The Obesity Epidemic: A Global Health Priority

Introduction to the Obesity Epidemic

The world is shifting at an alarming rate from infectious diseases to chronic non-communicable diseases. Without concerted action, 388 million people worldwide will die of one or more chronic diseases in the next 10 years (Daar et al., 2007). The number of deaths from these diseases is double the number of deaths that result from a combination of infectious diseases, maternal and perinatal conditions, and nutritional deficiencies (Daar et al., 2007). Chronic diseases will also have a huge negative economic impact. Over the next 10 years, China, India, and the United Kingdom are projected to lose $558 billion, $237 billion, and $33 billion respectively due to reduced economic productivity (Daar et al., 2007).

By 2020, it is estimated that two thirds of the global burden of disease will be attributable to chronic diseases, most of them strongly associated with diet (Chopra et al., 2002). The nutrition transition towards refined foods, foods of animal origin, and increased fats plays a major role in the current global obesity epidemic and is due to several factors: urbanization, changes in income and food price changes, modern technology, and globalization (Popkin and Mendez, 2007 and Popkin, 2006). Obesity is a precursor to many chronic diseases, including cardiovascular disease, type 2 diabetes, arthritis, and respiratory complications, which in turn have become major factors in the current healthcare crisis in the United States (Butchko and Petersen, 2004). Results from the 2002 NHANES survey indicate a doubling in obesity prevalence rates in adults and a tripling in prevalence rates among adolescents over the past two decades (Butchko and Petersen, 2004).

Because of these rapid changes, priority in a crowded global health agenda should go to addressing the forces that contribute to the obesity epidemic. It is especially important to act now as rates are increasing in developing countries since it is possible to intervene and prevent these countries from seeing levels of chronic diseases comparable to that of the United States and other developed countries. In this essay, we will review some of the main forces behind the obesity epidemic: decreases in physical activity with concurrent increases in technology, shifts in the food system, and the subsequent effects of globalization of transnational corporations. Addressing this epidemic and progressing towards possible solutions requires a multidisciplinary approach and coordinated efforts on a global scale.

Physical Activity and Technology

Technological forces at the community and individual levels that increase the level of comfort in everyday life also greatly contribute to the lower levels physical activity. The introduction of the automobile revolutionized way people traveled and extended the distances to which people can travel (Choi et al., 2005). Many children no longer walk to school, and people are able to commute longer distances for work. In China, about 14% of households acquired a motor vehicle between 1989 and 1997 and television ownership skyrocketed (Popkin and Mendez, 2007). Modern machines at home and in the workforce decrease the need for direct human efforts. Washers, dryers, and dish washers take away the opportunities of old-fashioned household physical activities (Choi et al., 2005). There is an increase of sedentary jobs due to the mechanization of the service sector (Popkin, 2006).

In addition to the luxuries that technology provides, children are influenced by the forces that they encounter in schools and in their neighborhoods. In many schools, physical education is removed from the curriculum due to budget cuts while vending machines with unhealthy snacks are still available. Due to the rise in crime rates in some neighborhoods, there is a perception that the streets are unsafe. Many parents do not allow their children to go outside and play in the parks or playgrounds and as a result, the children become hooked onto TV, games, and computers (Choi et al., 2005).

Shifts in the Food System

One of the most significant shifts in the food system relates to the marketing and sales of food (Popkin, 2006). Through advances in technology, the amount of processed foods has increased, and the subsequent fall of food prices has enabled the food and beverage industries to expand their markets abroad. The global value of food trade grew from $224 billion in 1972 to $438 billion in 1998, and this was accompanied with the consolidation of agricultural and food companies into large transnational corporations, which in turn developed global brand names and marketing strategies with adaptation to local tastes (Chopra et al., 2002). As these corporations penetrate new markets, they often use the strategy of purchasing large shareholdings in local food producers, wholesalers, or retailers (Chopra et al., 2002). For example, in China, transnational corporations significantly invested in local companies to produce, distribute, and retail both global and locally adapted products (Chopra et al., 2002). As commodity prices decrease and incomes increase, people tend to increase the diversity of their diet and shift into higher priced commodities and processed convenience foods (Popkin and Mendez, 2007).

Globalization and Obesity in Developing Countries

Until recently, obesity and the associated risk of chronic diseases have been perceived as problems of developed countries. However, the problems of overnutrition are increasing even in countries where hunger is endemic (Chopra et al., 2002). Many developing countries are experiencing shifts in food imports due to the increase in direct foreign investment in the food industry, especially through supermarkets and fast food restaurants (Popkin and Mendez, 2007). For example, between 1989 and 1998, sales by U.S.-owned food processing affiliates in Asia increased from $5 billion to $20 billion (Popkin and Mendez, 2007).

Urbanization has also played an important role in the obesity epidemic. Globalization has been associated with occupations that involve spending more time away from home, and the consumption of processed food and fast food meals have greatly increased (Popkin and Mendez, 2007). In general, people living in urban areas consume higher levels of fats and animal foods, along with lower consumption of vegetables (Popkin and Mendez, 2007). Even this, however, has begun to change as rural development increases (Popkin and Mendez, 2007). As a result of these various forces, people in the developing world are abandoning traditional diets that are rich in fiber and grain for diets that include increased levels of sugars, oils, and animal fats (Chopra et al., 2002).

Underlying the corporate expansions into and investment in developing countries is the principle of the rules of trade, set forth by the World Trade Organization (WTO). The WTO enforces and addresses these rules to facilitate increased global trade (Popkin and Mendez, 2007). The two key principles addressed are 1) a benefit that is granted to one Member State is required to be granted to all Member States and 2) the imported and domestically produced goods, services, and intellectual properties are allowed the same competitive advantages in the markets of importing countries (Popkin and Mendez, 2007). While these rules were designed to achieve non-discrimination, it inadvertently allows the WTO to assist with the market penetration and global advertising in developing countries (Chopra et al., 2002).

Future Efforts

The fundamental science behind the obesity epidemic is quite simple: dietary changes are exacerbated by a parallel decline in energy expenditure associated with reductions in daily physical activity (Chopra et al., 2002). However, what makes this epidemic so difficult to address are the additional forces that exist at various levels of society to provide the underlying currents to this epidemic. Although we are slowly becoming more aware of the magnitude of this problem, we need to act now and increase our efforts in order to address this complex yet pressing issue. Many researchers believe that since obesity is a multifaceted problem, it will take a multifaceted and long-term approach from all key stakeholders to solve it (Butchko and Petersen, 2004). However, the two most important fronts to start with include the community level and the national and international levels.

Efforts at the community and individual levels should include increasing education and awareness about the risks for obesity. People must be made aware that there is a problem in the first place before they can decide whether or not they want to change their habits. Since people generally go for the quick fix than use the approaches may require personal sacrifices and lifestyle changes, prevention and intervention programs should be customized for each individual so that they would be able to continue the different strategies long after they have completed these programs (Choi et al., 2005). For those people that are aware of the problem yet have no control over the types of food or exercise facilities available to them, that is where the policymakers come in.

Efforts at the national level are incredibly important as governments and policymakers have the largest potential to make a difference and spearhead efforts towards addressing obesity. Even though individuals have the right to make their own choices as to what they feel is best for them, they do not have control over forces such as globalization, marketing, and corporate investment. However, instead of fighting against the food and beverage industries, we would be even more efficient if we partner with them and work together. Governments should reiterate to these industries that the goal is not to take over their businesses, but instead to work towards a common goal to benefit the greater good. Governments can use subsidies or other incentives to promote corporate investment in poorer areas to ensure that fresh fruits and vegetables are affordable and help to promote healthier food choices (Popkin and Mendez, 2007). Price manipulation, public education, and clear food labeling are also effective strategies that can be implemented (Chopra et al., 2002). Governments could also work with the private sectors to focus on creating social environments that encourage physical activity, walking, and more nutritious food choices (Choi et al., 2005). This is especially relevant in the workforce where employees may not have access to healthy cafeterias or facilities to exercise in.

