One of the most important things about National Women’s Health Week is the strong emphasis on preventive screenings.  A preventive screening helps separate healthy individuals from persons who may have an undiagnosed condition.  Commonly, tests like mammograms and pap smears come to mind as preventive measures for women.

However, there is another type of preventive screening that women should pay attention to this National Women’s Health Week.  Women should get screened for osteoporosis.  Osteoporosis is the loss of calcium and decrease in overall bone mass.  As a result of this decrease, bones become fragile and break much more easily.  It occurs most often in older women after menopause.  While osteoporosis affects both men and women, women are five times as likely to develop the condition.

The National Bone Health Alliance (NBHA) has made a special effort to increase osteoporosis awareness through their 2Million2Many campaign. The basis of the campaign lies in this fact:  Each year, there are 2 million bone breaks that are no accident, but signs of osteoporosis. Each year, a third of patients with a hip fracture had a prior fracture. After fractures, four out of five women will never be tested for osteoporosis. Osteoporosis fractures will likely cost Americans $25 billion by 2025.

As part of their efforts and in honor of National Women’s Health Week, NBHA hosted a summit yesterday at the Kaiser Permanente Center for Total Health. Moderated by former Congresswoman, tireless health care advocate, and Disruptive Woman Nancy Johnson and the director of NBH David B. Lee, the summit brought new information to the health world.  The summit focused on the specific human and economic impacts of osteoporosis and the NBHA’s plan to reduce bone breaks 20% by the year 2020.  This “20/20 Vision” initiative would implement secondary fracture prevention initiatives throughout the nation.

NBHA’s website gives even more information about osteoporosis, videos of their “cast sculpture”, and resources.  You can also sign their pledge to go and get tested for osteoporosis.  There is currently no cure for osteoporosis.  However, getting tested early and knowing for sure can lead to daily practices that will help minimize the disease.  Daily practices include a diet with more calcium, exercise, and a prescribed medicine by your doctor.  Don’t be part of the 2 million that suffer in vain.  Get tested today.

Treat yourself this week.  Be healthy, be active, and for your mental health – get that ice cream.  After all, ice cream does have calcium that could prevent osteoporosis in the future.  (Here’s to wishful thinking at least!)

By Alanna Shaikh

The best place for a woman to give birth is a clean place. Not sterile – no surgical masks or hairnets – but clean. Free of dirt and bacteria. It minimizes the risk of infection for mother and baby, but it’s also comfortable enough to help a woman deliver calmly.

Unfortunately, many women don’t have a clean place to give birth. For example, they may be giving birth at home, where they have to use old or dirty bedding that they don’t mind being stained by the mess of childbirth and they don’t have a scalpel. Or they may be giving birth at a facility that is too overburdened to stay clean and can’t afford single-use equipment.

There are far too many reasons that women can’t easily access clean places to give birth. That puts women and their babies at risk for infection, especially of the genital tract and umbilical cord. More than a million babies a year die from neonatal infections.

Enter the birth kit.

A birth kit is a set of items intended to make any place into a clean place to give birth. Common things to include would be a clean drape made of cloth or sturdy plastic, a scalpel and clamps to cut the umbilical cord, and sterilizing wipes for hands and surfaces. The kit can be used for home deliveries, or brought to the clinic or hospital to be used there.

Birth kits are the kind of simple, low-cost intervention that can save a lot of lives. There’s not a lot of evidence for the kits right now; the best data review I could locate found only weak improvements in newborn health. The logic of birth kits is sound, though, and the potential for harm is very small. I think as kits are used more frequently, the evidence in their favor will increase.

In fact, I believe in birth kits strongly enough that I’m on the advisory team for AYZH, a social venture that features birth kits as one of their products. AYZH is working to set up a distribution model that lets rural women sell the kits for a small profit. This ensures widespread access to the kits for women who want to buy them, and it provides income to the women who sell them.

Alanna Shaikh is a global health professional currently based in Dushanbe, Tajikistan.

Adele Waugaman

By Adele Waugaman. It’s no secret that the rapid proliferation of social networks and the global spread of the mobile phone are transforming private and public sectors alike. The humanitarian world is no different.

In the music industry, network-centric technological innovations from Napster to Spotify have transformed the way we learn about, acquire, consume, and share music.  Similarly, in humanitarian crises, the democratization of information through connection technologies is enabling new actors to share and act on publicly available data about the crisis, local population needs, and the humanitarian response.

In an increasingly networked world, aid organizations find themselves having to adapt to these new information flows in order to retain their traditional roles at the center of the humanitarian system. These data streams are coming from groups who traditionally have not been perceived as part of the humanitarian sector — from volunteer mapping networks like the Standby Task Force and the Humanitarian Open Streetmap Team, to the local populations themselves.

Why is crowdsourced information helpful in humanitarian emergencies?

Take, for example, the need to locate health facilities after a major disaster.  In response to the Haiti earthquake, the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) asked the crisismapping community to locate and plot on a map 105 health facilities whose precise location was unknown (During the earthquake many buildings were heavily damaged or destroyed, including buildings that housed important government data and their curators).

Within 35 hour of the request from OCHA, 102 of the 105 facilitates had been identified, verified using satellite imagery at 15 cm resolution, mapped, and made available in open data formats.  This crowdsourcing of information condensed the time needed to complete this task from several days to just over one day, making it possible to transport the wounded to available clinics and enabling first responders in Haiti to focus their attention on other important tasks at hand.

This example and numerous others are profiled in a report produced last year by a team that included OCHA, the Harvard Humanitarian Initiative, the United Nations Foundation and the Vodafone Foundation. Entitled Disaster Relief 2.0: The Future of Information-Sharing in Humanitarian Emergencies, the report looked at how emerging digital volunteers networks were reshaping information management in humanitarian crises, using the response to the 2010 earthquake in Haiti as a case study.

The report was intended as a catalyst for further dialogue and action, and indeed it provoked an immediate and wide-ranging response, from coverage in the New York Times to a community blog series and other analyses, including those highlighting perceived shortcomings.

That conversation continues, and has contributed to efforts underway to build a new Open Humanitarian Initiative that seeks to improve information sharing and information management between humanitarian organizations, affected communities, and governments in disaster-prone countries.

To advance work in this space, it is clear that this kind of cross-sector collaboration is needed, and it is essential that local populations themselves are an integral part of the discussion.

This spring, at the CDAC Network Media & Technology Fair, together with a group of experts in communications with disaster-affected populations, I discussed some areas of further exploration needed as this exciting and transformative field grows.

Significant work remains to document best practice and establish evidence-based, evolving policy and technologies which will enable new pathways of information sharing, and implement new tools in accordance with a widely accepted ethical framework that upholds fundamental humanitarian principles.

We’ve made huge strides in demonstrating the power of social networks and open data to positively transform information management in humanitarian aid. With further research, collaboration, and investment from the private and donor community, strengthened community resilience and smarter disaster response is within reach.

Adele Waugaman is an independent consultant and fellow at the Harvard Humanitarian Initiative. Previously, she managed the United Nations Foundation and Vodafone Foundation Technology Partnership, one of the first and largest public-private partnerships leveraging wireless ICT to support and strengthen UN health and humanitarian work. Finder her on Twitter at @mobilizing or @Tech4Dev.

By Andre Blackman.

Change is here and it’s brewing vigorously.

However, the circle of people who are plugged into these innovations – these changes for impact – are still relatively small. Public health/health care haven’t traditionally been intensely exciting topics. Usually stories of communities dying from a particular disease or suffering from a societal norm that gives an unfair advantage, are covered in the news and even the textbooks. To be fair – those issues are very real but the fantastic part is that there are individuals, organizations and projects that are proliferating wildly across the globe to actually change them. For that very reason, we’ve created the FastForwardHealthFilmproject.

Storytelling is a centuries old method to pass down information to generations. Stories involved emotion, purpose and answers. All the things we need to be plugged into now in order to make sustainable impact and change across the spectrum of health. FastForward Health was created when we (myself, David Haddad and Aman Bhandari) came together from similar backgrounds in health communications, economics and policy and with aligned passions around the great innovations happening around the world. We noticed that the traditional health fields were not highlighting the absolutely positive things going on in the health landscape and we wanted to change that.

With a focus on showing the stories of these change makers, we sincerely hope to inspire and motivate others who care about health and positive social impact, to take part in: building important things, partnering with others doing great work and supporting them through time or financial donations. We want to help build the movement to take an idea and make it relevant for communities on both a micro AND macro level. Community health trickles upward to big impact. We’ve had the fortune of holding two great events in Washington DC and New York City – theinitiallauncheventinDC (which was sold out in 4 days of word of mouth only promotion) and participating in SocialMediaWeek’sHealth/WellnesstrackinNYC.

