washington: World Bank; 2012. 106 p.
Think Global is an initiative project within the International Federation of Medical Students Associations (IFMSA). It aims to develop a network of young medical students who are empowered to act on global health issues; and to equip students with core knowledge and skills, so as to train global leaders. For more, please visit: www.ifmsa.org.
Claudel P-Desrosiers is a 2nd year medical student at University of Montreal. She’s currently acting as the IFMSA Think Global Initiative coordinator and as IFMSA-Quebec President. On twitter: @c_pdesrosiers.
Charlotte Holm-Hansen is a medical student from Denmark, research assistant in epidemiology and has previously worked in WHO Department of Public Health and Environment for the the Danish ministry of Foreign Affairs. She’s leading IFMSA’s delegation to COP19.
Yassen Tcholakov is a fourth year medical student at the University of Montreal. He holds a Master of International Health from the University of Copenhagen has conducted climate change policy research. He is also member of the Trainee Advisory Committee of the Consortium of Universities for Global Health (CUGH). On twitter: @yassentch
Nick Watts has a background in medicine and economics. He currently works for the WHO, and the UCL-Lancet Commission on climate change and health.
This week, London School of Economics and Yale graduate Pooja Yerramilli returns to explore the role and need for multidisciplinary approaches to global health and cancer research.
It is no secret that over half of all cancer deaths in low and middle-income countries (LMICs) are preventable or avoidable. Primary and secondary prevention have long been advocated as cost-effective means for controlling cancer. And, as Kuguru, et. al. rightly point out, our moral imperative to prioritize prevention efforts stems in part from the fact that cancers that should be avertible or treatable often become terminal when reported in late stages. Indeed, the most prevalent cancers in India fall into this category. Lung and oral cancers are preventable by risk factor (tobacco), as is cervical cancer (HPV infection). Moreover, cervical and breast cancers may be “curable” through such treatments as surgery, if detected early. Yet these four cancers together constituted almost 40% of all cancer cases and approximately 36% of all cancer deaths in India in 2008. These trends are consistent with numerous reports from the Indian state of Andhra Pradesh, which reaffirm that 75-80% of cancer cases treated through the Rajeev Aarogyasri Scheme (RAS) are diagnosed in advanced stages and therefore face lower survival rates.
The need to focus attention on mass prevention seems obvious, begging the question: why haven’t LMICs already effectively done it? As part of my research on the financing of cancer care and control in Andhra Pradesh, I investigated this question.
A review of legislation in India suggests that the central government has in fact long prioritized cancer prevention. In 1975, the government established the National Cancer Control Programme (NCCP), and shifted the program’s focus toward primary and secondary prevention in 1984. However, my conversations with government officials and health care providers indicated that cancer prevention strategies are inadequate on paper and even more inadequate in practice, due to myriad economic, social, and political factors. These discussions revealed that we cannot merely say “cancer prevention” is the most cost-effective means of controlling cancer, but must develop and identify specific prevention strategies that are the most cost-effective in LMICs. As two key informants detailed, cervical cancer screening methods are a prime example of the need and promise of such interdisciplinary research.
Pap smears have long been accepted in many high-income countries as an effective screening method for pre-cancers. Unfortunately, according to several oncologists I interviewed, mass screening programs which include Pap smears are nonexistent in Andhra Pradesh. The inaccessibility of screening may in part be attributed to inadequate infrastructure as well as social, cultural, and economic barriers.
In India, Pap smears are commonly seen as overly invasive and embarrassing. A woman who seeks a Pap smear is presumed to engage in sexual activity, which in India, is rarely openly discussed. This stigma not only discourages women from seeking Pap smears, but also affects the design of preventative programs. As many oncologists suggested, prevention efforts in Andhra Pradesh remain piecemeal, and are largely funded by independent charitable organizations and individuals. Several physicians confirmed that when they conduct health camps, they target married women for Pap smears, thus operating within the cultural stigma and insistence that only this cohort is at risk for developing cervical cancer. And because women must simultaneously work, manage household chores, and look after children, they seldom visit health camps or clinics until they can no longer ignore their symptoms. Thus, despite the efforts of many hospitals to raise awareness of pre-cancerous symptoms, Pap smear delivery rates remain low. As one study confirms, non-compliance and community participation are of primary concern when designing cervical cancer screening programs.