Since globalization is contributing to the rising rates of obesity in developing countries, efforts at the international level are crucial to prevent this epidemic from getting worse. Governments and organizations need to work together on a global scale in order to achieve national objectives for the protection and promotion of public health (Chopra et al., 2002). One way to garner support for addressing obesity is through the creation of non-binding legal documents to promote global support for this issue (Chopra et al., 2002). Non-binding legal documents, which can be classified into intergovernmental resolutions and intergovernmental codes of conduct, have the advantage of flexibility while binding legal documents have the advantage of ensuring compliance (Chopra et al., 2002). The idea is to start with non-binding legal documents and then progress to the development of binding legal commitments (Chopra et al., 2002). Currently, the World Health Organization is promoting non-binding legal instruments through the resolutions of the World Health Assembly, but it is not planning on developing binding mechanisms yet (Chopra et al., 2002). Although introducing legal documents may seem a bit extreme to some, it may just be the driving force that is needed to unite international efforts and attention toward obesity.

Even though strategies at the community and national and international levels are necessary starting points, long-term goals require a multidisciplinary approach in order to coordinate efforts to increase the progress towards solving the obesity epidemic and subsequently to slow the spread of chronic non-communicable diseases. It is predicted that countries will lose billions of dollars and millions of lives over the next 10 years due to chronic diseases, so taking immediate action to address one of the biggest risk factors of these diseases will be worth it.

References
Butchko, H. and Petersen, B. 2004. The obesity epidemic: stakeholder initiatives and cooperation. Nutrition Today 39(6):235-244.

Choi, B.C.K., Hunter, D.J., Tsou, W., and Sainsbury, P. 2005. Disease of comfort: primary cause of death in the 22nd century. Journal of Epidemiology and Community Health 59:1030-1034.

Chopra, M., Galbraith, S., and Hill, I.D. 2002. A global response to a global problem: the epidemic of overnutrition. Bulletin of the World Health Organization 80(12):952-956.

Daar, A.S. et al. 2007. Grand challenges in chronic non-communicable diseases. Nature 450:494-496.

Popkin, B.M. 2006. Global nutrition dynamics: the world is shifting rapidly toward a diet l inked with noncommunicable diseases. The American Journal of Clinical Nutrition 84:289-298.

Popkin, B.M. and Mendez, M. The rapid shifts in states of the nutrition transition: the global obesity epidemic. In: Kawachi, I., Wamala, S., eds. Globalization and Health. New York: Oxford University Press. 2007:68-80.

Disaster Epi

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Disaster epidemiology is a relatively new field that seeks to examine health outcomes in the midst of disasters. Disaster epidemiology was essentially defined in the late 50’s in a review by Harvard professors, Saylor and Gordon, as they sought to apply general epidemiologic procedures to the investigation of disasters both natural and manmade (Armenian, 4). It aims to assess what services are necessary to those immediately affected by disasters and also to study short and long-term factors that influence health during disasters as an aid to policy makers who prepare for future calamities. Two difficulties with disaster epidemiology cited in a review on the subject deal with “characterization of the population at risk and exposed to the disaster” and “estimation of the exposure to the disaster” (Dominici, 9). Two goals of disaster epidemiology cited in another review describe the necessity of “needs assessment” and “improvements in contingency planning for future disasters.” (Van der Berg, 56) In this blog, I will briefly evaluate these two limitations and two goals in relation to a pair of similar articles written on mental health outcomes following Hurricane Katrina.

The first article is titled “Mental Health Service Use among Hurricane Katrina survivors in the Eight Months after the Disaster” by Dr. Wang et al. The article examines mental health service use in Katrina survivors, finding that few of the study subjects received adequate care. Most respondents cited enabling factors (preventative barriers) as the main reason why their care was limited. Disaster epidemiology has difficulty characterizing the population exposed and at risk to the disaster along with estimating the population’s degree of exposure to the disaster. This problem was addressed in the article by using data from a sample of 1043 pre-hurricane residents that were part of a Hurricane Katrina Community Advisory Group (CAG) defined by FEMA as residents directly affected by Katrina living in certain areas in New Orleans and adjacent states. The residents sampled were surveyed through random digit dialing. An initial issue with the baseline surveys is calculating the proportion of respondents to the survey. In this study, an estimated 42% of those contacted responded to the survey, but verification of the true proportion of respondents is impossible given that there is no way to determine which phone numbers were working numbers. This highlights one issue with disaster epidemiology, in that locating and tracking members of the target population can be difficult given the damage to infrastructure and population dispersal that is a natural consequence of disasters. (Wang 1404) Another problem with defining the target population was that telephone calls were used to survey the population. By the author’s own admission, one important limitation of this technique is that “the most disadvantaged and possibly most severely ill people” (Wang, 1410) are underrepresented because they may not have access to telephones. This point underscores another common problem in disaster epidemiology, locating or characterizing those heavily exposed to the disaster. Mental health severity was examined using the validated K6 screening method and health service use was evaluated using reasonably standard methods. Outcome assessment will not be examined in depth as it does not relate specifically to challenges in disaster epidemiology.

The paper found that a significant portion of respondents had abandoned seeking mental health services following the hurricane. Most respondents claimed a lack of enabling factors prevented them from seeking care. Additionally, the authors write that “only 15% of respondents who were directly affected and 36% of respondents with probably posttraumatic stress disorder or depression sought mental health care by six months (Wang, 1408). This finding aids greatly with both needs assessment and contingency planning for future disasters. Policy makers can use this information to strengthen mental health services in the wake of a similar disaster in the future. The authors also found that the majority of Katrina survivors who did seek out mental health services did so through the general medical sector rather than engaging specialty services first. They go on to advise policy makers that specialty health personnel should be integrated into the general medical sector in the event of a disaster so that the disadvantaged can get the care they need. This recommendation demonstrates the importance of disaster epidemiology in contingency planning. The discussion portion of the paper spends a great deal of time giving recommendations to policy makers on how to approach mental health service during disasters in the future.

The second article, by Dr. Kessler et. Al, is titled “Trends in mental illness and suicidality after Hurricane Katrina.” The authors did a cohort study of hurricane residents, surveying their mental health and then tracking developments in their health over two years. A similar method, as in the previous study, was used to characterize the populations. Respondents were selected through random-digit dialing and selected from the 1.4 million families that applied for assistance from the American Red Cross, and also from those families that were housed in FEMA hotels. While the same issues that the earlier study encountered undoubtedly exist in study (calculating the true proportion of respondents and surveying those without access to telephones), I will focus specifically on characterization of exposure in this paper – another difficulty in disaster epidemiology. The authors spend a significant amount of time discussing stresses and mental health issues in the New Orleans Metro Area as compared to surrounding states. One difficulty in making this comparison, however, is that an equal amount of exposure (the amount residents were affected by the hurricane) is assumed in all groups. No true comparison could be made between residents in the metro area and residents in the surrounding states if their exposures were on different strata. Since there is no truly objective way of defining the exposure, all residents who were characterized by the government as affected by the hurricane and who applied for federal support are treated as equally exposed in the study. This issue is common to disaster epidemiology, in that quantifying exposure to a disaster can be problematic.

In terms of needs assessment and contingency planning, the article makes important points that can be valuable to policy makers. The authors found that there was a significant amount of mental health distress in areas outside New Orleans and that policy makers should plan to spread additional services in areas outside the most affected zone in a future disaster. The authors also found that mental health issues were very weakly related to socio-demographic variables, meaning that mental health is a pervasive issue affecting all age groups and demographics in the aftermath of a disaster (Kessler, 10). Finally, by performing a cohort study and evaluating mental health issues 2 years after the hurricane, the authors were able to determine that the prevalence of distress does not drop significantly immediately after a disaster and that assistance should be provided to those affected by a disaster in the long-term.

