Student Commentaries Survey Global Health Topics

Although undernutrition will remain a significant issue affecting children’s health in low and middle-income countries (LMICs), among 42 LMICs rates of overweight and obesity grew an average of 0.7 percentage points per year. An estimated 19% of rural women and 37.2% of urban women are overweight or obese (Popkin, Adair, & Ng, 2012). Global trends toward overweight and obesity are rapidly becoming significant health issues in developing countries creating a double burden of malnutrition (Dang & Meenakshi, 2017). India is an example of one country where diets once consisted mainly of coarse grains such as “sorghum, barley, rye, maize, and millet”, and now consist of mainly processed food-products[1] consisting of “Rice and Wheat”(Popkin, Horton, Kim, Mahal, & Shuigao, 2001). The nutrition transition, or shift to high-fat, low-nutrient dense, processed food product has a significant effect on children’s nutrition and health. Among the most vulnerable to the impact of nutrient deficiencies are children aged 0- to 5-years.  Increasing nutrition in children in India is a complex issue; alleviating it would require fundamental changes in national policy that would need to improve sanitation, promote physical activity, as well as access to healthcare and healthful foods. Children in India require access to healthy, affordable food in order to combat food insecurity, hunger as well as high rates of obesity.

In low and middle income countries (LMICs), the health of poor, young mothers is a critical barrier to improving child health. Combined, preventable maternal disorders account for the highest mortality rate among women aged 20-24, and the fourth highest mortality rate among 15-19 year olds in LMICs[1].  Certainly, children of mothers with improved access to modern healthcare services are more likely to survive into adulthood than those whose mothers are poorly educated and lack access to medical care2, 3, 7.  Inaccessibility of healthcare services due to inability to accommodate user fees and cost of transportation represent individual financial barriers to achieving maternal health and child health in LMICs[2]. Only through subsidized intrapartum-care strategies that nurture breastfeeding, minimize micro-nutrient deficiency and eliminate financial barriers to poor women’s access to healthcare will child health improvement be complete.

It is common practice among randomized controlled trials and intervention studies to contrast risks and benefits before implementing on a larger scale (Melnyk & Morrison-Beedy, 2012; Sidani, 2014). Risk/benefit analysis is not a common practice, however, among short-term medical missions (STMM). STMMs are often comprised of a team of clinical personnel sent from a developed country to low and middle income countries (LMICs) to help with a specific medical need. Duration of a STMM can range between one day and a few years (Martiniuk, Manouchehrian, Negin, & Zwi, 2012). Many medical schools in developed countries encourage summer work experience in low and middle income countries (LMICs). Approximately 40% of medical students in the UK take a STMM trip over the summer (Martiniuk et al., 2012).  Additionally, many physicians take time off work to provide their skills in resource poor settings (Paul H Caldron, Impens, Pavlova, & Groot, 2017). The long term impacts of these STMMs are largely unknown and difficult to quantify. In a positive sense, STMMs can help in disaster relief contexts, where the burden of need exceeds the capacity of the local infrastructure. STMMs can also help mitigate burn out in physicians and staff working in resource poor settings (Paul H. Caldron, Impens, Pavlova, & Groot, 2016). Unfortunately, not all STMMs are well organized, and many end up producing long term damage in the communities being served (Rozier, Lasker, & Compton, 2017). A better understanding of STMMs is paramount, as some research indicates that these programs have increased in recent years, with the United States sending out the largest numbers of STMMs (Paul H. Caldron et al., 2016; Sykes, 2014). In fact, incidence of new physicians participating in STMMs has remained at approximately 10% since the early 2000’s resulting in a steady increase in prevalence (Paul H. Caldron et al., 2016). Despite growth in STMMs, very few programs collect outcomes data, and even fewer collect long term follow-up information (approximately 25%) (Sykes, 2014). It will be argued that a quantitative and holistic measure of STMM effectiveness must be created to evaluate the risks and benefits of individual STMMs.

There are 1.8 billion people between the ages of 10 and 24 today, making this the largest generation of young people in human history. (1, 2, 3) Characterized as the healthiest and most educated generation, there is a lot of hope for a more socially equitable and fair world.2 However, the current dialogue on health and sustainability is incongruent with the hope associated with youth—not nearly enough is being done to address the burden of disease that plagues youth around the world, especially in low and middle income countries (LMICs). The Sustainable Development Goals (SDGs), which began in 2015, set out to accomplish the UN’s most ambitious goals, including sections that address the health and well-being of youth. However, I question the dedication to the health of young people because of the lack of a more involved role for youth in the decision-making and implementation processes. These are issues that directly affect young people, and thus, should include young people past simply “investment” and towards participation. In order to improve young people’s health in LMICs and the future health of the world, I propose a more concerted effort for youth engagement in the UN’s SDGs, through community-based participation.