We are growing and making sure we capture as much as possible around storytelling in health innovation. The FastForward Health Film project will also be coming back to Washington DC in early Fall and to San Francisco for the American Public Health Association conference towards the end of the year. If you or an organization you know is interested in partnering/sponsoring us to reach more change makers – please don’t hesitate to reach out! You can always shoot me an email at andre@fastforwardhealth.org or for sponsorship opportunities sponsor@fastforwardhealth.org. Onward to health innovation!

Dr. Kate Tulenko

By Kate Tulenko. The world currently has a shortage of some 4 million health workers. This shortage is amplified by a complete mismatch between where health workers are stationed and where they are most needed.  The healthier and wealthier a community is, the more health workers it has. The poorer and sicker a community, the fewer health workers it has. The situation is worsening as every year hundreds of thousands of health workers move from poor, rural, and underserved communities to wealthier, metropolitan communities with a surfeit of health workers. This occurs both within countries (a nurse moving from a rural area to the capital city) and between countries (a doctor moving from a developing country to a wealthy country).

Governments and their development partners have struggled to address this problem. Many have tried mandating new graduates to provide a few years of service in underserved areas. These programs have met with variable success depending on the governments’ commitment and ability to enforce the plan. Since the publication of the World Health Organization’s well-thought out and evidence-based guidelines on increasing access to health workers in rural areas, some health systems are implementing mid- and long-term solutions such as recruiting and training health workers in underserved communities.

But governments are under intense pressure to solve the problem now. Some have tried rural retention schemes but many of these have been too expensive to maintain long term or scale up to the entire country. For example, Zambia has a rural retention program for physicians, but the program is funded by an external donor (not sustainable) and the salaries are significantly out of proportion with the salaries of other health workers as well as per capita income in the country. These programs also tend to be more expensive than necessary because ministries of health tend to design them without involving the workers in the rural areas that they want to retain or even workers in metropolitan areas that they want to post to underserved areas. The plans have no foundation in evidence.

There is a solution. Its fancy name is “discrete choice experiment” (DCE). A tool from the field of economics, DCE systematically asks individuals what levels of certain benefits such as housing, vacation, continuing education, improved work environment, and salary would be required for them to accept or remain in a job under given conditions. DCE has been proven in the health sector and other sectors to accurately predict needed incentives and has been proven in follow-up studies to lead to the desired level of retention. The challenge with DCE is that its traditional form has been very complex, requiring PhD-level economists to be flown in, and takes months to conduct and analyze. Recognizing that this isn’t feasible for most health ministries or faith-based health systems in developing countries, IntraHealth International, through its USAID-funded CapacityPlus project, designed a simpler version of the DCE that can be performed by most ministries of health or small organizations.

The process starts with small focus groups of health workers who can brainstorm new benefits that the employer may not have thought of, like internet access, a spousal educational allowance, or low-interest loans to buy a house or car. The focus groups then help define the various levels of benefits that should be tested. This informs the development of the final survey that is given to health workers. The analysis yields a variety of packages and the estimated percent retention they would yield. CapacityPlus has also created free software to compute the long-term costs of implementing the various retention packages to ensure that the chosen package is sustainable. The ministry then has an evidence-based retention package that it can roll out at a national level with confidence that it will succeed. For small health systems that find even this simpler DCE process too daunting, a quick look at the sample menu of retention benefits in our kit followed by focus groups with their workers can help design a more affordable, effective retention package.

It’s particularly important for health systems’ leaders to listen to the voices of all health workers, especially those already in underserved areas, precisely because these leaders have traditionally come from and listened to workers in major metropolitan areas. In addition, the majority of health system leaders are men whereas the majority of health workers are women.  The saying goes, “Those closest to the fire, get most warmed,” and it’s no surprise then that in most developing countries, as well as the US[1], health workers in cities are paid more than health workers in rural areas. No wonder rural health workers move to the cities! So let’s add a little DCE to the mix in the short run. In the long run to solve health worker maldistribution we need to recruit health workers from and train them in underserved communities. And who should you recruit from rural, poor, and other underserved communities? Just ask them!

[1]Medicaid, Medicare, and many private insurers pay more for the same service in metropolitan areas than in rural areas.

His primary strategy is to use an integrative approach to implement and build the infrastructure for new programs around the world, in consideration of communities that may be under-resourced, under-staffed, and lacking adequate methods of outreach. In a phone interview, he discussed his past and current projects that have showed promising results.

“Part of the solution has to be doing mental health care outside of specific treatment places—in primary care and other community settings. What has been leading edge in providing mental health services is how to creatively divide and distribute the sorts of skills needed to provide care, which means relying on non-specialists to deliver it…” said Dr. Belkin. “Not only doctors, but community health workers and even other members of the community who can be skilled up to take part in evidence-based treatment pathways. This is referred to as ‘task shifting’.”

He recently led an expert group meeting in Abu Dhabi, sponsored by NYU, to bring together global leaders in mental health and people managing primary health systems in low-income countries. The goal was to create a Global Mental Health Learning Network, a forum to figure out ways to accelerate adoption and scale up of consensus treatment guidelines in the World Health Organization’s mhGAP Intervention Guide for treating common mental health illnesses such as depression and anxiety.

“We coined the platform idea ‘A Billion Minds and Lives’,” said Dr. Belkin, “because if you think about the lifetime prevalence of mental disorders and treatment gaps for not being able to get care, we actually face the task of enabling the health care system to reach a billion lives and minds that it is not reaching now.”

Recently, in collaboration with colleagues who have extensive knowledge about the health care systems in Haiti and Africa, Dr. Belkin also published a “5 x 5” model, wherein he broke down mental health into basic skill sets which would be building blocks for program design and overcome the paralysis in creating a mental health system regarding who should do what, what training should consist of, and how much can be done with existing human resources. With five basic skill packages to manage common mental health disorders and five implementation rules to guide and steer successful use of these skills in an effective way, the researchers are now utilizing the formula to integrate mental health care in a primary health system in Haiti with Partners in Health.

“Fundamentally the sole idea of implementation has been that people in mental health don’t tend to think of services in a very systematic way,” explained Dr. Belkin. “If you think of care for HIV, you can divide it into specific tasks that need to be done: detect people who have the illness, markers for when it is getting worse, particular procedures that need to be done, counsel people about illness, how to self manage it and educate them on medications and how to adhere to them…If you identify the tasks, you can be more flexible about how you do them.”

Locally, Dr. Belkin has been involved in the Save Our Street (S.O.S.) campaign in Crown Heights, which operates on the CeaseFire model in Chicago by using community members who serve as “violence interrupters” who coach and mentor high-risk youth and gang members.

“They seemed to me like already established, functioning community credible street counselors and community health workers,” said Dr. Belkin. “If we enhance their skills a bit, like how we were able to train lay health workers in Africa who can learn basic health care methods…we really enhance their ability to do their primary job to council people out of certain lifestyles and behaviors, but to also be first line potential mental health providers. “

After holding focus groups with people coming out of Ricker’s Island (the main jail in New York City), Dr. Belkin discovered that the most common reasons why former prisoners kept being at risk for returning to jail were conditions such as relapsing, addiction, having poor family support, or depression. He is now testing this hypothesis by training CeaseFire workers in a counseling method known as “motivational interviewing” by linking them with a local hospital, which will help support and coach them in these skills and serve as a referral line for clients who require specific mental health treatments.

“So we really created this idea, that we are trying to create in low income countries, a solution of access which is to push out pathways of treatment deep into communities through credible points of contact, “ said Dr. Belkin. “This is good global conversation of how to reimagine what public mental health is—global utility as something that travels and solves problems well around the world.”

Just a few weeks ago, Dr. Belkin participated in a workshop hosted by the National Institute of Mental Health (NIMH) in Washington, D.C., which brought together federal health research funding and international development agencies who have generally not worked in the mental health arena. This is a new interdisciplinary approach by NIMH to recognize the need for increased collaboration.

“This is an example of momentum,” said Dr. Belkin, “United and motivated by increasing evidence of the huge effect of mental health on overall health and the difficulty of effectively treating other health conditions, these groups are appreciating that we need to think much more integrated in how we do research to strengthen low-income health systems that agencies such as USAID does. Bring people who don’t know each other to know what that evidence is to integrate and prioritize care within funding mandates.”

Alongside his research on sustainable program development and training the health care workforce, Dr. Belkin is also shaping the way global mental health education is delivered in U.S. public health and medical schools. We are eager to see the progress of A Billion Minds and Lives and the Global Health Learning Network as he is currently fundraising for the business plan. So far, the learning network received a positive response and will be initiating its first pilots based on ideas proposed in their last meeting.  Dr. Belkin says that the next cornered turn is to encourage the public to invest more in mental health improvement efforts since advocates and community members are currently unable to address the huge burden of unmet need.

