Maternal Health Vouchers

A Cost-Effective Solution for Safe Motherhood in Kenya

Many women do not receive adequate maternal health care due to the high-cost of services, which can result in financial catastrophe for uninsured, low-income families around the world. As of 2005, the World Health Organization estimated that 44 million households spent over 40% of their expendable earnings on health care, ultimately forcing 25 million families into poverty. ¹ Health care financing through a subsidized voucher program is one possible solution to address this issue. However, the effectiveness of vouchers in actually reducing costs for individuals depends on the following: 1) whether service and transportation costs are subsidized, 2) the degree of service availability, and 3) community perceptions about the quality of care. Focusing on financial burden, a recent study examined the effects of a reproductive health vouchers program on out-of-pocket expenses for family planning, antenatal, delivery and postnatal care services in Kenya.²

Health care Spending in Kenya

Over the past decade, government spending on health care in Kenya has remained consistently lower than that of neighboring countries. As a result, out-of-pocket spending is the largest source of payment for health care services. From 1996-1999, individual payments comprised 42%-48% of total health care expenditures. This financial burden is catastrophic for 5% of Kenyan households and even drives roughly 1.5 million people into poverty annually.³

Reproductive Health Vouchers Program

The Kenyan government implemented the reproductive health vouchers program in efforts to reduce maternal and infant deaths by increasing the rates of childbirth in health facilities and improving access to health services. Essentially, by subsidizing the cost of reproductive health care, the poor are incentivized to use those services. The program consists of three components: 1) safe motherhood (focuses on pregnancy and childbirth), 2) long-term family planning, and 3) gender-based violence recovery services. Firstly, the safe motherhood voucher covers four antenatal care visits, delivery care (e.g. Caesarean section), postnatal care within six-weeks, and treatment of neonatal complications. Secondly, the family planning voucher covers long-term prevention, such as implants, intrauterine contraceptive device (IUCD), and surgical contraception. Thirdly, is a gender-based violence recovery services voucher (available to all women). Since 2006, the program is being rolled out to various communities over time.

Photo: Global Health Photo

Methods

To examine the impact of the vouchers program, two rounds of surveys were administered to neighboring counties with similar population characteristics and available health facilities.

However, one county received vouchers while the other did not. Surveys were completed from May 2010 to July 2011 by 2,933 women aged 15-49 years, and from July to October 2012 by 3,094 women of similar ages. Statistical analyses (e.g. multivariate linear regression) were then conducted to assess the difference in out-of-pocket expenses and rates of care among voucher and non-voucher communities.

Results

Use of reproductive health services

Vouchers → more women received maternal health care

Over time, more women used the safe motherhood voucher when available. This increased from 15% to 44% by 2012. These women also used private health facilities at a much higher rate than women without vouchers. However, the use of family planning vouchers did not significantly change over time, as the number of women who paid for those services remained the same.

Changes in payment for services

Vouchers → less women paid out of pocket for safe motherhood services

Women from voucher sites paid significantly less for antenatal, delivery and postnatal care services than those from non-voucher sites. While vouchers contributed to less women paying for family planning, the greatest change was related to safe motherhood services.

Table 1. The average amount paid for health services (2010 – 2012) among voucher versus non-voucher sites.

		Voucher Sites	Non-Voucher Sites
Family Planning		No change	52% Increase
Safe Motherhood	Antenatal Care	20% Decline	78% Increase
	Delivery Care	52% Decline	16% Decline
	Postnatal Care	90% Decline	40% Decline

Implications

The findings of this study suggest that increasing the use of vouchers will result in significant cost savings for women who receive reproductive health services. Marketing campaigns and increasing the number of health facilities offering vouchers can help achieve this goal. Ultimately, providing financial assistance and access to health care can protect the most vulnerable individuals from being forced into poverty.

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Photo: University of Washington, School of Public Health

References:

1. World Health Organization (WHO). Designing health financing systems to  reduce catastrophic health expenditure. Technical Briefs for Policy Makers  No. 2. Geneva: WHO; 2005.

2. Obare, F, Warren, C, Kanya, L, Abuya, T, and Bellows, B. Community-level effect of the reproductive health vouchers program on out-of-pocket spending on family planning and safe motherhood services in Kenya. BMC Health Serv Res. 2015; 15: 343.

3. Chuma J, Maina T. Catastrophic healthcare spending and impoverishment in Kenya. BMC Health Serv Res. 2012;12:413.

4. Featured image: UNFPA

Humor, Anger and Incivility

Editorial

Techniques for using laughter for emotional transformation.

6-reasons-why-laughter-is-the-best-medicine

Photo: The Chopra Center

Feeling swamped, burned out and frustrated at work? Don’t worry, you’re not alone. In this fast paced society, overworking is common and even socially acceptable. Today, job expectations involve long hours slaving over a full plate of responsibilities that only seem to move from excessive to moderately tolerable. If you’re not stressed out then you must not be working hard enough, right? Wrong. At some point, this view became acceptable as genuine dedication was replaced with corporate hustling. But at what cost?

Burned out employees are more likely to experience emotions that can negatively impact work performance and overall well-being. This includes feelings of stress, frustration, disappointment, annoyance and resentment. If left unchecked, these emotions can easily spiral into anger with disastrous consequences. When acting from a place of rage, the outcomes can be devastating.

HUMOR FOR BETTER HEALTH

Humor provides an outlet for better health in a stressful work environment. When demands are high, people are more likely to be on edge. For those with a low tolerance for stress, this may lead to a reduction in creativity and innovation. In the worst cases, interpersonal conflicts arise, collaborative efforts demise, and frustration and anger ensues.

There are many ways in which humor serves as an effective tool for stress reduction and anger management. On a physical level, it minimizes the effect of cortisol, which is the “fight-or-flight” hormone released during highly stressful situations. Additionally, humor relaxes the body and releases more of those “feel good” hormones. Beyond that, humor also benefits mental health by promoting community bonding, solidarity and even creativity.

HOW TO LAUGH MORE

Laughter can effectively defuse rage by using opposite emotional states. On one end, anger is a rigid and serious emotion that occurs when expectations are not met. In contrast, humor is a flexible emotion that requires out of the box thinking. Therefore, in order to transform anger into humor, you must remember to not take life too seriously. This can be done through visualizations or drawings. For example, if you think of a colleague as a “dirt bag”, try to imagine an actual bag of dirt sitting on a desk, attending meetings and making calls. While it may appear “silly”, using humor in this manner can help to reduce tension and allow you to later address problems more constructively.

Next time rage is on the rise, take a step back and try to examine the situation in a lighthearted manner.

When events are taken lightly, humor has the opportunity to seep into the lives of even the most stressed out individuals. For example, in a 2017 study presented in the Journal of Managerial Psychology, researchers found that business executives, lawyers and doctors admitted to swearing in the workplace. While profanity is generally unacceptable in this environment, positive outcomes were still reported at the individual, interpersonal and group levels. As a result of not taking swearing too seriously, professionals and their colleagues were able to react to profanity with humor rather than anger. Numerous positive results were reported, including stress-relief, as well as enriched communication and social interactions. Overall, this study illustrates the benefits of experiencing life from a lighter and more humorous state of being. While I am not condoning profanity at work, I am endorsing life with more laughter.

