Global Environmental Change: We are all in it Together!!

With an increase in globalization and urbanization, comes a wide array of problems. Human activity has exponentially increased the effects of global warming on the environment and on the health of not only human beings, but all living creatures. “Together, global warming, population growth, habitat destruction, and resource depletion have produced a widely acknowledged environmental crisis” (McCally 2002). Furthermore, this environmental crisis is no longer concentrated on the local level; rather, it is a global problem that can only be dealt with through a collective and global effort. These global changes produce human health effects, some of which are difficult to assess and some of which are easily apparent.
Global warming—one of the greatest contributions to the current deterioration of the earth and it’s living things. What is causing global warming? The answer to this question is extremely complex. One main reason is the accumulation of green house gas and the depletion of the ozone layer. One of the articles this week states “The unusually rapid temperature rise (0.5°C) since the mid-1970s is substantially attributable to this anthropogenic increase in greenhouse gases” (McMichael et al 2006). Although low concentrations of greenhouse gas emissions are natural (in order to keep the earth from freezing), since the rise of industrialization, greenhouse gas emissions have increased exponentially. Combustion of fossil fuels, irrigated agriculture, deforestation, and cement manufacture are just some of the human activities that contribute to the rise in concentration of greenhouse gases (Houghton et al 1996). The three main greenhouse gases include: carbon dioxide, methane, and nitrous oxide, each of which have been extensively researched and have direct negative impacts on human health. The concentrations of these particular greenhouse gases have dramatically increased and have reached their highest levels over that last millennium (Albritton et al 2001). With this increase, comes the rise in overall global temperature and radical climate change. Consequences of this climate change include an increase in heavy rain events and prolonged droughts. Some of the direct effects on human health due to changes in temperature and weather include: changes in the rate of illness and death due to heat and cold and an increase in deaths/injuries/psychological disorders due to the change in frequency and intensity of extreme weather events. From lecture, it is apparent that the number of extreme-heat events (such as heat waves) have increased with the twelve-day heat wave of August 2003 in Europe being a prime example. The number of deaths due to this heat wave were staggering, with about 15,000 deaths in France alone and 35,000 deaths total (Lecture 2009, McMicheal 2006). This is particularly important for vulnerable populations such as the elderly, young children, athletes, and people who spend most of their time outdoors. Beyond these direct effects, there are several indirect effects of climate change, which have negative impact on health. One in particular is the rise in sea-level, which causes population displacement and damage to infrastructure, which ultimately increases the risk for infectious disease and psychological disorders. The increase in air pollution exacerbates asthma and other respiratory illnesses, which ultimately leads to premature death. Furthermore, there is a large pressure put on ecological systems, which change the activities of vectors/infective parasites thus increasing the incidence of vector-borne disease. These are just some of the indirect effects and ultimately all of these effects put a strain on the health care system and public health infrastructure, leading to inadequate care of infectious diseases, water-borne/food-borne diseases, and psychological disorders. (McMicheal and Haines 1997).
Ozone depletion is another consequence of global warming. In 1974, a group of prominent scientists (Molina, Rowland, and Crutzen) found that “ozone might be destroyed by industrially produced chlorine- and bromine-containing stable substances, such as chlorofluorocarbons (CFCs) commonly used in spray cans, refrigerators, and air-conditioners” (Molina et al 1974). This accumulation of CFCs and other industrial activities has contributed to the “ozone hole”, which is increased the influx of UV radiation at the earth’s surface and in the top layers of the ocean (de Gruijl and Van der Leun 1994). The direct impact of an increase in UV radiation on human health is the increase in cancers, especially skin cancer. A one-percent decrease in ozone yields a 1.56% increase in annual carcinogenic UV (Kelfkens et al. 2008). Beyond cancer, increased UV radiation is known to increase the incidence of cataracts. Scientists have estimated that the incidence of cataracts would ultimately rise by 0.5 percent for every 1 percent persistent decrease in ozone (Van der Leun et al. 1993). In addition to this human impact, the productivity of phytoplankton was found to be reduced by 6 to 12 percent directly under the ozone hole (Smith et al. 1992). These kind of effects on organisms at the bottom of the marine food chain will ultimately impact larger marine animals, and eventually humans.
Beyond the accumulation of greenhouse effects and ozone depletion, habitat destruction is another human activity that contributes to the changing environment. With habitat destruction comes the destruction and extinction of microorganisms, plants, animals, and other living things in addition to the detectable air pollution of burning forests. The additive effect of global climate change, ozone depletion, chemical pollution, acid rain, and the extinction of species all threaten biodiversity (Chivian 2001). Rainforests and coral reefs continue to be disrupted and with the decrease in biodiversity will come a detrimental effect of the world’s ecosystem. Biodiversity is the total complement of different living organisms in an environment and the destruction of it will lead to detrimental consequences for human health. In lecture, ecotourism was discussed, which is defined as “responsible travel to natural areas that conserves the environment and improves the well-being of local people” (Lecture 2009). Ecotourism is a prime example of how human activity is destructing natural habitats. With an increase of human contact with natural rain forests/coral reefs/other habitats, comes an introduction of new pathogens, particulate matter, diseases/viruses, which threatens the life of plants, natural bacteria, and ultimately all of the living organisms in that particular habitat. In some extreme cases, species who are exposed to various human activity and pollution have immediately become extinct. On the other hand, ecotourism helps the economy of the local people and raises awareness of the importance of environment conservation (many tourists donate money). Therefore, there must be a balance between human activity and helping the economy. If the problem of habitat destruction is not dealt with, soon enough, mass extinctions of species will ultimately affect the health of humans.
How can all these problems be fixed? The answer is that they cannot be, however, the process of environmental change can be slowed down. If current trends persist, climate change will be exponential which will ultimately endanger the health and lives of not only humans, but all living organisms. The first step that should be taken is to slow down or stop environmental degradation by implementing strict policies on air pollution (from combustion of fossil fuels, medical waste incineration, factory emissions, agriculture, etc.) and habitat destruction. The second step that needs to be taken is to achieve a collective effort (especially between developed and developing countries). Since these environmental changes are a global problem, a global initiative is needed. With aid from developed countries, developing countries will gain the required education, training, and technologies to effectively reduce environmental degradation. The last step that should be taken is to develop long-term educational strategies that will change the mindsets of individuals and institutions with respect to protecting the environment and promoting health. (McCally 2002)


References
Albritton DI, Allen MR, Baede APM, et al., eds. Intergovernmental Panel on Climate Change Working Group I. Summary for Policy Makers, Third Assessment Report. Climate change 2001: The Scientific Basis. Geneva, 2001.

