Nutrition Lessons from Peru

Posted on by nayavill

Well, just like that, June is coming to an end and so is my internship. You’ll recall that I spent my spring and summer Working from Home with the World Bank. During my practicum I performed a literature review of several low- and middle-income country’s health care systems and how they are working towards universal health care for all and incorporating nutrition services within these models. There are a multitude of learnings and moments of insight I could expound on, but I’ll focus on Peru’s efforts to reduce stunting in youth under-five years of age.

Stunting is a form of malnutrition that results from chronic undernutrition. Broadly speaking, undernutrition can present in four forms: wasting, stunting, underweight and micronutrient deficiencies. Stunting is diagnosed when a child presents with low height-for-age two standard deviations below the WHO Growth Standard deviation median. Wasting is low-weight-for-age and a sign of acute undernutrition; by definition one is wasted if he or she is more than two standard deviations below the WHO Child Growth Standard deviations weight-for-age median. Globally, the prevalence of under-five stunting and wasting are on the decline, but an unacceptable number of youths still suffer from undernutrition. In 2020, 149.2 million of the world’s under-five youth were affected by stunting and 45.4 million were affected by wasting. Among the global health and nutrition community, Peru is best known for its achievements in reducing the prevalence of under-five stunting from 28% to 13% in just eight years (2008-2016).

Stunting affects physical and mental growth. Early deficiencies in cognitive development can be catastrophic for an individual’s lifetime quality of life, educational opportunities, and economic earning potential. This has implications for the prosperity and development of nations at the population level. The economic cost of undernutrition is projected to be 2-3% of gross domestic product (GDP) on average and as high as 11% of GDP in some African and Asian countries each year. Figure 1 shows the effects of stunting on white matter tracts in the brain of a stunted infant (left) versus brain development of a healthy child (right) at two to three months of age. The density and richness of neural networks differ in the images and by the time a stunted child gets past their first thousand days they have up to 40% less brain volume compared to non-stunted children.

Figure 1: Representation of Neural Networks in a Stunted and Non-Stunted Infants.
Figure 1: Representation of Neural Networks in a Stunted and Non-Stunted Infants.
Source: Nelson, C. 2016. Brain Imaging as a Measure of Future Cognitive Outcomes: A study of children in Bangladesh exposed to multiple levels of adversity, Presentation at the Grand Challenges meeting, London, October 2016 and 2017

There is no silver bullet that fully accounts for Peru’s success in reducing under-five stunting. It can be attributed to a combination of grassroots advocacy, political commitment, and systemic changes in how nutrition services are prioritized and delivered. The details of this effective combination are too nuanced to delve into during a blog post, but the short version is: Peru’s government and leaders recognized the need to reduce stunting, it allocated money and resources to this end, and it iterated on programs and policies to reach its goal. One of my biggest learnings from the Peru case study is that health care is about trade-offs! I’ve read that health care is a triangle of tradeoffs between health, wealth, and equity. I certainly believe that to be true and it should be front-of-mind as more countries explore the means to provide a basic level of healthcare to their citizens.

Signing off,

Ashley

Addressing global threats in our own backyards

Posted on by nayavill

When faced with difficult choices, I often come back to a central question: what is my intention, and how can this decision help me work toward that? In March 2020, I was happily living in Guatemala, serving as the on-ground Director of Operations for a small birthing center, run by local midwives and funded by a US organization. What followed that month is now well known to all of us, and I had a difficult choice to make about whether I would return home to begin my Master of Public Health. My final choice to start the program had many factors, but one thing became crystal clear in my mind: my home had become the global epicenter for a public health disaster. There was so much work to be done, and I needed to figure out how I was going to serve my home country.

Part of the reason I felt passionately about my work in Guatemala is that I believe that investment in healthier families is a critical in working to end poverty in the region, and ultimately a necessary factor to stem migration. No one wants to leave their home to embark on a dangerous journey; it is borne out of necessity. Issues affecting immigrants and refugees in the U.S. (especially Latinx communities) have always been one of my major interest areas, and I hoped that I would be able to integrate this into my practicum. As a student in the Applied Epidemiology concentration of the MPH, I also intended to use my summer to beef up my skills in data analysis.

End TB pin
Ending TB from my backyard in NC!