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Reference

Featured Image: http://www.tipsywriter.com/blog/wp-content/uploads/2014/05/laugh-quotes.jpg

Millennial Workforce

Editorial

Spoiled, Lazy & Conceited – Shifting Perceptions to Engage Millennials

Stress-free strategies for cultivating passion in business.

Photo: Times Jobs

By 2030, millennials or Gen Y will account for 75% of the global workforce. ^(1,2)Engaging this young and technologically savvy group requires innovative tactics. What worked for past generations may not necessarily produce the same outcomes for Gen Y. Currently, 72% of U.S. employees are disengaged or actively disengaged. The high cost of employee turnover is estimated at 1.5 to 3 times an employee’s salary. This is due to the cost of recruitment, loss of institutional knowledge, training new hires, loss of member relationships and impact on morale. Therefore, it is vital that employers understand generational differences in order to implement effective interventions that foster employee commitment and retention. While the media has often painted Gen Y unfavorably—entitled and self-absorbed—the truth behind the millennial mindset is likely more complex. With increased attention, researchers are now examining the motivations of Gen Y for the purposes of cultivating corporate environments for the modern age.

Table 1. Definitions of Generations

Name	Span of Birth Years
Baby Boomers	1944-1964
Gen X	1965-1980
Millennials (Gen Y)	1981-1995

In a 2016 study by Indiana University, 1,798 retail workers were surveyed in order to examine generational mindsets and whether a positive work environment was associated with employee loyalty. ⁽¹⁾Researchers found that when compared to Gen X or Baby Boomers, millennials had drastically different perceptions of work, especially in regards to the concepts of duty, drive and reward. Additionally, millennials did not conceptually link organizational commitment with workplace culture. Therefore, having a positive workplace environment is not enough for millennials to stay committed to a particular company. Instead, they seek organizations that meet their needs for contribution and fulfillment.

Based on the findings in this study, numerous strategies are recommended to engage millennials in a manner that minimizes stress. For example, managers could adjust their performance appraisal process by showing millennials how their work positively supports organizational objectives and goals. Doing so cultivates a greater sense of meaning and commitment to the team. It also addresses three traits that researchers have found to be prominent in the millennial mindset: teamwork, communication with superiors, and frequent feedback. Reframing concepts of duty, drive and reward can ultimately facilitate a more productive environment, with a workforce that is committed, passionate and loyal. By embracing differences and acting with empathy, corporate leaders are shaping workplace environments that foster employee well-being.

Recommendations for engaging millennials:

Cultivate Duty

Show how individual work connects to the larger team goals.

Encourage Resilience

Frame failure as a positive learning experience that encourages alternative actions.

Support Innovation

Position work requests in terms of the larger organizational context.

Increase Communication

Promote frequent interaction with superiors through a performance evaluation plan that increases organizational communication.

Provide Feedback

Frequently assess activities and provide tangible evidence of appreciation.

learning-to-love-the-millennial-workforce

Photo: Metro Fax

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REFERENCES

Cambodia

Editorial, Uncategorized

Photo: UNICEF Cambodia, Antione Raab

CHRONIC DISEASES: A GLOBAL PANDEMIC

Chronic diseases have risen to the top as the leading causes of death and disability worldwide. Once considered a problem for the elderly in developed nations has now become a global pandemic. In 2012, over 50% of adults in the U.S. had one or more chronic disease. By 2020, chronic diseases will account for 73% of all deaths across the globe. However, nearly 80% of these deaths will occur in developing countries. The inequitable distribution of resources and access to healthcare will ultimately result in the greatest harm to the most vulnerable populations.

Cambodia, like many other developing nations, is experiencing a rise in noncommunicable diseases (NCDs), pervasive and long-term ailments that include cancer, chronic respiratory disease, diabetes mellitus, and cardiovascular disease. There are various determinants that can contribute to the rising prevalence of NCDs, including genetics, lifestyle choices, and the environment. While negative behaviors can often be changed through targeted public health interventions, ultimately, the social and physical environments must also change in order to support individuals in making healthier choices.

From a macro perspective, the current health status of Cambodia’s population is greatly influenced by its economic state of development and health care infrastructure. Ranked as a low-income country by the World Bank, Cambodia has a Gini coefficient of 31.8 and a Gross National Income (GNI) of $2,890 per capita.¹⁵ For the population of 14,865,000, inequity is high across socio-economic groups and noticeably different between rural and urban areas. This unequal distribution of wealth and resources inevitably impacts access to care. For instance, greater health care barriers are faced by 80% of the population, who populate rural and remote areas with minimal access to medical treatment facilities. Additionally, poverty is another barrier to care, as 45.9% of the population lives on less than $1.25 per day. ¹² As a result, nearly half of Cambodia’s population struggles to obtain daily necessities and is unable to afford the high cost of medical care, which accounts for over 60% of total health expenditures.¹²

global-witnesschhean_chenda_12_compressed-width-1280

Photo: Global Witness, Chean Chenda

Photo: Daily Mail.uk

It has also been speculated that the lack of access to health care has contributed to the country’s lower life expectancy at birth, which according to the World Health Organization (WHO) is 75 years for females and 70 years for males. ¹² Furthermore, the crude birth rate is 25 live births per 1000 people, while the crude death rate is 6.70 deaths per 1000 people. ¹⁷ Additionally, the fertility rate is 2.9 births on average per woman over a lifetime. ¹¹All of these factors are contributing to the rising demand for health care to both meet the needs of the growing population and minimize preventable deaths. ¹¹

The greatest suffering is experienced in rural communities, which lack access to available health care providers to adequately meet their needs. In 2008, there were only two physicians and eight nurses/midwives available for every 10,000 people living in rural areas. ¹⁷Additionally, by 2011 there were only eight health facilities and 72 hospital beds available for every 100,000 people. ¹⁷ However, during the same year, there were 710 new nursing graduates and 134 new medical school graduates. ¹³ This illustrates that while the number of nurses entering the health care workforce was and is promising, the shortage of physicians and lack of available health care facilities still remains problematic.

In addition to a lack of medically trained providers, rural communities face numerous obstacles in accessing care. For one, quality is a major concern. A substantial part of the population, approximately 21%, receives care from the private non-medical sector, which is comprised mostly of traditional and religious healers.¹³ This is concerning since most of these private facilities are not actively regulated, thus, making the quality of assurance questionable. Similarly, 49% of medical treatments occur through private facilities where quality assurance and regulation is minimal. ¹⁷ As a result, this negatively impacts the ability to prevent (via screening), treat, and manage NCDs for the most affected groups (e.g. low socio-economic status). This environmental barrier must change in order to provide greater access to health care nationwide.

