Question:
Select a Global Health problem of Interest to you and write a review and analysis of the health problem.
Malnutrition is its different form is regarded as one of the most prominent global problem in today’s scenario. It is estimated that more than 35% of death of the children who are less than 5 years old occurs as a result of malnutrition (1). The growth of a child is recognized internationally as an important determinant of public health. It is used for monitoring nutritional status and health parameter of the population. Children who are the victims of the growth retardationarising out of malnutrition mainly suffer from recurrent bacterial infections, which coincide with their poor diet plan. As a result they suffer from infectious disease like pneumonia, malaria and meningitis. Malnutrition is thus a global problem because it increases the outbreak of the infectious disease along with child mortality rates. Child malnutrition is also a driving force behind delayed mental development among the children, reduced intellectual capacity and below average school performance (2).
According to the reports published by the WHO, at least 7.6 million children who are under 5-year of age, died in the year 2010 (3). Of these, 7.6 million, 4.879 million died out of infectious disease like pneumonia, malaria and diarrhoea. 3.072 million death occurred during the neonatal stage arising out of the preterm birth complications, neonatal sepsis and meningitis. The condition is more pronounced in countries like India, Pakistan, China, Nigeria and Republican of Congo. Apparently it seems that the death is arising out of the infectious disease however, the actual underlying reason behind this is, children are suffering from malnutrition which makes their immune system weak and less effective to combat against bacterial attack. Thus showing that the affect of malnutrition is affecting the health of the childrenand thereby increasing the rate of mortality rate (3). Malnutrition or under nutrition decreases the survival, development and growth rate among the children.
Figure: Global Causes behind Childhood Deaths
Source: 3
The condition like childhood malnutrition and maternal under nutrition are linked and includes a wide array of consequences like intrauterine growth restriction (IUGR) that results in low birth weight (LBW), stunned growth or chronic restriction in growth. The malnutrition resulting from minerals and vitamins deficiencies in diet causes loss of weight and height. Many of the diseased conditions are associated with concomitant micronutrient deficiencies. Themicronutrients include Vitamin A, zinc, and iron and iodine deficiency. Apart from micronutrient deficiencies, undernutrition is also caused as a result of suboptimal breastfeeding. The condition is more significant during the first few years after the birth and thus further highlighting the need of proper nutrition during pregnancy and the association of maternal malnutrition with the childhood malnutrition. Conditions like stunned growth during early childhood, poor fatal growth during third trimester of pregnancy and severe wastening are associated with the consequences of childhood malnutrition. At least 178 million children who are under 5 years of age suffer from stunned growth and the majority of these children reside in South-Central Asia and sub-Saharan Africa. Moreover, 55 million children who are suffering from malnutrition are at a high risk of premature death. Children who are born malnourished as a result of IUGR are found incapable of completing their academic career with creditable records along with longer stay at schools. They also earn less after the attainment of the adulthood. They also have poor cognitive development and extremely poor economic potential. This legacy of lower income rate, poor health backup and poor access of adequate nutrition continues to affect the health and the mental stature of their upcoming generation and thus establishing a repetitive cycle of malnourishment (4).
Malnutrition prevails in different countries of the world. Several factors are responsible for the promotion of malnutrition. The dominant environmental factors include agriculture, soil erosion, drought and flood. Apart from this, there are also other contributing factors behind malnutrition like cultural barrier, poverty, disease, hunger, illiteracy and other socio-economic problems.Domestic violence or more precisely, physical violence against women procured by their life partner is a serious public health concern and also regarded as the potential cause behind child malnutrition. Women from any nationality can become victims of the Intimate Partner Violence (IPV) regardless of their education degree, income, ethnicity and age (5). According to the reports published by the World Health Organization (WHO), at least 15 to 71% of the women population become victims of life-time sexual and physical violence. The principal negative consequence of IPV includes mortality and morbidity among women who are in their potent reproductive age.It also gives rise to gastrointestinal problems, gynaecological problems, post-traumatic stress and suicidal activity. These negative consequences of IPV upon women are extended and in turn affect the child health either directly and indirectly. Here indirect affect include withdrawals of the maternal caretaking activities. The women victims of the IPV suffer from psychological and physical problems and thus making them incapable of providing quality care to their children. Moreover, IPV causes unplanned or unintended pregnancy, affecting maternal caretaking behaviour. The direct consequences of IPV include, children who are directly experiencing psychological stress has certain mental blockage that negatively influence their health. IPV occurring directly against women, also make the children more susceptible of coming under the risk of physical maltreatment, leading to malnutrition (6). Studies that have been conducted using the nationally representative samples showed that there lies an association between the lifetime physical exposureand abuse of sexual IPV and stunned growth among the children who are aged below 5 years in Kenya (7).