Take Nigeria, the country with the second largest number of child deaths globally.  Over the past few years, they’ve raised vaccine coverage in many parts of the country to nearly 70%.  But progress is fragile, and results uneven.  Some areas have coverage rates above 80%; others are barely providing any vaccine.  Economic status and presence or absence of donor funding don’t fully explain the disparities. It’s not just the money – there must be something more.

To find out, a team led by Dr. Chizoba Wonodi at our International Vaccine Access Center (IVAC), Johns Hopkins Bloomberg School of Public Health, worked with the government of Nigeria to interview 126 stakeholders in 8 states that best exemplify the successes and challenges in immunization coverage.   Dr. Wonodi’s team found that often, it’s not the amount of money that’s the problem – it’s getting that money to the right places at the right times, from the federal government all the way down to the community level. When that doesn’t happen, children go unvaccinated. Conversely, innovative mechanisms can lead to success stories. In one northern state, Zamfara, leaders used a “basket fund” to pool funds at the state and local level, ensuring that resources go where they are needed.

Other non-monetary issues were important as well. Inadequate transportation was cited in the study as a near universal barrier to vaccine delivery. Transportation contracts are one solution—these contracts could even be preferentially awarded to female-owned business, empowering women while improving service delivery (I really like this one!).

Inadequate cold chain, or the refrigeration required from ‘lab to jab’ to keep a vaccine viable, is another frequently cited barrier. Nigeria has invested in cold chain, and when I visited in July I saw what can be done and, unfortunately, what can sometimes prevent great ideas from being implemented.  They have lots of solar fridges, for example, but I learned that without a system to ensure regular repairs, that vital equipment can sit idly.  I can go on and on about what we found, but I suggest you read the brief report to get a better understanding of what is both most impactful and feasible.

The good news is that the government and many other stakeholders are fully committed to making a difference.  In fact, Nigeria is holding its first National Vaccine Summit, and I’m honored to be a participant.  The summit shows impressive commitment from the highest level, from the President, Vice-President, ministers, senators, and first ladies, right on down to the local governments.  The summit is also bringing in the private sector and other non-health groups even the Minister of Power is engaged to help ensure no interruption in those fridges!  It’s a huge effort, but one that will bear fruit in the coming months when a new pentavalent (Diphtheria, Tetanus, Pertussis, Hepatitis B, Hib) vaccine is introduced.

Investment in vaccines makes sense, and saving lives is well worth this effort.  The scaling up of new vaccines to 90% coverage is projected to save over $300M in direct health costs and add up to $17B to the economy in increased productivity!  That’s an investment worth making.

Most people in the world cannot say that. They do not share in the abundance we have come to expect and believe we deserve. They do not have the safe food or sanitary systems that support life, nurture health, and create prosperity. We bemoan the weaknesses of the best health care system in the world by day, and by evening tend manicured lawns and soak in baths with water that is safer and more pure than what most of the world’s population will drink.

Our government is designed to be responsive. Far too many people in the developing world can’t say that. In some cases, their governments have not attended to their needs; in other cases, corruption is so deeply ingrained it is taken for granted. Either way, the people experience barriers to better health that we can’t imagine.

I’ve seen this happen in my work outside the US and believe it’s time those of us in this country wake up from dream-like Disney-tale beliefs of far- away exotic lands. It’s time we realize that some of those far-away lands are nightmares created not only by tropical diseases (and increasingly chronic diseases as well) but by problems made all the worse by government corruption and corruption is a policy issue that requires attention.

We may disagree with our national, state and local governments, we may decry decisions made by important officials, but they do not, I believe, act – or fail to act – in ways that are as irresponsible or corrupt as these few of the many stories I can report from personal experience.

• The risk of being a girl. Women and girls are disadvantaged in many ways. Other bloggers on this site have made that clear. Mortality rates are high and care is limited. When food is limited, it is the girls who go without and when someone is ill, it is the girls who miss school to be caregivers.

In June 1984, however, came an even more shocking reality about something I hope is more widely known today. I represented the US at a meeting in Greece of policy officials from 44 nations, academic experts in ethics, biomedical scientists and theologians from world’s major religions. The case study I presented on infant mortality in the US was sad, but nowhere near as tragic as the respondent from China who reported on female infanticide rates of 99% in Chinese villages. Aside from obscure – but never outraged – mentions, I’d not hear much more about the subject until the May 4, 2010 issue of The Economist. By then, 100 million baby girls were missing in China and India. The crime does not end with the ordeal of all those girls who were killed, however, it is even perpetrated on those who lived. The resulting gender imbalances have caused increased abuse, forced marriages, violence, sex trafficking and other crimes against women as men are unable to mates.

• Even miracles aren’t welcome. I was new at Merck in 1988, arriving at about the time the company decided to donate Mectizan, a one-tablet per year medicine to prevent River Blindness (oncocerchiasis). At the time, 800 Million people were at risk of contracting this horrible, parasitic disease that had rendered entire villages blind by the age of 30. Eighty Million people already had the disease and were destined for blindness unless they were treated. Yet, the company could give away only 1 Million doses per year. Merck created a marketing group – yes, a marketing group – to give away the medicine. Even miracles, apparently, don’t fall off shelves into patients hands.  Along the way, I’d learn more tough lessons about corruption. Some ministries of health would want bribes before they’d accept the donation and clearly Merck could comply. But even in the absence of hard-core corruption, I’d learn of the “softer” side of “vanity” projects like high-tech hospitals to treat the wealthy, while basic public health needs went unattended.
• No good deed goes unpunished. Fast forward to 1994 – the very early days of debates about whether the pharmaceutical industry should be allowed to donate medicines at all. I was facilitating a dialogue between the industry and private relief agencies to address attempts to halt donations. At the time, Eli Lilly and Company (Lilly), the Food and Drug Administration (FDA) and several private relief organizations created another near miracle to provide Rwandan refugees with an antibiotic to treat wounds suffered in that country’s civil war.  Lilly wanted to donate 25 million doses of a medicine that had important features to prevent the machete wounds they’d suffered. Since the medicine was not yet approved in the US, then-Commissioner David Kessler, M.D., worked nearly non-stop over a weekend to complete the review and gave Lilly approval to make the donation. Several U.S. private relief agencies shipped it to Rwandan ports for the war relief effort. Did public acclaim for the US, the FDA, and Lilly follow? No. In fact, a public relations disaster was unleashed on everyone involved.

In an unfortunate turn of events, the United Nations High Commission for Refugees (UNHCR) miscalculated the flow of Hutus back to Kigali where the medicine was waiting for them. It sat in warehouses, its expiration date approaching. Lilly and the relief organizations attempted to recover the supplies and re-deploy them to other locations and offered to replace the expiring medicines with a fresh supply. Their efforts were thwarted by Rwandan government authorities.  Once the medicine expired however, the Rwandan government released the product, falsely alleging that Lilly had donated expired drugs and pouring fuel on the fire of those who would seek to ban donations altogether.

In the case of the donation of medicines, there’s a happy ending. Donations continue today, donation standards are high and the poor in many developing countries or those who’ve suffered from natural disasters benefit.

The girls haven’t fared as well, yet. I urge we keep them, in particular, but all corruption and oppressive government policy, in general, in mind in the work we do. Just as it is important to focus on the health of the developing world, it is also important to focus on the corruption and oppressive policies which create barriers to the systemic changes needed to see real advances in human welfare.

Olaoluwatomi Lamikanra

By Olaoluwatomi and Ufuoma Lamikanra. Growing up in a rural area in Nigeria, the fear of childbirth was a frightening reality. Deaths during childbirth touched everyone in the village where I (Ufuoma) lived. Another death was another tragedy, another reason for the community to be thrown into deep mourning and a helpless acceptance of what was seen as an unavoidable fate. Fifty or so years down the line, the reality is not much different.Women still die from delivery and pregnancy-related causes and there does not seem to be much difference whether it occurs in the urban or rural areas. There are stories everyday of lives lost in teaching hospitals as well as in local health centers. Many more lives are lost when women give birth at home or when they do not have skilled birth attendants in labor.

What are the main causes of death in pregnancy? The same five leading causes of death found anywhere else in the world. Hemorrhage, sepsis, unsafe abortions, hypertensive disorders, and obstructed labor^aa.  Hemorrhage is one cause that has a particularly devastating consequence as we do not have reliable blood banks, and the blood supply is epileptic or many times non-existent. A pregnant woman who needs blood in many instances is at the mercy of friends and relatives who have to donate blood. If she has no friends, family, or compatible blood donors, her life is definitely at risk.

