Showing posts from category global health.
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Coffee and Contraception: Combining Agribusiness and Community Health Projects in Rwanda
›“Population pressures and diminishing land holdings – due to high fertility rates, war and genocide, and subsequent migration – have caused a rapid decrease in the forested and protected areas and increased soil infertility and food insecurity” in Rwanda, USAID’s Irene Kitzantides told a Wilson Center audience.
Kitzantides, a population, health, and environment advisor and global health fellow, said “the population is projected to reach over 14 million by 2025” – nearly one-third more than today, due to the country’s high fertility rate of nearly 5.5 children per women–which could continue to negatively impact forests and food supplies.
In response to these challenges, USAID supported the Sustaining Partnerships to Enhance Rural Enterprise and Agribusiness Development (SPREAD) Project. SPREAD uses an integrated population-health-environment (PHE) approach to develop the coffee agribusiness and bring family planning, HIV/AIDS, and reproductive health services to coffee workers.
Combining income generation with health services was thought an effective way to “fulfill the overall SPREAD goal of improving lives and livelihoods,” said Kitzantides.
A SPREADing Mandate: Integrating Health and Agribusiness
SPREAD follows USAID’s PEARL I and II Projects, which focused exclusively on agricultural development. Coffee is still at the center of SPREAD’s activities, with $5 million of the project’s $6 million USAID budget earmarked for agricultural development.
However, a broader mandate to include health services emerged after recognition that greater income alone does not ensure greater quality of life. The additional health funding leverages SPREAD’s already established relationships with farming cooperatives to bring health services to traditionally underserved rural communities.
“We really tried to build on the existing assets of the cooperative,” said Kitzantides. “We also really tried to complement local and national public health policy and partners.”
The integration of health with agricultural goals, and the use of already established in-country health programs, has made SPREAD extremely cost-effective, with HIV/AIDS prevention education costing less than $2 per person.
Examples of SPREAD’s integrated work include:Combined health and agricultural lessons: Kitzantides and her colleagues trained nearly 400 animateurs de café, cooperative employees running the agricultural education programs, to incorporate public health objectives into their activities. Combining health and agricultural education into one session takes advantage of workers already trained during previous USAID programs. The combination also attracts more male participants, who traditionally shunned HIV/AIDS, family planning, and reproductive health campaigns and services.
Radio programming: SPREAD worked with the agricultural radio program Imbere Heza (“Bright Future”) to incorporate health messaging at the end of each program.
Mobile clinics: SPREAD works with cooperatives and local health centers to bring convenient services to farmers when they gather at sales or processing stations during harvests.Community theater: SPREAD hires local theater groups to perform skits on health. The farming communities “really love community theater and always ask for it,” said Kitzantides.
In its relatively short existence, SPREAD’s health activities have reached over 120,000 people with HIV/AIDS prevention messages; nearly 90,000 with messages discussing family planning/reproductive health; and almost 40,000 about maternal and child health. The project counts 347 women as new users of family planning services.
Lessons learned – which will be examined in more detail in an upcoming issue of Focus – include the importance of using community-based approaches to overcome perceived social barriers; the advantages of integrating cross-cutting activities at the outset of a program; and the need for strong monitoring and evaluation systems to measure the effort’s outcomes.
Jason Bremner of the Population Research Bureau said PHE projects such as SPREAD go “beyond what the health sector itself can do and find new ways of reaching underserved remote populations.” He presented a soon-to-be-released PRB map plotting the location of more than 40 PHE projects in Africa.
The success of SPREAD and similar projects demonstrates the potential for PHE approaches to bring reproductive health and family planning services to rural areas, Bremner noted, but there is still much work to be done to scale up this integrated approach – and to document its successes.
Sustaining SPREAD
Kitzantides said it took several years to integrate health activities with the already established agricultural programs. Since USAID funding for the program is scheduled to end in 2011, she is uncertain that the time remaining will be enough for SPREAD’s health partners to develop the logistical and financial capacities to become self-sustaining. But SPREAD has changed attitudes and beliefs, two key objectives that do not require sustained funding.