Works Cited

Armenian, Haroutune. "Epidemiology in War and Disasters."

Dominici, Francesca, Et Al. "Methodological Challenges and Contributions in Disaster Epidemiology." Epidemiologic Reviews (2005): 9-12.

Kessler, Ronald C., Et Al. "Trends in mental illness and suicidality after Hurricane Katrina." Molecular Psychiatry 4 (2008): 374-84.

Van der Berg, Bellis, Et Al. "The Public Health Dimension of Disasters - Health Outcome assessment of Disasters." Prehospital and Disaster Medicine (2008).

Wang, Philip, Et Al. "Mental Health Service Use Among Hurricane Katrina Survivors in the Eight Months after the Disaster." Psychiatric Services 58 (2007): 1403-410.

The Impact of War on Health by: Fabiola Enriquez

When it comes to the impact of wars on health, it is important to mention the great impact nuclear wars have on the environment and consequently, on the people’s health. Not only should we be concerned about the release of toxic chemicals from nuclear weapons, but we should also be aware of the damage the places of production and testing can cause to community living in those areas. Currently, there is a lot more information regarding of production sites in the United States than any other part of the world (1). It has been recorded that a majority of nuclear weapon production sites have to compensate retired workers since some suffer negative health effects from occupational exposure.

Not only are nuclear weapons to blame for increased health risks on humans, but we should also consider the destruction of buildings and homes by bombing. During World War II, 50 million people were displaced from their home and many cities including Warsaw, Berlin, Hamburg, Pisa, and Budapest were greatly damaged (1). The destruction of many homes included the demolition of irrigation networks making it impossible for inhabitants to get clean water. The population was at an increased danger of disease due to decreased availability of clean water and living in rundown homes with more individuals increased their risk to infectious diseases. In other countries like Japan, the damage was also intense, since bombs destroyed more than buildings. Bombarding caused the loss of rice harvest resulting in hunger, starvation and death.

Land mines are also a massive risk to the population that live among them. Countries around the world have thousands of land mines that do not follow international regulations, therefore there is no one controlling how close people live around those areas causing many deaths and injuries to civilians around the world. Land mines cause many deaths and they also prevent people from using this land for farming and agriculture. As a result, million of civilians starve to death because they are not able to utilize their country’s natural resources. Health concerns are not limited to humans, but they also include the pollution of soil, destruction of plant life, and disruption of water streams. Wars affect the health of people when pesticides and other air pollutants are used to threaten the safety of the population. The distribution of contaminants is utilized to destroyed crops and increase health risks in a desired population causing a great deal of stress for people’s health and their harvests.

When war takes over a country, it is important to consider that foreign troops are exposed to new virus, bacteria and parasites. Such was the case in 1990 when U.S. troops had been sent to the Persian Gulf, when Iraq went to war with Kuwait. According to records gathered by the University of Chicago, more than 50% of troops stated to have experienced an episode of acute diarrhea (2). Most of the soldiers that were affected by acute diarrhea were infected with Escherichia Coli and Shigella Sonnei. Medical staff found vegetables and fruits produced locally to be the culprit of these cases of gastroenteritis. After this produce was studied, they realized that these were the foods that caused acute diarrhea to most of the troops. Also, many soldiers were sent to field locations and cohabitated close to one another, shared substandard latrines and washing facilities, which gave place to the spread of these enteropathogens (2). Another major risk to the soldiers happened when a food handler got sick and was careless when it came to food preparation.

When troops are sent to foreign countries they run the risk of being to exposed to different kinds of pathogens that they would not have encountered in their native states. Such is the case of Leishmaniasis, which is a protozoan parasite that causes a visceral infection on the skin. Some of the symptoms experienced by the troops were fever, enlargement of the spleen, liver, and lymph nodes (2). Unfortunately, it was difficult of cases of visceral L. tropica to be diagnosed due to the lack of sensitivity or skin screening test. At the same times most people who were known to have this infection presented visible signs of Leishmaniasis. Those living in the urban areas were thought to be at lower risk of contracting the infection because they were less exposed to the vectors of and primary hosts which are the sandfly and desert rodent, respectively. Most troops were lucky to have been sent to these are when sandfly were at their lowest stage of activity (2).

War between any numbers of countries causes a great deal of devastation to their cities, buildings, crops, men, children and women. Women are greatly affected by war during this occurrence and after it. The United Nations made an effort to help women and sent them to a refugee camp in Oru Village, in Ogun State, Nigeria. Between January and March 2004, a study was performed to evaluate how forced migration affects the incidence of disease among women (3). Women provided accounts of their experiences during the war. Since most women were left to fend for themselves, a great number of them suffered the malevolence that comes with war and conflict. Women were raped by foreigners and those who realized no one could protect them. This put them at increased risk of contacting sexually transmitted diseases and HIV. Some women were even forced to engage in commercial sex work, some were physically abused and forced to marry.

War is known to negatively effect families, social, physical development, and to increase morbidity and mortality. We cannot forget about the impact it has on human’s mental health. Two studies performed in Afghanistan show the damage war caused a great number of inhabitants. A survey of 799 adults demonstrated that 67.7% of those who answered it had a diagnosis of depression, 72.2% experienced symptoms of anxiety, and 42% had post-traumatic stress disorder (4). Another crossectional study performed in Afghanistan used the responses of 1011 people and found that 38.5% of them experienced depression, 51.8% had symptoms of anxiety, and 20.4% had a diagnosis of PTSD (4). In the Balkans, children were also studied, and it was found that children between the ages of 9 to 14, showed high levels of post-traumatic stress symptoms which was related to the type and amount of exposure to traumatic events.

Similarly to the previously mentioned studies, others show an account in such places as Cambodia. Studies that included children, demonstrated that even after being followed for 3 years, these children showed 48% of Post-traumatic stress disorder, and 41% of depression symptoms (4). Even though traditional healers, monks, and elders had a great impact on the population’s mental health, after the war, this was not the case any longer. Many people during the war lost their respect and changed their beliefs making it difficult to find support during these traumatic times. Even if victims of war are taken to refugees, many times they do not show improvement because they have already experienced traumatic events and because they do not have the support system they had back at homes. Also, their personals beliefs could get in the way of the thorough understanding of Western ideas, when it comes to mental health.

Children are negatively impacted by war in many ways. Not only is their health jeopardized, most also develop mental disorders as well as developmental issues. Children are usually in need of an adults care, but when war happens this relationship in interrupted because of parents’ dead or separation from family members. Many times children are forced to fend for themselves and even take care of younger siblings once parents are gone. Children are not permitted to develop properly because now they have to assume the role of a parent and provider (5). Seeking proper health care is also a disadvantage of children during war. Most kids are not mature enough to know the importance of received health services and many times ignore this part of their lives. Also, children might have been physically injured and they might not be able to attend school or learn any physical work that would have allowed them to support their families in the future. Without an education or necessary work experience, these children are at a great disadvantage when they grow up.

During war, most children will not receive proper health care, which includes immunizations. This increases their vulnerability to a variety of diseases that could threaten their life. The lack of food also increased their risk of disease because of malnutrition. Sometimes children are recruited to fight in wars making them highly susceptible to injuries and death. Since children do not have the development of an adult they find themselves at a great disadvantage when they themselves engage in warfare (5). It is necessary for programs that focus on helping those that have been exposed to war to include physical rehabilitation and mental health services.