Chivian E. Environment and health: 7. Species loss and ecosystem disruption—The implications for human health. CMAJ 2001; 164: 66-69.

De Gruijl FR, Van der Leun JC. Estimate of the wavelength dependency of ultraviolet carcinogenesis in humans and its relevance to the risk assessment of stratospheric ozone depletion. Health Phys 1994; 67: 319-325.

Houghton JT, Meira-Filho LG, Callander BA, Harris N, Kattenberg A, Maskell K, editors. Climate change, 1995—the science of climate change: Contributions of Working Group 1 to the second assessment report of the Intergovernmental Panel on Climate Change. New York: Cambridge University Press, 1996.

McCally M. Life support: The environment and human health. Cambridge, Massachusetts: MIT press, 2002.

McMicheal AJ, Haines A. Global climate change: The potential effects on health. BMJ 1997; 315:805-809.

McMicheal AJ, Ranmuthugala G. Global Climate Change and Human Health. IN:Kawachi I, Wamala S, eds. Globalization and Health. New York: Oxford University Press; 2006: 81-97.

Molina MJ, Rowland FS. Stratospheric sink for chlorofluoromethanes: Chlorine atom-catalyzed destruction of ozone. Nature 1974; 249: 810-812.

Smith RC, Prezelin BB, Baker KS, Bidigare RR, Boucher NP, Coley T, et al. Ozone depletion: Ultraviolet radiation and phytoplankton biology in Antarctic waters. Science 1992; 255: 893-1040.

Van der Leun JC, De Grujil FR. Influence of ozone depletion on human health. In: Tevini M, editor. UV-B radiation and ozone depletion. Boca Raton, FL: Lewis Publishers, 1993. Pp.95-123.

Global Warming is Global Warning

As former Vice President Al Gore said, “Global warming will be the greatest environmental challenge in 21^st century,” from the movie Inconvenient Truth, the global warming indeed represents one of the biggest threats to human health now particularly the health of our future generations. According to McMicheal’s article, the global temperature has risen approximately 0.5’C over the past century and unfortunately it seems like this global mean temperature increase will be continuous for a long time.  Rising global temperature foresees possible related impacts on human life such as extreme weather events, air pollution, water-food borne disease and vector-rodent borne disease (2). These direct and indirect effects of global climate change on the health would aggravate levels of diseases and furthermore result in increasing in the morbidity and mortality of human lives. The impact of human activities on the earth climate system over the past century is probably major cause of global climate change because this is global human actions not merely action of individuals. The one of the serious contributions of global climate change is from the use of great amount of fossil fuels such as oil and petroleum which eventually resulted in increasing amount of carbon dioxide (greenhouse gas) in the atmosphere. These accumulations of carbon dioxide are now higher than ever before and will ultimately cause the global warming. 

Health impacts of climate change include the direct impacts of extreme events such as storms, floods, heat waves and wild fires and the indirect effects of longer-term changes, such as drought, changes to the food and water supply, resource conflicts and population shifts (1).
Projected climate changes are likely to affect the health status of millions of people, particularly those with low adaptive capacity (2). Climate change is expected to continue to contribute to the global burden of disease and premature deaths, especially in developing countries. The health impacts of extreme climate-related events include increasing mortality, vector-borne diseases, effects of poor air quality, and possible impact of psychological stresses from experiencing of extreme events (2).

As the earth’s temperature continues to increase, we can expect on significant change in infectious diseases pattern around the globe. Intergovernmental Panel on Climate Change (IPCC) warned that rising temperature may results in the altered spatial distribution of some infectious disease which increase or decrease of the range and transmission of potential threats (4). Rising temperature could result in larger mosquito population at higher elevation in the tropics which could in turn contribute to the spread of malaria, dengue and other infectious borne infections (4). Back in my college years around 2001 in Hawaii, we had dengue fever outbreaks starting from Maui to all over the islands which resulted in sickened more than 100 people in Hawaii. More rainfall in certain areas and warmer temperatures overall around tropical areas provided optimal conditions for mosquito which spread the virus that causes dengue to breed and expand into new territories. The Intergovernmental Panel on Climate Change (IPCC) has reported that by 2085 climate change will put an estimated 3.5 billion people at risk of dengue fever which is a disaster (4). Global warming favors the spread of diseases since the extreme weather events create conditions conducive to disease outbreaks. This climate change associated with infectious diseases will threaten not only human lives but also wildlife, livestock and all creatures in forest and marine. Therefore we must develop laboratory-based surveillance systems that can provide early warning of an impending dengue epidemic to abate more victims.

We cause air pollution directly through our use of electricity, fuels, and transportation by emitting greenhouse gas mainly carbon dioxide due to rapid expansion of industrialization. According to the Healthy People 2000 report, an estimated 50,000 to 120,000 premature deaths are associated with exposure to air pollutants every year in U.S. and people with asthma experience more than 100 million days of restricted activity, costs for asthma exceed $4 billion, and about 4,000 people die of asthma (5). Air pollution causes not only asthma, but more serious disease that ranged from the changes to difficulty breathing, wheezing, coughing and aggravation of existing respiratory and cardiac conditions (2).  The International Union of Air Pollution Prevention and Environmental Protection Associations (IUAPPA) was organized on 1964 to promote the exchange of information and development of understanding on air pollution prevention and environmental protection among 40 countries. IUAPPA designed various programs, conferences worldwide to help address the key atmospheric and environmental challenges of the global air pollution (7).