While Cambodia has many environmental obstacles, there are also several opportunities that can be utilized to improve public health. For instance, the increasing rates of education can be a means to share knowledge and facilitate change. Currently, the primary school enrollment rate is at 98% and the total adult literacy rate is at 77.6%. ¹² Education may serve as an outlet to inform the public on the negative consequences of poor behaviors (e.g. smoking) and how to alternatively make healthier choices.

Photo: UNDP

Another opportunity is to utilize the international aid coming into Cambodia. In 2010, contributions targeting health care reached $199 million.¹²However, more than half of this aid went towards treating communicable diseases, such as HIV, TB and Malaria. A focus on infectious diseases has swept across the international community, non-governmental organizations (NGOs) and the Cambodian government. Multi-sectoral collaboration (including many of the 30 aid partners), has given rise to new policies, which focus monetary funds primarily on lowering infectious disease rates. The implications of such an agenda is that the prevention and treatment of many noncommunicable diseases may be overlooked.

In order to develop a broad and accessible healthcare system that benefits all people, a stronger emphasis needs to be placed on the prevention and treatment of NCDs. Based on current rates, chronic diseases will have the greatest impact on population health overtime. The result of this focus will inevitably be perceived in the near and far future. Ultimately, a greater percentage of the population will benefit from access to healthcare and an improved standard of living overall.

Photo: Buffalotours

The Rising Burden of NCDs

Studies show that chronic diseases are increasing in prevalence, while communicable, maternal, neonatal, and nutritional causes of disability-adjusted life years (DALYs) are declining.¹⁸ DALYs represent the number of healthy years lost to due disability or premature death. According to the World Health Organization’s 2014 Noncommunicable Diseases Country Profile on Cambodia, NCDs caused 44,200 deaths accounting for 52% of all total deaths. ¹⁵ By comparison, communicable, maternal, perinatal and nutritional conditions only accounted for 31,450 deaths or 37% of total deaths. ¹⁵This trend has been quantified by various studies, which provide evidentiary support for why more agency should be placed towards the prevention, treatment and management of NCDs.

The Global Burden of Diseases, Injuries, and Risk Factors Study compared changes in disease rates in Cambodia from 1990 to 2010. ¹⁸ This study determined the greatest burden by the absolute number of DALYs lost and then ranked each disease from 1 (best) to 15 (worst) according to the age standardized DALY rates. In 1990, the leading causes of DALYs lost were due to lower respiratory infections (rank: 8), followed by diarrheal diseases (rank: 3), and then malaria (rank: 8). In 2010, the leading cause of DALYs lost still remained to be lower respiratory infections but with a lower ranking of 4. However, the disease with the second greatest burden was now ischemic heart disease (rank: 13), followed by stroke (rank: 12). Overall, from 1990-2010 lower respiratory infections declined by 50% while ischemic heart disease increased by 75% and stroke increased by 55%. ¹⁸ Additionally, diarrheal disease, which was once the leading cause of burden, showed the greatest decrease in DALYs by 50%. ¹⁸ Similarly, other communicable diseases have had great reductions in DALYs, such as malaria (40%), meningitis (25%), and tuberculosis (10%). ¹⁸ In contrast, from 1990-2010, many NCDs have increased in disease burden, such as diabetes (110%), Cirrhosis (85%), COPD (25%), and other cardio and circulatory diseases (20%).¹⁸ This shows that infectious diseases are declining while NCDs are rising in prevalence and severity.

Cambodia's Homeless on the Streets of Phnom Penh

Photo: Paula Bronstein, Getty Images

Since 2010, the prevalence of NCDs has continued to rise. In 2014, 7,400 people suffered from a stroke, while diabetes prevalence rose to 229,000. ¹⁴ The annual environmental burden for cardiovascular disease was calculated at 4 DALYs per 1000 capita. ¹⁴ In addition, cancer now affects 6,842 males and 8,374 females in Cambodia. ²¹ The most common cancers in males include liver (1,444 cases), lung (796 cases), and colorectal cancer (445 cases). ²¹By comparison, the most common female cancers are of the cervix uteri (1,512 cases), breast (1,255 cases), and liver (820 cases). ²¹ According to the WHO, the annual burden of lung cancer is 0.3 DALYs per 1000 capita, while for all other cancers is 2.0 DALYs per 1000 capita. ¹⁴Overall, the burden of cancer is high, which means that there is a large number of preventable deaths that are associated with unhealthy environments.

NCDs cause tremendous suffering, especially for individuals who go untreated. This is compounded with the fact that a majority of NCD deaths occur in individuals under 60 years old, with males accounting for 56.2% and females accounting for 34.8%. ²⁰ This is highly problematic since most NCD deaths impact the working population, which reduces the labor force in Cambodia. The economic impact is high, as the productivity losses associated with absences, accidents and disability were found to be 400% greater than the cost of treatment.²⁶ Ultimately, the economy would benefit from increased population treatment for NCDs. However, when families have to contend with the early death and/or disabilities of a household financial provider, the families are pushed into poverty due to the high cost of chronic treatment. Therefore, it is clear that more cost effective prevention and treatment options are needed.

Photo: MSAVLC

Photo: ICRC

Major Determinants and Risk Factors of NCDs

There are various underlying socio-economic, cultural, political, and environmental determinants of NCDs. For instance, globalization and urbanization have contributed to more sedentary lifestyles and the wide distribution of highly processed foods. Low-income households are large consumers of these high calorie, low nutrient items, due to their extensive availability and low costs. Similarly, current government policies in Cambodia make cigarettes affordable and widely available. For instance, at current rates, a pack of Marlboro cigarettes costs only $1.15, which is surprisingly less than the cost of a liter of Milk selling at $1.99. ²⁵ The outcome is a physical environment that supports unhealthy behaviors, thus, enabling individuals to engage in common risk factors that are responsible for many chronic diseases.

This is evident in the high rates of modifiable risk factors such as unhealthy diets, physical inactivity, and tobacco use, as well as intermediate risk factors such as high blood pressure and obesity in the population. Currently, the prevalence of daily tobacco smoking among Cambodians is at 30%. ¹² Also, 12.1% of the population is overweight, 11.2% are physically inactive, 2.1% are obese, and 27.6% have high blood pressure. ²⁰ Furthermore, alcohol consumption is high at 5.5 liters per capita. ¹⁵ As such, it is no surprise that the leading risk factors that accounted for the greatest burden of disease in 2010 were dietary risks, household air pollution from solid fuels, and tobacco smoking, amongst others. ¹⁸

Of the total risk factors, dietary risks accounted for 9%, household air pollution accounted for 8.5% and smoking accounted for 7%.¹⁸ These risk factors lead to cardiovascular and circulatory diseases, diabetes, cancer, diarrhea, lower respiratory infections, chronic respiratory diseases, and many other NCDs. Public health efforts should focus on educating and empowering the population on methods to minimize the risk of developing these high burdening diseases. For instance, behavior modification could target the four main modifiable risk factors, which include tobacco smoking, alcohol consumption, dietary risks, and physical inactivity. Engaging in these behaviors can drastically impact health. For example, smokers are 20 times more likely to develop lung cancer than those who have never smoked. ²⁶ Similarly, inactivity and obesity resulting from poor diet increases the risk of death by at least 50%. ²⁶ Thus, focusing policy and public health interventions on lowering these risks would dramatically aid in reducing NCDs.

