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In-door Air Pollution Impacting the Health of Women & Children in Developing Countries: Priority for Health Policymakers

In-door air pollution (IAP) caused by unprocessed wood fuels is impacting the health of the poor, where disproportionate numbers are residing in developing countries.[1] Approximately 90% of rural households in developing countries are relying on wood, dung and crop residues as their main energy source and the numbers are expected to increase.[2] Such energy sources are cheap and easily available locally. However, there are not very clean nor efficient. Besides the fuels, poor functioning stoves and housing conditions make them highly vulnerable. Although a massive shift to kerosene is expensive, promoting the use of charcoal with enhanced stove system will reduce the health impact.

IAP caused by unprocessed wood fuels is threatening the health of the poor in many ways. When they are burned, they leave behind high concentrations of invisible breathable particles of a variety of gases and chemical products. For example, study in rural part of Nigeria shows that the mean concentration of nitrogen dioxide, sulphur dioxide, carbon monoxide, and hydrogen sulphide always stay higher than the permissible limit.[3] The amount of these substances in a poorly ventilated home can exceed WHO’s standard of particle size by more than 20 times.[4]  Particles less than 2.5 micro can penetrate deeply into the lungs and cause multiple health issues.[5] In fact, there are substantial literatures indicating positive correlations between higher concentrations of total suspended particulates and higher rates of mortality.4,5,[6]

As a result, nearly 2 million deaths from various illnesses were reported and among these deaths, 44% were due to pneumonia, 54% from chronic obstructive pulmonary disease, and 2% from lung cancer, where women and children accounted the highest.[7] In rural part of many developing countries, women do most of the cooking, thus they are subjected to continued exposure. It is estimated that 59% of all the deaths attributed to IAP are among female.[8] Children are also considered the second victims. While cooking mothers often carry young children, thus children are exposed to those breathable particles for prolonged period. As a result, 56 % of all the deaths attributed to IAP are among children younger than 5 years old.7 Indeed, the health impact of women and children creates huge economic burdens to the community and in general to country.

To avert the deaths we need to promote alternative energy sources. Although a massive shift to kerosene is preferred, in rural setting it is a very expensive investment, thus is not a cost-effective strategy. However, many alternative mitigation strategies can be promoted to save lives.  The use of charcoal in the few pockets where unprocessed wood fuels are being used widely would be more affordable. Such a measure would have immediate health benefits and lower the mortality. Charcoal, when burned, releases reduced concentrations of harmful particles and more useful energy than unprocessed wood fuel.9 By supplementing with behavioral changes such as keeping children away from stoves and cooking areas, it is possible to achieve significant reduction in mortality. To compensate the wood harvested, the promotion of charcoal use should always be introduced with strong forest policies such as tree replanting to encourage sustainable forest and woodland. Furthermore, to offset part of the emissions due to carbon combustion, it is critical to adapt low-carbon and more productive charcoal production techniques. Sugar charcoal is considered to contain pure carbon than wood charcoal, for instance.[9]

Along with the promotion of charcoal, major changes in housing designs is also crucial to allow adequate ventilation. For example, allowing cooking areas to remove excess hot air and introduce clean air. Replacing the traditional cooking stoves with technologically enhanced stoves will also help to minimize the emission of pollutants. Over the years various types of technologically improved stoves have been tested in many parts of developing countries. The Clean Cook stove, which is tested in Ethiopia, showed reduction in the average particles concentration by half, for example.[10] Similarly cleaner cooking technologies are testing various improved stoves for their efficiency in villages in India, Bangladesh, and Haiti.[11],[12]

The health impact of IAP from unprocessed wood fuel is very huge and should be a priority for policymakers in developing countries. Recognizing this, in 2010, the formal U.S. Secretary State, Hillary Clinton, made a speech in which she underscored the huge impact of IAP in many developing world. There is no doubt that the above mitigation strategies will help reduce some of the health impacts.

[1] Duflo E, Greenstone M, Hanna R “Indoor air pollution, health and economic well-being” Published by Copernicus Publications on behalf of the Institute Veolia Environment.