1. Leaning, Jennifer. Environment and Health: 5. Impact of War. CJMA 2000; 163(9): 1157-1161
2. Bennett T, Bartlett L, Olatunde OA, Amowitz L. Refugees, forced displacement, and war. Emerg Infect Dis . 2004 November
3. Hyams, Kenneth C. Hanson, Kevin. Wignall, F. The impact of Infectious Diseases on the Health of U.S. Troops Deployed to the Persian Gulf. University of Chicago Press, 1995. Clin Infect Dis 1995; 20:1497-1504
4. Farhood, L. The Impact of War on the Physical and Mental Health of the Family. Soc Sci Med. 1993 Jun;36(12): 1555-1567

Santa Barbara, J. Impact of War on Children and Imperative to End War. Croat Med J. 2006 December; 47 (6): 891-894

The Impact of Modern Wars and Armed Conflicts on Children

Introduction to Globalization and War

According to Hick (2001), the newest development of globalization is the expansion of global capitalism. In that sense, globalization is the manifestation of an old system of market liberalism that occurs on an international level. One negative effect of globalization is changing the nature of warfare through the perpetuation and encouragement of modern wars and armed conflicts. Modern wars, based primarily on the changing politics of economic globalization, are usually intranational in nature and occur mostly in developing countries (Hick, 2001). Free trade opens developing countries to transnational corporations that exploit both the people and the resources by selling and purchasing products such as luxury items and weapons. Examples include diamond wars in Sierra Leone and Angola and oil conflicts in Sudan (Hick, 2001). Not only do these corporations create the conditions for some of these wars, but some are even directly involved. The number of children living in poverty is growing as globalization expands markets across national boundaries and increases the incomes of a select few (Hick, 2001).

The changing face of modern wars and armed conflicts now involve targeting children and exploiting and killing children more systematically than ever (Hick, 2001). A major development that brought about this change is the increasing sales and availability of small arms in the local communities of developing countries. These weapons readily facilitate the ignition and sustainment of wars that victimize children (Machel, 2001). In 94% of the conflicts since 1990, small arms were the only weapons used (Peters and Richards, 1998). Consequently, children are greatly affected by the intranational wars and armed conflicts in their war-torn countries. They face constant violence and dangers, the more common of which includes death, displacement and separation from family, sexual violence, and recruitment as child soldiers. It is imperative that we become more aware of the perils and desperation that these children encounter in order to address the issues and protect them from these infringements of their human rights.

Impacts on Children

Death
The most direct consequence of armed conflict that children face is death. UNICEF estimates that 90% of global conflict-related deaths since 1990 have been civilians, with 80% of these being women and children (2006). From 1985 to 1995, about 2 million children have been killed and 5 million have been disabled (Hick, 2001). About 800 children are killed every month by landmines (Hick, 2001). In the Democratic Republic of the Congo, about 1,270 excess deaths occur every day due to malnutrition and infectious diseases (UNICEF, 2006).

Displacement
As a result of armed conflict, people are forced to leave their homes to escape from danger and either become internally displaced people (IDPs) who stay in their own countries or refugees who flee to other countries (Hick, 2001). According to O’Hara and Southall (2007), there are 13 million IDPs and 3.5 million refugees in sub-Saharan African countries. In Darfur, there are 2 million people living in displacement camps (UNICEF, 2006). Worldwide, there are 40 million refugees and children account for 50% of that (Hick, 2001). One million children are orphaned and 12 million are homeless as a result of armed conflict (Hick, 2001). Displacement results in dangerous situations for children because they are more likely to be raped, tortured, murdered, or recruited as child soldiers (Machel, 2001). Many are separated from their families and friends. Within the first days and weeks of displacement, many children die due to malnutrition and diseases (Hick, 2001). There is a limited supply of food and water, and refugee and IDP camps often serve as breeding grounds for diseases such as malaria, diarrheal diseases, and respiratory infections (Machel, 2001). Ideally, these camps should be safe, but many IDP and refugee camps are often highly militarized and used to traffic arms, which results in high levels of violence, sexual assault, and substance abuse (Hick, 2001). Donated emergency food aid may be diverted from displaced populations to military groups, and men in charge of distribution may abuse their power, which puts women and children at a disadvantage (O’Hare and Southall, 2007). In general, IDPs are worse off than refugees because they have to move repeatedly, are more difficult to reach due to fighting or government policies, and unlike the refugees, have no specific agency or body of law for protection (Hick, 2001).

Sexual Violence
During times of war, women and girls are particularly vulnerable to sexual violence. Displaced and separated from family and friends, many girls resort to prostitution as a way to obtain food, shelter, or papers (Machel, 2001). Other girls are abducted into armed groups and forced into sexual slavery (Hick, 2001). Rape is a constant threat and is often used as a weapon for ethnic cleansing by armed groups to humiliate and terrorize the perceived enemy (Machel, 2001). The direct consequences of rape and prostitution include unwanted pregnancies and contraction of sexually transmitted diseases and HIV/AIDS (Machel, 2001). The indirect consequences of sexual violence are the traumatic long-term effects on the psychological and physical development of these girls (Hick, 2001). Not only does violence cause painful psychosocial and emotional damage, but even worse, it erodes these girls’ trust in adults (Hick, 2001).

Recruitment into Armed Forces – Child Soldiers
It is estimated that there are about 300,000 children under age 18 who are participating in armed combat (Hick, 2001). Most are adolescents, but some can be as young as 10 (Machel, 2001). While the Convention on the Rights of the Child (CRC) prohibits nongovernmental forces from recruiting children less than 18 years of age, it allows states to establish their own minimum age requirement for voluntary recruitment that is not necessarily 18 years of age (Hick, 2001). The trend towards the use of child soldiers can be attributed to the dwindling supply of adult soldiers and the availability of small arms (Machel, 2001). In addition, some commanders prefer child soldiers because they are more obedient and easier to manipulate than adult soldiers (Hick, 2001).

There are 3 main ways that children join armed forces: they do so voluntarily, they are abducted, or they are sold by their families. First, many under-age combatants voluntarily join armed forces to avoid starvation and to substitute for an education since many schools have shut down (Peters and Richards, 1998). Others believe that it is a way to protect their families or to obtain revenge (Machel, 2001). Weapon training pays quicker dividends than school and brings food, money, a warm bath, and instant adult respect (Peters and Richards, 1998). The military unit serves as both a refuge and a surrogate family (Hick, 2001). Secondly, children can be forcibly recruited or abducted by armed forces, civil defense, and paramilitaries (Machel, 2001). They are especially vulnerable to recruitment in refugee or IDP camps. Last but not least, poverty plays a significant role in the recruitment of child soldiers because some parents offer their children’s services for monetary compensation (Machel, 2001). On the other hand, children from wealthier families are less likely to be recruited because their families are able to buy their freedoms or use legal or political influence to challenge their recruitment (Machel, 2001).

Current and Future Efforts to Protect Children’s Rights

One of the most prominent movements toward legal framework concerning the promotion and protection of children’s rights was the adoption of the Convention of the Rights of the Child (CRC) in 1989 by the United Nations General Assembly. World leaders wanted the world to recognize that children had human rights too and felt that a special convention was necessary to give special care and protection to children under 18 years of age. CRC was the first legally binding international instrument to incorporate the full range of human rights, including civil, cultural, economic, political and social rights (UNICEF, 2006). CRC has been endorsed by 191 states, making it the most widely ratified international instrument in history (Hick, 2001).