Photo: Phnom Penh Post

Health Policy Suggestions

Prevention: reducing risk by targeting tobacco, alcohol, physical activity, and diet

In order to promote population health and well-being, education efforts should focus on the most wide spread and damaging habits. Scientific evidence has shown this to be smoking, alcohol consumption, physical inactivity, and unhealthy diets.¹⁸One method to change these behaviors is through policy change. For instance, public health interventions can be implemented in primary schools, which have high attendance rates and therefore, serve as prime locations to educate children on nutrition early on. Also, government subsidies for fruits and vegetables may help alleviate the financial barrier for those unable to afford fresh produce. Additionally, the Cambodian government could legislate to follow global agreements by supporting the commitments under the Framework Convention on Tobacco Control (FCTC). Furthermore, public smoking bans in certain areas (e.g. schools) and tighter advertising regulations may also help reduce current smoking rates. Overall, education should approach the four main risk factors with an aim to change social norms, all the while implementing policies that promote a healthier physical environment.

Photo: Khmer Times

Cambodian villagers play volleyball at Sre Ampel village, Kanda

Photo: Financial Times

Treatment: strengthening quality and access to primary health-care systems

Increasing quantity and quality of healthcare providers

A greater medical workforce is needed to keep up with population growth and the expanded coverage of care. One method to increase healthcare professionals, such as physicians and nurses, is by providing financial incentives (e.g. loan forgiveness) for students to pursue healthcare in Cambodia. However, before newly trained professionals enter the field, there needs to be a national standard for quality of care that is implemented and assured. In order to do so, the health workforce strategy must be revised, and training (both pre-service and in-service) must be strengthened. ¹²Also, capacity building and knowledge sharing is needed in order to effectively spread information on standard treatment protocols and quality accreditation. This must occur across various health care groups, including the private sector and universities.

Increasing access to care – expanding coverage and reducing costs

One reason NCDs are negatively impacting Cambodia’s population is due to the lack of access to affordable quality care for screening, treatment, and disease management. However, the government has been making changes towards improving access. The Cambodian Government recently implemented the second Health Strategic Plan 2008-2015 (HSP2). Focus has now moved towards implementing the National Strategic Development Plan (NSDP) 2014-2018, which aims to improve population health and access to resources in a sustainable fashion.¹² One positive outcome is the expansion of Health Equity Funds (HEFs), which now cover 80% of the poorest people in the country and helps reduce the financial obstacles to receiving care. However, 20% of the poorest population still lacks access and the financial resources to obtaining quality healthcare. Therefore, this underserved population should be targeted through outreach services and facility based coverage. Strengthening and coordinating the resources of NGOs to assist in supporting the WHO’s Cooperative Strategic Agenda (2008-2015) may help achieve full coverage. ¹²This would also support the development of a national social health protection policy and financing mechanisms that target the poor.

In addition, low-cost medications should be provided to high-risk patients (e.g. hypertensive) or those requiring long-term treatment due to chronic disease (e.g. cancer). With advancing technologies, cost effective strategies for NCD prevention and treatment are becoming more common. Optimism is high, as new strategies are estimated to prevent 80% of diabetes and global heart disease in the future. ²⁶ For instance, high blood pressure can be effectively managed with medication at a low cost of only a few cents per day. ²⁶

Furthermore, with expanded coverage, screenings for disease must also increase. This is vital, since many NCDs are not curable, and most have a slow onset and long duration. Thus, early detection combined with treatment and management will provide the greatest benefit for patients. This has occurred in many high-income countries which have had increased rates of survival due to cancer treatments combined with early detection and screening. ²⁶ For instance, the 50-year relative survival rate for all cancers diagnosed in the US from 1975-1977 was 49% compared to 68% from 2004-2010, reflecting advances in treatment and early diagnosis. ²⁴

Overall, a serious problem faces Cambodia. On the one hand, policy makers must consider how to manage the growing element of NCDs and how to reduce the negative physical, financial, and national burden that they have on the population. On the other hand, decision makers must utilize the countries current resources of international aid and upcoming policy reform in order to emphasize education and implement broad-based healthcare availability. Ultimately, in order to reduce the impact of NCDs in the future and improve the health of Cambodia’s population, policy efforts should focus on expanding healthcare coverage, reducing treatment costs, and both increasing and improving screening, treatment, and disease management.

Photo: UNICEF Cambodia

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Maternal Mortality a Leading Cause of Death in Cambodia. Department of Planning and Health Information, Ministry of Health, Reproductive Health Association of Cambodia, PRB. 2003. Web. Received from: http://www.prb.org/Publications/Articles/2003/MaternalMortalityaLeadingCauseofDeathinCambodia.aspx
Degan, Guy. Lack of adequate sanitation triggers child health concerns in Cambodia. UNICEF. 7 May 2008. Web. Received from: http://www.unicef.org/infobycountry/cambodia_39558.html
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Wipfli, Heather. “Busting the Myths of NCDs.” University of Southern California. Lecture. 3 Feb. 2015.
Cambodia. Water Aid. 2015. Web. Received from: http://www.wateraid.org/where-we-work/page/cambodia.

Cover photo: http://timeoutvietnam.vn/Files/uploads/20151124/images/nhung-dieu-co-ban-can-biet-truoc-khi-du-lich-campuchia-3.jpg

APPENDICES

Table 1. Demographic and economic indicators for Cambodia

Indicator	Data	Latest year	Source
Total population	15,205,539 14,865,000	2013 2014	11 15
Crude death rate (per 1000)	6.70	2004	17
Crude birth rate (per 1000)	25	2004	17
Life expectancy at birth (yrs)	72 (Both Sexes) 75 (Female) 70 (Male)	2012	12
Total fertility rate	2.9 per woman	2013	11
Total adult literacy (%)	77.6%	2008	12
School Enrollment rate	98% net, primary	2012	3
Ranked low, middle or high income?	Low-income	2012	3
GNI per capita ($)	$2,890	2013	13
Gini coefficient	31.8	2011	3
Population living below $1.25/day (%)	45.9%	2010	12
Major imports	Refined Petroleum (10%) Light Rubberized Knitted Fabric (10%) Other Synthetic Fabrics (3.6%) Raw Sugar (2.1%) Gold (2%)	2014	3
Major exports	Postage Stamps (14%) Knit Sweaters (12%) Knit Women’s Suits (7.7%) Non-Knit Women’s Suits (5.5%) Non-Knit Men’s Suits (5.3%)	2014	3
% deaths due to infectious disease	20.16%	2011	8
% deaths due to NCDs	52%	2014	15
Top 3 diseases (in terms of deaths): 1. Ischemic heart disease (10.1%), 2. TB (9.6%), 3. Stroke (8.7%)	8.5 8.2 7.4 (Thousands)	2012	11
Top 3 diseases (in terms of DALYs lost): 1. Lower respiratory infections, 2. Ischemic heart disease, 3. Stroke	6,600 (Age standardized DALYs 1-15: 4) 8,500 (Age standardized DALYs 1-15: 13) 7,400 (Age standardized DALYs 1-15: 12)	2012, Age stand. DALYs: 2010	18 11
DALYs lost (%)	N/A
Top 3 causes of DALYs lost: 1. Maternal, neonatal, nutritional, 2. Other NCDs (non-malignant neoplasms; endocrine, blood and immune disorders; sense organ, digestive, genitourinary and skin diseases; oral conditions; and congenital anomalies), 3. Cardiovascular diseases and diabetes Risk Factors accounting for most disease burden: 1. Dietary Risks, 2. Household Air Pollution, 3. Smoking	~ 820,000 ~ 610,000 ~ 600,000 9% DALYs 8.5% DALYs 7% DALYs	2012 2010	11, 18