[2] Bruce N, Perez-Padilla, and Albalak R (2000) “Indoor air pollution in developing countries: a major environmental and public health challenge” World Health Organization

[3] Oguntoke O, Opeolu BO, Babatunde N (2010) “ Indoor air population and health among rural dwellers in Odeda area South-Western Nigeria” Ethiopian Journal of Environmental studies and management. 3(2): 1-8.

[4] Yassi A, Kjellstrom T, de Kok T, Guidotti TL. Health and energy use. Basic Environmental Health. New York: Oxford University Press; 2001:315.

[5] United States Environmental Protection Agency. Revisions to the National Ambient Air Quality Standards for Particles Matter. Federal Register, July 18 1997, 62: 38651–38701.

[6] World Health Organization. Indoor Air pollution and Health: Fact sheet. No 29

[7] World Health Organization. Indoor air Pollution and health: Fact sheet accessed on 2/26/2014.

[8] Skolnik R (2012) “Global health 101” 2nd Edition: American Public Health Association Press. Page 146-147.

[9] FAO Corporate Document Repository “Chapter 10-using charcoal efficiency retrieved on 3/2/2014.

[10] CEIHD/Gaia Association (2007) “ Indoor air pollution monitoring Summary report” Center for Entrepreneurship in international health and development, School of public health, University of California, Berkeley California.

[11] Abhishek Kar, Ibrahim H. Rehman, Jennifer Burney, S. Praveen Puppala, Ramasubramanyaiyer Suresh, Lokendra Singh, Vivek K. Singh, Tanveer Ahmed, Nithya Ramanathan, Veerabhadran Ramanathan. Real-Time Assessment of Black Carbon Pollution in Indian Households Due to Traditional and Improved Biomass Cookstoves. Environmental Science & Technology, 2012;

[12] A. M. Mobarak, P. Dwivedi, R. Bailis, L. Hildemann, G. Miller. Low demand for nontraditional cookstove technologies. Proceedings of the National Academy of Sciences, 2012; DOI: 10.1073/pnas.1115571109


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Amenable Mortality rates: Evidence for the US Health Care System’s Inferiority

            I asked my cousin to pass the gravy. After I took the bowl and spread the brown goo over my turkey, my uncle went on to ask, “So Nick, what do you think of Obamacare?” Knowing he wasn’t really looking for my opinion but an argument, I poked the bear. “I think it is ridiculous a great industrialized nation like the US doesn’t offer health care for all its citizens,” I responded. Immediately, my cousin exclaimed, “BIG DEAL! You know how many people from those ‘socialized’ nations in Europe come here for their health care… It is not a problem with OUR health care system but the health of people here are poor, because we have the freedom to live the way we want…”


Before I turned this into a full on debate that would surely ruin Thanksgiving dinner, I ended the conversation with a “let’s agree to disagree.” Nevertheless, I started to think about what my uncle said. Yes, the health of the US is surely not stellar but does the health care system really not play a role in this. Maybe. One study cited that health care only has a 10% contribution to total US health, while behavioral patterns accounted for 40% (1). But does that really mean that US health care is as good or better than other countries?? Then I remembered an article and concept that I read in a previous policy class which would have surely won the argument: AMENABLE MORTALITY RATES.

Amenable mortality, or mortality that “should not occur in the presence of timely and effective health care,” (2) is a strong indicator of the US’s mediocre health care system. It is one of the methods that attempt to separate the contribution of health care to population health from other determinants of health. Dr. Nolte and Dr. McKee in a 2012 Health Affairs article showed that, between 1999 and 2007, Americans under 65 years old had a worse amenable mortality rate than some of its peers across the Atlantic, including UK, France, and Germany. In this time period amenable mortality rates dropped the least for the US, 18%, and at the end of 2007, US had the overall highest rates. However, rates were similar in the over 65 years old population. This led to the authors’ conclusion that health care in the US is effective but only to those who have access to it (over 65 -year olds have access through Medicare). Furthermore, in the discussion, the authors cited a separate study, which showed that those most likely to receive appropriate care were associated with those who used VA services and had insurance (2). Therefore, it is hard to doubt that the ACA and universal access to insurance will lead to greater access to health care and better health for America overall.