Now that we have this framework, we need to build on these foundations to ensure that it is implemented properly to further the efforts to protect the rights of children. We can attain these goals by working at the local and global levels to address both the upstream causes and downstream effects of armed conflicts. Locally, efforts to increase community awareness of exploitation and violence in developing countries are necessary because consumers need to be conscious of their roles in creating demand for luxury products. These demands drive corporations to generate markets to obtain resources from these countries, which in turn fuels conflicts in intranational wars. There needs to be some sort of balance to curb the corporations’ exploitations of developing countries. Thus, punitive systems should be established to hold corporations accountable for their actions and roles in perpetuating global wars. Governments can serve as key players in the implementation of these legal systems. According to Peters and Richards (1998), governments tend to spend less on health and education and more on defense if there has been a recent conflict. Thus, governments in wealthy countries need to reassess their values and set examples for corporations and other organizations to lower the risk of armed conflict abroad, perhaps by reducing the percentage of the gross domestic product spent on military expenditures or enforcing stricter regulations for weapons sales. These governments also need to recognize the link between their roles in supporting or encouraging wars and the resulting physical and emotional violence that many children face on a daily basis.

Globally, stricter standards need to be imposed to control the unchecked exploitation of resources and luxury items by transnational corporations. Legal and disciplinary mechanisms need to be established and supported to hold parties responsible for their actions. For example, although international tribunals have been established and exercised their powers by punishing perpetrators of genocide, war crimes, and crimes against humanity in Yugoslavia and Rwanda, they need continuing political and financial support to maintain these efforts (Machel, 2001). Increased communication and cooperation between international parties could be a way to facilitate discussions of long-term support for such efforts.

While local and global efforts address the upstream causes of armed conflict, downstream effects in the war-torn countries need to be addressed as well. Peace-building and peacekeeping efforts need to focus on child protection issues as conflicts end. Since IDP and refugee camps are unsafe grounds for children who become separated from their families and friends, emergency humanitarian work should focus on establishing and maintaining family reunification programs. Adolescents, especially former child soldiers, need to be reintegrated into society in an appropriate and gentle manner. They should be included in community-building, reconstructive efforts, and relief programs.

In order to increase efforts to protect children, both upstream causes and downstream effects need to first be recognized and addressed by all parties involved. Only then will negotiation and cooperation on the local and global level make further progress to protect children from the devastating impacts of war.


References

Hick, S. 2001. The political economy of war-affected children. Annals of the American Academy of Political and Social Science (575)106-121.

Machel, G. 2001. The impact of war on children. Vancouver: UBC Press.

O’Hare, B. and Southall, D. 2007. First do no harm: the impact of recent armed conflict on maternal and child health in sub-Saharan Africa. Journal of the Royal Society of Medicine (100)564-570.

Peters, K. and Richards, P. 1998. ‘Why we fight’: voices of youth combatants in Sierra Leone. Africa: Journal of the International African Institute (68)183-210.

UNICEF. 2006. Child protection information sheet: protecting children during armed conflict. Retrieved 5 April 2009. http://www.unicef.org/protection/.

War and Public Health

Veeral Shah
PM 565
Blog paper 2

An examination of the role of the Public Health Community in preventing armed conflict
War and terrorism have had and continue to have profound social, political, economic and health costs far beyond the official termination of conflict. Historically, the health care community comes to conflicts during or after the duration of conflict and usually not in a preventative sense. Although, this model is understandable given the unique circumstances surrounding conflict, the current model deals little with the concepts around whether health care professionals (HCP) on the ground can serve as preventative agents as well as curative agents in times of conflict. Obviously, in many cases, this should not be understood to mean that health care professionals bear full responsibility for alerting the public as to the potential human rights violations, but it does not absolve them either. Groups such as Doctors without Borders have continually sought support from the international community regarding medical aid to those in need, but in a twenty-first century framework more steps must be taken. It is difficult to assess how much power an organization outside the borders of a particular region can exert on the persons of that region and how ethical is it to impose the idea of one’s will, whether it be political or social, upon another, especially in situations where help is not explicitly requested. Governments have run into political quagmires as a result of such partisan, unilateral thought processes in most recent memory the United States and Iraq. When examining the enormous complexity faced by individuals seeking to make government’s yield to help those in need, an HCP understandably feels overwhelmed and powerless, thereby concluding that their respective actions have no impact on the government at large. However, in actuality, HCP’s are uniquely positioned to alert intra and extra governmental and non-governmental entities on the atrocities occurring on a grassroots level.
The indirect, or secondary, public health effects of conflicts have been caused by population displacement, food shortages, and collapsed basic health services. Recent examples of mass population movements that attracted widespread media attention have included the Kurdish exodus from northern Iraq in 1991; widespread internal displacement and migration to neighboring countries by Somalis in 1992–93; the displacement of several million persons in the former Yugoslavia between 1992 and 1995; and the migration of up to two million Rwandans in 1994. A new term–complex emergency–has been coined to describe situations affecting large civilian populations that usually involve a combination of factors including war or civil strife, food shortages, and population displacement, resulting in significant excess mortality.1 The evolution of complex humanitarian emergencies tends to follow a relatively consistent pattern:
1. Domination of government by one political faction
2. Discrimination against minority ethnic or religious groups or against majority groups by ruling minorities
3. Widespread human rights abuses leading to civil unrest, violence and open armed conflict.