Table 2. Environmental situation for Cambodia

Indicator	Data	Latest year	Source
Environmental Health
Environmental Burden of Disease (%)	Deaths: 25% of total burden	2004	14
Top 3 greatest contributors to environmental burden of disease (DALYs): 1. Diarrhea, 2. Respiratory Infections, 3. Unintentional injuries (other than road traffic)	27 18 5.9 (DALYS/1000 capita) per year	2004	14
Deaths due to Indoor Air Exposure (Deaths/year)	6,600 deaths/year	2004	14
Deaths due to Outdoor Air Exposure (Deaths/year)	300 deaths/year	2004	14
Global Climate Change Threat	N/A
Water and Sanitation
Water Situation (scarcity)	33% people lack access to safe water	2008	27
Population using improved water and sanitation (%)	Sanitation: 22% (Rural) 76% (Urban) Overall: 67% Water: 61% (Rural) 90% (Urban)	2011	12
Burden of Disease from Diarrheal Disease	27 DALYs/1000 capita (per year) 10,000 children die/year	2004 2014	14 27

Table 3. Maternal, child and nutritional health situation for Cambodia

Indicator	Data	Latest year	Source
Maternal health
Antenatal coverage, at least once (%)	89%	2010	1
Antenatal coverage, at least four times (%)	59%	2010	1
Skilled attendant at birth (%)	71%	2010	12
Contraceptive prevalence (%)	51%	2007	11
Maternal mortality ratio	250/100,000 live births 170/100,000 live births	2010 2013	12
Child health
Annual number of under-five deaths	40/1000 (38/1000 live births ) * 388,880 births = 14,777.44 deaths	2012 2013	12 11
Infant mortality rate	45/1000 live births	2010	17
Child mortality rate	Prob. of dying before age 15: M: 20%, F: 16%	2012	11
Neonatal mortality as proportion of all under-five mortality	(18/1000 live births) * (38/1000 live births) = 0.47368 deaths (6,999.77 deaths/year) 18/1000 live births	2012 2013	12
Nutrition
Percent of babies born with low birth weight	8.2%	2012/13	17
Children exclusively breastfed < 6 months (%)	73.5%	2012/13	17
Children still breastfeeding 20-23 months (%)	3.51%	2010	1
Children moderately or severely underweight (%)	< 5 yrs old: 28%	2012/13	17
Children moderately or severely wasted (%)	11%	2010	1
Children moderately or severely stunted (%)	39.5% (under 5 years old: 40%)	2012/ 2013 2014	17 12
Vitamin A supplementation full coverage (%)	71%	2010	1
Households consuming iodized salt (%)	84%	2010	1
Children 1-year-old receiving measles immunization (%)	90%	2007	11

Table 4. Noncommunicable Disease situation in Cambodia

Indicator	Data	Latest year	Source
Major Diseases
Total # of NCD deaths	44,200	2014	15
% of NCD deaths to people under 60 yrs.	Males: 56.2% Females: 34.8%	2008	20
Stroke	7,400 Age Standardized Death rate: 101.49/100,000 ppl	2014 2011	15
COPD	1.1 DALYs/1000 capita per year	2004	14
Diabetes prevalence	229,000	2014	22
Cancer Deaths & Cases	Deaths: 13% = 11,050 Cases: M: 6842 F: 8374	2014 2012	15 21
Top 3 cancers (males) 1.Liver, 2. Lung, 3. Colorectal	1444 cases 796 cases 445 cases	2012	21
Top 3 cancers (females) 1. Cervix, 2. Breast,3. Liver	1512 cases 1255 cases 820 cases	2012	21
Risk Factors
Current Daily Tobacco Smoking prevalence (%) overall, males, females	30% 42% 3%	2014 2011	12 15
Physical inactivity overall, males, females	11.20% 11.40% 11.10%	2008	17
Alcohol consumption per capita	5.5 liters	2010	15
Overweight (%) overall, males, females	12.1% 10.8% 13.2%	2008	20
Obesity (%) overall, males, females	2.1% 1.5% 2.7%	2008	20

Covert Killer

Editorial, Uncategorized

By 2020, cancer cases in the United States are expected to increase by 24% in men and 21% in women.

Some of the most common types of cancer expected to rise include melanoma, prostate, liver, kidney, lung and breast cancers.

The Modern Paradox – Luxury is Toxic

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The modern lifestyle is one of luxury and convenience. From beverages to beauty products, todays consumers have a vast array of options to choose from to satisfy their daily needs. Freedom of choice in a competitive marketplace, that is the beauty of living in the United States.

In a minimally regulated system, overconsumption in the pursuit of luxury has become toxic. Companies now use chemicals to enhance products, reduce costs, and increase profits. The Food and Drug Administration (FDA) and the Environmental Protection Agency (EPA) are supposed to regulate exposure to toxic chemicals. However, the system has failed. There are approximately 85,000 registered chemicals, but only 200-300 have been tested for safety.

Chemicals are “innocent until proven guilty” in the U.S.

In America’s free marketplace, consumer products are considered safe until proven otherwise. The 1976 Toxic Substances Control Act (TSCA) was enacted to regulate potentially hazardous exposures. However, the act does not require chemicals to be tested for safety before being released to the public.

On June 22, 2016, the TSCA was updated with the passing of the Lautenberg Chemical Safety for the 21^st Century Act (LCSA). The intention is that the EPA will improve the screening of active chemicals used today for toxicity in humans. Whether or not this will actually work is unknown.

The number of chemically engineered goods has and continues to rapidly surpass the regulatory systems in place. Each year, approximately 2,000 new chemicals are introduced into consumer items. Personal care products, foods, and household cleaners are just a few places where they are present. We are all eating, drinking and using toxic products everyday. However, with the backlog in toxicity testing, we may never know what is killing us before it’s too late.

The Covert Killer: Caramel Color

Caramel coloring types III and IV in carbonated beverages contributes to 25% of the U.S. population’s exposure to the carcinogen, 4-Methylimidazole or 4-MEI (1). The U.S. National Toxicology Program (NTP) conducted experimental studies on rats and found that exposure to 4-MEI led to increases in leukemia, as well as adenomas and carcinomas of the lung. While no human data is available yet, these findings were enough to categorize 4-MEI as a carcinogen.