“We used to talk about growing coffee, making money, buying material things like bikes – not about problems like malaria, HIV/AIDS, etc.,” said one SPREAD agricultural business manager during the program’s evaluation. “Someone could have 5 million Rwandan francs in the house but could suffer from malaria where medicine costs 500 Rwandan francs, due to ignorance. You have to teach people about production, you have to also think of their health to improve their lives.”
Photo Credits: Irene Kitzantides, courtesy David Hawxhurst; condom demonstration, courtesy Nick Fraser; community theater group, courtesy SPREAD Health Program; Jason Bremner, courtesy David Hawxhurst. -
New Maternal Mortality Statistics: A Catalyst for Increased Investment
›Maternal mortality rates in many low income countries, such as India, are declining, according to a recent study by researchers at the Institute of Health Metrics and Evaluation (IHME) at the University of Washington. According to the report, maternal deaths have fallen from 526,000 a year in 1980 to 342,900 in 2008. This news, while welcoming, has caused dissent among some global health activists who fear donors and policymakers will dismiss the issue and call into question the higher maternal mortality rates last reported by the United Nations. While concerns over monitoring and evaluation raise important methodology questions, this news must also serve as catalyst for world leaders and donors to take action and recognize that investing in women pays.
The data reported by IHME only concludes what maternal health advocates already know. “We know how to save women’s lives, we don’t need a cure…this is a political problem and political will is essential,” said Theresa Shaver, director of White Ribbon Alliance, at a Wilson Center event in December 2008. Greater funding for family planning and access to emergency obstetric care and HIV/AIDS services should all be included in a scaling up resources for improved maternal health programs. “Without HIV, annual maternal deaths would have been 281,500 in 2008,” said Richard Horton, editor of The Lancet, in last week’s Lancet comments.
Investing in contraception and family planning services through vertical funding mechanisms can reduce maternal mortality rates by addressing all of a woman’s health needs at the time of service. To widen the platform of comprehensive services for women and their families, efforts to link public health services and offer more at one location should be expanded. “Many women have expressed a need for contraception and family planning services…when you offer family planning services on-site with HIV services, you have a huge uptake in family planning use,” shared Michelle Moloney-Kitts, assistant coordinator at the Office of the U.S. Global AIDS Coordinator at a the Wilson Center in December 2009.
Yet political will remains in short supply. “Despite strong advocacy efforts, political leaders have either ignored the call or failed to make the health of women in pregnancy a priority,” stated Horton. Six countries–Afghanistan, Democratic Republic of Congo, Ethiopia, India, Nigeria, and Pakistan–account for over half of all maternal deaths worldwide, and increased investment in these countries will improve maternal health targets, such as Millennium Development Goal (MDG) 5 seeking to reduce maternal deaths by 75 percent.
Progress is possible and “policymakers are more likely to act on issues that they think they can do something about,” said Jeremy Shiffman, associate professor of public administration at Syracuse University, at the Wilson Center in March 2009. The maternal health community must rally around these positive findings and galvanize support for greater financial contributions. “Two decades of concerted campaigning by those dedicated to maternal health is working,” said Horton.” “[G]reater investment in that work is likely to deliver even greater benefits.”
Calyn Ostrowski is the program associate for the Wilson Center’s Global Health Initiative.
Photo Credits: A woman in India safely delivers her baby in the hospital through the Madhya Pradesh Health Sector Reform program. Courtesy Flickr user Department for International Development -
The Food Security Debate: From Malthus to Seinfeld
›Charles Kenny’s latest article, “Bomb Scare: The World Has a Lot of Problems; an Exploding Population Isn’t One of Them” reminds me of a late-night episode of Seinfeld: a re-run played for those who missed the original broadcast. Kenny does a nice job of filling Julian Simon’s shoes. What’s next? Will Jeffrey Sachs do a Paul Ehrlich impersonation? Oh, Lord, help me; I hope not.