The conflict eventually leads to a destruction of infrastructure, diversion of resources away from social services, especially prevention programs such as child immunizations and antenatal care. Naturally, hospitals and surgical centers in the areas surrounding conflict may be overwhelmed by the needs of war wounded and general medical services suffer from lack of staff and shortages in essential medical supplies.1
Primary prevention is the basic strategy of public health, and epidemiology is one of its essential tools. In situations of armed conflict, however, epidemiology can be practiced safely and reliably in very few areas. Hence, the traditional documentation, monitoring, and evaluation elements of disease prevention may be ineffective in these situations. The provision of adequate food, shelter, potablewater, sanitation, and immunization has proved problematic in countries disrupted by war. Primary prevention in such circumstances, therefore, means stopping the violence.
More effective diplomatic and political mechanisms need to be developed that might resolve conflicts early in their evolution prior to the stage when food shortages occur, health services collapse, populations migrate, and significant adverse public health outcomes emerge. The notion of national sovereignty embodied in the United Nations Charter has sometimes forced the international
community to stand by and watch extreme examples of human rights abuses until a certain threshold of tolerance has been crossed and strong action has been taken, as in the case of Somalia. By the time such action has been taken, however, the conflict has often advanced to a stage where any involvement by outside forces is costly and dangerous. Cautious, neutral, but determined diplomacy of the kind practiced by the Atlanta-based Carter Center in Ethiopia, Sudan, Haiti, and Bosnia-Herzegovina might serve as a model for future conflict resolution efforts.2 Epidemiologists and behavioral scientists might play a role in this process by systematically studying the dynamics and characteristic behaviors that sustain conflict situations and by seeking to identify measures that might reduce the level of tension between opposing sides.
Secondary prevention involves the early detection of evolving conflict-related food scarcity and population movements, preparedness for interventions that mitigate their public health impact, and the development of appropriate public health skills to enable relief workers to work effectively in emergency settings. Disaster detection activities in the form of early warning systems have existed for some time; however, these systems have tended to focus on monitoring natural rather than man-made hazards. Such systems, implemented by a range of United Nations agencies and US Government–supported programs, routinely monitor crop yields, food availability, staple cereal prices, rainfall, and household income in a number of African countries, as well as conducting periodic vulnerability assessments. The information generated is published and disseminated widely in periodic bulletins and has proven useful in predicting natural disasters, such as drought throughout southern Africa in 1992.3 Nevertheless, these systems have generally not developed early indicators related to human rights abuses, ethnic conflict, political instability, and migration. Other groups such as Africa Watch, Physicians for Human Rights, Amnesty International, and African Rights have conducted assessments of vulnerability in countries, such as Burundi, relatively early in the evolution of civil conflict. The problem with such assessments is that the results are often ignored by the governments of those nations able to intervene unless their security interests are perceived to be threatened. Early in 1992, for example, reports by several nongovernmental organizations (NGO) on the deteriorating situation in Somalia were largely ignored by the international community. Epidemiologists might play an important role in developing and field testing the sensitivity and predictive value of a broad range of early public health emergency indicators.
The inability of the world to promptly address the explosive epidemic of cholera among Rwandan refugees in eastern Zaire, in July 1994, underscored the lack of emergency preparedness planning at a global level.3 This epidemic highlighted the inadequate reserves of essential medical
supplies and equipment for establishing and distributing safe water, as well as revealing a lack of technical consensus on the most appropriate interventions. Agencies that did have the appropriate skills and experience, such as Oxfam and MSF, lacked the necessary resources, and those agencies with the resources and logistics, such as the United States military, lacked the technical experience in emergency relief. Preparedness planning needs to take place both at a coordinated international level and at the level of countries where complex emergencies might occur. Relief agencies need resources to implement early warning systems, maintain technical expertise, train personnel, build reserves of relief supplies, and develop their logistic capacity. At the country level, all health development programs should have an emergency preparedness component that should include the establishment of standard public health policies (e.g. immunization and management of epidemics), treatment protocols, staff training, and the maintenance of reserves of essential drugs and vaccines for use in disasters.4
Front-line relief workers in complex emergencies are often volunteers recruited by NGOs who sometimes lack specific training and experience in emergency relief. They require knowledge and practical experience in a broad range of subjects, including food and nutrition, water and sanitation, disease surveillance, immunization, communicable disease control, epidemic management, and maternal and child health care. They should be able to conduct rapid needs assessments, establish public health program priorities, work closely with affected communities, train local workers, coordinate with a complex array of relief organizations, monitor and evaluate the impact of their programs, and efficiently manage scarce resources. In addition, they need to function effectively in an often hostile and dangerous environment; such skills are specific to emergencies and are not necessarily present in the average graduate of a medical or nursing school. Therefore, relief agencies need to allocate more resources to relevant training and orientation of their staff, as well as providing adequate support in the field. Indigenous health workers in emergency-prone countries, while often familiar with the management of common endemic diseases, also need training in the particular skills required to work effectively under emergency conditions.
Tertiary prevention involves prevention of excess mortality and morbidity once a disaster has occurred. The health problems that consistently cause most deaths and severe morbidity as well as those demographic groups most at risk have been identified. Most deaths in refugee and displaced populations are preventable using currently available and affordable technology. Relief programs, therefore, must channel all available resources toward addressing measles, diarrheal diseases, malnutrition, acute respiratory infections, and, in some cases, malaria, especially among women and young children. The challenge is to institutionalize this knowledge within the major relief organizations and to ensure that relief management and logistical systems provide the necessary resources to implement key interventions in a timely manner. Initially, both refugees and displaced persons often find themselves in crowded, unsanitary camps in remote regions where the provision of basic needs is highly difficult. Prolonged exposure to the violence of war and the deprivations of long journeys by refugees cause severe stress. Upon arrival at their destination, refugees–most of whom tend to bewomen and children–may suffer severe anxiety or depression, compounded by the loss of dignity associated with complete dependence on the generosity of others for their survival. If refugee camps are located near borders or close to areas of continuing armed conflict, the desire for security is an overriding concern. Therefore, the first priority of any relief operation is to ensure adequate protection and camps should be placed sufficiently distant from borders to reassure refugees that they are safe. To diminish the sense of helplessness and dependency, refugees should be given an active role in the planning and implementation of relief programs. Nevertheless, giving total control of the distribution of relief items to so-called refugee “leaders” may be dangerous. For example, leaders of the former Hutucontrolled Rwandan government took control of the distribution system in Zairian refugee camps in July 1994, resulting in relief supplies being diverted to young male members of the former Rwandan Army.5 Surveys indicated that households headed by single women had diminished access to food and shelter material, leading to elevated malnutrition rates among children in those
households.
In the absence of conflict resolution, those communities that are totally dependent
on external aid for their survival because they have either been displaced from their homes or are living under a state of siege must be provided the basic minimum resources necessary to maintain health and well-being. The provision of adequate food, clean water, shelter, sanitation, and warmth will prevent
the most severe public health consequences of complex emergencies. It would seem that the temporary location of refugees in small settlements or villages in the host country would have fewer adverse public health consequences than their placement in crowded, often unsanitary camps. Although studies to compare health outcomes among refugees in camps and in free settlements have not been possible, surveillance data from Guinea and Malawi indicate that refugees in local villages have fared better than those in camps.6
During the past decade, much progress has been made among the major relief agencies in standardizing approaches and procedures in public health emergencies (ie Sphere Project). Training courses designed specifically for public health in emergency settings have been developed in Europe, the United States, and Australia. Standard guidelines and essential drugs lists have been developed and are routinely used in emergencies. The role of military forces in providing security and in directly providing emergency assistance has grown rapidly in recent years. Military forces have played a prominent role in relief operations in northern Iraq, Somalia, the former Yugoslavia, Zaire, Rwanda, and Haiti.6 The involvement of the military is often ambiguous, confusing the various tasks of peace-keeping, peace-enforcing, and providing relief. No one would doubt the logistical advantages of the military; however, this is not always matched with appropriate experience in the technical aspects of a relief operation. Furthermore, military assistance is expensive and because it depends on political decisions by national governments, it cannot always be integrated into disaster preparedness planning.
Relief management decisions need to be based on sound technical information, and assistance programs need to be systematically evaluated–not merely for their quantity and content, but also for their impact and effectiveness. Responsibilities for technical coordination and implementation of relief programs should increasingly be shared with proven, competent, and experienced NGOs. Greater resources need to be allocated to personnel training, emergency preparedness planning, and the maintenance of regional reserves of essential relief supplies. These activities need to include government and nongovernment agencies in countries where emergencies are likely to occur. Recent emergencies have followed a predictable pattern of political unrest, civil war, human rights abuses, food shortages, and, finally, mass population displacement. There has been almost no preparedness for these emergencies within the public health community. Agencies involved in health development projects need to be aware of political realities in certain regions of the world and should integrate preparedness planning into all aspects of public health programs. Health information systems should incorporate plans to simplify and focus on major health problems in the event of emergencies. Immunization, diarrheal disease control, and community health worker training programs should likewise incorporate emergency contingency plans. Finally, increased attention needs to be given to the challenges of rehabilitation of national health services following the cessation of armed conflict and the repatriation of large numbers of refugees to their country of origin.

References
1.B.S. Levy and V.W. Sidel, “Preface,” in B.S. Levyand V.W. Sidel, eds., War and Public Health (New York:
Oxford University Press, 1337).
2. World Health Organization. World Report on violenceand Health (Geneva: World Health Organization,
2006).
3. RJ. Rummel. Death by Gomment: Genocideand MmMurderSince lWO(New Brunswick, NJ, and London
4. Transaction Publications, 1334). A. Zwi, A. Ugalde and P. Richards. “The Effects of War and Political Violence on Health Services’’ in L. Kurtz, ed., Encyclopedia of Violence, Peace and Conflict (San Diego, CA: Academic Press 1999): 679-690.
5. R.M. Garfield and A.I. Neugut, “The Human Consequences of War”, in B.S. Levy and V.W. Sidel, eds., War and Public Health, supra note 3.
6. V.W. Sidel, “The Impact of Military Preparedness and Militarism on Health and the Environment”, in J.E.
Austin and C.E. Bnich, ecls., Be Environmental Comequences of War (New York: Cambridge University Press,2000).

Several bad habits of highly ineffective global public-private health partnerships

Steven Covey must be proud right now as his “Seven Habits of Highly Effective…” business book series are now entering the realm of global health. It makes sense though that his concepts would emerge in the talks about partnerships for global health in public and private realm. Business is the common denominator in both realms, even though the global public good is the selling point for cooperation.