This manufactured caramel color has no other purpose than to make beverages appear darker. Companies believe that by including this chemical into soft drinks, it will ultimately lead to an increase in sales. Apparently, people prefer soda that’s brown not yellow.

CA Proposition 65: Labeling Toxic Consumer Goods

In 2011, California listed 4-MEI as a carcinogen under Proposition 65 of the Safe Drinking Water and Toxic Enforcement Act of 1986. Proposition 65 requires warning labels for any carcinogen exceeding a “no significant risk level” (NSRL). A no significant risk level is the lifetime average daily exposure associated with a 1-in-100,000 cancer risk (1). This amount for 4-MEI is equal to 29 μg/day. In response, soft drink manufacturers announced that they would lower the concentration of 4-MEI in products sold in California.

Years later, did they really follow through?

In a 2015 study by Johns Hopkins University, researchers tested the concentration of 4-MEI in 110 soft drink samples from stores in California, New Jersey, Connecticut, and New York (1). Various brands were tested, including A&W Root Beer, Diet Coke, Malta Goya, Diet Pepsi, Pepsi One and Regular Pepsi. The average and maximum amount of 4-MEI concentrated in beverages varied dramatically across brands and states. The highest and lowest concentrations across all locations was found in Malta Goya (mean: 945.5μg/L; maximum: 1104μg/L) and Diet Coke (mean: 9.8μg/L; maximum: 10.4μg/L).

A&W Root Beer

Diet Coke

Malta Goya

Diet Pepsi

Pepsi One

Regular Pepsi

Mean

4-MEI (μg/L)

68.2

9.5

963.3

78.4

119.7

75.9

61.8

10.2

915.8

304.5

501.5

291.2

Researchers found that 4-MEI concentrations were overall higher in samples purchased in the NY area compared to those purchased in CA. This is evidence that Proposition 65 and other state-level interventions can incentivize manufacturers to reduce chemical exposures and associated risks among consumers.

Soda Consumption: A Social Epidemic

The National Health and Nutrition Examination Survey (NHANES) calculated the average daily consumption of carbonated beverages in the United States (1). The highest consumption of soda was found among adolescents (ages 16 to 20 years old) and young adults (ages 21 to 44 years old), with approximately 57% of this population consuming 2-3 cans daily. However, this trend varied by beverage type. Colas were found to be the most popular beverage consumed, regardless of age. In contrast, root beer and pepper colas were the least popular.

Soft Drink Consumption

A& W Root Beer

Diet Coke

Malta Goya

Diet Pepsi

Pepsi

One

Regular Pepsi

Mean 4-MEI (μg/L)

68.2

9.5

963.3

78.4

119.7

75.9

61.8

10.2

915.8

304.5

501.5

291.2

Age Range (years old)	Soft Drink Consumption (% pop.)
Children (3-5)	30.1%
Adolescents (11-15)	56.5%
Young Adults (16-20)	57.1%	1.6 – 3.2 cans daily
Adults (21-44)	57.9%	1.5 – 3.5 cans daily
Adults (45-64)	48.4%
Older Adults (65-70)	34.9%

Cancer Risk

For this study, risk is defined as the lifetime excess risk of developing cancer associated with the consumption of soft drinks. United States federal regulatory agencies set an acceptable cancer risk goal for consumer products as 1 case per 1,000,000 exposed individuals.

Based on average daily consumption patterns and the concentrations of 4-MEI found in soft drinks, researchers identified which beverages posed the greatest risk for consumers. Malta Goya, Pepsi, Diet Pepsi and Pepsi One resulted in 4-MEI exposures with associated risks exceeding 1 excess case per 10,000 exposed individuals.

The lifetime risk of developing cancer is 100 times greater for consumers of caramel colored soft drinks with 4-MEI (Malta Goya, Pepsi, Diet Pepsi and Pepsi One)

Acceptable Risk: 1 case/1,000,000 exposed individuals

Current Risk: 1 case/10,000 exposed individuals

Cancer Burden

The consumption of soda is contributing to rising rates of cancer. But to what degree?

Burden is the lifetime (70 years) excess cancer cases associated with the consumption of beverages by the U.S. population. The number of people who will develop cancer in their lifetime from Pepsi One is approximately 1,000 in California and 4,000 in New York. Comparatively, the number of Malta Goya consumers predicted to develop cancer in their lifetime is roughly 5,000 in both states.

Average Exposure	Pepsi	Pepsi One	Diet Pepsi	Malta Goya	Coca Cola	Diet Coke
CA	1,044	958	628	5,011	167	76
NY	4,009	4,014	2,437	4,764	156	82

pepsi-soda-can-wallpaper-59351-61136-hd-wallpapers-1024x742

What Can We Do?

1. Federal Regulation

Advocates, NGOs and constituents should pressure policy makers to increase regulation on consumer goods with 4-MEI. Toxic exposure to this carcinogen is unnecessary and should be eliminated.

2. FDA Intervention

The FDA could set a maximum 4-MEI concentration level for beverages sold in the United States.

3. Avoid Drinking Soda

Individuals should avoid drinking soda with caramel coloring, especially Malta Goya, Pepsi, Diet Pepsi and Pepsi One.

Ultimately, relying on political regulations is not enough. The process of creating and implementing restrictions on carcinogens is too slow to keep up with the rapid pace of chemical engineering. Everyday, new toxins are being introduced into consumer products. Chemicals are continuously being modified and exposures are on the rise.

However, advocates should still pressure regulatory bodies to progress towards a system that more effectively minimizes harm to the population’s health. California’s Proposition 65 is one example of success where other states should follow.

People have power as consumers. By avoiding the consumption of soda, individuals can make a statement to companies about the quality of products desired. By choosing healthier alternatives to chemically enhanced products, people are shifting trends that influence what businesses produce in the future.

The most effective way to limit toxic exposure is with you. You have the power to create an immediate impact towards a healthier life. You choose what you eat, drink and use everyday. While our products may be toxic, our choices don’t have to be.

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REFERENCES

1) Caramel color in soft drinks and exposure to 4-methylimidazole: a quantitative risk assessment, Tyler Smith, et al., PLOS One, doi:10.1371/journal.pone.0118138, published online 18 February 2015.

2) Another reason to cut back on soda, Consumer Reports, news story accessed 20 February 2015 at consumerreports.org.

3) Popular soda ingredient poses cancer risk to consumers, Johns Hopkins University Bloomberg School of Public Health news release accessed 20th February 2015 Via EurekAlert!

Maternal Mortality

Editorial, Nina Kharazmi || Photography

830 women die from pregnancy or childbirth each day around the world.

99% of all maternal deaths occur in developing countries.

(World Health Organization)

Photo by: United Nations

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INTERNATIONAL WOMEN’S DAY

March 8^th, International Women’s Day (IWD), offers a great opportunity for people to champion gender equality as they celebrate the historical achievements of women in the social, economic, cultural and political fields (1,2).