Even if these health care providers’ efforts to target symptomatic women were successful, several oncologists agreed that their initiatives could not truly qualify as screening. Screening by definition must entail the investigation of both symptomatic and asymptomatic individuals. Yet, according to one physician, in a country as large as India, the scaling up of Pap smears to cover the entire population may be financially infeasible.
These limitations seem to suggest that comprehensive and consistent cervical cancer prevention efforts in Andhra Pradesh are simply futile. However, recent research may provide alternative solutions. Several studies have compared the effectiveness of Pap smears with those of the recently innovated visual inspection with acetic acid (VIA) method and HPV DNA test in communities in Andhra Pradesh (and other LMICs). HPV DNA tests in particular may not only be more sensitive and specific than Pap smears, but also may reduce reliance on infrastructure and specialists. Therefore, such methods as self-collected HPV DNA tests may prove most suitable to regions such as Andhra Pradesh, which have inconsistent health infrastructure and a population reluctant to seek invasive tests at clinics due to cultural taboos.
Research currently under way is investigating the cost-effectiveness of these cervical cancer screening methods, to determine which are most scalable in resource-limited settings. The vast infrastructural, social, cultural, and economic barriers to access seem daunting, but multidisciplinary research may minimize some of these challenges and thereby improve health care delivery. The collaboration of researchers across such disciplines as biomedical sciences and health economics may facilitate the development of novel disease control methods while we also tackle the long term and fundamental health systems challenges that preclude consistent access to services across the cancer care and control continuum.
Pooja Yerramilli is a Yale graduate and MSc. candidate at the London School of Hygiene and Tropical Medicine and the London School of Economics. She has been involved in cancer advocacy efforts for several years, and was an active participant in policy discussions regarding smoking behaviors and insurance coverage of smoking cessation treatments at Yale. She recently worked with the Indian Institute of Public Health to complete a research project on the Financing of Cancer Care and Control in India.
This week on TGH – regular blogger and NCDFREE change-maker Jo Jewell of the World Cancer Research Fund talks about health policy and its role in Global Health.
It has become abundantly clear over the decades that there are sometimes major issues adopting policies to prevent people from becoming ill through non-communicable diseases (NCDs). Starting with tobacco and now evident with alcohol, unhealthy diet and obesity, proposals for effective policy action – which centre on the need to reduce exposure to these risk factors - often fail to make it onto the agenda, are repeatedly blocked in government, or are challenged in the courts of law. While this is down to a combination of factors, accusations of ‘nanny state’ have been at the forefront acting as a barrier to government action.
It’s clear that the public cares a lot about health – the way in which governments choose to run our health care systems generates a lot of media coverage and is guaranteed to be a hot topic in the run up to any elections. Beyond health care, public health is often less visible, and the types of broader policies designed to influence public health appear to gain less immediate traction with the public. (Admittedly, public health can still hit the headlines and catch governments off guard, as is sometimes the case when the shocking extent of health inequalities within our countries is revealed). But it is when policies are perceived as being too interventionist, restrictive of choice or paternalistic that public health can really provoke headlines, controversy and debate (think ‘fat fascists’ or similar). At the forefront of opposition to these policies is the criticism that public health wants to ‘nanny’ the population – and, not wanting to risk public outcry, this can translate into a distinct lack of effective action by government.
It cannot (or, should not) be implied therefore that consumers are somehow only fulfilling their desires. Nor should it be suggested that the inevitable downstream health effects are simply an unfortunate consequence that must be tolerated because people ‘want’ to be obese or ‘want’ to become addicted to tobacco. Our choices and actions – which determine our health – are rarely made on a completely rational or informed basis but are in fact influenced in large part by our external environment, and in ways over which we may have little control. I don’t therefore buy the short-sighted, hands-off argument that people should be allowed do as they please and just be a little more responsible. I don’t believe it is as simple as that.
What this means is that we in fact need a whole suite of stronger policies to respond. These policies should target the factors in the environment that influence our behaviours, and the objectives of policies should be carefully designed to achieve maximum benefit. For example, we know that children’s dietary behaviours are influenced by marketing, and that the amount of exposure is critical in shaping their preferences and food choices. So well-designed policies that broadly protect children by reducing exposure to all forms of marketing of unhealthy foods and place tough rules on the manipulative content of the marketing are entirely justified.