I’ve already seen the finale. Not the one where Jerry, George, and Kramer go to jail — the denouement of the original “Simon and Ehrlich” show. After the public figured out that each successive argument (they never met to debate) over Malthus’s worldview was simply a rehash of the first — a statement of ideology, rather than policy — they flipped the channel.
Foreign Policy could avoid recycling this weary and irrelevant 200-year-old debate by instead exploring food security from the state-centric perspective with which policymakers are accustomed. While economists might hope for a seamless global grain production and food distribution system, it exists only on their graphs.
Cropland, water, farms, and markets are still part and parcel of the political economy of the nations in which they reside. Therefore they are subject to each state’s strategic interests, political considerations, local and regional economic forces, and historical and institutional inefficiencies.
From this realistic perspective, it is much less important that world population will soon surpass 7 billion people, and more relevant that nearly two dozen countries have dropped below established benchmarks of agricultural resource scarcity (less than 0.07 hectares of cropland per person, and/or less than 1000 cubic meters of renewable fresh water per person).
Today, 21 countries—with some 600 million people—have lost, for the foreseeable future (and perhaps forever), the potential to sustainably nourish most of their citizens using their own agricultural resources and reasonably affordable technological and energy inputs. Instead, these states must rely on trade with–and food aid from–a dwindling handful of surplus grain producers.
By 2025, another 15 countries will have joined their ranks as a result of population growth alone (according to the UN medium variant projection). By then, about 1.4 billion people will live in those 36 states—with or without climate change.
For the foreseeable future, poor countries will be dependent on an international grain market that has recently experienced unprecedented swings in volume and speculation-driven price volatility; or the incentive-numbing effects of food aid. As demand rises, the poorest states spend down foreign currency reserves to import staples, instead of using it to import technology and expertise to support their own economic development.
Meanwhile, wealthier countries finding themselves short of water and land either heavily subsidize local agriculture (e.g., Japan, Israel, and much of Europe) or invest in cropland elsewhere (e.g., China, India, and Saudi Arabia). And some grain exporters—like Thailand—decided it might be safer to hold onto some of their own grain to shield themselves from a future downturn in their own harvest. All of this is quite a bit more complex than either Malthus could have imagined or Kenny cares to relate.
It hardly matters why food prices spiked and remained relatively high—whether it is failed harvests, growing demand for grain-fed meat, biofuels, profit-taking by speculators, or climate change. Like it or not, each has become an input into those wiggly lines called grain price trends, and neither individual states nor the international system appears able or willing to do much about any of them.
From the state-centric perspective, hunger is sustained by:1. The state’s inability or lack of desire to maintain a secure environment for production and commerce within its borders;
In some countries, aspects of population age structure or population density could possibly affect all three. In others, population may have little effect at all.
2. Its incapacity to provide an economic and trade policy environment that keeps farming profitable, food markets adequately stocked and prices reasonably affordable (whether produce comes from domestic or foreign sources); and
3. Its unwillingness or inability to supplement the diets of its poor.
What bugs me most about Kenny’s re-run is its disconnect with current state-centric food policy concerns, research, and debates (even as the U.S. administration and Congress are focusing on food security, with a specific emphasis on improving the lives of women.—Ed.).
Another critique of Malthus’s 200-year-old thesis hardly informs serious policy discussions. Isn’t Foreign Policy supposed to be about today’s foreign policy?
Richard Cincotta is a consultant with the Environmental Change and Security Program and the demographer-in-residence at the H.L. Stimson Center in Washington, DC.
Photo Credit “The Bombay Armada” courtesy of Flickr user lecercle. -
Population and Sustainability
›“The MAHB, the Culture Gap, and Some Really Inconvenient Truths,” authored by Paul Ehrlich and appearing in the most recent edition of PLoS Biology, is a call for greater participation in the Millennium Assessment of Human Behavior (MAHB). MAHB was created, he writes, because societies understand the magnitude of environmental challenges, yet often still fail to act. “The urgent need now is clearly not for more natural science…but rather for better understanding of human behaviors and how they can be altered to direct Homo sapiens onto a course toward a sustainable society.” MAHB aims to create an inclusive global discussion of “the human predicament, what people desire, and what goals are possible to achieve in a sustainable society” in the hopes of encouraging a “rapid modification” in human behavior.
