Sunday, May 18, 2014

Global Health Critical Reflection #4

One day during my Peace Corps service in Sierra Leone, I was walking home from school and as part of my daily ritual, I walked to my principal’s house to spend time with his eight month old daughter, Fatima. But that day was different. When I went to see Fatima, her eyes were glazed over and her skin was looking pale and yellow. Her mother informed me that she had vomited earlier in the day and had diarrhea. I didn’t think much of the sickness since children seemed to be sick all of the time in Sierra Leone. The next day I was awoken in the morning by one of my fellow teacher’s informing me that Fatima had passed away in the night.
I walked over to my principal’s house and was greeted by the many friends, family members, and community members who came to give their sympathies. I walked straight up to my principal’s wife, Mrs. Turay, who was like a mother to me during my time in Sierra Leone. I went to hug her not even hesitating to think if this was a culturally appropriate gesture. After the embrace, she looked me straight in the eyes and in perfect English said, “Rachel, Fatima was taken from me.”
The child mortality rate in Sierra Leone is the worst in the world (At a glance: Sierra Leone, 2013). During my service, I was constantly hearing about a child dying in my town. Even though I heard about these deaths, I still felt detached from these morbid statistics. When I saw Mrs. Turay in so much pain over her lost daughter, this child mortality rate became a reality for me. In the U.S., if you know a family who has lost a child, it is one of the most traumatic events that affects not only the family but the whole community. I know families in Madina that have lost up to three children. The pain these families bear is unremarkable.
Fatima’s passing is one of the reasons why I am in this class. After witnessing how the death of a child can affect an individual, a family, and a community, I wanted to better understand the root causes of those deaths and what can be done to prevent these tragedies. In Dr. Bhutta and Dr. Black’s article “Global Maternal, Newborn, and Child Health – So Near and Yet So Far,” they outline the social determinants of health that contribute to this severe data – access, the environment, poverty, education, conflict, and gender inequity – just to name a few, each aspect sets the stage for despair amongst millions of families around the world (2013). As I was reading this portion of the article, I was shocked to think that all of Mrs. Turay’s children survived the 11-year civil war, but her youngest daughter could not survive the water the whole family drinks every day.
As I try to understand the complexities of child mortality rates, I often question the validity of the data. Dr. Bhutta and Dr. Black noted that most deaths are confirmed through “oral autopsies” and “in 2010 only 2.7% of the deaths among children younger than 5 years of age were medically certified” (2013).  Therefore, most children are dying in low-income countries and we are not certain what they are dying from. We can extrapolate assumptions based on prevalence of infectious diseases, but is that enough? The need for accurate surveillance is critical and resources most be adequately appropriated to improving these measures.
In terms of interventions, the authors explained the importance of community health worker trainings and toolkits (Bhutta & Black, 2013). Investing in these trainings and resources can be beneficial in poor communities, but for real change, there needs to be a shift in attitudes. Children dying in Africa should’ve never become a norm and families and parents, like Mrs. Turay, should be given time to grieve and process the loss of a child. As I continue the process of developing into a public health professional, I will be reminded of those families who have experienced the tragic loss of a child. I will use those emotions to demand for change, because although I could not help Fatima, there are more Fatima’s and more Mrs. Turay’s who are also demanding for a change.

References

At a glance: Sierra Leone. (2013, December 27). Retrieved from UNICEF: http://www.unicef.org/infobycountry/sierraleone_statistics.html

Bhutta, Z., & Black, R. E. (2013). Global Maternal, Newborn, and Child Health - So Near and Yet So Far. The New England Journal of Medicine, 2226-2235.