Opponents (whether in government, with industry, or people politically/philosophically opposed to ‘big government’) attempt to undermine such public health efforts in any way possible. First they claim the policy measures are an unfair restriction of freedoms, then they pull apart the evidence. For example, the NYC supersize soda restrictions proposed by Mayor Bloomberg were portrayed as being an unfair and an unjust restriction of choice that ‘coerced’ consumers. In fact, people would still have been able to order as much soda as they wanted but the default was simply changed to make it more difficult. In order to further stall the policy, opponents also cast doubt on the evidence. So wrapped up in the whole ‘nanny state’ debate is a second criticism that the proposed policies won’t be effective anyway, because people will continue to ‘seek out’ unhealthy food and drink, alcohol or cigarettes.
Changing the narrative
When people say that these sorts of interventions are nanny state, I ask: do you want to go back to a time when you breathed smoke for the duration of transatlantic flights, or risked your life driving at night because the driver coming towards you was blind drunk?
Policies in these areas were once controversial, but have nowcome to be part of social norms and valued. My colleagues and I often reflect upon the fact that at some point in the future people will surely look back and think we were mad to ever let companies manipulate children through marketing junk food.
Through policy it will be possible to create new social norms over time, where people grow up valuing health and seek out opportunities to lead healthy lifestyles. But there is also an immediate task, which is to bring people with us on this journey – and the media needs to be a key ally, not an opponent, in promoting the benefits of public health policy. This way governments will have confidence that the public supports action. And, if they are then empowered to take a comprehensive approach, rather than piecemeal action here and there, we are much more likely to see impressive results over time.
I truly believe that accusations of ‘nanny state’ need to be re-examined. At its core this is a question about the role of the state and what the relationship between government, society and individuals should look like. This is by no means a new question and there has long been a debate in politics and philosophy around the ‘social contract’, legitimacy of state intervention, and what approach will produce the best outcomes for society.
When it comes to preventing NCDs, unnecessary deaths and disability, I feel that we – as a community – have a legitimate rationale to support intervention to protect and empower people. Particularly when it is so patently clear that industries with a completely different set of interests and motivations are allowed to interfere by influencing our behaviours. Very few public health policies have an ultimate aim of removing personal choice entirely – they are much more likely to focus on regulating the “worst excesses of manipulation” by private interests, changing the environment and cues so as to tip the balance from unhealthy to healthy. It is the duty of the state to protect the population and we all need to do a better job at communicating this so that people are better able to judge for themselves whether the government is actually taking away freedoms or simply trying to re-empower its citizens.
This article was commissioned by NCDFREE, in collaboration with Remedy Healthcare and Local Peoples.
Jo Jewell is the Policy and Public Affairs Manager at World Cancer Research Fund International, based in London. He has a background in European politics and has a Masters in Health Policy, Planning, and Financing. His experience mainly relates to food and alcohol policy, and his work has focused on advocacy at the European and global levels. He is a member of the Global Steering Committee for the Young Professionals Chronic Disease Network. His contributions to this blog represent his own views and opinions.
The second article in our series commissioned by NCDFREE, this week, young change-maker Shauna Downs writes about reconnecting with food as an essential step in overcoming the local and global burden of NCDs. Shauna is a PhD candidate at the Menzies Centre for Health Policy in the School of Public Health at the University of Sydney.
Our food environment largely shapes what we eat based on what food is available, affordable and acceptable. My most jarring experience relating to just how important our food environment is in terms of health and NCDs is when I did my Masters research in a remote Aboriginal community in northern Canada. I was shocked to see that the few vegetables in the community’s only store were both rotting and exorbitantly priced. Alongside these rotting vegetables were aisles of cheap ultra processed foods. If that wasn’t bad enough, they even trucked in buckets of fried chicken from Montreal (which was 7hrs by road). Not only was the food environment suffering in this community but so was the health of its population. In contrast to the superior health of Aboriginal peoples in the past, this community was now experiencing high rates of overweight and obesity, diabetes rates were skyrocketing and community members were dying far too young.
How did this happen? One thing for sure is that our food environments have changed – and diets have changed along with it. We have lost the connection with food and where it comes from. As the world has become more globalised, so too has our food system. It has led to the infiltration ultra-processed food throughout our food supply. One of the main problems with this infiltration is that the relentless pursuit of sales and profit growth by transnational food companies has led to our food environments being saturated with unhealthy food.
So what can we do about it?
VOTE WITH OUR FORKS!