An event witnessed by my husband/my father 35 years ago and still true of the problems besetting the health sector in Nigeria today!

Amina (not real name) was a pregnant woman who was rushed into a general hospital after several hours in labor. Examination at the health facility revealed she had a ruptured uterus. She was wheeled into theatre almost immediately and her uterus was repaired. There was no blood available so even though she had lost a lot of blood she did not receive any. Following Amina’s operation, doctors warned her to lie on her hospital bed but she refused, saying it was strange for a woman to lie down on the bed doing no work. She insisted on getting up every morning to sweep the hospital compound. She did this for a few days and one morning she did not wake up!

Nigeria has a MMR of 840/100,000^a. This rate varies widely with the highest rates of 2420/100,000 in the northern regions^b. As in any other parts of the world, MMR in Nigeria are dependent on where a woman lives (urban vs rural areas) and the female literacy rate^c , which in turn determines her level of empowerment. Is she able to contribute to discussions about her health or are the health decisions left for her husband or in-laws to make?

I (Olaoluwatomi) worked in a mission hospital southwest of Nigeria and one of the major problems we had when it came to maternal care were from women who did not register at the antenatal clinic. In the middle of the night it was not rare to be called to attend to a woman with post partum hemorrhage or obstructed labor. Many times she was brought in from  ‘prayer’ houses, which are semi-health facilities where women went to have their babies. The health qualifications of those in charge of the homes was suspect, and with the number of complications coming our way, it was obvious that they were not skilled birth attendants. The women cited lack of funds to pay for antenatal care at the mission hospital, but we had some women who had attended antenatal care at our facility end up at the mission homes and then back at our facility when problems arose. They were often persuaded by friends, mothers, and in-laws to go to ‘prayer’ houses, usually because of the fear and stigma attached to caesarian sections which they might be subjected to in hospitals. A “real” woman gives birth naturally without being cut, she is told.

Projects to Improve Maternal Health:

With the unacceptable high MMR, what is being done to improve the cruel lot of Nigerian women?  Will Nigeria be able to achieve the United Nations Millennium Development Goal No. 5 to improve Maternal Health, in three years time? A number of initiatives, too few in my opinion, have been started to reduce MMR.  

One of the southwestern states, Ondo has introduced a health scheme which provides free health care to pregnant women. It is called the Abiye program^d. It aims to reduce maternal mortality in the state by introducing health rangers who are assigned to 25 pregnant women and are responsible for visiting them on a regular basis, helping them develop a birth plan, identifying complications, and ensuring referrals to the health center or comprehensive health center when problems are identified. In addition, the government has introduced legislation that makes it mandatory for maternal deaths to be reported. This has helped to dissuade women from seeking traditional birth attendants and ensure that women have their deliveries attended by skilled health care workers.

The health rangers also provide postnatal care and are given locally made tricycles to help them reach their patients or transport patients to the nearest health facility from their homes.

This initiative by the Ondo state government helps address many of the factors that lead to high maternal mortality rates in Nigeria. The introduction of a free scheme helps to ensure that no one is denied access to health care who needs it and cannot afford it. It also ensures that women have access to contraceptives, attendance during labor by skilled health attendants, and the provision  of emergency obstetric services.

In Northern Nigeria, the PRINN-MNCH program (Partnership for Reviving Routine Immunization in Northern Nigeria- Maternal Newborn and Child Health Initiative) sponsored by the UK and Norwegian Governments has been working for six years in four states with extremely poor health indicators. It is stakeholder-driven, leading to community ownership of programs aimed to help improve health statistics. It provides comprehensive emergency obstetric  care clusters, skilled birth attendants, and community emergency transport schemes which help to reduce the delay in seeking health care for pregnant women at various levels^e.

The maternal mortality figures are high, but the number of complications during pregnancy are often much higher. Studies show that for every woman who loses her life during pregnancy, 20 more women suffer complications. These complications include hemorrhage, sepsis, vesicovaginal fistula (VVF) amongst others. Obstetric Fistulas are seen more commonly in Northern Nigeria than Southern Nigeria with rates of 2.11 per 1000 births^f. Obstructed labor gives rise to obstetric fistulas more commonly, and early marriage and pregnancy are major contributing factors to the incidence of fistulas in Northern Nigeria.

With poor access to health care facilities, women with fistulas end up as pariahs in their communities. They are seen as outcasts and are more likely to be sent away from their matrimonial homes because they have urinary and or fecal incontinence. They end up being ostracised by the very communities that they belong to, not being able to fend for themselves because they lack educational or training skills. There are a few centers that repair fistulas but many times the women and their families do not have enough funds to seek care and may not have the means to get to the centers where repairs can take place. The work of many NGO’s has helped alleviate costs. Médecins sans Frontières has a center in Jahun, a town in the northeastern part of Nigeria, where they provide fistula repairs free of charge to women who need it^g.

Recommendations:

My childhood fear of pregnancy and childbirth has long been replaced with deep sadness and despair whenever I hear of yet another preventable death of a young mother trying to give “life”. Currently, there is far too little government intervention to stop these deaths. Although under the constitution, the right to life is non-justiciable, I strongly believe that the government should be held accountable for not doing enough within its resources, to save the lives of young women.

Ensuring that women’s health is a priority by the government at all levels would go a long way in reducing that the high rates of maternal mortality. How can this be done? Education! Female literacy rates have been seen as predictors of maternal mortality rates in many countries^c. Educating the woman empowers her to become a major stakeholder in decisions regarding her health. She is enlightened and has the power to ensure that her health is not treated as a non-issue. She is able to identify and correctly interprete danger signs and is less likely to be deceived by old wives tales regarding complications in pregnancy. If she is educated she is more likely to be economically empowered, and can thus also provide funds when necessary to ensure access to health care services. This would lead to a significant reduction in maternal mortality rates.

In addition to educating girls, the government must adopt and vigorously implement the UNFPA’s Safe Motherhood strategies: access to contraception for all women to avoid unintended pregnancies, skilled care at the time of birth for all pregnant women and quality emergency obstetric care for those with complications. The judicious use of our resources will go a long way to erase the fears and tears of all.

However, safe motherhood will not just happen. Safe motherhood is women’s human rights that must be fought for.

Olaoluwatomi is a physician from Nigeria who is interested in the availability of health care delivery services in subsaharan Africa, especially in the rural areas. She has worked in Mission hospitals and with an International NGO and has been exposed to communities where the dire need for the provision of health care sevices was the stimulus she needed to pursue a career in public health. She hopes to work for organizations whose goal is to eliminate this disparity and establish in the near future a chain of clinics sited in rural areas known for their first-rate service, providing services at affordable costs!

References:

1. MSF Field News: Infographic- The Avoidable Crises of Maternal Health. http://www.doctorswithoutborders.org/news/articlefull.cfm?id=5850&cat=field-  news&t=2
2. WHO Global Health Observatory Data Repository: Maternal Mortality Indicators. http://apps.who.int/ghodata/?vid=240
3. Maternal Mortality in Northern Nigeria: A population based study Eur J Obstet Gynecol Reprod Biol 2003 Aug 15;109(2):153-9. Adamu YL et al,
4. Female Education and Maternal Mortality: A worldwide Survey. Chryssa McAllister, Thomas Baskett. JOGC November 2006
5. Towards Reducing Maternal Deaths in Ondo, Sade Oguntona, the Nigerian Tribune 15 March 2012             http://tribune.com.ng/index.php/features/37639-towards-reducing-maternal-deaths-in-ondo-state
6. Maternal Newborn and Child Health care in Northern Nigeria: How PRINN-MNCH is intervening? http://www.prrinn-mnch.org/documents/Brochure_howPRRINN-MNCHintervenes_6page_final.pdf
7. West Afr J Med. 2010 Sep-Oct;29(5):293-8.Vesicovaginal fistula: a review of nigerian experience. Ijaiya MA, Rahman AG, Aboyeji AP, Olatinwo AW, Esuga SA, Ogah OK, Raji HO, Adebara IO, Akintobi AO, Adeniran AS, Adewole AA.
8. Podcast: Preventing and treating Obstetric fistulas in Nigeria http://www.msf.org.uk/podcast_ep82_20110308.news
9. J Obstet Gynaecol Can. 2006 Nov;28(11):983-90.Female education and maternal mortality: a worldwide survey. McAlister C, Baskett TF

Kate Otto

By Kate Otto. What do you think is the key to a great mHealth tool?  Is it efficiency?  Scalability?  Interoperability with similar systems?

I would argue none of the above.

I would say that the key to a great mHealth tool is a great health worker at the helm.