  1. Schroeder M.D., Steven A. “We Can Do Better – Improving the Health of the American People.” New England Journal of Medicine. no. 357 (2007): 1221-8.
  2. Nolte, Ellen, and C. Martin McKee. “In Amenable Mortality – Deaths Avoidable Through Health Care – Progress in the US Lags that of Three European Countries .” Health Affairs. no. 9 (Sep 2012): 2114-22.

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Small Innovations, Big Impacts _Key to Strengthening Health Systems

With  the growing failure to deliver safe  and affordable treatment and daunting increase in number of deaths of  men, women and children. Innovations in health products, practices, and technologies have the potential to revolutionize global health.

I came across this article through Karen Grepin’s Blog and thought how amazing this tradition was , a 75 yr old tradition of gifting new mothers a maternity kit as they leave the hospital and how mothers choose them over the cash. My eyes lit up when I saw the contents of the box and wait –it  costs less than $180. Bravo ! I  couldn’t help but relate this to the low infant mortality rate in Finland and thought about how many mothers in low income settings would find it appealing with strategies/innovations like this to seek care and  deliver in health care facilities.

Fig 1: Maternity Box,Finland and its contents  & Image Courtesy-BBC



Joy Teni is a newly appointed midwife in a primary health care center in South Sudan. After taking charge in the only PHC in this northern region , she realized that women only opted to use the natural family planning –Lactational Amenorrhea Method ( LAM ) and believed that modern methods would prevent them for giving birth in future. In an attempt to change this situation , Joy created a visual display of family planning methods which she used  during antenatal care visits, as well as with post-natal mothers and husbands. Briefly after doing this she noticed a change in pattern of using the modern family planning methods. And how much did this cost ?Zero. Marketing an old idea into a new one is also innovation and What a simple and effective way to address the problem!

Fig 2: Modern Family Planning Methods, Display-South Sudan & Image Courtesy:MSH


Do I think we can address serious issues within health systems by simple innovations? Yes.

What’s stopping countries with limited funding to take advantage of innovations like this?If critics consider that these innovations are contributing to the problem of healthcare funding, it only seems reasonable to argue and show how successfully they can contribute to a solution.

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Healthcare in Conflict: Implementing Reform during Reconstruction



Social uprising is the new normal. This is evident to anyone with access to a television within the past few years. From Occupy Wall Street to the wonders of the Arab Spring, people all over the world are demanding changes to a status quo where a small minority seemingly reaps all benefits the world has to offer while leaving the majority to fight for remaining crumbs. In these movements, the central ideology being fought for is the idea of justice. The faces of these unjust societies range from authoritarian regimes to unchecked capitalist powerhouses. As the process of reconstruction takes place (whether it be physical or mental), a common demand is the reform of health care systems. This is not surprising considering the intertwined nature of the right to health with the mechanisms through which they are disseminated.

A common hallmark of pre-conflict nations’ is an inequitable distribution of health care goods and services. In the case of the Arab Spring, democratization of governments creates an interesting opportunity to renovate their health care systems from the ground up. “The framing of social issues into a rights-based framework allows the world to see the marginalized as protagonists rather than subjects of oppressive systems. That gives them the agency to make social change, as opposed to when they were labeled as passive recipients of generosity” (2). New demands call for new ways of ensuring people’s right to health.

So how is this done? For starters, certain factors have to be taken into consideration. They include:

  1. Health status of the nation
  2. Acute and future health care needs of the population
  3. State of health care infrastructure post conflict
  4. How was health care delivered prior to conflict
  5. Availability and capabilities of the health workforce

Once you know what you are actually working with, a plan can be set in motion. Health care redevelopment is another stage driven process with many overlapping actions which includes:

  1. Development of a national policy framework,
  2.  Reliable financial plan
  3. Equitable service allocation plan
  4. Institutional and human capacity building
  5. Infrastructure redevelopment
  6. Community development and engagement with civil society

 As we continue to witness countries make these transitions, special attention will be paid to the manner in which health reform is implemented. The reprogramming of people’s expectations requires incoming governments to take heed if peace is what is sought. In this respect, it could be stated that the success of reform implementation is an indicator of long term stability since it is accepted that an “…early commitment to reform is one of the most effective tools new governments can use to prove their legitimacy” (2). 