Economic status and ill healthare inverselyproportional to each other (10). Poverty is another social determinant of childhood malnutrition. According to the World Food Summit, the majority of the people who are residing in the third world countries or the developing countries are residing below the poverty level. They do not have adequate access of food all the time and hence score low in nutritional quotient. This food insecurity has three different hierarchical levels including availability, access and utilization. The availability of food is often scored via proxies occurring at the level of population like national agricultural output. On the other hand, the utilization and access are measured on the parameters based on household and individual levels respectively. Here poverty arises as a result of the unemployment, low wages and lack of education. This food insecurity creates an unhealthy household environment, promoting childhood malnutrition. People who are residing under the low socio-economic status are most vulnerable of getting affected with food insecurity. This is due to the fact that they lack the purchasing power which can be regarded as a principal determinant of ability-to-afford adequate source of nutritional food. The householdsfalling under the low economic backup, who fail to afford nutritious food or rather say adequate food for their daily living suffer from malnutrition and the condition is mostly prevalent among the children. This malnutrition in turn causes poverty as the malnourished individuals fail to secure good academic excellence and have poor physical strength to perform their best at their professional field. Thus, poverty and malnutrition among the children are mutually exclusive (8). The incidence of malnutrition is 2.7 times higher among the children of the families who reside under the belt of lower household wealth index. Alongside, rapid growth of the population and political commitment case an indirectaffect on childhood malnutrition (11).
Figure: Food Insecurity in the Developing countries
Source: 8
Inequalities in health or gender biasness are also important determinants of childhood malnutrition. Pronounced gender bias exists in the majority of the countries of South-Asia. The people residing in South Asian countries, with a special mention in India and Pakistan prefer sons to the daughters. This preference arises on the grounds of economic, religious and social stability of sons in comparison to that of daughters. This form of gender discrimination also affects the quality care among the children. Like the daughters are discriminated in the grounds of providence for adequate nutritious food, proper healthcare and education. This results in increased girl child mortality along with the increased reported cases of girl child malnutrition. The preference of sons is extended to such an extent that female fetus is aborted and this case is relevant even to female infanticide. The gender biasness is also reflected in the other basic clinical needs, like immunization and nutrition. The male children are most likely to receive the minimal banner of nutrition and immunization in comparison to that of the female children. This lack of proper immunization increases the girl child mortality. Moreover, lack of immunization and its relation to mortality rate is further escalated to tenfold via the presence of malnutrition (9).
Malnutrition is an overall burden over the childhood mortality and morbidity. It causes more than 20 million of children round the world to suffer from severe wasting. An untold number of students suffer kwashiorkor. Over the decades the basic control policies that were undertaken for the severe acute malnutrition was inpatient rehabilitation. This was assisted with fortified milk formulas. ready-to-use therapeutic food (RUTF) is recommended for the treatment of childhood malnutritionby international consensus guidelines. The RUTF is fortified spread in nature that consists of peanut paste, oil, milk powder and a micronutrient supplement. The therapy is applied under the outpatient settings for acute to severe malnutrition. As per double-blind, randomized placebo-controlled trail, routine administration of amoxicillin and cefdinir to the out patients children suffering from severe malnutrition showed marked improvements in rate of recovery, mortality rate along with significant improvements in weight gain and mid-upper circumference of the arms (12).
Figure: Nutritional Recovery and Time of Death upon the application of Antibiotics
Source: 12
Inspite of having a better outcome, atleast 10 to 15 % of the children from the selected focused group failed to recover from the ill-effects of malnutrition. Moreover, the condition of infectious disease arising out of the poor immune system among the malnourished children continued. The majority of the studies have shown that there is still a high prevalence of infections among the children who were hospitalized for severe malnutrition and this infection was clinically significant. This observation has led to the elucidation of the new treatment guidelines for malnutrition that recommends the routine antibiotic use for both in and out patient students. However, the outpatients’ students are less likely to have systemic infection in comparison to that of the patients who are admitted with severe malnutrition complication in the inpatient care. However, the contrasting reports suggest that the use of antibiotics among the malnourished children in order to control clinically acquired infection is not a solution for malnutrition and perhaps harmful for the children. This is because, unnecessary use of the antibiotics is associated side-effects along with the generation of antibiotic resistance. Moreover, treating malnourished children with RUTF is complex and costly (12).
There is a strong sense of association between the maternal education and health of the children. The children who are born to educated mothers, suffer from less from malnutrition which is being manifested among the children in the form of underweight, stunned growth and muscle wasting. Research which is carried out under various settings in Jamaica, Bolivia and Kenya showed that the maternal education is associated with the nutritional outcome among their children (13). There are three prospective links via which maternal education can modulate the health of their children. The first link is the formal education of the mother that directly transfers the gained knowledge of health among the future mothers. Secondly, numeracy and literacy skills, which the women generally acquire during their school education refines their capability toidentifyillness and they seek proper treatment for their children. Additionally, the educated women are in a better position to read the medical instruction procured by the doctors while nursing their children. Third, proper enlighten of basic education makes the women more receptive towards the modern medicines. Moreover, maternal education has a strong link with the socio-economic structure and children nutritional status. Educated women are more likely to lead a steady life whilegetting posted to higher paying jobs, getting married to established men with higher education with higher income and getting to live in better and hygienicneighbourhood. This has influence both on children mental and physical development. However, educated and established mothers are more likely to suffer from job related stress which gives rise to depression and this depression affects the health of the child leading to poor nutritional outcome. Moreover working mothers generally remains busy and stay away from home for long hours and thus get less time to care for their children. The same logic goes equally well with the father and this lack of care also causes nutritional deficiency among their children (13).