My name is Kate Otto and I work with the World Bank and other partners to develop and test the effectiveness of mHealth tools on health outcomes.  Based on two recent mHealth experiences – one with health extension workers (HEWs) in rural Ethiopia and another with midwives in urban Indonesia – I have noted a recurring lesson in this emerging field: that technology is not the solution itself but simply a means to arriving at a solution.  The people behind the tools are what make the difference between success and failure.

Too often, the sleek and impressive nature of new technologies makes the headlines: how they solve all the problems that human beings tend to mess up so sorely, how they avoid any mishaps in the first place with a fool-proof design.

Yet the truth is, the success of mHealth tools and applications are based largely on the intrinstic motivation of the end user – and how tools can be designed to leverage, not stamp out, that motivation.

Our product in Ethiopia allows HEWs to register expecting mothers and newborns so that they receive back appointment reminders, creating a patient schedule for the HEW and increasing the likelihood that she’ll deliver the proper care at the proper time, ideally decreasing maternal mortality, increasing vaccinations, and decreasing infant and child mortality.  But if a HEW does not deeply care about saving lives, if the tool does not work smoothly with her rugged lifestyle, if she cannot see the immediate benefit of using it over the status quo system, then will she take the effort to use it properly or consistently?

In Indonesia, it struck me that most midwives who helped developed the tool cared less about cutting data entry time from their day, and most about having quickly aggregated data fed back to them to compare across other neighborhoods: how did they compare and how could they improve performance?  I can’t say I had initially thought to design a feedback report into the system – but it quickly became part of the plan.

I would encourage investors in mHealth to think of the investment not as one in technology, but as one in human capital – if you’re doing it right.  This means spending extensive time iterating on design with end users, testing final models to ensure incentives are aligned across all partners, training providers and system administrators to work independently from a donor or innovator, and ensuring that the outcomes desired by the end users are being attained.

We must continue to invest in technology for health, but we must do so wisely: at the hand-holding the phone, and pay attention first to the people behind the tool.

Kate Otto works in the field of public health, experimenting at the intersection of new technologies and human behavior. She works with the World Bank in Ethiopia assessing the impacts of mobile phone tools on maternal health outcomes, and with Innovations for Poverty Action in Zambia, applying behavioral economics to find health systems solutions.  Kate has finished writing a book called Everyday Ambassador: Changing the World Starts with Changing Yourself.  More information is available through her website, TEDx talk, Facebook page, and on Twitter.

By Elita Wong.

To accomplish their mission, groups are becoming increasingly creative with the way they are approaching traditionally challenging obstacles in providing health services. Ideas range from introducing digital and mobile health to streamline communications and provide safer care, to ensuring that low-cost immunizations are delivered to everyone, preventing the proliferation of infectious agents. The race is on to increase public awareness to emphasize the importance of social involvement between communities and individuals across the globe.

Despite much criticism about the inability of most countries to meet these objectives, poverty has declined in many countries and regions, infectious diseases have been better controlled, and child mortality rates have improved. The MDGs have also held countries accountable for maintaining measurable outcomes and initiating more specific interventions since their establishment.

When looking ahead, we should consider recommendations from the World Health Organization’s most recent MDG report, which identified a major inhibitory factor in advancement that may seem unavoidable, but is most certainly not. We are failing to address widespread disparities in progression rates towards MDG attainment for the impoverished and disadvantaged based on sex, age, ethnicity, or disability.  In a snapshot, the poorest children have made the slowest progress in terms of improved nutrition, women are still lacking full and productive job opportunities, and advances in sanitation often bypass the poor and those living in rural areas.

So what are the next steps to address the needs of the most vulnerable populations to fulfill our universal desire for a new standard of living? Proposed solutions range from high-tech interventions such as using tablet computers for HIV education and mHealth for midwives, to more process-oriented plans such as health care workforce scale up.

For the next two weeks, we will be running a series of posts that will provide insight from the movers and shakers in international health development from around the world. We hope that the posts in this series provide readers the opportunity to view these local examples from a global perspective, and we invite and encourage each one of you to join the conversation. Our goal is to give a taste of the most current projects aimed at achieving a more sustainable, inclusive and equitable future, and to shed light on public health work that is often kept behind the scenes.

Please share your thoughts with us this week and next on the blog, Facebook, or Twitter with hashtag #DWGlobal.

By Andre Blackman.

For those of you unfamiliar with the TED (stands for Technology, Entertainment and Design) brand, the original conference started a number of years ago to showcase “ideas worth spreading”. With the groundswell of new concepts to transform health care (mobile technology, film, design elements, etc.) emerging in the last few years – it only makes sense that TED applies its brand to health and medicine.

Painting by Disruptive Woman Regina Holliday

For the first time in Washington DC (held in California in years past), TEDMED truly brought together leaders from health, medicine, science, technology – with a sprinkling of celebrity flare including Gabrielle Reese and Katie Couric, to make for engaging conversation. The sheer firepower of innovators and decision makers at the Kennedy Center gave me hope for some real movement on finding some solutions. There were a few folks that really highlighted concepts I care about.

Things got kicked off for me when Dr. Francis Collins, head of NIH, took the stage discussing the importance of moving faster in the medical science arena to develop better techniques to cure diseases. The fact that a young man (15 year old) living with progeria was able to attend and inspire the audience with his story solidified reality for the audience. This was important for me, especially because storytelling is what we are focused on with FastForward Health and I’m personally interested in people over statistics in the future of public health.

Risa Lavizzo-Mourey, CEO of the RobertWoodJohnsonFoundation and a personal heroine of mine because of her work – also dropped some knowledge on the crowd around issues that reflect on what needs to be recognized in public health. Much of what RWJF is focused on is growing health initiatives where we live, work and play (and as Jane Sarasohn-Kahn would add: where we pray as well!). “Health is essential to the productivity of our country” mentioned Risa. This is where public health really becomes relevant – looking at the far reaching consequences of inaction for our society. In this case, economics.

Finally, John Hoffman of HBO had me thoroughly excited about the upcoming documentary –The Weight of the Nation. A series looking at obesity in America and what can be done about it. Also great to see partners such as Kaiser Permanente, the Dell Foundation, NIH and CDC being involved with this project. Getting a glimpse at the series which premieres next month, May 14 and 15th, got my mind going about film, storytelling and public health – once again applications to the FastForward Health project.

After it’s all said and done – TEDMED was a great gathering of minds for networking, idea sharing and inspiration. Over the past few years of being in this space, it’s wonderful to see things heating up for positive impact. Or maybe the potential for impact. Now it’s time to take the conversation home and not lose the energy. What can we do to see actual change over the next 3 months? 6 months?

That’s the true power of TEDMED and other events like it. Come together, then do together.

By Elliot Patton.

A sustainable community is one where emphasis is placed on livability and efficiency.  It provides its inhabitants with ample public transportation options, and also encourages mixed land use where residential and commercial facilities coexist to decrease the need for motorized transportation.  An inhabitant of a sustainable community should be able to access all necessities easily on foot or by public transportation.  These compact communities are a move in the opposite direction of the suburban sprawl that has characterized the development of past decades, and which has defined the lifestyle of hundreds of millions of Americans.  Another important aspect of these communities is their inclusion of green space, which is very important both for the processing of CO2 and for making the community a pleasing place for an inhabitant to be a part of.  The positive impact that these communities would have on the environment, human health and the inhabitants would be absolutely enormous.

The biggest gains to be made from transitioning to more sustainable communities come from reduced automotive travel; burning fossil fuels for transportation is one of the most obvious ways that we harm our environment on a regular basis.  The Department of Transportation estimates that about 18% of annual CO2 emissions come from passenger vehicles.  When it comes to abating these emissions, much of the focus is on engineering more fuel efficient cars, but a much more reasonable and immediately available source of abatement would be to reduce the number of miles that we drive.  ­­According to the Federal Highway Administration, the average American drives almost 37 miles every day, and reducing this number would have a huge impact on our environment.  In addition to greenhouse gas emissions, extra miles on the road impact individuals and their environment in countless ways.  Water pollution occurs when rain washes fluids off of the road and into our fresh water sources, our landscapes are destroyed and useful land wasted by the enormous number of parking spaces that must be available for our cars.  In addition to the cost to our environment, spending too much time in cars is also detrimental to our health and wellbeing.  First of all there is the increase in daily exercise that comes with walking rather than driving, and there is also the opportunity cost of the time that we spend in the car that could be spent working or with family.  By creating a community infrastructure that is less focused on a car-centric lifestyle, we can decrease emissions drastically and improve the health of our population.