For over a century, IWD has been recognized as a time when governments, industry, and NGOs collectively act to better women’s rights through rich and diverse activities, such as political rallies, business conferences, networking events and artistic performances. Today, we need this involvement more than ever as we move forward on a foundation of past historical success.

As we celebrate the past, we must look towards the future and continue to fight for women’s equality. There is still progress to be made, especially in regards to education, health, positions of power in business and politics, and the prevention of violence against women. The truth is clear: every girl deserves a future that is equal, safe and rewarding.

Photo by: Bill & Melinda Gates Foundation

Photo by: Medium

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WOMEN’S EQUALITY AND HEALTH

One way to close the gender inequality gap is to focus on reducing preventable maternal deaths. According to the World Health Organization (WHO), 830 women die from pregnancy or childbirth each day around the world (3). Nearly 75% of all maternal deaths are due to delivery complications, severe bleeding, infections, high blood pressure during pregnancy and unsafe abortions (5). In 2015, approximately 303,000 women died from maternal health complications, most of which could have been prevented (3).

Solutions to avoid or treat pregnancy complications are well known. It is vital that women receive prenatal and postpartum care, as well as skilled care during childbirth. However, women are unlikely to receive adequate care in remote areas and in regions with minimal skilled health workers, such as sub-Saharan Africa. In 2015, only 40% of pregnant women in low-income countries had received the four recommended antenatal care visits (3). Other factors that inhibit women from seeking or receiving care include poverty, distance, inadequate services, cultural practices and lack of information. These barriers must be addressed at all levels of the health system in order to tackle maternal mortality. The timely diagnosis and management of pregnancy related complications is a matter of life or death for the mother and baby.

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Photo by: Erin Goodrow

Photo by: New Security Beat

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THE SUSTAINABLE DEVELOPMENT GOALS

On September 25^th, 2015, member states of the WHO adopted the Sustainable Development Goals (SDGs) with 15-year targets to end poverty and ensure prosperity for all (4). One objective is to reduce the global maternal mortality ratio (MMR) to less than 70 per 100,000 births (3). However, 99% of all maternal deaths occur in developing countries, reflecting the inequities in access to health services. For example, the MMR in 2015 was 239 per 100,000 live births in developing countries versus 12 per 100,000 live births in developed countries. Additionally, over half of the global maternal deaths occur in sub-Saharan Africa, particularly among rural and low-income communities. Overall, women in developing countries have many more pregnancies and have a higher risk of death due to pregnancy. The probability that a 15-year-old woman will die from a maternal cause is 1 in 180 in developing countries versus 1 in 4,900 in developed countries (3). In order to achieve the SDGs, women need greater access to reproductive health services, especially those in low-resource settings.

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PRIORITIZING MATERNAL HEALTH

WHO and numerous organizations have been working to reduce maternal mortality rates by increasing research, providing evidence-based clinical guidance, setting global standards and delivering technical support. During the United Nations General Assembly in 2015, the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030) was launched as a road map for the post-2015 agenda presented in the SDGs. The aim is to end all preventable deaths of women, children and adolescents, as well as provide an environment for health to thrive. In order to implement this strategy, WHO and partners are working on the following regarding reproductive, maternal and newborn health care: addressing inequalities in access to services, ensuring universal health coverage, addressing causes of maternal mortality and morbidities, strengthening health systems and ensuring accountability for quality care.

For efforts to succeed, the world must unite in prioritizing maternal health. Advocates, organizations, and governments need to take a stand against women’s inequality and provide greater agency, support and resources towards tackling maternal mortality.

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REFERENCES

* Cover photo: Center for Strategic and International Studies

Tobacco

Editorial, Uncategorized

The Rising Prevalence of Tobacco Use in Developing Countries

https-static01-nyt-comimages20120821science21global_span21-global-jumbo

http-www-accrafm-comkitnescacheimages800x01-10629266

http-cloudfront-mediamatters-orgstaticuploaderimage20150706tobacco3

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TOBACCO & MORTALITY

“Tobacco is the only legal drug that kills many of its users when used exactly as intended by manufacturers” (15).

According to the World Health Organization (WHO), tobacco use is responsible for six million deaths each year (15). This includes an estimated 600,000 people who die from second-hand smoke. Health outcomes include death and/or disability from chronic diseases, such as cancer, stroke and chronic respiratory diseases. Additionally, smoking increases the risk of death from infectious diseases.

Overwhelming evidence suggests that tobacco marketing greatly influences tobacco use and initiation (3-5). As such, bans on tobacco marketing can greatly reduce individual tobacco use.

GLOBAL TRENDS IN TOBACCO USE

↓ Developed Countries ↑ Developing Countries

Tobacco use in many high income countries is decreasing rapidly. This is due to government marketing bans and increased public education about the harms of smoking. In contrast, the prevalence of smoking is increasing in many middle- and low-income countries. According to the WHO global report on trends in tobacco smoking 2000-2025, males are more likely to smoke than females, and the prevalence is rising most dramatically in the African Region and the Eastern Mediterranean Region (13).

Photo by: Merinews

Photo by: World Not Tobacco Day Africa

Table 1. Age-standardized prevalence of current tobacco smoking among persons aged 15 years and older (14,16).

Country	CURRENT TOBACCO SMOKING (%)
	Year 2000			Year 2015
	Men	Women	Both sexes	Men	Women	Both sexes
High-income
Canada	29.3	27.5	27.5	17.7	12.2	14.3
Sweden	32.8	32.9	32.9	20.4	20.8	20.6
Upper-middle-income
China	56.2	3.3	30.4	47.6	1.8	26.3
Lower-middle-income
India	33.8	5.7	20.2	20.4	1.9	11.0
Pakistan	35.2	7.5	21.8	41.9	3	22.9
Low-income
Zimbabwe	29.8	2.7	16.1	31.2	2.1	16.65

TOBACCO MARKETING TRENDS

Tobacco marketing is 81 times greater in Pakistan, India and Zimbabwe than in the United Arab Emirates, Canada and Sweden (7).

In 2003, member states of the World Health Assembly adopted the Framework Convention on Tobacco Control (FCTC) (6). This agreement provided 180 nations with evidenced-based steps to minimize tobacco sales and ban tobacco marketing. This legally binding treaty even provided agricultural alternatives to those growing tobacco, so as to minimize the economic hardships faced by local producers. Nearly 13 years later, what is the present state of tobacco marketing trends?

A recent study led by the World Health Organization examined the global tobacco marketing environment by comparing 462 communities located in 16 low-, middle- and high-income countries (1). Researchers found that exposure to tobacco marketing is 81 times greater in Pakistan, India and Zimbabwe than in the United Arab Emirates, Canada and Sweden (7). Additionally, the tobacco industry is targeting poor urban youth in developing countries (10-12). This is due to cheaper marketing costs and the greater potential to reach more people in densely populated regions. Furthermore, according to the WHO study (1), high levels of tobacco marketing (e.g. posters, print media and cinema) was even found in 14 middle- and low-income countries that had ratified the FCTC. Countries that ratified this agreement were required to implement a comprehensive ban on tobacco advertising, promotion and sponsorship. However, many developing countries are lacking in agency and governmental capacity to fully implement the recommendations of FCTC (2). This is worsened by the alarming influence of the tobacco industry in lobbying their interests (8,9).

