HIV/AIDS and Empowerment of Women

One of the major themes to emerge out of our experience in India was seeing the impact of HIV/AIDS on women and the work that some of the programs we studied do to enlighten women about their human rights, teach them skills to negotiate safe sex, and reduce the stigma against HIV+ positive women. As of 2005, women accounted for 38% of India’s adult prevalence (0.9%)and as we all know women are biologically more susceptible to HIV infection. We also know that illiteracy, poverty and harmful cultural practices make women more vulnerable to gender violence, disease, and other forms of abuse.

One tool these programs seem to have in common is teaching women marketable skills like sewing, processing spices, or making trinkets to sell. Microfinance schemes have also been successful in empowering women to pull themselves out of poverty and abusive situations. If marketable skills are what empower women, the most important skill in the 21st century globalized and IT savvy India is computer skills. It seems to me that teaching rural illiterate women rudimentary reading, writing skills would give them more self efficacy than sewing and making trinkets. Semi-literate women can be taught rudimentary computer skills that they can use to find secretarial jobs etc. This all sounds easier than done because there are so many obstacles that these women face, including a society that places no value whatsoever on their lives, but these are just some ideas I have been musing about.
Any thoughts?

U.S. no longer tallest country in world

I'm posting this article in its entirety because I think it's very relevant to Public Health.

U.S. no longer tallest country in world

By MATT CRENSON, AP National WriterSun Jul 15, 12:22 PM ET

America used to be the tallest country in the world. From the days of the founding fathers right on through the industrial revolution and two world wars, Americans literally towered over other nations. In a land of boundless open spaces and limitless natural abundance, the young nation transformed its increasing wealth into human growth.
But just as it has in so many other arenas, America's predominance in height hasfaded. Americans reached a height plateau after World War II, gradually falling behind the rest of the world as it continued growing taller.
By the time the baby boomers reached adulthood in the 1960s, most northern and western European countries had caught up with and surpassed the United States. Young adults in Japan and other prosperous Asian countries now stand nearly as tall as Americans do.

Even residents of the formerly communist East Germany are taller than Americans today. In Holland, the tallest country in the world, the typical man now measures 6 feet, a good two inches more than his average American counterpart.
Compare that to 1850, when the situation was reversed. Not just the Dutch but all the nations of western Europe stood 2 1/2 inches shorter than their American brethren.
Does it really matter? Does being taller give the Dutch any advantage over say, the Chinese (men 5 feet, 4.9 inches; women 5 feet, 0.8 inches) or the Brazilians (men 5 feet, 6.5 inches; women 5 feet, 3 inches)?

Many economists would argue that it does matter, because height is correlated with numerous measures of a population's well-being. Tall people are healthier, wealthier and live longer than short people. Some researchers have even suggested that tall people are more intelligent.
It's not that being tall actually makes you smarter, richer or healthier. It's that the same things that make you tall — a nutritious diet, good prenatal care and a healthy childhood — also benefit you in those other ways.
That makes height a good indicator for economists who are interested in measuring how well a nation provides for its citizens during their prime growing years. With one simple, easily collected statistic, economists can essentially measure how well a society prepares its children for life.

"This is the part of the society that usually eludes economists, because economists are usually thinking about income. And this is the part of the society that doesn't earn an income," said John Komlos, an economic historian at the University of Munich who was born in Hungary, grew up in Chicago, and has spent the last quarter century compiling data on the heights of nations.
Height tells you about a segment of the population that is invisible to traditional economic statistics. Children don't have jobs or own houses. They don't buy durable goods, or invest in the stock market. But obviously, investments in their well-being are critical to a nation's economic future.

For several years now, Komlos and other researchers have been trying to figure out exactly why the United States fell behind. How could the wealthiest country in the world, during the most robust economic expansion in its history, simply stop growing?
"It's absolutely fascinating," said Eileen Crimmins, a demographer at the University of Southern California. "Maybe we've reached the point where we're going to go backwards in height."

Like many human traits, an individual's height is determined by a mix of genes and environment. Some experts put the contribution of genes at 40 percent, some at 70 percent, some even higher. But they all agree that aside from African pygmies and a few similar exceptions, most populations have about the same genetic potential for height.
That leaves environment to determine the differences in height between populations around the world, specifically the environment children experience from the moment of conception through adolescence. Any deficiency along the way, from poor prenatal care to early childhood disease or malnutrition, can prevent a person from reaching his or her full genetic height potential.

"We know environment can affect heights by three, four, five inches," said Richard H. Steckel, an Ohio State University economist who has also done research on height trends in the United States during the 19th century.
The earliest stages of life are the most important to the human growth machine; at age 2 there is already about a 70 percent correlation between a child's height and his or her eventual adult stature.
All of this means a population's average height is a very sensitive indicator of its most vulnerable members' welfare.

Not surprisingly, rich countries tend to be taller simply because they have more resources to spend on feeding and caring for their children. But wealth doesn't necessarily guarantee that a society will give its children what they need to thrive.
In the Czech Republic, per capita income is barely half of what it is in the United States. Even so, Czechs are taller than Americans. So are Belgians, who collect 84 percent as much income as Americans.