Cities are constructed over long periods of time, and altering their fundamental structures can appear to be an unobtainable goal.  Some of the new development that is needed in order to create a sustainable community can be achieved by utilizing “brownfield” locations which have been deemed undevelopable due to the presence of harmful substances.  These unused locations are able to be cleaned and restored to developable status, but this additional expense often makes development of these sites cost prohibitive.  Cities including Pittsburgh, Seattle, Atlanta and Portland have utilized brownfield sites as part of sustainable development efforts, and these areas have turned into booming economic centers for the cities.  In addition to playing a role in sustainable development, cleaning and redeveloping brownfield sites has the dual benefits of removing health hazards and creating opportunities for economic growth.

The need for more sustainable development has not been overlooked by those in the federal government; in 2009, the Environmental Protection Agency, The Department of Transportation, and the Department of Housing and Urban Development came together to form the Partnership for Sustainable Communities.  This partnership was bred from the recognition that the environment, transportation and housing are inherently interconnected, and that it would benefit all three organizations (and more importantly, the American people) to collaborate on issues of development.  EPA Administrator Lisa P. Jackson explained the partnership’s efficiency by noting that “working across agencies gives us an opportunity to share knowledge, resources, and strategies that will improve public health and the environment, cut costs and harmful emissions from transportation, and build more affordable homes in communities all over the country.”  The formation of this partnership, and the efforts that they have put forth in the years that they have been active, is a very good sign for the prospect of becoming more sustainable on the community level and throughout the country as a whole.

Creating communities that embody the principles of sustainability is a long term task, but one that must be completed in order to vastly improve the human experience on this planet.  We cannot continue to expand into the suburbs, requiring more roads and more parking spaces and forcing individuals to waste years of their lives behind the wheel of a car simply going to and from work.

Our built environment influences our behavior, and our behavior influences our health and the health of the world we live in.  Let’s change the way we fashion our built environment in the future.

Here are some links to more information about the issues discussed in this post:

• Pittsburgh Brownfield Development: http://www.pittsburghgreenstory.org/html/brownfields.html
• Transportation CO2 Emission Statistics: http://climate.dot.gov/about/transportations-role/overview.html
• Partnership for Sustainable Communities’ Website: http://www.sustainablecommunities.gov/

By Mary Ann Swissler.

As we celebrated Earth Day this past Sunday, the author is cautiously optimistic about a new era with a healthier environment.

They’re not copays or premiums yet there’s no doubt that polluted air and water exact a high health cost. Still, the arguments over how to deal with that part of the healthcare equation have gone back and forth for decades. Last year, for instance, an Institute of Medicine study on links between the environment and breast cancer concluded that while some toxins cause cancer, it’s impossible to match one specific chemical to one specific case of cancer.

Now, however, the Affordable Care Act has changed the rules of the game. Its guiding principle is “do no harm,” and the legislation sets out a new standard for evaluating research on the alleged harmful effects of pollution. It’s similar to the different standards of evidence in civil and criminal law. In the past, something like the criminal-law standard of “beyond a reasonable doubt” prevailed. Now the federal government standard in research cases will be the same as in civil law: If a preponderance of the evidence suggests that some substance is harming people’s health, that’s a basis for action.

The details are found in a document called the National Prevention Strategy, released last year as part of a 2010 presidential mandate. It notes, “Safe air, land, and water are fundamental to a healthy community environment.”

Included as a goal of the strategy is to increase the availability of health professionals to “identify, prevent, and reduce environmental health threats.”  Clinicians, the document states, “can provide information and counseling on how to prevent, treat, and manage environmental-related exposures, including indoor air pollutants, lead, mercury, and pesticides.” The National Prevention Council is “working diligently toward finalizing the implementation plan and it should be ready in the coming months,” according to a source inside Health and Human Services.

If all goes well, and that’s a big if considering how strongly our political climate favors polluters, this strategy can help turn back the tide of toxins in the environment. For instance, it took 21 years for the new federal mercury standards to become law and it quickly faced a challenge from the Congressional Review Act. Luckily, the objection failed. The new rule which promises to eliminate 90 percent of mercury emissions from coal-fired power plants, can proceed.

Just as environmental improvements brought about by the Clean Air Act have, according to the EPA, prevented some 160,000 premature deaths, the new environmental standards are expected, within a few short years, to greatly reduce the incidence of many health problems in this country, including asthma and heart attacks. The National Strategy provides hope—if it survives the Supreme Court’s ruling on the Affordable Care Act and is sustained by future administrations—of progress against many pollutants, even though neither the strategy document nor the Affordable Care Act grants new government enforcement powers regarding clean air and water.

Still, the raw ambition of this plan is exciting. My recommendations as a keen researcher of activism and politics for making it work:

1. Involve environmental engineers in this prevention strategy. They’ll find solutions for industries rather than just handing down edicts from on high. Face it, environmentalists—we’ve won. It will be a long slog but we now have public health laws on our side.
2. Address environmental racism and low-income biases. Incinerators, for example, are more likely to find homes in politically weak neighborhoods, which not coincidentally are where people of color and those with low income live.
3. Stress job-creating abilities and have fighting words ready when attacked by moneyed interests. Better yet, sell it to the American public now, emphasizing the state and local impacts. Otherwise, it’s too theoretical.
   The truth is pollution controls don’t cut into job creation. Instead they cut into short-term corporate profits meaning companies don’t plough their profits back into their operations. Hence the corporate resistance to pollution controls.
4.  Create incentives for business, not only penalties. Part of the billions of dollars collected in fines each year should be used to entice businesses to invest in environmental cleanup technologies. It could do wonders for their quarterly financial statements and thus their motivation to do good.  This wiggle room for corporations could end the “job killer” canard once and for all, when it comes to pollution controls.

By Laura Harwood.

I recently caught up with Don to learn what the Partnership is doing in the environmental space to help create and promote a safe and healthy economy. He shared many examples of local agency leaders, or “heroes,” as he calls them, people who have emerged as local agents of change by implementing innovative, community specific programs.

Some shocking realities emerged about our economy’s wealth gap and the tremendous potential for a clean or green economy to create jobs for the low-income individuals in their communities. Some of CAP’s initiatives include the Community Economic Development (CED) program, Job Creation and Green Jobs project, as well as deconstruction and recycling programs.

In order to learn more about how you came to be Don Mathis, I reviewed some of your previous interviews and bio. You have a long history in this type of work, so could you tell me a little more about your background?

Well I started as a volunteer for Head Start when I was in grad school at University of Delaware–I was a really good volunteer and a really bad grad student. I was a TA in the Philosophy Department and there was a Head Start directly across the street from my office. When school got exceptionally boring, I would go over to the center and play with the kids, which was good at the time because there weren’t many male volunteers. More than a few kids didn’t have a dad or a male figure in their life. So I started volunteering more and going to class less and one day they asked, “Why don’t you work for us?”

I quickly learned a lot while on staff. I found that there are very modest ways that one can act that make big differences in the lives of people and families–that became good enough for me.

I’ve been very fortunate to be involved with programs that directly help people while driving policy agendas in ways that are helping people.

DW is one of your biggest fans; you are the first Man of the Month to receive this honor twice, which is in line with our environmental theme — we are doing our due diligence to “recycle.” (Don laughs.) This month, we wanted to tie in your work to the White House EPA event, National Public Health Week and Earth Day.

What we focus on is economic security and anti-poverty, so the hook with helping the environment is that both the priorities are preventive in nature. If you look at the poverty statistics that U.S. Census Bureau reports, it is just outlandish. It is the highest number of poor people in the history of America. What CAP does is come in and make sure people have good health and that their environment is safe so that when the EPA passes the mercury rule or clean air rule it proportionally affects low-income families better because they don’t have the resources. They are the most susceptible to toxins. So the hooks are clear between clean air, getting rid of mercury, clean water, healthy environment and healthcare. What the research actually shows, Laura, is that if you are healthier as a kid, you’re less likely to be poor as an adult.

Community Action Partnership is the leading organization of its kind that serves such a large population. How does your work tie back to energy and the environment specifically?

The green jobs/green economy offers a lot of potential. You can go to a community college and get a certification in weatherization. You can get into an apprenticeship program without a 4-year degree and do good energy stuff. The energy piece is a growth opportunity and I’m not just talking solar panels, but clean water to wind turbine farms. I was in the middle of nowhere West Virginia last year on this wind farm. They have job openings there where the lowest paying job is $22/hour and they can’t find people to fill those jobs because there’s nothing else there. That’s the potential that clean energy economy offers.

Lisa Jackson, the EPA Administrator, has communicated a clear and simple message about a green, healthy environment and a healthy economy. In honor of Women’s History Month, she recently stressed this connection at a round table:  “You do not have to choose between a healthy environment and a healthy economy.” Do you agree with her position?