Governments, NGOs, and other key stakeholders need to take a stand against the tobacco companies. Media and advocacy work must continue to focus on the populations currently being abused by corporate greed. Urban youth in developing countries are the greatest target of the tobacco industry, and therefore, should become a major focus for public education initiatives about the harmful effects of tobacco use. Nations across the globe have already taken a positive step forward by agreeing to the Framework Convention on Tobacco Control. People must now take the next step by supporting fellow nations in implementing this agreement to ban tobacco marketing. Financial resources, capacity building and continued media attention are needed now more than ever. A healthier and more equitable world is possible in the future, but there is a long way to go.

Photo by: Health Care Administration

Photo by: Pinterest

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If you enjoyed this post, please like & share below.

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REFERENCES

1) http://www.who.int/bulletin/volumes/93/12/15-155846.pdf

2) http://www.triplepundit.com/2015/12/developing-countries-targeted-tobacco-marketing/

3) The role of the media in promoting and reducing tobacco use. NCI Tobacco Control Monograph No.19. Bethesda: National Institutes of Health; 2008.

4) DiFranza JR, Wellman RJ, Sargent JD, Weitzman M, Hipple BJ, Winickoff JP; Tobacco Consortium, Center for Child Health Research of the American Academy of Pediatrics. Tobacco promotion and the initiation of tobacco use: assessing the evidence for causality. Pediatrics. 2006 June ;117(6):e1237–48. doi: http://dx.doi.org/10.1542/peds.2005-1817 PMID: 16740823

5). Pierce JP, Choi WS, Gilpin EA, Farkas AJ, Berry CC. Tobacco industry promotion of cigarettes and adolescent smoking. JAMA. 1998 Feb 18;279(7):511–5. doi: http://dx.doi.org/10.1001/jama.279.7.511 PMID: 9480360

6) World Health Organization. Parties to the WHO Framework Convention on Tobacco Control. Updated 26 July 2016. Retrieved from http://www.who.int/fctc/signatories_parties/en/

7) Gilmore, Anna. Big tobacco targets the young in poor countries – with deadly consequences. The Guardian. 1 December 2015. Retrieved from https://www.theguardian.com/global-development/2015/dec/01/big-tobacco-industry-targets-young-people-poor-countries-smoking

8) AMESCA regional plan 1999-2001. London: British American Tobacco: 1999. Available from: http://legacy.library.ucsf.edu/tid/kiz13a99/pdf [cited 2014 Jul 15].

9) Lee S, Ling PM, Glantz SA. The vector of the tobacco epidemic: tobacco industry practices in low and middle-income countries. Cancer Causes Control. 2012 Mar;23(1) Suppl 1:117–29. doi: http://dx.doi.org/10.1007/ s10552-012-9914-0 PMID: 22370696

10) Perlman F, Bobak M, Gilmore A, McKee M. Trends in the prevalence of smoking in Russia during the transition to a market economy. Tob Control. 2007 Oct;16(5):299–305. doi: http://dx.doi.org/10.1136/tc.2006.019455 PMID: 17897987

11) Gilmore AB, Radu-Loghin C, Zatushevski I, McKee M. Pushing up smoking incidence: plans for a privatised tobacco industry in Moldova. Lancet. 2005 Apr 9-15;365(9467):1354–9. doi: http://dx.doi.org/10.1016/S0140- 6736(05)61035-5 PMID: 15823388

12) Neuwirth B. Marketing channel strategies in rural emerging markets: unlocking business potential. [Internet]. Evanston: Kellogg School of Management; 2012. Available from: http://www.kellogg.northwestern. edu/~/media/files/research/crti/marketing%20channel%20strategy%20 in%20rural%20emerging%20markets%20ben%20neuwirth.ashx [cited 2013 Aug 15].

13) World Health Organization. Global Health Observatory (GHO) data: Prevalence of tobacco smoking. Accessed 1 December 2016. Retrieved from http://www.who.int/gho/tobacco/use/en/.

14) World Health Organization. Prevalence of tobacco smoking. Accessed 1 December 2016. Retrieved from http://gamapserver.who.int/gho/interactive_charts/tobacco/use/atlas.html

15) World Health Organization. WHO global report on trends in tobacco smoking 2000 – 2025. Updated 2016. Accessed 1 December 2016. Retrieved from http://www.who.int/tobacco/publications/surveillance/reportontrendstobaccosmoking/en

16) World Health Organization. WHO global reports on trends in prevalence of tobacco smoking 2015. (2015). Retrieved from http://apps.who.int/iris/bitstream/10665/156262/1/9789241564922_eng.pdf?ua=1

Pakistan

Editorial, Nina Kharazmi || Photography

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Honor Killings in Pakistan

Over 1,000 women are brutally murdered in Pakistan each year.

October 6, 2016

Photo by: Borgen Magazine

Pakistan is a patriarchal society where women’s behaviors are traditionally limited by cultural restrictions in order to preserve their chastity. Any deviant behavior is therefore deemed immoral and brings dishonor upon the family. Consequently, women labeled as deviant are often murdered by male relatives or neighbors in order to restore familial honor and reputation within the community (1). These brutal acts of murder are known as honor killings. Each year, over 1,000 women in Pakistan are murdered in the name of honor.

While “immoral behavior” includes infidelity, it also encompasses a range of unexpected behaviors. For instance, women are often murdered for being raped, refusing an arranged marriage, dressing “inappropriately” or acting flirtatious. It can also be warranted by familial quarrels over property ownership, inheritance issues, or a woman’s desire to marry for love. Many times women are even murdered on the basis of suspicion alone (2).

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Photo by: Gospel Herald

Human rights groups have been pressuring the Pakistani government to put an end to honor killings. However, authorities have been unsuccessful and have often even turned a blind eye. In many cases, murders are not even investigated, leaving perpetrators free from prosecution (3).

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Photo by: BBC

This issue has gained international attention, especially with the rising number of high-profile honor killings this year. One such case was Qandeel Baloch, a Pakistani social media star, who was strangled to death by her brother in July. Pakistani filmmaker and activist, Sharmeen Obaid, also heightened international attention towards this issue in her Academy Award winning documentary, A Girl in the River: The Price of Forgiveness.

In response to the rising campaigns for women’s rights, the Pakistani government passed a bill ensuring that killers receive a mandatory life sentence (4). Previously, a killer could be pardoned for murder if he gained forgiveness from the victim’s family. This new legislation no longer allows freedom from impunity. Even still, it remains uncertain whether this law is enough to deter honor killings. However, activists everywhere are celebrating this new step in the right direction towards ending violence against women.

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