Foreign aid to low middle-income countries continues to be the main approach for delivering assistance to poor countries facing wars, shortage of food and health disasters. That aid is usually delivered in forms of direct financial assistance or supply with the needed items. Foreign aid takes different forms, and is primarily facilitated through international donor agencies, mainly to overcome major health problems and scarcity of food. These agencies usually deliver food and medicines, either directly to needy people or through a local entity. Also, some governments of wealthy countries offer financial assistance to some poor countries’ governments to help them overcome shortages in necessary needs or balance their budgets. Low middle-income countries have relied on foreign aid over decades to a point that it becomes fully integrated in their national policies and plans for handling their domestic affairs. Foreign aid has saved millions of lives over the last half century in so many poor countries and is a valuable contributor for global combating of diseases and hunger. But, self-help is more reliable than foreign aid in providing sustained services. So, I believe that the global focus should be on helping the poor countries to become self-sufficient and able to design and implement local policies that could address their national demand.          

Foreign aids are important to help LMICs overcome the resource gaps that they frequently face in the endeavor to provide adequate and quality healthcare to all. Foreign aids such as Developmental Assistance for health and other private or public international organizational funds have played an important role in helping LMICs progress towards achieving the Millennium Development Goals, and continue to help the developing countries overcome some of the resource barriers as they aspire to achieve the Sustainable Development Goals. But aid alone is not responsible for the perceived improvements or changes in the LMICs’ healthcare system. Aids only provide a fraction of the resource requirements and the rest need to be borne at the domestic level. Aids need to be supplemented by the recipient country in terms of finances and utilized in a productive and strategic manner to produce desired improvements in the healthcare system. Thus, foreign aids alone will not be able to improve healthcare in LMICs without adequate logistic, economic and strategic commitment by recipient country itself.

Sustainable Development Goal (SDG) seventeen is to revitalize the global partnership for sustainable development. This entails financial support, debt relief, sharing technologies and sharing scientific knowledge with developing countries (Sustainable Development Goals: 17 Goals to Transform Our World, 2017). Another part of this goal is to help these countries establish trading systems. Foreign aid is an important aspect of this goal but is not sufficient on its own to create a lasting impact on lower middle-income countries (LMICs). Aiding a country is not meant to be a long-term solution. The goal of providing aid is that it will help the country in need develop a better economy that can eventually survive and sustain on its own without relying on the help of others. For aid to be most impactful and result in a permanent fix, the recipient must learn to be self-sufficient, to take full advantage of all the opportunities that aid can provide. The combination of foreign aid and self-help is the only way permanent and lasting effects can be made in developing countries. However, the concept of foreign aid is quite controversial. There are people who believe aid alone is sufficient to improve developing countries, but in this commentary, I will describe why I disagree with that opinion. I will list and define reasons that I believe it takes more than simply giving a country money to make an impact. Specifically, I will focus on Sub-Saharan Africa and the health outcomes that can improve with the help of foreign aid and self-help. I will also give my recommendations about the health outcomes I think aid would be most beneficial in improving.

Population health is a complex issue that requires coordinated efforts. While some countries lag behind in population health achievements, others are thriving. To help low- and middle-income countries (LMICs) improve population health, other nations as well as international programs give foreign aid to LMICs. While this foreign aid is provided in an effort to improve important health factors and achieve global health goals, foreign aid has at times contributed to political disruption, resentment among healthcare staff, and decreased government investment in population health (Cailhol et al., 2013; Lu, Cook & Desmond, 2018). In other cases, foreign aid can be used in collaboration with recipient countries to strengthen and empower these societies and set them up for independence (Logie, Rowson & Ndagije, 2014). In this commentary, I use the case of Rwanda as an example of effective use of foreign aid and outline the steps that were taken in Rwanda to achieve improved population health. Using Rwanda as a model, I advocate for foreign aid policies that empower the recipient country by inviting them to have a partnership role in strategizing, developing, and implementing the interventions with a long-term goal of sole ownership of the program by the recipient country.

The world around us and the environment in which we live have long been known to play a major role in the health of populations. Air pollution has now become the world’s largest environmental health risk (Mannucci & Franchini, 2017) and indoor air pollution is also of great concern (Bruce, Perez-Padilla, & Albalak, 2000). Much of the burden of disease related to environmental pollution falls on low- and middle-income countries (LMICs) (“Inheriting a sustainable world?”, 2017). Vulnerable populations such as pregnant women, newborns, and children are at a magnified risk for health problems resulting from air pollution (Mannucci & Frannchini, 2017). In 2015, 26% of deaths of children under five could have been prevented through environmental risk interventions (Pruss-Ustun et al., 2016). Because indoor air pollution is a large contributor to outdoor air pollution and has such severe consequences, I chose to focus on improving indoor air pollution in one of the areas where rates of this pollution are the highest, Sub-saharan Africa. The use of improved cookstoves in conjunction with distinct kitchen areas separate from the home will decrease pollutant exposure, thus decreasing under 5 death.