Yes, I do agree with Lisa. A clean economy is a green economy and as I mentioned earlier, there is tremendous value for low-income people for these types of jobs where you don’t have to have a 4 year degree.

We really need a comprehensive, thoughtful plan that helps ensure we have healthy communities and healthy people and thereby healthy, employable workers and citizens. And if we don’t, there is a cost associated with it that is inescapable if we don’t take responsibility. People criticize the Affordable Care Act and say, “Well, what do we need this for?” When people go to emergency rooms, who do you think picks up that cost?  It’s not a zero-sum game. We need that type of responsible environment for our country. The good thing is, as dismal as this may seem, there are solutions. We can mix conservation, diversify our energy systems; bottom line is we need to be creative and conscientious. We need to reward, incentivize, and educate our young generation that these issues are important.

“Science is important!” There’s a radical thesis there (laughs). But it’s true, and there are naysayers that discount science, but they do so at the expense of themselves, their children and future generations.

In general, do you have an overarching goal you are trying to achieve for the people you serve as it relates to the environment?

The importance of responsible health and environmental policy is that if we really want to make a commitment to having families be economically secure, it has to be more than just about a good job. A good job is necessary, but it’s not sufficient and it has to be in the context of a community that’s environmentally sound or at least working to get there where there is some bottom line access to health services. These are all things that are interdependent and these dynamics are interrelated. The good news is that we can address all the variables separately in ways that enhance the quality of life for everybody.

Closing thoughts?

One of the things we’ve become more involved in are deconstruction programs. Deconstruction is when they tear down a building or house and instead of “junk-yarding” everything away; you salvage the grit, the wood, the recyclable stuff, and turn them into products that can be purchased in the open market. This is really an emerging field. Think about scrap metal for everything. So many CAA’s are getting into deconstruction because it is good for the environment, reduces landfill waste, provides jobs and promotes the resale and reuse of goods. I have some new photos that show these people working in these deconstruction or “Demo Depot” centers.

To learn more about the Partnership’s programs that Don oversees or how you can get involved, visit: www.communityactionpartnership.com. Also, check out CAP’s new project website: Community Economic Development (CED) at www.PartnershipCED.org.

The following guest post is written by Alexandra Dunn who is the Executive Director & General Counsel of the Association of Clean Water Administrators.

By Alexandra Dunn. Water.  A universal element without which we cannot live.  When polluted and contaminated, public health is compromised.  Children die every minute due to dirty water on our planet.  The amount of freshwater on Earth is finite.  As such, many experts say the next war will be over water.

Ensuring access to clean and safe water should be one of the top priorities of our nation.  And yet, here in the United States, our drinking water and wastewater infrastructure is crumbling – rated a D- by the collective civil engineering community.  People pay more for satellite television and cell phone service per month than they do for drinking water and wastewater services.

When the Clean Water Act was enacted in 1972, rivers burned.  Lake Erie was declared dead.  The endangered sturgeon were gone from the Hudson River.  Ecosystems were dying.  And people who depended on the water environment for a living and to feed their families – commercial and subsistence fishers – found their livelihoods and tables threatened.

The Clean Water Act’s enactment over Presidential veto in 1972 marked a dramatic turn of events.  It was what is known as a civic republican moment.  When people come together and demand change.  Among its dozens of powerful and useful provisions to control water pollutions, the Act put in place the Construction Grants Program for clean water infrastructure.  The Program resulted in some of the largest public health gains of the past 50 years by building sewage treatment facilities, sewage conveyance systems, and related critical infrastructure.   We did not build everything new – pipes in the ground today in many cities still date from the turn of the century and facilities built for 1970 level populations are now undersized.  Nonetheless, the federal government stood hand in hand with states and communities as these investments were made.  The water got cleaner.  People and ecosystems got healthier.  We recognized the critical value of clean and safe water.

In 1987, things changed.  Congress replaced the grant program with the Clean Water State Revolving Loan Fund.  The philosophy was that water is a local community issue, not a federal priority.  Localities should be paying for the needed investments themselves.  While elements of the philosophy certainly made sense, over time, the modest increases to the Fund have not kept pace with the investment needs.   Today, water infrastructure investment is funded 90 percent by people like you and me through our water bills.  The economy is weak, and water service rates can only go so high before people – especially the elderly and those of low income – can’t pay.  Adding to the infrastructure stressors are a growing population and more intense and erratic wet weather events associated with climate disruption.  The Environmental Protection Agency itself says without a recommitment to infrastructure investment we risk a return to the water quality crisis of the late 1960s and early 1970s.

The Clean Water Act enters early middle age this year as it turns 40.  Isn’t mid-life a time for reassessment of priorities?  A gut check to see if we’re on the right path?  Nothing could be more important to public health and the quality of life we want to enjoy in the future in our nation than clean water.   It is time as a nation to develop and implement a sustainable funding source for our critical water infrastructure.  We need our lakes, our rivers, our streams to be healthy so that we can be healthy.   Let’s not take the gains of the past 40 years for granted.  Clean water is worth our time, attention, and investment.

The Clean Water Act set forth an ambitious goal in 1972 – to restore the physical, biological, and chemical integrity of the nation’s waters.  We are not there yet.  It is time to recommit to, and reinvest in, water.  For our health and the health of the environment and all that depends on clean water.

In November 2006 an interesting study was released by the United Nations that showed that more greenhouse gas emissions are produced by growing livestock for meat than all the planes, trains, ships, cars, trucks, and all forms of fossil fuel based transportation combined. Cattle produce nitrous oxide and methane, which is 23 times as heat trapping as carbon dioxide.

Livestock is also a major source of the degradation of our land and water. One third of the Earth’s land surface is now being used for livestock, most of it is permanent pasture but also includes 33% of the global arable land that is being used to produce feed for livestock. The land is becoming degraded due to overgrazing, erosion, inadequate livestock management, deforestation, forest fires and climate change. We now lose more than 20,000 square miles of fertile land to desertification worldwide every year.

Water pollution from animal wastes, antibiotics and hormones, chemicals from tanneries, fertilizers and pesticides make livestock one of the most damaging sectors to our earth’s scarce water sources. According to the World Heath Organization and NASA, water shortages are currently affecting 1.1 billion people and by 2050 will affect nearly half of the 10 billion that the UN estimates will be our total population at that time.

Do you know what meat is doing to our beautiful rainforests? It’s killing them. 70% of the rainforest that has been cut down is being used to graze livestock. And when we destroy the rainforest for hamburgers, we are losing so much more than trees.  Nearly half of the world’s species of plants, animals and microorganisms are at risk of extinction over the next quarter century due to rainforest deforestation. More than 20% of the world’s oxygen is produced in the Amazon Rainforest alone and in addition to being the “Lungs of the Earth” rainforests may very well hold the key to the cures for many human diseases. The U.S. National Cancer Institute has identified 3000 plants that are active against cancer cells – 70% of these plants are found in the rainforest. Experts estimate that the last remaining rainforests could be consumed in less than 40 years. All in the name of cheap hamburgers.

One acre of land can produce 165 pounds of beef OR 20,000 pounds of potatoes. And it takes 23 gallons of water to produce a pound of tomatoes. By comparison, it takes over 5000 gallons of water to produce just one pound of beef. Sit down and digest those facts for a while.

In addition to the health of the planet, there are also many human health benefits to a plant based diet. However, since my contribution to this book is limited to 800 words, instead of trying to summarize it in a couple paragraphs, I am just going to recommend you watch the documentary “Forks Over Knives.”

Albert Einstein once said, “Nothing will benefit human health and increase the chances for survival of life on Earth as much as the evolution to a vegetarian diet.”

I think Einstein was on to something. But you can decide for yourself.

As a health care blogger who cares deeply about the role of women, I was surprised by how forcefully I was moved by the issues that were raised throughout these events.  When presented with a full picture of the link between human health and the environment, I knew that my engagement with this issue could not end when I left the last event at the White House.

That is why this April, in Honor of Earth Month, Disruptive Women is running a series of blog posts showcasing issues where health and the environment intersect.  In these posts, our guest bloggers examine the link between health and the environment from various angles, each highlighting areas of professional and personal importance.  My hope is that these posts will open your eyes and encourage deeper reflection and further discussion on the topic of health and the environment.

PwC polled 1,060 U.S. adults in February 2012 to learn their social media habits tied to health. Among all health consumers, the most common use of social media in health is to access health-related consumer reviews of medications or treatments, hospitals, providers, and insurance plans, as shown in the graph.