The pandemic has made it abundantly clear how public health departments are critical infrastructure in the US, and I was hoping to learn more about what it would be like to work for one. That’s why I was excited about the opportunity to work with the Tuberculosis (TB) Control Program at the North Carolina Department of Health and Human Services. For this project, I will be helping to strengthen community partnerships to prevent active tuberculosis. As part of the process to seek permanent resident status, applicants are required to undergo a medical exam which includes a test for latent TB. Latent TB can turn into TB disease, which requires much more difficult treatment and can spread to others. After COVID-19, it has become abundantly clear how important it is to prevent the spread of respiratory infections like TB and pay special attention to vulnerable populations who often bear the greatest burden.

This project will have two major components: compiling a database of all active practitioners that provide these exams (civil surgeons), and using this database along with existing data to estimate how many potential latent TB infections are detected annually, along with how many “status-adjusters” are seen each year. These data will bolster the case for funding for an educational program for civil surgeons on how to counsel those with latent TB and encourage them to treat the infection before it progresses.

I’m excited to dive into this project because it really embodies the reason I came back to the U.S.: global health issues are local issues. If the U.S. public health infrastructure was better equipped, we might have been able to stem the spread of COVID-19 in this country and around the world. TB is a growing threat globally and it’s critical to address it at home in North Carolina.

-Jaclyn

Global Health Practicum in the time of COVID-19

Posted on by nayavill

For most people, myself included, the pandemic upended our way of life, from the way we socialize to the way we work. Currently, I work as a pediatric surgeon, so prior to starting my MPH, I figured that I would have to find a practicum experience that would be flexible with regard to my work schedule; allowing me to meet my clinical responsibilities while fulfilling my practicum requirement. More importantly, I wanted an experience that would allow me to marry my research interest in access to prenatal care and neonatal outcomes in sub-Saharan Africa. For all these reasons, I was extremely excited when I got the opportunity to work with the UNC Gillings Zambia group which focuses on “improving public health, locally and globally.” Specifically, I was selected as a practicum intern for the Antenatal Care/ Postnatal Care Research Collective – Household Survey (ARCH), a multinational collaborative that aims to optimize birth outcomes in low resource settings. I don’t think that I could have asked for a better practicum opportunity, as it aligned perfectly with my interests.

In my role, I will be working to help with study start-up and implementation of a new longitudinal household survey of 5,000 households in Lusaka, Zambia. The goal of this survey is to gain a better understanding of the behavioral and reproductive health of women of reproductive age. Ultimately, the results from the study will provide estimates of the burden of maternal, newborn, and infant disease; and provide information regarding key risk factors and social disadvantages that contribute to adverse maternal and neonatal outcomes. I am excited to be part of this study, albeit in a small way, because I think we know little about factors related to preconception and antenatal care of women in resource-limited areas. This area of research is particularly important because I think better understanding will provide information not only regarding factors affecting maternal health, but also regarding the burden of birth defects and help to inform planning for and improving neonatal outcomes.

During my practicum experience, I will be working to develop training materials for field research staff and recruitment materials for study participants.  Over the last few weeks, I have been working on getting acquainted with the study protocol, and meeting key personnel for the study. I have also started working on some of the participant recruitment materials.  It has been really interesting having meetings on Zoom to discuss the study and its initiation. It has made me long more for in-person meetings, because I think that it would have been great to meet some of the people with whom I’d be working. I also think that it would have been an amazing opportunity to be on ground in Lusaka. I am still hoping that I will be able to visit the Zambia Hub in the future.  In spite of the challenges regarding not being in-person, I have been fortunate to have a preceptor who has been available and easily accessible.

There are number of things that I am looking forward to in my practicum. Firstly. I am looking forward to learning how to carry a research study from a concept, to one that is actualized in practice. I am also looking forward to developing the training schedule and materials that will be instrumental in initiating the study. I feel that this project will allow me to think critically about an important part of research study implementation, in which I have little experience. Lastly, I hope that this experience will provide opportunities to build relationships with researchers who have similar interests, in improving prenatal access to care and neonatal outcomes, in resource-limited settings.  As a physician who is interested in global surgery and research, my involvement will therefore provide me with the skills to develop study management tools, train research staff in international settings, and establish methods to monitor data quality. Given that the study is still in the early stages of implementation and initiation, I believe that I will gain valuable experience regarding the successful implementation of a research protocol.

Although I expect to have a busy summer, I’m planning on making the most of the sunny days by doing as much work as I can outside :).

‘Desola