The BALANCED Project, lead by the Coastal Resource Center at the University of Rhode Island, released its first “BALANCED Newsletter.” To be published biannually, the newsletter highlights recent PHE fieldwork, unpacks aspects of particular PHE projects, and shares best practices in an effort to advance the BALANCED Project’s goal: promoting PHE approaches to safeguard areas of high biodiversity threatened by population pressures. The current edition examines the integration of family planning and reproductive health projects into marine conservation projects in Kenya and Madagascar, a theater-based youth education program in the Philippines, and the combining of family planning services with gorilla conservation work in Uganda. The newsletter also profiles two “PHE Champions,” Gezahegh Guedta Shana of Ethiopia and Ramadhani Zuberi of Tanzania.
“Human population growth is perhaps the most significant cause of the complex problems the world faces,” write authors Jason Collodi and Freida M’Cormack in “Population Growth, Environment and Food Security: What Does the Future Hold?,” the first issue of the Institute of Development Studies‘ Horizon series. The impacts of climate change, poverty, and resource scarcity, they write, are not far behind. Collodi and M’Cormack highlight trends in, and projections for, population growth, the environment, and food security, and offer bulleted policy recommendations for each. Offering greater access to family planning; levying global taxes on carbon; introducing selective water pricing; and removing subsidies for first-generation biofuels are each examples of suggestions advanced by the authors to meet the interrelated challenges. -
Family Planning in Fragile States
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“Conflict-affected countries have some of the worst reproductive health indicators,” said Saundra Krause of the Women’s Refugee Commission at a recent Wilson Center event. “Pregnant women may deliver on the roadside or in makeshift shelters, no longer able to access whatever delivery plans they had. People fleeing their homes may have forgotten or left behind condoms and birth control methods.”
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Thinking Outside the (Lunch) Box: Meat and Family Planning
›May 3, 2010 // By Dan AsinJoel Cohen, a renowned population expert and professor at Columbia and Rockefeller universities, recently gave a lecture simply titled “Meat.” As it was co-sponsored by the International Food Policy Research Institute and the Population Reference Bureau, I was hoping for an insightful discussion of meat eating and its implications for feeding a world of nine billion. While I think Cohen avoided the question of whether meat eating is ultimately sustainable, I was pleased that he included two key insights: the potential for family planning services to contribute to food security, and the importance of using multidisciplinary approaches to solve today’s global problems.
Family Planning for Food Security
In working to improve food security, Cohen said policymakers and practitioners need to focus on those who are most vulnerable. To this end, he identified five groups and suggested targeted policies for each:While the healthy eating policies will not surprise food security experts, his recommendations on family planning might. He highlighted what should be–but is not always–apparent: that tackling food security without thought for family planning is like attempting to fill an empty bucket without first plugging the holes.
Feeding the one billion hungry people in the world today is an enormous challenge that cannot be met by any single policy. Instead, it will take an array of partial solutions, and offering family planning services to women and young people is an important part of the package. Such projects can help reduce the number of children being born into hunger by allowing women and couples to assess their economic and food situations and plan according to their needs and wishes. Voluntary family planning services and materials will not solve the food security challenge on their own, but they can make it more manageable, especially in the long run.
Family planning’s potential contribution to food security is just one part of Cohen’s larger take-home message: population, economics, environment, and culture all interact. To meet today’s multidisciplinary challenges, single-sector approaches are not up to task.