Serious floods have occurred in developing countries where the dangers associated flooding can be very devastating. Floods can be caused from rising sea levels which leads to increased coastal flooding through direct inundation and an increase in the base for storm surges, allowing flooding of larger areas and higher elevations (1).  Recent reports by the National Academy of Sciences and others have concluded that increasing atmospheric concentrations of carbon dioxide and other gases can be expected to cause a global warming that could raise sea level a few feet in the next century. Estimates for the year 2025 range from five to twenty-one inches above current sea level, while estimates of the rise by 2100 range from two to eleven feet (8).

Despite the warnings being given about the harmful effects of global warming and other environmental problems, most individuals are doing very little about it today. Various methods and suggestions are being offered to reduce the effects of global climate changes. For example, we can simply save the earth by recycling on an everyday basis at home. And the benefits of recycling are many, from reducing the effects of industrial production to saving money as well as the earth.

There are lots of things we can do to postpone a global warming. According to Time magazine there are 51 things we can do to save the earth and I will list several of them. First, we can substitute ethanol as an alternative fuel that could finally wean the U.S. from its expensive oil habit and in turn prevent the millions of tons of carbon emissions. Second, replacement of light bulbs to fluorescent light bulb will be beneficial since the cost of fluorescent light bulb is three to five times as much as conventional incandescent bulbs yet use one-quarter the electricity and last several years longer. Third, hanging clothes dry instead of using dryer after washing in a warm water rather than hot water will be helpful to reduce electricity and energy. Fourth, recycling plastics, glass and paper is another ways to save the earth. Almost everybody is used to receiving junk mail in the mailbox which most are completely worthless. If we dismay the usage of this worthless paper mails, it would save at least 150,000 trees annually as these would not be cut down for the requirement of paper (3). Many people therefore report to recycled paper or the use of Internet to spread their message to people now. Also paying your bill online will help to reduce labor of delivery and transportation as well as saving your money from purchasing stamps. In addition, we can reduce plastic pollution by simply using a cloth bag instead of wasting plastic ones at the grocery stores. Imagine how plastics cause global climate change. Foremost, the disposals of plastic products are not biodegradable and more seriously it produces greenhouse gas emissions from manufacturing. If the greenhouse gas emissions reach dangerous concentration levels, it leads to changes in the temperatures globally and changes in the levels of the sea and other bizarre climatic conditions like I have mentioned earlier. Therefore, recycling can help reduce the need to manufacture paper, plastics, metals and glass and this would save energy needed to manufacture new products (3).

            Meanwhile there are things we can do to postpone global climate change, further research is immediately needed to better understand the complex linkages among climate and the health. Climate change displays a wide range of challenges to human health because it will bring other social and environmental factors that also affect the health outcomes. Significant reductions in greenhouse gas emissions, recycling and further research for education and prevention of global climate changes can be fulfilled at both governmental and individual levels.

Human health is ultimately dependent on the health of the planet and its ecosystem: therefore reducing carbon dioxide and other greenhouse gases should be seen as a public health priority. 

Most importantly, the United States needs to play a leadership role in addressing global warming now since our former President Bush has been downplayed the urgency of global warming for last 6 years. The United States has long been the biggest emitter of greenhouse gases while we also have the greatest financial, technical and political resources to set global action in motion. The U.S. has received worldwide criticism for failing to adopt the greatest international agreement for the reduction of some greenhouse gases, the Kyoto Protocol, which has been accepted by nearly every other country but U.S. It is mainly because President Bush thought that this protocol would harm American ECONOMY ($). However, the international compromise on safety precautions against greenhouse gases needs to be the first step to protect our lives (9). At individual level, probably your choice of vehicle is your single most important environmental decision to prevent pounds of carbon dioxide into the atmosphere every year. And when it comes to buying appliances, purchase a highly efficient model that has the Energy Star, awarded by the Environmental Protection Agency. We can monitor your newspaper's coverage of this issue and write in response to any stories or letters that dismiss global warming. Finally we can contact our senates, governor, and state legislators to promote energy efficiency, nonpolluting transportation alternatives, and the development of clean, renewable sources of energy for cleaner earth. Policy makers need to address global warming in preventive strategies to slow global warming, offsetting global warming through climatic engineering and adaptation to the new climate (8). Then we can reverse the greatest environmental challenges in the 21^st century to the greatest resolutions.

 

1.     Ebi, K.L., Mills, D.M., & Smith, J.B (2006). Climate Change and Human Impacts in the United States: An Update on the Results of the U.S. National Assessment. Environmental Protection Agency., Volume 114, Number 9

2.     MnMicheal, A., Woodruff, R.F., & Hales, S (2006). Climate Change and Human Health: Present and Future Risks., Lancet , 367: 859-869

 

3.     Park, A., (2007) 51 Things we can do to save the environment. Retrieved February 14, 2009 from http://www.time.com/time/specials/2007/environment/article/0,28804,1602354_1603074,00.html

4.     IPCC (200) Executive Summary Climate Change and Water  Retrieved from February 14, 2009 from http://www.ipcc.ch/pdf/technical-papers/ccw/executive-summary.pdf

5.     Healthy People 2000, Environment Health, Retrieved on February 22, 2009 from http://www.healthypeople.gov/Document/HTML/Volume1/08Environmental.htm

6.     U.S. Environment Protection Agency, Global Change Air Quality Assessment: CSp and the role of EPA. Retrieved from February 20, 2009  from http://www.epa.gov/appcdwww/apb/globalchange/quality.htm

7.     The International Union of Air Pollution Prevention and Environmental Protection Associations, Retrieved on February 22, 2009 from UAPPA http://www.iuappa.com/about.htm

8.     Potential Impacts of Sea Level Rise on the Beach at Ocean City, Maryland (1985, 1.0 MB PDF), was edited by James G. Titus with papers by James G. Titus, Stephen P. Leatherman, Robert G Dean, Craig Everts, and David Kriebel (EPA 230-10-85-013). Retrieved on February 21, 2009 from http://yosemite.epa.gov/oar/GlobalWarming.nsf/content/ResourceCenterPublicationsSLROcean_City.html

9.     Kyoto Protocol, Retrieved on February 22, 2009 from http://en.wikipedia.org/wiki/Kyoto_Protocol

Sub-Saharan Africa Nigeria and the Polio Eradication

One of the most valuable and cost-effective tools for preventing and controlling diseases in the world is through vaccination. It is generally and routinely administered to induce immunity which prevents people from premature death, falling sick, suffering, and also reduces the disability-adjusted life years lost (DALYs). The World Health Organization (WHO) in 2002 estimated that about 1.4 million deaths occurred among children under the age of five all due to preventable diseases such as polio, tetanus, measles, tuberculosis, rubella, etc [1]. It is therefore necessary and important for all humans to understand and acknowledge the effectiveness of vaccines available to eradicate diseases like poliomyelitis (polio). The poliovirus can not survive outside the human host over a long period of time, thus making the vaccine highly effective and inexpensive which also provides a life-long immunity [2].