Global Health Critical Reflection #3

One of my neighbor boys in Sierra Leone, Mohammed*, was always sick. I often saw his mother toting the two-year-old to the traditional healers in my town. I was intrigued by this because his father was earning two salaries from his job as a teacher at the secondary school and as an employee at the local mining company. The two incomes were a comfortable amount for a family of four to live and be healthy in Sierra Leone. (Although I’m sure he was supporting extended family and friends who did not live with him.) I was surprised that the family had enough money to take Mohammed to the hospital in the district capital, but chose not to.
Mohammed had many of the common physical features for undernourished children in West Africa – potbelly, “moon-face”, and slender limbs – characteristics of kwashiorkor as well as other nutrient deficiencies (World Food Programme, 2014). Mohammed ate from the same pot as his family, usually the traditional dish of rice with an oily leaf sauce. I never saw him eating any dried fish that is typically served in the sauce, which sustains many families with a relatively adequate source of protein. In Sierra Leone, it is culturally inappropriate to give a small child fish, because of local taboo. I hypothesize that this taboo stemmed from incidents of children choking on small fish bones. Either way, Mohammed was not getting all of the micro-nutrients necessary for physical and mental development. What was the association between Mohammed’s sickness and malnutrition? How does his family’s socio-economic status relate to his nutritional status?
In sub-Saharan Africa, high child mortality rates are attributed to acute respiratory infections, birth complications, diarrhea and malaria (World Health Organization, 2013). Undernutrition is an underlying risk factor between these illnesses as 45% of all childhood deaths are linked to undernutrition (World Health Organization, 2013). In “Maternal and child undernutrition: global and regional exposures and health consequences”, the researchers explore the connection between undernutrition and other preventable diseases. According to multi-national trials, “the pooled relative risk for morbidity associated with zinc deficiency is 1.09 for diarrhea, 1.25 for pneumonia, and 1.56 for malaria” (Black, 2008). In other words, there is a strong correlation between increasing nutrition deficiencies and increasing incidence of infectious disease. But why?
According to Peter Katona and Judit Katona-Apte, the interaction between nutrition and infection can be better understood through a cyclical pattern (2008). Due to the inadequate dietary intake, the immune system is damaged, which affects and subsequently increases the probability of disease incidence (Katona & Katona-Apte, 2008). A common symptom of many diseases is the loss of appetite, wherein the child will continue to experience undernourishment, thus repeating the cycle (Katona & Katona-Apte, 2008). Unfortunately this pattern is common amongst children in low-income countries, especially in sub-Saharan Africa, where 21.9% of children are underweight and 56.9% of children are stunted (Black, 2008).
Mohammed’s frequent visits to the witch-doctors can be explained through this vicious cycle of undernourishment and disease. Despite these physical constraints, there were cultural forces inhibiting Mohammed from living a healthy lifestyle. One day I saw the whole family packing their bags to spend the night at a relative’s house. The father told me that the traditional healer was going to sleep in their home to expel the evil spirits that were causing Mohammed’s sickness.
Evidently, culture plays a significant role in the health of children, but why did Mohammed’s mother not take him to the hospital if they had the money for it? Despite strong evidence that wealthier children are healthier children, I believe Mohammed’s parents were overwhelmed with societal norms and deep-rooted cultural beliefs, which led them to prepare imbalanced meals for Mohammed and to seek treatment from traditional healers rather than clinicians at the hospital.
Clearly, undernourishment is tangled into the complex system of social determinants of health and unfortunately, Mohammed was experiencing the adverse implications of that system.

*Name changed.

References

Black, R. E. (2008). Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet, 243-260.
Katona, P., & Katona-Apte, J. (2008). The Interaction between Nutrition and Infection. Clinical Infectious Diseases, 1582-1588. Retrieved from http://cid.oxfordjournals.org/content/46/10/1582.full
World Food Programme. (2014, March 8). Retrieved from Hunger: http://www.wfp.org/hunger/malnutrition/types
World Health Organization. (2013, September). Retrieved from Children: reducing mortality: http://www.who.int/mediacentre/factsheets/fs178/en/