And those height differences translate into real benefits. A number of studies have shown that disease and malnutrition early in life — the same things that limit a person's height — increase a person's chances of developing heart disease and other life-shortening conditions later on. Though tall people are more likely to get cancer, they suffer less mortality overall than short people.
International statistics bear it out. Life expectancy in the Netherlands is 79.11 years; in Sweden it's 80.63. America's life expectancy of 78.00 years puts it in somewhat shorter company, just above Cyprus and a few notches below Bosnia-Herzegovina.

"Obviously America is not doing badly. It's not at the level of developing nations," Komlos said. "But it's also not doing as well as it could."
His latest research paper, published in the June issue of Social Science Quarterly, suggests the blame may lie with America's poor diet and its expensive, inequitable health-care system.
"American children might consume more meals prepared outside of the home, more fast food rich in fat, high in energy density and low in essential micronutrients," wrote Komlos and co-author Benjamin E. Lauderdale of Princeton University. "Furthermore, the European welfare states provide a more comprehensive social safety net including universal health care coverage."

In the United States, by comparison, an estimated 9 million children have no health insurance.
Komlos' most recent data indicate a small uptick in the heights of white Americans born between 1975 and 1983, a suggestion that the gap may finally be closing. But there has been no similar increase among blacks, a suggestion that inequality may indeed play a significant role in the height gap.
In another recent paper, Komlos and Lauderdale also found height inequality between American urbanites and residents of suburbs and rural areas. In Kansas, for example, white males are about as tall as their European peers; it's big cities like New York, where men are about 1.75 inches shorter than that, that drag America's average down.

Now Komlos has started comparing the heights of children to determine at what age Americans begin falling behind their peers across the Atlantic. Not surprisingly, he sees a difference from birth, an observation that suggests prenatal care may be significant contributor factor to the height gap.
But it is unlikely that Komlos will ever find one simple factor to explain why Americans have fallen behind other rich countries in height. In all likelihood it is caused by a combination of things — a little bit health care, some diet, a sprinkling of economic inequality.

"In some ways it gets to the fundamentals of the American society, namely what is the ideology of the American society and what are the shortcomings of that ideology," Komlos said. "I would argue that to take good care of its children is not part of that ideology."
Whether that's true is debatable; the height gap doesn't measure how much Americans love their children. But at a minimum it does indicate — in raw feet and inches — whether the nation is giving its youngsters what they need to reach their full biological potential, or selling them short.

I miss India

I was watching a stupid commercial on TV the other day that was supposedly set in India and it played some Indian music, and I felt a pang in my heart. Could this be? I miss India, but when asked what do I miss I can't really pinpoint it. Do I miss the trash everywhere, the noise, the pollution, the lack of Starbucks?
No I miss the spirit of it. I miss an intangible something that India left in me and I suppose that it leaves in everyone who ventures into her exotic wonder.

I enjoyed being there and I thought it was an extraordinary journey, especially for someone like me who comes from a culture that doesn't allow its girls and women any measure of independence, including the ability to travel across the world alone (read that to mean without family or husband). And while certain things did not turn out as I'd hoped, the overall experience has given me a deeper insight into the field of public health, what it means to really work in the field, what it means to work in a development country, and finally just how much independence and self-reliance I can cultivate within myself.

I've been working on my reflections for school and I've been reading Edward Luce's book and things are starting to fall into place and make much more sense now, I only wish I read the book while I was there. Nevertheless, I'm getting a deeper understanding of the cultural and religious character of the Indians, among other things, and this puts things in perspective for me. I highly recommend the book if anyone's interested in the rise of modern India and while it was written by a British journalist who lived in India for over 5 years, he does have an Indian wife and seems to have a less westernized view than most books written by a foreigner might. I'm sure this will not resonate well with the Hindu Nationalists, but I don't care.

Can the IT fix India's problems?

According to Edward Luce, remnants of the Gandhian philosophy still hold the imagination of the Indian elite that the Indian village is the sacred cornerstone of Indian society and life. And while that sentiment is slowly decreasing among the masses, the elite continue to view the village with romantic lenses, despite the fact that none of them reside in villages, and millions of Indian villagers migrate to the cities and would rather live in slums than be back at the village, since it does not provide any economic opportunities for their families.

There's also a widespread notion that if information technology will revolutionize the village, reducing the tide of migration to the cities. While I believe that technology is the answer to many global problems, I fail to see how IT alone is going to solve the problems of the Indian village, which often lack electricity, paved roads, and water and sanitation. Millions of villages still practice nothing more subsistence farming, do not own the land, and those who do often have to dissect the family plots between their children and future generations, making their land smaller and less reliable.

Unless the IT industry first invests millions in building up the village infrastructure, including investment in agrotechnology to mechanize agriculture,its impact on rural development is questionable. Villagers will continue to flock to the cities and remit their earnings back to their families, despite their ability to connect to the web back the village. While I think access to the internet and information will do nothing but enhance the villagers life, as far as priorities are concerned, basic infrastructure must come first.