Social media enables people to be better health “consumers” by giving them peers’ views on health products and services. Notably, PwC found that 45% of consumers said information found via social media affects their decision to seek a second opinion from another doctor — this, above the 42% of people who use social media to help them cope with chronic conditions, diet, exercise or stress management. Furthermore, 41% of people said information they find via social media helps them choose a specific hospital or physician. And — listen up, pharma and medical device companies, along with health insurance plans – one-third of people said social media influence their decisions about taking certain medications or undergoing specific procedures, or selecting a health plan.

Social media also helps people manage personal health administration, such as making appointments, getting appointment reminders, referrals, and discounts for services (think: Groupon for dermatology), customer service, and determining wait times at emergency rooms.

The report features examples of health industry segment leaders who are successfully engaging in social health, such as Aetna. The health plan offers Life Game, an online social game that engages people in setting and working toward personal wellness goals. What’s notable about this is that health plans haven’t historically been trusted by consumers to get up-close-and-personal with their health. But as health consumers look for useful and well-designed online tools, the health industry can build bridges for both health and trust.

Physicians are still the most trusted touchpoint across health industry segments, when it comes to people sharing information via social media, compared to hospitals, health plans, and drug companies. While 61% of health consumers trust information coming from doctors via social media, and 41% would be likely to share information with doctor, this drops to 55% and 39% vis-a-vis hospitals, 42% and 34% for health insurers, and 37% and 28% with drug companies.

“Embrace social media as a mindset, not just a channel,” PwC counsels these industry players. Tactically, this means these organizations must not just ‘talk and listen,’ but analyze and integrate the learnings from conversations into insights and actions:

For pharma, PwC recommends moving forward while minimizing regulatory and legal risk in the absence of FDA regulations for social media use. PwC says pharma should ”move beyond marketing” by tapping into social networks to populate clinical trials and inform product development and innovation.

For health providers, social media can provide collaborative opportunities for care coordination — and new ways of delivery better quality care at lower costs.

For health plans, social media can drive population health management for newly-insured people looking toward implementation of the Affordable Care Act: for example, aggregating data generated through social networks to inform condition management.

Health Populi’s Hot Points: In a section titled, “A future look,” PwC focuses in on the potential value of patient data generated through social networks. As the U.S. morphs toward performance-based payment – accountable care, writ large – the patient health record must bring together more than traditional claims data. The observations of daily living, from mood to calories taken in and exercise, complement the usual clinical data to provide a 360-degree picture of a person’s health and health behaviors. As U.S. Surgeon General has said, and I frequently quote, health is where we “live, work, play and pray” — not in the doctor’s office. PwC’s discussion on how to integrate social data into the EHR is an important one, which is just beginning to get traction beyond a few of us HIT wonks who have been involved in social media for the past decade. The question is succinctly put by Kevin Abramson of OptumHealth in the report: “How can we use this information to better understand the outcomes we see in the claims data?” To do this, and get to ‘social/health intelligence,’ Abramson’s company OptumHealth, along with many other data aggregators (from Big Data companies to nimble start-ups who “get” slices of clinical/personal health) will drive toward these solutions.

Don’t forget that large numbers of patients aren’t yet sharing on social networks. Even though more consumers are engaging with social media for health, it’s still important to segment the market and provide tools, apps, and services that provide what different consumer groups want. PwC notes that so-called “young invincibles” are more likely to share personal information, and Boomers less so. And less you risk techno-optimism when it comes to social health, note that people over 65 in poor health were least likely to trust, share and engage using social media in the PwC survey. And this cohort represents the most intensive (read: most expensive) users of the health system.

Ultimately, even with the growth of social media, getting the un- and dis-engaged health consumer to re-engage continues to be a challenge for all health systems.

This post first ran on Health Populi on April 18th.

Every year 40,000 women die of breast cancer, but almost 420,000 die of cardiovascular disease, a number that exceeds that of men.  Despite significant declines in death rates for lung cancer in men, death rates for women are on the increase and 72,590 women are expected to die from lung cancer in 2012. Stoke deaths among women each year exceed 82,000.

For years, women’s health was defined as reproduction (pregnancy, maternal health, contraception, etc.)   Then 20 years ago we were able to say the word “breast cancer” openly in media and print.  Showing some progress has been made.  But, as the above statistics show, women are afflicted with and dying from major diseases that, with rare exceptions, affect women differently and disproportionately.  Being male or female is an important determinant of risk for many diseases.  What we need to stress is biological differences in men and women are causing these disparities.  This is fundamental to women’s health and we need to acknowledge that.

In 2001, the Institute of Medicine (IOM) issued a report stating that “every cell has a sex”, that “sex matters” and that “differences in health and illness are influenced by individual genetic and physiological constitutions.”  And when we say “sex” we refer to biological differences.  The IOM recommended that we “study sex differences from womb to tomb” with the overarching message: the effects of female hormones do not explain the differences between male and female physiology.  Understanding these differences will translate to improvements in disease prevention, diagnosis, and treatment.

Until the last 20 years, clinical studies involved mostly men where the “typical 70 kg man” became well-known:  white, middle class, 30-50 years of age who became the standard on which our knowledge of human biology was based.  This ignored women and minorities.  Conclusions from early studies were drawn and then extended to the general population.  Unfortunately, we are still victims of these missteps in medicine.  Progress in including women and minorities in clinical studies in sufficient numbers to allow statistical power has been slow.  The IOM most recently convened to discuss this issue in their meeting, Sex-Specific Reporting of Scientific Research in August 2011, and the need for sex-specific reporting was clearly stated.

It isn’t just about the difference in disease incidence, although the numbers are striking.  Two to three times more women suffer from depression; women are nine times as likely to be diagnosed with Lupus and three times more likely to get Multiple Sclerosis.  Women react to drugs differently than men and have different rates of absorption, metabolism, and elimination.  Men and women experience different levels of relief from pain medications and suffer different consequences to injuries to the muscles and head.  What really needs to be understood is physiological, genetic, hormonal and environmental differences between men and women that affect the incidence, prevalence, severity, time of onset, and treatment of so many diseases and conditions.  Yet so little research or attention is being paid to the sex differences therein.  What is known is not being disseminated properly (e.g.  included in curricula of medical schools) or widely (e.g  doctor’s offices).

We know, for example:

Alzheimer’s Disease:  The protein that is associated with this disorder (tau) collects in the hypothalamus  and  the patterns and amounts differ in men and women.  Also, there is evidence that brain metabolism differs in the two groups which implies that men and women age differently.   The result may be different risks, symptoms, and prognosis for men and women which may lead to the need for different treatments.

Bone Health:  There are known sex differences in adipose (fat) and muscle stem cells that affect wound healing, in rates of bone fractures and knee osteoarthritis , and in the perception of pain and analgesic response.   Sex hormones affect these conditions and will, undoubtedly, be instrumental in therapeutic interventions.

Coronary Heart Disease:  Traditional disease management approaches that focus on symptoms that are prevalent in males and often fail to identify those women critically at risk for heart disease.  Recent data indicate that women are disproportionately more likely to die of cardiac arrest before hospital arrival compared to men.

A recent released study involving over 30 million insurance and prescription claims records found major gender differences: women are prescribed more drugs than men, have poorer adherence rates, and do not always receive the appropriate prescription drug treatments.

Minorities at Additional Risk: Being female is not only a risk for many diseases, but being female and a minority places many women at extraordinary risk.  In metastatic breast cancer, African American women are more often than white women diagnosed with “triple-negative breast cancer.”  When women are first diagnosed, their tumors are tested for estrogen and progesterone receptors and for over-expression of a protein called HR2.  In 15 -20% of women, results show these women are negative for all three proteins and it occurs more often in African American women.  This means they would not be candidates for certain hormonal therapies such as tamoxifen, leaving them with standard chemotherapy as the only choice.

This begs the question: Why don’t we know more about these differences and what they mean?  For one reason, the medical journals that our physicians read often don’t contain analysis by sex. Many studies still don’t include enough women or minorities to stratify by sex and report the differences. Researchers applying for grant funding for sex differences research  are at a disadvantage partly because there are few, if any, sex-based scientists on the review committees.  And now, with money tight, it will be that much more difficult.

We need to get beyond a focus on “women’s health” or perhaps even beyond a disease-specific mentality.  We need to collect and understand basic determinants of sex and race and understand the genetic implications.  We need more animal studies.  We need more tissue and blood studies for sex-specific biomarker development. Women are not small men.  We need more studies that demonstrate that the difference is real.  Only then, will we be able to provide the most appropriate medical advice to our whole population.

In spite of the fact that women are 51% of the population we are classified as a ‘’sub-population’ by our government.  It is time we dropped the ‘sub’ and become full-fledged members and our health and well-being is given the serious attention it deserves.