Poliomyelitis (polio) is a threat to everyone but a major threat to children under five years anywhere and everywhere in the world with the poliovirus. The disease is highly infectious and is caused by a deadly virus. Humans become infected when the poliovirus enters and lives in the throat and gastrointestinal tract, intend invades into the bloodstream and is carried into the central nervous system. This transfer can then cause severe and total paralysis within hours because it destroys the motor neuron cells [3]. Most people infected with the poliovirus have no visible symptoms initially; however it causes permanent and irreversible paralysis usually in the legs and may even cause death [3]. Amongst those paralyzed, 5%-10% die when their breathing muscles become immobilized [1] due to the fact that, the motor neuron controls the muscles used for respiration, swallowing, circulation, arms and legs of the human body [3]. It is scary to know that, the poliovirus can spread through person-to-person contact with the stool of an infected person. The virus is shed intermittently in feaces for several weeks and during this period causes the disease to spread rapidly. Polio may also spread through oral or nasal secretions widely before cases of paralysis are seen [2].

In 1988, the World Health Assembly (WHA) all member state of the World Health Organization (WHO) launched a global initiative to eradicate Poliomyelitis (polio) in the world by the end of 2003 [1]. All countries worked together to achieve the objective to prevent 855,000 death, 40 million disability-adjusted life years (DALY’s), and 4 million cases of paralysis by 2050 [2]. So far, 10 million doses of oral polio vaccines (OPV) have been successfully administered to help the polio eradication process [2]. The polio eradication campaign has reduced the indigenous countries with wild polio from seven to four counties: India, Nigeria, Pakistan and Afghanistan as of 2008[1]. A single child who remains infected with polio is a threat to other children all over the world because the poliovirus can easily be imported into a polio-free country and can spread rapidly among un-immunized populations [1]. For a successful eradication process, the WHO monitors progress; countries perform surveillance for acute flaccid paralysis (AFP). The WHO African Regional Office (WHO-AFRO) and the U.S Centers for Disease Control and Prevention (CDC) are also involved in strengthening infectious disease surveillance and response in Africa [8].

In 2003, the political and Muslim religious leaders in the northern part of Nigeria, Kano, Kaduna, and Zamfara states halted the polio vaccination campaign. Each state in Nigeria has its own administrative control over their health affairs at both the primary and secondary levels; immunization falls in the primary level. The government has control at the tertiary care level. However, even though they set health policies for the nation, the Kano state government was able to stop the campaign themselves while the federal government could not do much because the Kano government had the authority to take firm decision concerning vaccinations [9]. These leaders boycotted the polio vaccinations because of the rumor that the United States had contaminated the poliovirus with an anti-fertility agent as well as HIV virus (which cause AIDS) against the Muslim world [4]. This boycott caused an eleven-month halt in the poliovirus vaccine eradication campaign. The boycott also generated controversial issues among the Muslim community in Nigeria and the government, while the leaders continued to encourage parents not to allow their children to be vaccinated. It was reported by the New York Sun that, the fear arising to boycott the polio eradication campaign was because of the war in Iraq [6]. A World Health Organization doctor, Ali Guda Takai who investigated the polio cases in Kano made this statement to the Baltimore Sun, “what is happing in the Middle East has aggravated the situation. America fighting with the Middle East concludes that they are fighting Muslims [7].” To continue the eradication process, a meeting was held with UNICEF, WHO, the Government of Nigeria, the local state leaders and the state governor of Kano, Ibrahim Shekarau to resume the campaign. The agreement was made and the Nigerian government sent leaders to South Africa, India, and Indonesia to observe testing of the polio vaccine and to bring back proof of non- contamination [10]. It is essential for the general public to trust health care providers because lack of trust could draw back important campaigns such as the boycott in Kano, Nigeria did for the eradication process. Another problem WHO encountered was the suspicion of the aggressive mass vaccination campaign going on because basic health care in Nigeria was not easily available [7]. It was probably too good to be true to have the vaccination free of charge. The boycott in northern Nigeria resulted in new cases in neighboring countries such as Ghana (8), Burkina Faso (7), Cameroon (1), Benin (1) Chad (5) and Togo (1) all linked to Nigeria [5]. Since the polio virus can be very infectious, between 2003 and 2005, 25 previously polio-free countries were re-infected due to importations [1]. Currently, 36 countries are declared free from polio; America still remains the largest and first global region that effectively eliminated polio in their population in 1994, while the Western pacific followed in 2000, and the 51 countries in Europe region got certified polio free countries [1]. It has however been difficult to eradicate the polio in these regions of the world, Northern Africa, India and the Middle East. There must be a continuous massive vaccination campaign to build an immunity wall mainly around countries like Nigeria because disease surveillance becomes very important to track down all the information needed to eradicate the polio disease all over the world [5].
For a successful future in vaccination eradication campaigns, the health care providers and all other agencies involve must address cultural, political, and religious issues to enable a smooth and fast process. The campaign must stress on how valuable the vaccinations are using pictures more than words in their posters, mainly because of the educational level in these African countries. The media must be involved to help reach people through local radio stations, local television broadcasts, and by using their local artists to compose local music, plays and other forms of entertainment that the native people can easily understand. This approach will help the locals to develop trust and confidence in the vaccination about to be ministered. It is also important to keep agents and volunteers who are willing to learn and do a little extra effort to help eradicate future diseases.
It is still very important for Nigeria to eradicate the polio disease mainly because about 82% of all cases have come from Nigeria causing global burden [5]. Bill Gates in Nigeria to lead the way and support polio-free Africa has caused states governors to put in more effort to enable a polio-free Africa [12] as others like America and Europe have already achieved to be polio-free countries, with the determination of the WHA, Africa and the other remaining countries can get there. The eradication of polio is raising awareness so much that a movie has been made. The movie talks about some challenges the health organizations and governments face during the final stages of polio eradication. The film also follows health workers as they immunize Indian and Pakistani children [13]. This movie would create awareness for the public to understand some challenges health care professional go through to provide a better and safer world for all of us to live in. This movie “The Final Inch” has also been nominated for the Oscar which is good because it will increase the awareness about the disease and eradication process.
Even though there are challenges and controversies concerning vaccinations, it is still very effective and inexpensive to save more lives than to lose lives. As health providers, we all have to help in educating people around us about the importance of eradicating all diseases especially preventable diseases in the world. The polio eradication process even though it drifted a little, there is still hope that polio in all countries over the world with aggressive eradication plans and campaigns, with set goals, the eradication will be met and we will all enjoy the polio-free world. I’ll start my part by talking to my family and friends back home in Ghana about the importance of vaccinations for example.