The Many Faces of Meat
Cohen offered two competing perspectives on meat eating. On the one hand, average global meat production generates a fraction of the calories and protein, per unit of land, that could be derived from plant sources. It is likely the “largest sectoral source of water pollution,” said Cohen, and is at least partly responsible for the spread of over a dozen zoonotic diseases. It contributes to only 1.4 percent of world GDP while comprising 8 percent of world water consumption.
These hidden “virtual water” costs made headlines in Britain the other week, when a study on global water security published by the Royal Academy of Engineering popularized the Water Footprint Network’s earlier findings that that an average kilogram of beef requires 15,500 liters of water–over eight times the volume needed to produce the equivalent weight in soybeans and greater than 10 times that needed for the equivalent amount of wheat.
On the other hand, Cohen pointed out that meat production provides livelihoods for an estimated 987 million of the world’s rural poor, and has important cultural significance in many societies. And it can provide many essential nutrients, even in small doses.
In one study he cited, children living in Kenya who were provided 1 ounce of meat a day received 50 percent of their daily protein requirements and showed greater increases in physical activity and development, verbal and arithmetic test scores, and initiative and leadership behaviors as opposed to students who received the calorie-equivalent in milk or fat.
The Four Factors: Population, Economics, Environment, and Culture
Clearly, Cohen’s four factors all come in to play when evaluating meat’s role in food security. An analysis of any global health issue that looks at only one factor would miss indispensable parts of the problem.
“Population interacts with economics, environment, and culture,” Cohen concluded. “If you use that checklist when somebody gives you a simple-minded solution to a problem, you can save yourself a lot of simple-minded thinking.”
Photo: Pigs on a farm, courtesy Flickr user visionshare. -
Food Security Comes to Capitol Hill, Part Two: Women’s Edition
›April 30, 2010 // By Schuyler NullThe focus on food security on Capitol Hill continued with Wednesday’s House Hunger Caucus panel, “Feeding a Community, Country and Continent: The Role of Women in Food Security.” According to panel organizers Women Thrive Worldwide, “over half the food in developing countries – and up to 80 percent in sub-Saharan Africa – is grown by women farmers, who also account for seven in ten of the world’s hungry.”
The panel illuminated some of the inequities routinely faced by female farmers that often prevent them from using the same inputs as men (tools, fertilizer, etc.), bar their access to credit, and force them onto less productive land.
“Women around the world face unique economic and social barriers in farming and food production,” said Nora O’Connell of Women Thrive Worldwide. “But they are key to increasing food security and ending hunger, and all international programs must take their needs into account.”
Panelist David Kauck of the International Center for Research on Women (ICRW) cited the State Department’s Consultation Document on the Global Hunger and Food Security Initiative: “Economic output could be increased by 15-40 percent and under-nutrition reduced by 15 million children simply by providing women with assets equal to those of men.”
According to the 2008 ICRW report, A Significant Shift: Women, Food Security, and Agriculture in a Global Marketplace:Women also are more likely than men to spend their income on the well-being of their families, including more nutritious foods, school fees for children and health care. Yet agricultural investments do not reflect these facts. Women in forestry, fishing and agriculture received just 7 percent of total aid for all sectors.
One of the most fundamental problems faced by women in developing countries is a lack of basic education leading to illiteracy and innumeracy, making it difficult for women to understand agricultural policy or the fair market values of their products. Therefore, men are much more likely to control valuable markets.
In addition, women are less likely to learn about and adopt new agricultural technologies and best practices. Lydia Sasu, director of the Development Action Association, said that when she attended agricultural school in Ghana she was one of only three women, compared to more than 40 men, in her class.
Women in developing countries rarely own the land they farm, which can make it difficult to apply for credit and extension services without collateral. According to the ICRW report:In Uganda, women account for approximately three out of four agricultural laborers and nine out of 10 food-producing laborers, yet they own only a fraction of the land. Women in Cameroon provide more than 75 percent of agricultural labor yet own just 10 percent of land. A 1990 study of credit schemes in Kenya, Malawi, Sierra Leone, Zambia and Zimbabwe found that women received less than 10 percent of the credit for smallholders and only 1 percent of total credit to agriculture. Women receive only 5 percent of extension services worldwide, and women in Africa access only 1 percent of available credit in the agricultural sector.