The food industry makes products that they think we want but by demanding healthier products, we have the power to influence what arrives on our grocery store shelves. We can refuse to buy products that have more than five ingredients or that more closely resemble chemicals than food.
ADVOCATE FOR REGULATION.
We need to advocate for regulation that makes it easier for everyone to make healthier food choices. We need to embrace the nanny state! We can support regulation that limits the quantity of salt in foods and marketing of unhealthy foods to children and encourage governments to tax soft drinks and provide subsidies for fruits and vegetables for low-income families.
Where I think we can really make a difference NOW is in the local food supply chains. Although it’s important to think global in terms of the food system, we need to act locally. Whether it’s by supporting local farmers markets or simply buying the locally produced fruits and vegetables in the supermarkets – we need to start buying products produced domestically. As demand for locally produced food increases more and more, it will create a larger and more stable market for local producers and will in time, bring down prices (making it easier for lower income groups to buy and eat locally). Regulation can help speed this process along. Countries, states or cities could take a similar approach to that taken by Brazil and Japan and ensure that schools spend 30% of their food budgets on food procured from local farmers. This has three obvious benefits. One, it increases access of nutritious foods to children; two, it creates a market for farmers which provides them with stability in terms of distribution; and three, it reduces food miles having a positive environmental impact.
BOLD LEADERSHIP BY LOCAL GOVERNMENT.
New York City has taken the lead in many aspects of improving the quality of the food supply. They have banned trans fat, began the sodium reduction initiative in the US, attempted to ban the sale of large sodas and have tried to increase access to fresh produce. They provided vendor licenses for 1000 green carts that can only sell fresh fruits and vegetables in the city’s boroughs. More recently, NYC doctors began providing prescriptions for fresh fruit and vegetables to low income families at high risk of NCDs. The program turns local farmers markets into pharmacies! Every local government should look to Mayor Bloomberg for inspiration on how to tackle public health in a bold and innovative way.
RECONNECT WITH THE FOOD SYSTEM.
Reconnecting with the food system will not be easy on the global level. It’s a complex problem and will require multifaceted solutions involving many sectors but we can’t use this as an excuse for inaction. Ensuring that healthy foods are available, affordable and acceptable is possible but it will require passion, persistence and vision from government. We need to demand healthier products and greater transparency about what’s in the food we consume. We can buy and eat local and we can take time out of our busy schedules to eat with friends and families and cook meals from ingredients rather than boxes and jars. We can commit to closing inequalities in fresh food access, demand bold leadership on regulation and empower kids through education to grow up with the knowledge of good food and how to prepare it. I think it’s clear that we need to take action – so take out your forks and vote!
This article was commissioned by NCDFREE, in collaboration with Remedy Healthcare and Local Peoples.
Shauna Downs is a PhD candidate at the Menzies Centre for Health Policy in the School of Public Health at the University of Sydney. Her PhD project examines trans fat policy in India using a food systems approach. Her main interest is in the relationship among the nutrition transition, chronic disease and the use of multisectoral policies to improve the quality of the food supply. In addition to her PhD work, Shauna is a Research Assistant in the Food Policy Division of The George Institute for Global Health. Prior to beginning her PhD, Shauna worked at the University of Alberta (Edmonton, Canada) where she was a Research Coordinator in Community Nutrition. Her research focused on adolescent and child obesity prevention, primarily in schools.
Only few years’ back, if you would ask any public health professional from Bangladesh, what is the most challenging experience they face! They would say communicable diseases, water borne diseases, child and maternal mortality and malnutrition – referring to under nutrition. Now this situation is slowly but steadily being replaced with new challenges like rapid urbanization, climate change, disaster, migration and raising prevalence of non-communicable diseases and its risk factors – obesity/over weight, tobacco use, unhealthy diet, physical inactivity and substance abuse! Unfortunately women and children, once the main victim of under nutrition, are becoming over weight and obese – especially in urban areas.
So why this shift? I have some theories and again these are just my personal thoughts based on observations and evidences. Lets look into the raise of having sugary beverages and junk foods in Bangladesh. Each year the world-renowned food chains are opening new outlets, giving attractive promotions during each of the festivals. Why? Because the market scope for such “in fashion” foods are rising by each day, if not each hour. What about the sugary drinks! During the last one decade a new raise in “Energy Drinks” is being observed. All these products has very effective and attractive marketing strategy which will “make” you believe that these gives you nothing but “Energy” and makes you a “Man”! And we all know that sugar-sweetened beverages are linked to more than 180,000 obesity-related deaths worldwide each year, according to new research presented at the American Heart Association conference. And what about processed food? This silent beast is also on raise as well as within the form of “Entrepreneurship”!