References

Poliomyelitis (January.2008)In World Health Organization online .Retrieved February 10,2009, from
http://www.who.int/mediacentre/factsheets/fs114/en/index.html

Krym, Valerie F., and Russell D. MacDonald.” Global efforts to eradicate polio.” Canadian Medical Association Journal 170(2004): 2009.

How the poliovirus works (2000) In National Museum of American History online Retrieved February 10,2009, from
http://americanhistory.si.edu/polio/virusvaccine/how.html

Obadare, Ebenezer (2005) “A crisis of trust: history, politics, religion and the polio controversy in Northern Nigeria.” Patterns of Prejudice Journal 3 (2005):265-284.

Pincock, Stephen (2004) “Poliovirus spreads beyond Nigeria after vaccine uptake drops.” BMJ Journal 7328(7435):310

Pipes D (2005) A conspiracy theory spread polio. New York Sun. Available: http://www.danielpipes.org/article/2644. Retrieved 11,February, 2009

Murphy J (2004) Distrust of US foils effort to stop crippling disease. Baltimore Sun. Available: http://www.baltimoresun.com/news/nationwide/bal-polio0104,
1, 6396183.story?ctrack=1&cset=true. Retrieved 11, February, 2009

Nsubuga P, McDonnell S, Perkins B, et al. ( 2002) “Polio eradication initiative in Africa: influence on other infectious disease surveillance development” BMC Public Health 2:27 http://www.biomedcentral.com/1471-2458/2/27 Retrieved 11,February,2009

Odutola A (2004) Nigeria polio, politics and power play. African Networks for Health Research and Development (AFRO-NETS) http://www.afronets.org/acrchive/200401/msg00069.php. Retrieved 10, February, 2009


10.Yahaya M (2005) Polio Vaccines-Difficult to swallow. The story of a controversy in Northern Nigeria. Institute of Development Studies. http://www.ids.ac.uk/IDS/KNOTS/PDFs/VaccYahyaNigeria.pdf Retrieved 08, February, 2009

11. Wipfli, H. Global Efforts to Eradicate Polio. Presentation observed at the University of Southern California, February 9, 2009.

12. Global Polio Eradication Initiative (2009) Gates: "Nigeria can lead the way to a polio-free Africa." http://www.polioeradication.org/content/general/LatestNews200902.asp#GATES Retrieved 13, February, 2009

13. Ryan H (2009) The Final Inch. Polio film nominated for Oscar.
Rotary International News . http://www.rotary.org/en/MediaAndNews/News/Pages/090126_news_finalinchfilm.aspx%20Retreived%2013, February, 2009

Breastfeeding by HIV-positive mothers: Damned if they do, Damned if they don’t

The issue of breastfeeding by HIV-positive mothers in developing countries and other resource-poor settings presents a quandary to health providers, researchers, public health officials, and policy-makers, as well as to the mothers themselves. Every year, approximately 530,000 infants and children become infected with HIV.[i] In countries most affected by HIV/AIDS, the under-5 mortality attributable to HIV may be as high as 30 per 1000, as is the case for Botswana, Namibia, Swaziland, Zambia, and Zimbabwe. In sub-Saharan Africa, HIV-attributable deaths for those under 5 comprised 7.7% of under-5 deaths in 1999.[ii] Most instances of HIV infection in infants and children occur as a result of mother-to-child transmission (MTCT),[iii] which may occur during pregnancy, labor and delivery, or breastfeeding.[iv] The risk of MTCT with breastfeeding is 30-45%, up to two years after delivery. This number is reduced to 16-23% with peripartum antiretroviral treatment[v] (ART).

Given such high MTCT rates through breastfeeding, the best route for HIV-positive mothers to take is to avoid breastfeeding their children altogether. However, in resource-poor settings, most families do not have the means or the knowledge to carry out replacement feeding feasibly and safely. To illustrate, infant formula may easily be mixed with contaminated water in these areas,[vi] bringing about increased risk of infection by life-threatening diseases other than HIV. These include diarrhea and respiratory disease. In fact, approximately 20% of child deaths in the world are due diarrhea.[vii] Furthermore, protection against diarrhea is about 6-fold for breastfed infants versus formula-fed infants in the first six months of life; while protection against acute respiratory infection is about 2.5-fold.[viii]

Mothers in these communities are also more likely to be illiterate and unable to the read the directions for mixing proper proportions of water and formula. Even those who are aware of the proper proportions may be apt to dilute the infant formula in an attempt at cost savings.6 Either way, children in these situations are underfed as a result of infant formula use. Breastfeeding, on the other hand, provides all of an infant’s required nutrients until about 6 months of age and is an important source of nutrients thereafter,3 ensuring proper growth and development for the child. Thus, it is important for mothers to breastfeed in resource-poor settings where child malnutrition is prevalent. Finally, breastmilk boosts infants’ immune systems, providing them with a number of antibodies and other essential agents.[ix]