Kent Buse and Andrew M. Harmer divulge into this notion of seven habits of highly effective global public-private partnerships in their paper titled Seven habits of highly effective global public-private health partnerships: Practice and potential. Similar to their paper’s structure, this blog will mirror related topics. Before recommendations and identifying good and bad habits, let’s discuss some important contributions by having global health partnerships (GHPs) to global health.

GHPs have always done a great job on “getting specific health issues onto national and international agendas” and gathering “additional funds for these issues” (Buse & Harmer, 2007). Raising awareness and gaining additional funds are positive successes by global health partnerships. These partnerships allow the health topics of AIDs and TB be included in typical educational outreach in most countries along with many worldwide efforts as seen by Stop TB’s promotion of DOTS. Without the GHPs, the world would not have so many commercials and fundraisers for global diseases.

By having GHPs, research and development for international health have risen. New drugs along with better, affordable, and efficient practices are becoming used and adopted. According to an open letter to leaders of G-8 nations, “GHPs report pipelines with over 8 diagnostics, 25 drugs, 8 microbicides, and 50 vaccines in development addressing diseases predominantly affecting the poor” (Open Letter, 2005). From these statistics, public-private partnerships seem to have faster and superior solutions to diseases (for example with drugs and vaccines) than just a solely private entity such as pharmaceutical companies. It seems that these partnerships make sense for stimulating growth and better solutions in global health especially for vulnerable populations.

As an overall contribution, most GHPs seem to enhance the efforts to establish better healthy “norms and standards in treatment protocols, technical management, and financial strategies” (Druce & Harmer, 2004). GHPs do have a promising aspect in theory. The capability of actually solving the global health problems can finally happen without involving the bureaucracy and politics. Well, maybe that is too promising to say as GHPs have yet to prove of drastically altering countries and other groups’ agendas for a better and healthy world. Change has been said to come but without changing the business approach to GHPs, no change will be significant or remain long.

If change is going to happen, many unhealthy habits must be amended for GHPs to be effective. First, GHPs do not entirely represent their legitimate stakeholders such as low-income countries with a strong voice in the decision-making. An average of 17% in the 23 GHPs fitting the selection in the study by Buse and Harmer shows that constituencies from low- and lower-middle-income countries (LMICS) are on governing bodies as the private sector has an average of 23% (Buse & Harmer, 2007). Of course, this does not mean that the final decision is not reflective to the LMICS. Most of the choices are heard intently to the countries where programs are implemented. The problem lies when the private conglomerates still go ahead with the project when having a split in the LMICS voting members. There must be a process to improve the contribution of local perspectives either by increasing representatives or induction materials. Now this leads to diversity and gender equity on the governing body as those factors are also important, but understood pretty well in America so let’s move on.

Another unhealthy habit is poor leadership and governance especially since there is a lack of specifying roles and responsibilities, performance monitoring, oversight and management, and transparency in decision making. This is probably the biggest challenge and worse habit of GHPs. It is difficult to correct since there is not an independent and unbiased entity that can perform as oversight, management, and mediator. Corruption is a reality when discussing leadership and global governance. From witnessing first hand, even the most loyal and pure individuals have a price or very susceptible especially during that one bad day where they give up on personal principles. Similar to businesses, GHPs will have no problem to make transaction to any entity or people who will have the responsibilities on decision-making, monitoring, and/or management. “When the commercial sector has a monopoly position with respect to a product, or the GHP requires critical assets from a particular corporation, the GHP is not in a strong position to dictate principles of good corporate ethics” (Buse & Harmer, 2007). For more on corruption please read Sonya Soni’s blog below as she discusses the topic further. Of course, the idea of making the United Nations to have that oversight and management role will be a bust due to lack of enforcement. Where does that leave the world?

The world and all its’ global citizens should demand that GHPs to adopt several better habits in hopes for a better global health. First off, GHPs must show “humility”, assimilate their efforts with local planning processes, and minimize local transaction costs (Buse & Harmer, 2007). By being humble, GHPs will hopefully shed the biased agenda and become more open and big picture minded. Another habit is GHPs need better representation for their stakeholders and better oversight (Buse & Harmer, 2007). This means that there must be some sort of standardization and rules created among all GHPs. They have to be universal and fair for all especially for managing conflict of interest. Overall, GHPs must be honest and share their demands upfront in hopes to reach a common agenda that will accomplish problem. This can happen by having accountabilities for each partner along with build a good-faith trusty relationship. In addition, shifting to better habits will lead to incentives for encouragement while remaining with the bad habits should lead to some sort of significant and meaningful sanctions such as trade embargo.

Through cooperative efforts, the business of public and private partners in global health must ensure the world that a sufficient amount of global public goods are created and shared (Skolnik, 2008). Business minded and greed driven are the two realities for most partners, but the strongest link between public and private entities should be solving these health problems now in hopes that prevention will save the world hundred times more than reacting deeper in a crisis. It only makes sense that making a business of global public goods for GHPs can rapidly increase by having better represented shareholders throughout the public and private sectors along with better oversight.

References:

Buse, K., & Harmer, A. (2007). Seven habits of highly effective global public-private health partnerships: Practice and potential. London: Social Science & Medicine, Volume 64, Issue 2, January 2007, Pages 259-271.

Druce, N., & Harmer, A. (2004). The determinants of effectiveness: Partnerships that deliver review of the GHP and ‘business’ literature. London: DFID Health Resource Center.

Open Letter. (2005). Open letter to the leaders of the G-8 nations. 17 June 2005.

Skolnik, R. (2008). Working Together to Improve Global Health. In Essentials of Global Health (p. 264). Suddbury, MA: Jones and Bertlett Publishers.

Stakeholder Corruption: An Inexcusable & Unexamined Macro-threat to the Advancement of Global Health Governance

Introduction to the Problem of Global Health Governance Corruption

            The former United Nations Deputy Secretary-General Louise Frechette once proclaimed, “The solution lies not in turning one’s back on globalization, but in learning how to manage it.  In other words, there is a crying need for better global governance...” (World Health Organization, 2000). As the governance of global health issues shifts from a Westphalian to a post-Westphalian paradigm, in which both state and non-state actors respond to transnational health threats and opportunities, it has been increasingly salient to establish a unified understanding and vision of what global health governance exactly entails. The six dimensions of governance have been firmly established and applied to various international legal and business sectors: voice and accountability; political stability and lack of violence; institutional effectiveness; regulatory quality; rule of law; and control of corruption (Lewis, 2006). All of these indicators have been proven to influence the environment within which health care services function in both the developing and developed world, and yet governance indicators for global health have still not been adapted (Lewis, 2006). The integrity that global health governance is founded on is ensured by checks on the accountability and transparency of the thousands of governmental, private, and non-profit stakeholders that span the globe. Arguably the most inexcusable, preventable, and unexamined macro-threat to the state of global health governance has been the lack of legalistic mechanisms and socially just standards that hold these stakeholders accountable for the actions that both directly and indirectly influence the health of humanity. This most often results in rampant institutional corruption, or the exercise of public power for private incentives and gain. It has been noted that “bribes, corrupt officials, and mis-procurement undermine health care delivery in much the same way they do for police services, law courts, and customs whose functions become compromised by the culture of poor governance and corruption” (Lewis, 2006). Dr. Paul Farmer, MD, PhD, a world-renown Harvard physician and prophet of social justice, introduced the theory of “structural violence,” or the presence of powerful societal and governing forces that override individual knowledge and choice, and largely explains how institutionalized corruption has contributed to the widening gap in health inequities globally (Menon-Johansson, 2005). Craig N. Murphy further proposed that “contemporary global governance avoids attacking state sovereignty, favors piecemeal responses to crises, and has emerged at a time when creative intellectual leadership was not matched by courageous political leadership” (2000). As Murphy illustrates, two of the weaknesses in global governance, the absence of challenging the actions of sovereign entities and lack of “courageous political leadership,” have bred widespread institutional corruption, whether or not it was intended.