Few years back while doing a school based awareness campaign on anti-tobacco issues one 13-year-old boy asked me “if tobacco is so bad for health then why doesn’t the government shuts down the industry”? The only answer I had was “by showing that they pay tax and do less harm”. This is the dilemma we all – people working for the prevention and control of NCDs face. From public health arena we also have numbers – both for deaths and disabilities. But those numbers are not as attractive as the “revenue” numbers! According to the a report by Centre for Policy Dialogue food beverage and tobacco industries give the highest share for annual inflation in the country for the year of 2013. And sadly this is the “Number” what policy makers and bureaucrats like to hear!
Another issue that is being discussed almost everyday and by everyone! Safe food! Because unfortunately food can just as easily kill as it keeps people alive, where excessive use of pesticide, unregulated street food and lack of awareness about food safety sicken millions annually. Since the country still depends on agriculture, with decreasing land and increasing population farmers look forward for getting more yielding in each of crops they harvest. And while doing so many farmers in the country use an excessive amount of pesticide in agricultural products and ignores the serious health impacts on consumers.
Unfortunately the “philosophy of making profit at any cost” puts consumers at risk. A common practice among food vendors is to spray fish, fruits and vegetables with chemical preservatives including formalin – a commercial solution of formaldehyde and water – to boost food’s lifespan and appearance. The chemical’s short-term effects include: a burning sensation in the eyes, nose and throat; coughing; wheezing; nausea; and skin irritation. As for potential long-term health consequences, formaldehyde has been identified as a human carcinogen. Almost all diet related NCDs renal failure, cancer and liver damage – all potentially fatal – can be linked to the consumption of unsafe food, but the “extent of food-borne illness is yet unknown.
We all know that tobacco makes a lot of people a lot of money. Both forms of tobacco use – smoking and smokeless – are on the rise in Bangladesh. Two in five people aged 15 years or more use tobacco in one way or another. A WHO study estimated that, annually around 57000 people lost their life prematurely as a result of tobacco use and 382000 people becomes disabled.
What is the way out? Honestly I don’t know! As of yet I don’t know but one thing I know that until we show the correct numbers to the people who makes the decision “Profit” will always trump “Health”!
Translational Global Health facilitates the translation of findings from basic science to practical applications in Global Health practice and, thus, meaningful health outcomes for diverse populations and societies.
“In short, human-driven climate change poses a great threat, unprecedented in type and scale, to well-being, health and perhaps even to human survival.” - Prof Anthony McMichael
About the Bloggers
Lead Blogger Dr Alessandro Demaio is an Australian Medical Doctor with a Masters in Public Health. In 2010, Sandro began a PhD in Global Health with the University of Copenhagen, focusing on Non-Communicable Diseases (NCDs). His primary research was based in Mongolia. From 2013 Alessandro is a Postdoctoral Fellow at the Harvard Global Equity Initiative at Harvard Medical School and an Assistant Professor at the Copenhagen School of Global Health; and Co-Founder of NCDFREE.
Sandro is joined by a sensational team of Guest Bloggers from around the globe; specialists in economics, humanitarianism, policy, law, health promotion and more:
Global Health & Classical Music, Imperial College London
Research Fellow, Harvard University
Assistant Clinical Professor of Emergency Medicine, Columbia University College of Physicians and Surgeons
Dr Fred Hersch
MD & Research Fellow, The George Institute for Global Health
Dr Fiona Lander
Lawyer & MD
Health Economist, PricewaterhouseCoopers London
Dr Jenny Jamieson
MD & Humanitarian Specialist, Médecins Sans Frontières
Policy Specialist, World Cancer Research Fund
Dr Kremlin Wickramasinghe
Medical Doctor & Researcher in NCD Epidemiology, University of Oxford
Global Health and Economics, London School of Hygiene and Tropical Medicine and the London School of Economics
Health Researcher, University of Copenhagen
Director of Global Health Communications, American Cancer Society
Global Health and Nutrition Researcher, Menzies Centre for Health Policy, University of Sydney