The benefits and dangers of breastfeeding by HIV-positive women pose a difficult dilemma. In 2006, WHO, UNICEF, UNFPA, and UNAIDS came together to form an inter-agency task team (IATT) on prevention of HIV infections in pregnant women, mothers, and their infants. After a review of relevant studies and programs, the IATT determined that in resource-poor settings where safe replacement feeding is not feasible and sustainable, the benefits of exclusive breastfeeding by HIV-positive mothers far outweigh the risk of MTCT in the first six months of life.3

One will undoubtedly find horrendous health disparities prevalent in studies of and work in global health. But this author finds the issue of breastfeeding by HIV-positive women in resource-poor settings particularly abominable. The idea that a mother must choose between probable infection and even death of her child by HIV or another infectious disease is unthinkable. Further, that young children must be put at great risk for morbidity or mortality due to diarrhea or malnutrition in order to avoid HIV by MTCT is difficult to stomach. No one is deserving of HIV or any other disease, the least of whom are infants and children. Needless to say, the author of this blog believes that much more attention and resources must be focused on HIV-positive mothers in resource-poor settings, as well as on their children.

Given the child mortality attributable to HIV and to diarrheal diseases and how these two are related through breastfeeding by HIV-positive mothers, it is imperative that global health efforts target HIV-positive mothers, particularly in developing countries. The issue encapsulates a multitude of global health problems—contaminated water, lack of proper sanitation systems, undernutrition, to name a few. These are longer-term issues to be addressed. More immediately, pregnant women who have HIV should be targeted for ART. As discussed above, the risk of MTCT decreases when the mothers undergo ART while pregnant and while breastfeeding. However, it is still best for HIV-positive mothers to choose replacement feeding when it feasible and can be done safely. Thus, global health efforts and resources should be put into research and development of programs for safe and feasible replacement feeding for infants and children of HIV-positive women in resource-poor settings. Such programs may consist of education on proper replacement feeding, distribution of potable water, and subsidies for the purchase of infant formula. Given the importance of healthy children to the future of their societies and economies, such programs would prove a cost-effective investment, producing a wealth of returns. Indeed, breastfeeding by HIV-positive mothers and its implications on mortality and global burden of disease make it an exceedingly important issue to be addressed by the global health community.

[i] UNAIDS (2006). AIDS epidemic update. Geneva, Switzerland: UNAIDS.
[ii] Walker N, Schwartlander B, Byce J (2002). Meeting international goals in child survival and HIV/AIDS. The Lancet, 360, 284-289.
[iii] WHO, UNICEF, UNFPA, UNAIDS (2006). HIV and infant feeding: New evidence and programmatic experience. Geneva, Switzerland: WHO.
[iv] WHO, UNICEF, UNFPA, UNAIDS, World Bank, UNHCR, WRP, FAO, IAEA (2003) Hive and infant feeding: Framework for priority action. Geneva, Switzerland: WHO.
[v] Gaillard P, Fowler MG, Dabis F, Coovadia H, van der Horst C, van Rompay K, Ruff A, Taha T, Thomas T, de Vincenzi I, Newell ML (2004). Use of antiretroviral drugs to prevent HIV-1 transmission through breast-feeding: From animal studies to randomized clinical trials. Journal of acquired immune deficiency syndromes, 35(2), 178-187.
[vi] Anderson GC (1989). The Nestle affair. Science, 244(4906), 844-845.
[vii] Skolnik R (2008). Essentials of global health. Sudbury, MA: Jones and Bartlett Publishers.
[viii] WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality (2000). The Lancet, 355(9209), 451-455.
[ix] Mead MN (2008). Contaminants in human milk: Weighing the risks against the benefits of breastfeeding. Environmental Health Perspectives, 116(10), 427-434.

The Continual Polio Crisis

For centuries, infectious diseases have lead to a great burden, causing disability and mortality for people worldwide.  As countries have developed, technologies advanced, and pharmaceuticals created, infectious diseases have become less of a burden, giving way to chronic disease.  However, in most developing countries, infectious disease remains a major cause of disability and mortality.  The toll of infectious disease is difficult to accept when we speak of diseases that can be easily prevented with a vaccine.  Such is the case with the polio, a virus that invades the central nervous system, which can lead to paralysis or death in severe circumstances.  The vaccine against polio is highly effective, inexpensive, and provides lifelong immunity against the tremendously devastating effects of the virus.

For many years, polio was endemic to over 125 countries, but vaccination efforts proved useful in eliminating the disease in most of these.  The World Health Assembly launched the Global Polio Eradication Initiative in 1988, ensuring that all countries were able to work towards eliminating polio from their population [3].  A country or a nation is certified polio-free after demonstrating several components.  First, there must be three consecutive years of zero new cases of “wild” polio.  Second, they use surveillance methods to account for new disease burden.  Finally, they maintain the capabilities to detect, report, and respond to any new cases caused from travel or importation of the virus [6].  The Americas were the first large global region to effectively eliminate polio from the population.  Consisting of 36 countries, the Americas were declared polio-free in 1994.  The Western Pacific followed suit in 2000, certifying its 37 countries and areas polio-free.  Finally, the 51 countries in the European Region were certified polio-free in 2002 [3].  The remaining illness was found in Northern Africa, the Middle East, and India.  Eradication efforts in these areas, however, have proven a little more difficult.  As of 2008 Afghanistan, Pakistan, India, and Nigeria remain the only four countries worldwide where polio is endemic [4].  

The road to elimination of polio in these areas has been very rocky and massive campaign efforts have met extreme resistance, particularly in India and Nigeria.  Due to the nature of the disease, it is necessary to vaccinate at least 90% of the children in order to prevent further spread of the disease [6].  The course of vaccinations in Nigeria showcases the importance of reaching this number of children.  With simply one infected person, polio was imported to neighboring Chad in 2003 where the disease was no longer endemic.  However, not all children in Chad were vaccinated at the time, and polio once again began to spread quickly.  This began a subsequent rapid spread to people in 25 neighboring countries that were previously considered polio-free until 2005 [3].  Massive efforts were again launched to stop the spread of the disease and regain the prior elimination status.  In Nigeria, however, religious leaders caused panic in the people about the vaccine.  Rumors spread that the vaccines were contaminated and would transmit HIV/AIDS or cause infertility in the recipient [2].  The government stopped all polio vaccination attempts for eleven months.  Meanwhile, polio was rapidly spreading through the Nigerian people and quickly being exported to surrounding countries. 