            The chaos that cripples global health governance is largely due to the failure of governments, non-profit organizations, donor, and private corporations from clearly defining and aligning their goals, objectives, activities, roles, and responsibilities when addressing a specific global health issue (WHO, 2000). Furthermore, the lack of incentives for strong sectoral performance are especially undermined by ineffective management, weak productivity, and poor performance (Lewis, 2006). Measures to analyze the performance of global health’s governing stakeholders simply do not exist, such as hiring qualifications (Lewis, 2006). The absence of monitoring the institutional and sectoral policies and actions of stakeholders have largely escaped scrutiny and censure, most probably due to the stagnant paradigm that any form of public service is morally justified and welcome (Global Health Reporting, 2008). Each type of stakeholder succumbs to its unique obstacles and challenges in terms of corruption. First, whereas the introduction of the corporate world in the field of global health has garnered increased funding, research, and development, it has also brought forth increased corporate authority in global health policy-making through intimate collaboration with international bodies, such as the World Bank (WHO, 2000). This opens the door for unchecked corruption among corporate players and uncertainty of their incentive to promote health in the developing world, especially due to their primary focus on profits rather than health as their outcome objective (WHO, 2000). For example, the World Health Organization has expressed its worry over the tobacco companies’ active involvement in the formation of global tobacco regulation policies, and has warned national governments about the industry’s potentially insincere motives (Collin et al., 2002). Second, in terms of donors as significant stakeholders in global health, “perceptions are powerful factors in shaping behavior. If investors perceive corruption or patients perceive poor quality, it discourages private investment or health demand” (Lewis, 2006). Thus, respected institutions and politically stable governments that base their global health efforts on integrity and transparency are more attractive to private investors and donors. Third, numerous non-profit organizations serve as channels of advocacy and lobbying for certain global health issues often with narrow agendas, and thus possess the potential of supporting governments and private organizations that submit to their needs, but engage in corruption to achieve goal outside those of the non-profit organization’s focus (Thomas & Weber, 2004). Finally, numerous governments lack the skills and/ or incentive to provide effective stewardship over their countries’ health systems. Universities, non-profit organizations, and the local media in developing countries may lack the resources to serve as effective regulators over both their government officials (Global Health Reporting, 2008). It is of utmost importance to note that the absence of governing accountability at the highest levels trickle down to the micro-leadership level of health systems. For example, health professionals and administrators may succumb to under-the-table payments due to low pay, irregular salary payments, lack of government attention, and the need to keep services afloat (Lewis, 2006). Thus, vulnerable patients must pick up the financial slack of corrupt governments who prioritize their personal wealth over the well-being of their constituents (Lewis, 2006).

Evidence of the Association Between Stakeholder Corruption & Poor Global Health Outcomes

             Although the association between government corruption and health has not been studied nearly as robustly as health’s connection to other macro-deficiencies, such as the absence of medical technology in the developing world, it is still an evidence-based one that needs to be highlighted. “Only governments sensitive to the demands of their citizens appropriately respond to needs of their nation” (Menon-Johansson, 2005). The three most influential dimensions of governance related to a country’s public health profile were government effectiveness, the rule of law, and corruption (Menon-Johansson, 2005).  Researchers have discovered that as governments become more ethical, fewer of their nation’s women die in childbirth, more physicians exist per population, access to clean water improves, and life expectancy increases among adults (Menon-Johansson, 2005). Studies have also illustrated that government corruption practices are correlated with health outcomes of child and infant mortality, the likelihood of an attended birth, immunization coverage, and low birth weight (Menon-Johansson, 2005). Improvement in governance also elevates the country’s Gross Domestic Product (GDP), as well as higher investment in health and education, compared to the military (Menon-Johansson, 2005). In addition, the success of public health spending in reducing child mortality depends on a government’s integrity rating (1-5 range based on level of perceived corruption), with higher integrity associated with lower mortality rates (Lewis, 2006). The infectious disease profile of many developing countries is also influenced by their governing standards, as it has been proven that HIV prevalence decreases as the governance improves for each governance indicator (listed previously), as well as mean governance (Lewis, 2006). In terms of specific national governments, Slovakia, Tajikistan, Bangladesh, India, and Sri Lanka rank as possessing the highest association levels between a weakened health care system and corrupt government (Lewis, 2006). A comparative study in five South Asian countries (Bangladesh, India, Nepal, Pakistan, and Sri Lanka) found that in all but Sri Lanka, most health service payments were made under-the-table to submit to the demands from providers, and bribes were mandated in all five countries for admission to the hospital, to secure a hospital bed, and to purchase subsidized medications (Lewis, 2006).

            A more subtle, but nonetheless threatening, level of governing corruption exists among private foundations as well. An unintended form of corruption due to the absence of global health governance monitoring can be exemplified by the most highly regarded private foundation in the field of global health, the Bill & Melinda Gates Foundation. Besides serving as the largest private donor for global health initiatives, the foundation’s advisory board members are included in the decision-making processes of almost all major global health governing institutions, such as the Global Health Council. However, unlike institutions such as the World Health Organization, it is excused from any form of democratic or political accountability (Global Health Reporting, 2008). One of the foundation’s most criticized acts of contradiction in promoting and harming the public health of a country was its investment in the Italian petroleum company Eni (Piller et al., 2007). The foundation garners huge financial rewards from its investments in a company that has initiated an epidemic of adult bronchitis, childhood asthma, and blurred vision among children due to the fumes and soot from over 250 toxic chemicals that are released from its towers (Piller et al., 2007). It was discovered that the Gates Foundation contributed $218 million towards polio and measles immunization and research worldwide, but has invested $423 million in oil conglomerates such as Exxon Mobil Corporation and Chevron Corporation that causes pollution levels in developing countries that surpass standards set in affluent countries (Piller et al., 2007). Researchers also revealed that hundreds of investments by the Bill & Melinda Gates Foundation, totaling at least $8.7 billion (41% of its assets), have been entrusted to for-profit institutions that counter the foundation's socially just goals and philosophy (Piller et al., 2007).

Recommendations & Possible Solutions

            At the epicenter of devising a potential solution to the non-existent regulatory mechanism for global health governance is the principle that “global governance cannot replace the need for good governance in national societies. In fact, in the absence of quality local governance, global and regional arrangements are bound to fail or will have only limited effectiveness. In a way, governance has to be built from the ground up and then linked back to the local conditions” (Lewis, 2006). Thus, since few top-down approaches have proven to be effective in curbing stakeholder corruption levels in global health, the solution may lie in first assuring that corruption ceases at the micro-levels of a country’s health care system. Community-driven campaigns, social media efforts, and community-based organizational advocacy efforts must be implemented in order to hold governments and large institutions from slipping into intended and unintended forms of corruption and misalignment of actions with the needs of patients and communities. Only then do citizens possess the power to monitor its government and corporate capacity to implement sound policies, manage health resources, and provide services efficiently and ethically (Lewis, 2006). For sustainable change to take effect, international legal measures must be coupled with grassroots initiatives, which has been a largely unexplored area for the formation of ensuring governance standards are met by each country (Taylor & Bettcher, 2000).

Works Cited

Bulletin of the World Health Organization (2000). Global public-private partnerships: part II-what are the health issues for global governance?; 78(5).

Collin J, Lee K, Bissell K. (2002). The framework convention on tobacco control: the politics of global  health governance. Third World Quarterly; 23(2): 265-282.

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