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Implementing (faith in) Reform



The process of putting a decision or plan into effect; execution.



To make changes in something, typically a social, political, or economic institution or practice, in order to improve it.

To implement healthcare reform is to execute massive systematic change that will improve health, no small charge for any government. (See: Affordable Care Act). But Webster doesn’t mention the most important factor in achieving the implementation of reform…


 The People!


We cannot implement reform until we acknowledge and appreciate who drives change, and true reform cannot occur without their buy-in. Any country could come up with the best healthcare system in the world, and it will mean nothing if its citizens don’t have enough faith in the system itself to utilize it.

Here in the United States, we love our freedom. We love it so much that we will kill for it, even ourselves. God help the fool who tells us we can’t eat food past 8pm, or who mandates that our sodas come in smaller containers. But when it comes to that heart surgery to unclog our arteries or that medication to lower our blood pressure, you better believe we have a right to demand it. How do you implement healthcare reform in a country that prides itself on life, liberty, and the pursuit of a Big Mac? How do you create pride, faith, and hope in a system people know they need but spend their lives actively avoiding?

Maybe it’s a case of lost hope, specifically in the ability of governments and corporations to deliver. If people are going to buy into a healthcare system, that system better buy into them. I believe that people want to be healthy. (As students of global health we have to believe that to keep our sanity!) I have to believe more than just the fear of going broke due to accident or illness prompts us to generally agree that having health insurance is a good thing. I am less inclined to believe that Americans have bought into the Affordable Care Act, and it is this lack of faith that is paralyzing.

So how do we create it? Since Americans seem hesitant to learn from healthcare models outside our borders (a big part of our problem in the first place), a look at the Veterans Administration healthcare system proves that creating a system that people value is invaluable to the success of health reform. The VA overcame a reputation of bureaucracy, hospital-centered care, and staggering inefficiency in the 80’s and 90’s to become the largest integrated healthcare system in the US today, recognized for leadership in dispensing information, improving performance, caring for more patients with fewer resources, and setting national benchmarks in patient satisfaction.1 The VA is arguably one of the best examples of a healthcare system absolutely dedicated to servicing the needs of its clients. Not only do vets buy into the system because they are entitled to its lifetime benefits, but because they have faith their healthcare providers have bought into them. The VA was able to enroll 800,000 new clients in 2002 because they created a system that people wanted to be a part of.1

I believe that people value health; It’s about time they valued their healthcare. But change won’t happen until the users believe that it will, and it is faith in the reform itself that ultimately decides its fate.

The proof is in the pudding. Or maybe, in this case, the frozen yogurt. 


1Perlin, J. B., Kolodner, R. M., & Roswell, R. H. (2004). The Veterans Health Administration: quality, value, accountability, and information as transforming strategies for patient-centered care. The American Journal Of Managed Care10(11 Pt 2), 828-836.

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How to Unlock Reform When Keys Are Used for Protection

Growing up in Brooklyn in the 90’s, I sometimes used to run home with my keys between my fingers, Wolverine style, in case an attacker featured on the local news appeared. I, personally, thought it was an unusual habit until I started sharing with other women who told me they had their own versions of defense armor.

The common fear is a symptom of a bigger problem: the high prevalence of violence against women. A 2013 study by the World Health Organization, London School of Hygiene and Tropical Medicine and the South African Medical Research Council, produced this grim fact: 35.6% of women surveyed in 80+ countries reported physical and/or sexual intimate partner violence (IPV), or sexual violence by a non-partner. That’s more than 1 in 3 women worldwide.

With the United Nations International Day for the Elimination of Violence Against Women quickly approaching on November 25th, the global community is reminded of how much work still needs to be done.