Global Health Critical Reflection #2

In September, 2009, I was beginning my third year at the University of Pittsburgh. The first month of classes seemed similar to my first two years, but at the time, Pittsburgh had been a part of national and international news, and not because of the University. The three rivers city was preparing to be the host of the next G-20 summit, in which international leaders from the 19 richest nations in the world and the European Union would meet to discuss the global economy and trade (G20, 2014). The topic of this year’s annual meeting was to reform the International Monetary Fund (IMF) and the World Bank, so these entities could better function in the economic market of the 21st century (G20, 2014). As a student, who was currently enrolled in a Global Studies course, I was excited about the opportunity to observe such a significant international event, but I did not expect nor was I prepared for my home to turn into chaos. Protesters from across the U.S. formed coalitions to show their opposition to the G20 summit and the actions that would take place as a result of the meeting. From my vantage point, as the summit’s date drew closer, I saw men and women from many different backgrounds forming crowds in the streets, yelling in unison, and some even becoming violent, destroying local businesses in my neighborhood (Yahoo News, 2014). What was the source for this destructive behavior? Why had the G20 summit angered so many people?
In his article “Globalisation is good for your health, mostly”, Richard Feachem tried to negate the views of globalization opposition (2001). Feachem argued that there were three main flaws amongst the protests against globalization: not understanding the economic benefits, ignoring the social and political advantages, and not providing an alternative to globalization (2001). For his first argument, Feachem listed four countries, China, India, Uganda, and Vietnam, whose economies have prospered in the new age of globalization. With the increase in gross domestic profits in these nations, disparities are also increasing, wherein vulnerable populations continue to be marginalized and not reap the benefits of flourishing economies. Although Feachem provided some counterarguments to the development of these inequities, there is strong evidence for the association between globalization and inequality. For example, India now holds a position in the G20, but it’s most rural provinces and home to more than one third of the nation’s population, experience the repercussions of trade liberalization with Indians in these areas having lower incomes, education levels, and life expectancies (Sachs, 2002). While many of these disproportionalities in India can be attributed to the shifts in the global economy, Feachem failed to mention the role of governance and corruption in terms of poverty, and how corruption can be fueled through globalization.
Like many African countries, I witnessed tremendous inequities in Sierra Leone, especially in regards to foreign mining companies. Recently, the Agence France-Presses (AFP) reported that one of the most precious diamonds of the last decade was found in the small West African country – the diamond is worth roughly $6.2 million (Yahoo News, 2014). During my Peace Corps service, I visited a few of my friends who lived in the district where the diamond was discovered, Kono District. At that point I had lived in Sierra Leone for about a year and had become accustomed to the way of life, but when I went to the district capital of Kono, Koidu, I was shocked. The rough road to Koidu was enough indication that this area of the country was highly affected by the 11-year civil war. In Koidu, every other building on the partially paved roads was dilapidated and had advertisements for diamonds. I was saddened by the fact that wealthy countries, like Australia and Great Britain, were stripping this low-income country of its natural resources, in areas like Kono District, where many young girls leave school to prostitute their bodies to local miners in order to feed their families. This unbelievable chain of events can be traced back to globalization, in which people are fighting preventable diseases in places like Sierra Leone and India, the same place where diamonds are sold or t-shirts are made to benefit those of high-income countries.
Feachem argues that globalization is “good for your health”, but it’s apparent that his perspective lacks a sense of reality in low-income nations. I am not completely opposing Feachem, but I believe his view needs to be better balanced. Unfortunately, I did not fully understand or learn why the G20 protesters in Pittsburgh were infuriated through my Global Studies class in 2009, but through my time in Sierra Leone, I gained a broader worldview of how the ideologies, like that of the G20 and the World Bank, affect the people who are often times exploited the most through the trends of globalization.

References

(2014, February 21). Retrieved from G20: https://www.g20.org/
Feachem, R. G. (2001). Globalisation is good for your health, mostly. BMJ, 504-6.
Sachs, J. D. (2002). Understanding Regional Economic . Working Papers: Center for International Development at Harvard University, 88. Retrieved from http://web.archive.org/web/20070701042206/http://www.ksg.harvard.edu/CID/cidwp/088.pdf
Urbina, I. (2009, September 24). Protesters Are Met by Tear Gas at G-20 Conference. The New York Times, p. A10. Retrieved from http://www.nytimes.com/2009/09/25/us/25pittsburgh.html
Yahoo News. (2014, February 22). Retrieved from Sierra Leone unearths $6-million diamond: http://news.yahoo.com/sierra-leone-unearths-6-million-diamond-183933013.html