Furthermore, India needs to improve its urban infrastructure, governance, and extend its manufacturing sector to provide jobs for millions of unskilled or semiskilled people, much as China has done. While China has largely embraced the cheap goods manufacturing and employed millions of semiskilled workers and pulled them out of poverty, India's manufacturing sector has mainly been capital intensive not labor intensive. Luce argues that this is due to the strict labor laws instituted by Jawaharlal Nehru, prime minister of India after Independence, and while strict laws like "License Raj" have been abolished as of 1991 giving way to the IT revolution in India, strict labor laws that make it impossible to fire someone despite their incompetence keeps Indian businesses from expanding their labor force during boom times, which they would be stuck with during recessions.

Economist and other experts, including India's prime minister Manmohan Singh believe that rapid urbanization and a strong manufacturing sector hold the keys to India's future development. This has generally been true of most countries' path to development. However, before mass urbanization India must reform it's national economic policies to encourage urban employment growth and do away with the bureaucratic and political barriers that have discouraged investment in urban infrastructure.
The villagers are not going back to the village, even if agriculture became mechanized, there still would not be enough jobs for them in the village. More of them will continue to migrate to the cities and India can no longer afford the unplanned chaos that occurs in its cities, not to mention the fact that migrant laborers contribute to the HIV/AIDS epidemic as we've previously discussed.


Reference: Edward Luce In Spite of the Gods. The strange rise of modern India. Doubleday, 2007.
P.S. Thank you Paul Lee for the book recommendation.

Some Musings on Water

July 2, 2007

I've been thinking about possible solutions to many of the public health problems that I witnessed in India. Foremost on my mind of course are poverty, overpopulation, water and sanitation, women's rights and of course the emerging epidemic of HIV/AIDS. These are major challenges and require multi-sectoral and creative solutions in a political atmosphere that is not always supportive of public health.

Let's take water and sanitation for example. Water management and sanitation are crucial public health issues for India, as they are for most developing countries that lack strong public infrastructure. There is tremendous unplanned growth in Indian cities as millions migrate from the villages in search of better economic prospects often leading to overcrowded slums and horrid living conditions. Therefore, India has an urgent need for investment in its water and sanitation infrastructure and public-private partnerships have previously proven to offer real solutions by bringing in financing, technical expertise, and expedited project implementation. According to the WHO estimates, every U.S. dollar invested in water and sanitation yields economic returns of $3 to $34 and has other more important benefits such as improved quality of life, reduced morbidity and mortality from waterborne disease, especially for children, and is real progress toward reaching the Millennium Development Goals (Mulford).

We've talked about water and sanitation issues in Dr. Shahi's class (Emerging Trends in Global Health) and the privatization of water was always a controversial topic. Yet today in India, most water and sanitation systems are managed by the public sector and most fail to deliver the promised water and the tank drivers and numerous other bureaucrats have to be constantly bribed to do the job that they're supposed to be doing. Most water and sanitation systems in India lack the capacity for effective water management and often lose nearly 50% of their water due to leaky pipers and illegal tapping of water pipes. Partnerships with the private sector based on performance based contracts would increase the efficiency, bring in much needed finance and accountability but must be transparent and have effective governance and social consciousness would be a huge plus. Moreover, to further strengthen its public health infrastructure, India must strengthen its legal and regulatory standards to support such public-private partnerships.


Public Health Message on Water Use


On the flip side of the tortilla, most of the U.S. is experiencing droughts this year with the Western states leading the way, California has only received 3.6 inches of rain in the past year and faces a tough fire season because of the dryness. And most of the seeds my granny and I planted, with the exception of the tomatoes (well she did most of the planting really) have not even sprouted. On a larger scale farmers nationwide are forecasting a reduced harvest and loss of entire crops (NPR).
On a more positive note, however, more and more people are becoming aware of the need to live a more responsible and sustainable lifestyle in this country thanks to documentary films like The Inconvenient Truth and there has been a considerable shift of opinion on whether global warming is actually occurring. This I believe is a major step forward for this country given the fact that up until just recently our President was denying the fact that the climate is indeed changing.

My evidence for this increased awareness is anecdotal of course. I have not conducted any surveys, it is merely based on my observations of more coverage of environmental issues in the media, more dialogue in the country, and perhaps my own increasingly raised awareness of the issue. Yet, we still take the most precious natural resource for granted and I believe that there's a much needed effort to get people to use water more judiciously and efficiently before we are forced to contend with increased prices, rationing, and forced conservation. But how do we change patterns of behavior in an entire nation, nay the world, if it is so difficult to change our own personal patterns of behavior.

So while I saw slum after slum in Delhi where people live in makeshift homes and lack access to basic services like water and sanitation, I am now contending with the fact that I live in a country which consumes its rich resources and that of the rest of the world without any regard to sustainability. It's time for a paradigm shift and it starts with you and me.

References: D.C. Mulford