Sadly, for such complex and deeply rooted issues like gender-based violence, there’s no specific cure for which to fundraise and distribute. But, the WHO believes that public health’s direct service and cross-disciplinary approach can be used to heal those who have been affected and deter future incidents from occurring. In response to an attack, women will most likely seek medical care. As the first person she sees, the report suggests training and equipping all healthcare workers with the necessary tools to treat the patient’s physical and mental health.

The prevention part is a bit more involved and calls for comprehensive reform, including enhancing government participation in enforcing policies and laws that condemn gender-based violence, empowering women through education and financial support, and changing social norms that perpetuate violence against women, among other reforms dependent on the culture and context. The recommendation is to find and finance local approaches, such as these two UN Women endorsed programs:

A Call for Help in Samoa

The Samoa Victim Support Group (SVSP) launched a 24-hour help line as a prevention and response mechanism for the 1 out of every 2 women who have reported IPV nation-wide. The service provides counseling, accommodations in local safe houses, and reports to local police. Knowing that someone is there to listen and help has led to about 2,000 calls in since it began in April 2013.

Patrol by Street Vendors in Fiji

In Suva (whose population is almost the size of Samoa’s!), the Streetwize Project turned to the large population of street merchants to publically condemn and arrest men they witness commit violent acts against women. The selected individuals received trainings by Streetwize on how to identify and approach gender-based violence and by the Community Police Unit on how to perform citizen’s arrests. 64% of women in Fiji report IPV, a statistic that will hopefully decrease with continued efforts to change morals.

On this November 25th, I’ll be thinking about these organizations and the many others who fight for keys to be used as just that: keys.

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We’re all in this together! … or are we?

Implementing reform of the Affordable Care Act has been a major point of interest in the media recently.  There have some discrepancies between the different enrollment systems.  Implementation on state level through state based exchanges has been going well since the opening on Oct 1.  However at the federal level there have been many different issues with implementing the new reform and enrollment processes.  At the state level there is better outreach, better functioning of the websites, more accessibility, and more direct help for coverage sign up.  For example in Connecticut (my home state woohoo!) has had 4,418 enrolled in Connecticut as of a week ago, outpacing other states and the national enrollment.

This does not fair well for those living in states that have not opened exchanges.  Altogether, 106,000 people have enrolled in health coverage nationwide last month, a figure far below administration projections.[1]

Check out CT’s user friendly site!

Obamacare-healthcare-exchange-website-please-wait-AFP<— The dreaded!

What does this mean for the US? Although the Affordable Care Act is a federal program and reform for the whole country, there are many pitfalls to this system including the fragmentation of having state by state exchanges.  It is still early in the reform implementation process to fully see how this all will unfold. However looking to other countries that have implemented reform successfully can be somewhat of an indicator.  Health insurance design has a major impact on access, cost and the health of a country.  Countries such as the UK and Canada which have no cost sharing have high rates of equitable access to care throughout the country no matter age or income level.  Due to cost sharing the burden of cost is reduced and creates more access for low income patients to seek care without worry of the cost.  With no limits on deductibles and complex insurance systems, the US has very low accessibility and high costs.  The US is a unique country in that it creates disparities through both Medicare and Medicaid and poses a major challenge for equity promotion in the country.[2]  This inequality is further exacerbated through the decision to implement state by state exchanges.  There needs to be action at the state and federal level to better implement the reforms so that all Americans can gain the access they need to health care.  The country is still at the inauguration of implementing the reform here in the US, hopefully the federal enrollment system will be able to distribute access to health care in a more equitable manner than we are currently seeing (for optimism sake!).

For more information and to follow the implementation timeline of the ACA check out

[1] Levey, N. (2013) Healthcare plan enrollment surges in some states after rocky rollout.,0,6486939.story#ixzz2lFQiSJEm

[2] Cathy Schoen, Robin Osborn, David Squires, Michelle M. Doty, Roz Pierson and Sandra Applebaum
(2010) “How Health Insurance Design Affects Access To Care And Costs, By Income, In Eleven Countries” Health Affairs, 29.

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