Once the ban on the polio vaccine was lifted, public health professionals in Nigeria were faced with the daunting task of mass immunizations.  Not only were they faced with the need to immunize the thousands of children, they needed to extensively educate the people on the truths of the disease, the benefits of the vaccine, and dispel any myths they had heard.  Convincing extremely religious people that their religious leaders gave incorrect information did not prove easy.  The mass vaccination campaigns proved helpful to get a large number of children newly vaccinated after the spread to neighboring countries.  Yet, many more children remained unvaccinated, either because of lack of access or because the parents refused the vaccine.

Similar issues have also been faced in India with people being afraid of the vaccine and the possible side effects, either due to rumors, religious beliefs, or simple ignorance on the matter.  Gautam Lewis, a 23-year-old polio survivor was adopted from an orphanage in Kolkata, India as a child and taken to live in the United Kingdom [1].  He decided to return to India as an adult and help with the vaccination campaigns there, similar to those conducted in Nigeria.  His videos (http://www.freedomintheair.org/?p=1545) demonstrate that the efforts of public health workers are often futile.  They met extreme resistance with people of rural India, especially those of the Muslim faith due to similar rumors about the vaccines causing infertility.  Lewis was able to convince some parents that the benefits of the vaccine far outweigh the costs of becoming crippled such as he was.  However, he faced many cultural barriers.  Some women explained that even though they wanted to vaccinate their children against polio, their husbands would beat the women if they found out.  Additionally, some people that answered his knocks at their homes insisted that the children were not theirs, even if the women were nursing one of the infants.  Lewis was only able to coax the parents to a certain extent, but he knew that he could not convince everyone simply because the cultural and religious beliefs were too strong for the parents to waiver on their opinions.  Unfortunately, Lewis’ experiences in India were very similar to the vaccination efforts (and not exceptional outcomes) in Nigeria. 

The experiences in Nigeria have proven two things: the need for surveillance of disease worldwide to help prevent the further spread of illness in non-endemic areas, and that people who opt out of vaccines are putting not only their own children at risk, but also the lives of all those they come into contact with.  The rapid spread of polio in Northern Africa in the countries surrounding Nigeria was halted relatively quickly due to use of their surveillance and reporting systems.  Health professionals were able to track exact cases, treat them immediately, and report to the World Health Organization, requesting immediate assistance.  Without these methods, the imported virus could have taken a much larger toll and lasted for a longer period of time before being eliminated from those countries again.  The concept of not vaccinating due to beliefs is a much trickier situation to approach.

Learning from the Nigerians, we know that the spread of disease can be rapid and that the effects are magnified in populations where not all children are vaccinated.  Currently in the United States, there is a new trend developing to not vaccinate children.  Reasons are varied, from the belief that vaccines contain thimerosal, to religious beliefs that God will protect all people from illness and thus vaccines are unnecessary.  We will examine the former issue.  Thimerosal, an organomercury compound that is a known human toxin, was used in trace amounts in some multi-dose vaccines as a preservative to prevent the growth of bacteria and fungi in the vaccine [4].  This preservative has sparked huge concern in autism awareness communities, where many parents attribute their child’s autism to the thimerosal in vaccines.  Thus, parents that have one child with autism are generally avoiding vaccinations of subsequent children to attempt to prevent autism a second time.  Additionally, many people that work around this population have become hypersensitive to these claims and are also avoiding vaccinations.  However, since 1999, the vaccines routinely given to children that contained thimerosal have been reformulated to use other preservatives that do not contain mercury [4].  The facts and causes of autism may not be discovered in our lifetime, but the effects of large masses of people not being vaccinated may quickly catch up with us.  These pockets of society that are choosing to not be protected against a myriad of infectious diseases could soon fall victim to severe illness, as well as spreading the disease quickly. 

So, what role should the government, or regulatory agencies, play in enforcing immunization requirements?  Currently in the United States, ensuring vaccination compliance is left to each individual state as requirements for entering the school system.  In California, for example, children are required to show proof of at least beginning vaccination series before entering kindergarten.  However, as stated previously, any parent is allowed waive their child’s vaccination requirement for personal or religious reasons.  Therefore, at any given school we could find a large variance of immunization compliance, making some children very susceptible to contracting an infectious disease.

In future vaccination campaigns, the public health workers should design their campaigns to completely address cultural and educational issues.  A partnership should be formed between the prominent leaders in the country, both religious and political, and public health workers to ensure that both parties are being sensitive to the needs of the other.  With this as a foundation, it might be easier to reach more people in the rural communities of developing countries in vaccination efforts.  Of the countries that once were endemic to polio, over 96% of them have now eliminated the disease and the world is very close to eradicating the disease.  By increasing efforts that are more culturally, spiritually and politically sensitive in combination with similar mass vaccination campaigns, eradication of polio could occur within the next few years.

References

1. Passport from Polio (2008) In Freedom in the Air online.  Retrieved February 8, 2009 from http://www.freedomintheair.org/?p=1545.

2. Pinock, S. Poliovirus spreads beyond Nigeria after vaccine uptake drops.  British Medical

Journal 2004.

3. Poliomyelitis (January 2008) In World Health Organization online.  Retrieved February 7, 2009, from http://www.who.int/mediacentre/factsheets/fs114/en/index.html.

4. Thimerosal in Vaccines (January 14, 2009) In U.S. Food and Drug Administration online.  Retrieved February 7, 2009, from http://www.fda.gov/Cber/vaccine/thimerosal.htm#t1.

5. Wild Polio Virus 2000-2009 Data (February 3, 2009) In World Health Organization online.  Retrieved February 7, 2009, from http://www.polioeradication.org/content/publications/AbujaCommitments_04Feb2009.pdf.

6. Wipfli, H. Global Efforts to Eradicate Polio.  Presentation observed at the University of Southern California, February 9, 2009.

Globalization: Enemy or Friend?