“The fundamental barrier to women in agriculture,” said USAID’s Kristy Cook, “is access to assets.” Cheryl Morden of the International Fund for Agricultural Development (IFAD) said we have reached the “tipping point,” where action on this issue seems inevitable on the international policy level. However, she questions how quickly that momentum can translate to change on the ground.
The State Department has made improving women’s lives an important part of both their Global Hunger and Food Security Initiative and the Global Health Initiative. ”Investing in the health of women, adolescents, and girls is not only the right thing to do; it is also the smart thing to do,” said Secretary of State Hillary Clinton in January.
Reproductive health and family planning services will be key to both initiatives. A policy brief by ICRW’s Margaret Greene argues that poor reproductive health can have negative effects on women’s educational and economic opportunities. As Secretary Clinton said, “When women and girls have the tools to stay healthy and the opportunity to contribute to their families’ well-being, they flourish and so do the people around them.”
Photo Credit: “Transplanting at rainfed lowland rice in Madagascar,” courtesy of flickr user IRRI Images. -
Maternal Health Solutions in Peru
›Media reports on the neglected discussion of maternal and child health often focus on the problems and projects in sub-Saharan Africa or South Asia, which is understandable, as a disproportionate 90 percent of global maternal deaths occur in these two regions. Last month, however, PBS correspondent Ray Suarez reminded us that maternal and child mortality affects countries all over the world, including Peru, where “maternal death rates has historically been unusually high,” he noted in a report for NewsHour.
“Few people in the highlands of central Peru own automobiles and it’s hard to know exactly when the next bus is going to rumble by,” said Suarez. “Villagers are a long way from the nearest health clinic, even further from a fully equipped clinic.” Unfortunately, this scene could describe most developing countries struggling to reach the Millennium Development Goal (MDG) 5 target of reducing maternal deaths by 75 percent by 2015. Maternal health advocates argue that MDG 5 does not require a cure, but rather increased political willpower.
“Health officials, obstetricians, nurses, and community activists looked for ways to make better use of existing resources and connect expecting mothers with them,” said Suarez, reporting from the remote town of Vilcashuaman. At the Casa Materna, or “mother’s house,” nurses plot on a felt, bulls-eye map the names, due dates, geographical proximity, and travel times of pregnant women in nearby villages. Utilizing two-way radio communication, Casa Materna stays in contact with these remote villages and can signal the regional hospital, hours away in Ayacucho, for ambulance assistance for women needing emergency obstetric care.
Delivery teams at the Ayacucho hospital are familiar with indigenous languages and cultures, and welcome traditional practices, such as displaying herbs and giving figurines to new mothers. “The medical professionals in the area know bringing delivering mothers to the hospital can mean the difference between life and death and are prepared to be as accommodating as possible to lure women from home delivery,” reports Suarez. In the Ayacucho district, maternal mortality rates have decreased by 50 percent in five years.
While Suarez said “cultural competence, a welcoming atmosphere, and low-cost, high-result treatment strategies” may seem “pretty smart and straightforward,” it is important to evaluate the regional health system at a larger level, and consider additional factors, such as access to family planning, that may have contributed to Ayacucho’s success in reducing maternal mortality.
Another part of the solution is improving transportation and referral strategies, but increased research is needed to evaluate best practices and scalability of programs such as the one in Ayacucho. On May 19-20, as part of the Maternal Health Dialogue Series, the Wilson Center’s Global Health Initiative will host a two-day conference on “Improving Transportation and Referral for Maternal Health.” Speakers working on transportation and referral strategies in Bolivia, Ghana, and India will share their experiences and best practices.
Calyn Ostrowski is the program associate for the Wilson Center’s Global Health Initiative.
Photo Credits: Mothers in Peru learn to identify risk factors during pregnancy. Courtesy of Flickr user International Women’s Health Coalition