Global Health Critical Reflection #1

In “Child health promotion in developing countries: the case for integration of environmental and social interventions,” Dr. John Ehiri and Julie Prowse investigate the root causes of child mortality rates in low-income countries and identify possible approaches that these countries should incorporate in their health management programs (1999). The authors used diarrhea to demonstrate the complexities of diseases attributable to child mortalities and morbidities (Ehiri, 1999). As I read the black and white text of the article, vivid images of my time as a Peace Corps Volunteer in Sierra Leone disrupted my concentration. I felt a personal connection to the authors’ analysis, as several children close to me passed away during my two years in West Africa, usually from diarrhea and other preventable illnesses. Although it is difficult to be reminded of these losses, this reality provides me with a source of motivation to understand the systems and inter-connected factors that affect child health in the developing world.
In order to address child health, the general term, “health”, needs to be clearly defined. Although there are many models that define health, I think of health as a balancing continuum between physical, mental and social well-being, which corresponds to the definition outlined by the Dutch Conference in 2009, “the ability to adapt and self-manage” (Huber 2011). Dr. Ehiri and Ms. Prowse proposed that frequently too much emphasis is placed on the physical well-being of children, and more resources and research need to focus on the improvement of environmental and social influences of child health as these are the risk factors associated with common diseases (1999). The authors state that prevalent childhood diseases in low-income countries are often inter-related, which further illustrates the need for a holistic, comprehensive approach to improving child health (Ehiri, 1999).
The World Health Organization encouraged an “integrated case management approach” to tackle the five most common diseases that cause child mortality (Ehiri, 1999). Although this article is dated to 1999, it is interesting to observe that four of these diseases are still on the list today: malaria, diarrhea and acute respiratory infections, with malnutrition as an underlying risk factor between all three (WHO, 2013). 45% of all childhood deaths are linked to malnutrition, which validates Dr. Ehiri’s and Ms. Prowse claim that many of these infectious diseases are inter-related (WHO, 2013).
In the review article, Dr. Ehiri and Ms. Prowse claim that most childhood diseases can be traced back to poverty and lack of education (1999). In Sierra Leone, I witnessed this connection with many families in my community. As a teacher, I witnessed many of my students missing school in order to work on their families’ farms. Often times, parents neglected to see the importance of education in their children’s lives and this attitude would usually get passed onto the children. The domino-effect of little to no education was carried from generation to generation, which exacerbated the communication of health misconceptions and misinformation within families and communities.
I observed many of the unhygienic practices associated with the development of diarrhea that were outlined in the article, like inadequate re-heating and storage methods (Ehiri, 1999). Another habit that was common in Sierra Leone was not properly washing one’s hands before eating, which is customarily performed with only hands. Environmental factors, like flies, were also an issue in my community. One day, I witnessed three young children defecating beside my neighbor’s kitchen, which created an advantageous environment for insects to fly from the feces to the prepared food. Why were these children unsupervised? Why didn’t anyone teach them about hygiene and proper places to defecate?
Dr. Ehiri and Ms. Prowse proposed that the implementation of food-hygiene educational programs through the hazard analysis critical control point (HACCP) approach would help address some of these issues (Abdulsalam, 1994). Today, a highly recognized initiative, the WHO/UNICEF’s Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD), does not explicitly include the preparation of food, and the underlying environmental and social conditions, but it does focus on hand washing and drinking water, amongst other practices (2013).
It is my hope, through ongoing research and continued collaboration between international agencies, like WHO and UNICEF, and low-income countries, children, most vulnerable to death from diarrhea and other infectious illnesses, will reach the equilibrium of health, wherein physical, mental and social wellbeing is part of a normal life in countries like Sierra Leone. 

References
 (2013). Children: reducing mortality. World Health Organization. http://www.who.int/mediacentre/factsheets/fs178/en/
(2013). Ending preventable deaths from pneumonia and diarrhea by 2025. World Health Organization. http://www.who.int/maternal_child_adolescent/news_events/news/2013/gappd_launch/en/index.html
Abdulsalam, M. and F.K. Kaferstein. (1994) Food safety in primary health care. World Health Forum 15(4), 393-9.
Ehiri, John E. & Julie M. Prowse. (1999). Child health promotion in developing countries: the case for integration of environmental and social interventions. Healthy Policy and Planning, 14(1), 1-10. http://www.ncbi.nlm.nih.gov/pubmed/10351464

Huber, Machtel, et al. How should we define health? (2011) BMJ 343, 4163. http://www.bmj.com/content/343/bmj.d4163