Globalization has impacted infectious disease in both negative and positive ways[1]. As global organizations join forces to address disease in deprived populations, globalization has also shown to bring about more disaster into the same deprived people. Western economic ideals may affect the way leaders perceive their own countries and allocate their resources in different areas while ignoring the health needs of their people. Not only are deprived populations affected by globalization, developed nations are also influenced by the global trades happening in our time. The increased transportation of products from around the world has not only made food and materials accessible to everyone, but we have also come in contact with a diverse pathogens.

Zimbabwe’s cholera outbreak has been described as the “one of the world’s largest ever recorded” by the WHO[3]. As of January 2009, it has infected more than 60,000 people and killed more than 3,100. Before this outbreak, Zimbabwe had been successful at keeping cholera under control through national prevention programs. According to the WHO, half of the cholera cases were recorded in Budiriro, on the western outskirts of Harare[3]. Some other major concentrations places have been Beitbridge, and Mudzi. This cholera outbreak displayed common oversights of many countries. For instance, we perceived the country’s reluctance of acknowledging that they were experiencing the first signs of a severe outbreak, as well as country’s inability to disperse their health care providers to the places where they were needed the most.

The idea that globalization could have a positive impact on other countries is exemplified by the WHO efforts in conjunction with the Ministry of Health and Child Welfare’s efforts to control the epidemic. Their struggle has focused on increasing awareness on prevention and treatment. They have noticed that most of the deaths have occurred in remote areas of the country because people do not have the resources and the transportation to access health services. At the same time it has been difficult for the government to provide their citizens with suitable health facilities and staff[5]. Unfortunately, the government of Zimbabwe has not been able to mobilize resources to pay their medical staff or to organize them into brigades that reach remote areas in need of health services.

Globalization has allowed nongovernmental organizations to provide basic needs to different areas that have been affected by the cholera outbreak. These organizations are able to bring doctors, nurses and other health staff to places that where the government has been able to reach. It has been suggested that in order to control this massive outbreak, it is necessary for nongovernmental organizations, the United Nations and local government to join forces and focus on case management, water and sanitation, social mobilization and provision as well as mobilization of financial resources[4]. Zimbabwe needs to provide for its local health care professionals as well as increase the number of staff able to reach diverse regions affected by the cholera outbreak.

Another great example of the positive impact of globalization has been the successful efforts to eradicate polio from Latin America and the Caribbean [2]. The Pan American Health Organization introduced a campaign, in countries that had endemic cases of polio that focused on national vaccine days where children under five would be immunized. These campaigns were complimented by crusades that visited each household that had not been reached by the twice-a-year campaigns [2]. It was a cost-effective program that cost $120 million saved millions from Polio’s debilitating symptoms such as, paralysis, and other life-threatening motor problems.

The impact of cholera on the Zimbabwe people has been attributed to the flaws in water sanitation and transportation as well as the unavailability of oral rehydration salts. Oral rehydration salts are solutions made of glucose and other salts that should be added to clean water in order to save patients from dehydration. The Global Task Force on Cholera Control reports that about 80% of individuals infected with cholera could have been treated with oral rehydration therapy and thus prevented many deaths.

Joining forces had proven to be the best response to epidemics and infectious outbreaks. In the case of Polio, the Inter-Agency Coordinating Committee, using representatives from the PAHO, UNICEF, The US Agency for International Development, the Inter-American Development Bank, and the Canadian Public Health Association integrated their efforts and contributed $110 million to the cause [2]. Together, they were able to reach more areas with high risk of Polio infection. Not only was mobilization improved, but also strategies of vaccine provision and health education were enhanced. Financing the immunization campaigns became more effective as well as increasingly organized. Leaders were able to set up surveillance programs capable of attending to any new cases and keeping them under control.

The government of Zimbabwe committed an error when they encouraged their inhabitants to prepare homemade solutions of the oral rehydration solution out of salt and sugar. This act prevented the successful treatment of many people affected by dehydration as a result of the cholera. The WHO guides case management to concentrate on health education and preventive measures. Health educators are encouraged to focus on instructing individuals to prepare the solution at home by using clean water. They can learn how to administer the solution to their children and how often the children should drink it.

Zimbabwe’s response has been criticized because it was not as promptly as it needed to be. According to the WHO, Zimbabwe underreported the cholera cases when the outbreak first erupted. As a result, the Cholera Command and Control Center have been established along with epidemiologists, logisticians, water and sanitation experts, and health workers [4]. Countries that rely greatly on tourism are many times reluctant to report their first signs of an outbreak because they fear that their tourism will be affected especially when it involves an infectious disease like cholera. Globalization allows ideas, cultures, and practices to be exposed to more parts of the world. Unfortunately, many times, this has a negative impact on those marginalized communities. The exposure of different practices allow for stigma to arise which is represented by the fear of certain governments to acknowledge when they are experiencing an outbreak.

The common culprit in cholera outbreaks is consumption of water from contaminated sources [4]. Zimbabwe’s inhabitants were affected because of defective water-piping systems. Health educators have concentrated on teaching hand-washing but many of these individuals cannot rely on clean water sources. Water-piping systems have to focus on safely disposing of sewage water in order to prevent the entry of bacteria into the clean water used for consumption and washing.

As mentioned by Saker et al, economic crisis leads many governments to reduce their amount of health expenditure in order to allocate the majority of financial resources in immediate predicaments. Structural adjustment of many governments is also mentioned as being the cause of a country’s inability to control an outbreak. Prompt response can be limited when authorities have to focus on other governmental crisis.

1. Saker et al. “Infectious Disease in the Age of Globalization”. Chapter 2. 19-35

2. “Eliminating Polio in Latin America and Caribbean” Class reading. 39-46

3. Gardwood, Paul. “Global, national efforts must be urgently intensified to control Zimbabwe cholera outbreak” World Health Organization. 2009

4. “An old Enemy Returns” World Health Organization. 2009

5. Gardwood, Paul. “ Health System Problems Aggravate Cholera Outbreak in Zimbabwe”. World Health Organization. 2009

6. London, Owen D. “ WHO’s Attempt to Eradicate Polio are Thwarted in Africa and Asia”.