Tackling malnutrition among the children is directly associated with the proper achievement of the Millennium Development Goal (MDG) 1 that deals with elimination of hunger and MDG (dealing with child mortality) and MDG 5 (reducing the rate of maternal mortality). The achievement of the majority of these goals in the domain of human development hinges upon the eradication of the childhood malnutrition. The importance of eradication is important because cast a significant impact on productivity, health and proper educational achievement. In spite to this, the African continent, government has either undermined or underestimated or provided a lukewarm attitude towards malnutrition. They showed less interest in investing money and time on malnutrition or ensuring alleviation of the process of malnutrition. Corruption that associated to each level of the governmental sectors is another driving force behind the childhood malnutrition. This corruption prevented the observance of the educational and awareness programs in the urban areas alongwith adequate supply of the food to the people who are living below the poverty level. Moreover, the misuse of the government aided funds hasgenerated division among the people and the political wars has caused wastage of money and increased mortality rate among the human race that have increased the consequences of malnutrition. Over the last few decades,the policies framed by the government at the institutional level have neglected the rural and agricultural development. Policies that was planned to reduce close budget gaps like theadjustment programshave ceased huge human development deficits especially among the poor.
The first attempt that was made to address the problem of malnutrition among the children was done via “Freedom from Hunger Campaign” which was initiated by the FAO and other developmental agencies. The campaign was aimed to indulge the authorities of the developing countries in examining the reasons of malnutrition and food crisis along with elucidating sustainable solutions. However, such a novel and worthy intention was not been fulfilled in all parts of the world adequatelyafter six decades. Lagos Plan of Action (1980 to 1985) and Regional Food Plan for Africa (1978 to 1990), the neonatal attempt of the government to handle the food security situation on the continent, failed due to gaps in the financial funding and organizational structures. However, African Government has committed to uplift the public expenditure on agricultural needs towards the dawn of the new millennium. This was done via signing the Maputo Declaration on Agriculture and Food Security in the year 2003.This remains as myth rather than transforming into reality. The trend continues ascertaining miserable days with respect to hunger and malnutrition in the majority of the areas in the continent (14). The concerned government failed to ascertain the fight against malnutrition as a priorityas they have not critically measured the weightage of malnutrition.
Improving governmental policies for the upliftment of the political will and optimal application of community-adapted strategies in tackling the issues of childhood malnutrition is fundamental. Childhood malnutrition should not only be identified as a public health issue but be given prominence as fundamental human rights especially for the children to eat. Initiating life with a disadvantaged condition, filled with adverse consequences of malnutrition (like mental retardation, ill health, morbidity and mortality) is neglected but cast a prominent in the overall development of the population. The fight against corruption is the only way to cease this problem effectively. Other approaches include:Application of advanced grade agricultural techniques in order to increase the amount of food production. It will help to fight against malnutrition. Provision or the subsidization of the ministries in the domain of agriculture is also required to deliver quality fertilizers, framing genetically modified food, which are capable of growing under adverse weather conditions and promotion of the overall improvement of yield. Apart from agriculture, improvement of the transport system, is also required, which will provide adequate access to the locals to trade local food products in order to raise the incomes of the families, especially important for the group of population who reside below the poverty line. Observance of the baseline surveys are also important to ascertain the prevailing socio-cultural peculiarities exiting among separatecommunity during the proper implementation of the practical program. Such observations are vital and will help in the avoidance of the vertical programs. The ministry of environmental health of the all the countries must indulge in awareness programs in order to safe guard the degrading condition of the surrounding environment. Sustainable and feasible irrigation programs must be rapidly scaled up. This should be done in the areas, which are majorly affected by drought. In the developing countries the solution of the problems associated with malnutrition encompasses a multi-sectoral approach with must contain well defined and proper achievable goals. The ministries of education, health, agriculture, environment, universities and the research organisations including both governmental and non-governmental or international must work together in sync for tangible outcomes (14).
Future research involving the proper acceptability of the modern agricultural technologies, latest farming techniques and genetically modified foods should be strictly undertaken. The socio-cultural peculiarities of the milieu are the basic rulethat needs to be understood. Implementing some of the health promotion programs might sound complex and unproductive as they are vertical and culturally in adapted but effort must be taken to resolve the same. Implication of the proper community representatives in the programs from the initial planning stage can be cited as the principal determinants of the ownership, sustainability and acceptability of the program.
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