Understanding Undernutrition in Mozambique

Trying to Understand Undernutrition in Mozambique

By Elizabeth Rose

This article is a summary of an article previously published by the author in BMC Nutrition and the full article can be accessed here: https://www.ncbi.nlm.nih.gov/pubmed/27182448

Recent increases in globalization, urbanization, and the availability of processed foods high in sugars, sodium, and fat have contributed to a shift in focus from undernutrition to overnutrition in developing countries. Despite this shift, undernutrition continues to be a major problem, particularly in rural Africa. Among low- and middle-income countries (LMICs), the prevalence of chronic malnutrition, or stunting (height-for-age z-score less than -2), was 28% in 2011. When disaggregated by region, the prevalence of stunting in sub-Saharan African countries rose to 40% and in Mozambique, a country on the southeastern coast of Africa, the prevalence was even higher at 44%.

As the period for reaching the Millennium Development Goals (MDGs) drew to a close in 2015, assessing the reasons behind why goals were or were not reached will help guide future human development efforts in LMICs. Insufficient nutrition is a cross-cutting condition that both directly and indirectly impeded progress towards three MDGs: One (eradicating extreme poverty and hunger), Two (achieving universal education), and Four (reducing child mortality). In 2012, 25% of children under five years old (or 162 million children) suffered from stunting worldwide, with an additional 15% of children (112 million) classified as underweight (weight-for-age z-score less than -2).

Maternal prenatal nutrition and poor intake of micronutrients, such as vitamin A, by the infant in the “first 1000 days” (i.e. conception to age two years) can cause irreversible developmental damage and impediments in physical and cognitive growth that last into adulthood. Thus, proper nutrition in early childhood is important and poor nutrition at this age has been correlated with lower cognitive performance in school and decreased success in the labor market as an adult, which further perpetuates the cycle of poverty and undernutrition. Undernutrition, which includes stunting, underweight, and wasting (weight-for-height z-score less than -2), is the largest preventable cause of death among children under five years and is directly or indirectly attributed to 45% of child deaths (3.1 million). Ninety-eight percent of undernourished children live in developing countries, and while the prevalence of undernutrition has decreased across almost all world regions over the past two decades, rates have been increasing in Africa, mandating a better understanding of the determinants of undernutrition in this geographical setting.

Compounding the poor nutritional indices of Mozambique described above are the salient disparities in health care, outcomes, and budgeting allocations among the country’s provinces. The centrally-located Zambézia Province has the lowest per capita budget for health and education in Mozambique. It also has the lowest access to safe water (only 26% of people had access to safe water in 2009), the highest sanitation deprivation among children (73% of children did not have access to sanitation facilities in 2008), and the highest poverty headcount (71% of the population lived in poverty in 2008). Furthermore, this province also had some of the lowest performance indicators for health outcomes in the country, including the highest under 5 mortality rate (206 per 1000 live births, 10 year average 1998-2008) and among the highest child stunting rates (46%, 2008). Zambézia Province has been labeled as a development “priority province” and as such, numerous national and international programs have been undertaken, yet undernutrition rates have remained relatively stable. Aligning with the World Health Organization (WHO) recommendations that countries place the management of undernutrition as a public health priority, we sought to study the determinants of undernutrition among children under five years of age, over a four-year period, so as to inform future interventions and health practices that aim to reduce the prevalence of undernutrition in Zambézia Province.

In order to study the determinants of undernutrition in this population, we conducted two population-based cross-sectional surveys of ~4000 female heads of households each in Zambézia Province, Mozambique from August–September 2010 (Baseline) and April–May 2014 (Endline) as part of the USAID-funded Strengthening Communities through Integrated Programs (SCIP) grant. Anthropometric measurements were collected on 560 children aged 6–59 months at Baseline and 912 children at Endline and classified as: “stunted,” a height-for-age z-score less than -2; “wasted,” weight-for-height z-score less than -2; and “underweight,” weight-for-age z-score less than -2.

The results of this study included the following: Of children under age five years, 43% were undernourished in 2010 and 55% in 2014. The most common form of undernutrition was stunting (39% in 2010, 51% in 2014), followed by underweight (13% in both 2010 and 2014), and wasting (7% in 2010, 5% in 2014). Child’s age was found to be associated with stunting and Vitamin A supplementation was associated with a 31% (p=0.04) decreased odds of stunting. Children who were exclusively breastfed for at least six months had an 80% (p=0.02) lower odds of wasting in 2014 and 57% (p=0.05) decreased odds of being underweight in 2014. Introducing other foods after age six months was associated with a five-fold increased odds of wasting in 2014 (p=0.02); household food insecurity was associated with wasting (OR=2.08; p=0.03) and underweight in 2010 (OR=2.31; p=0.05). Children whose mother washed her hands with a cleaning agent had a 40% (p=0.05) decreased odds of being underweight. Surprisingly, per point increase in household dietary diversity score, children had 12% greater odds of being stunted in 2010 (p=0.01) but 9% decreased odds of being underweight in 2014 (p=0.02).

The prevalence of stunting in our study was “very high prevalence” as per WHO classification and also in comparison to worldwide rates of stunting in other LMICs that range from 5% to 65%. Recorded rates of wasting and underweight, as defined by the WHO, were categorized as “poor” and “medium prevalence,” respectively. Stunting prevalence is of particular concern since it reflects long-term structural factors of undernutrition and can serve as an indicator of a population’s well-being.

In conclusion, almost half of studied children aged 6-59 months in Zambézia Province were undernourished, revealing the need for sustained efforts to ameliorate this high prevalence rate. Of particular concern is the high rate of stunting that increased from 2010 to 2014. Intensified efforts to increase rates of vitamin A supplementation should be implemented, as well as other disease prevention measures such as interventions aimed at sustaining high rates of vaccine uptake. Interventions related to breastfeeding and hand washing practices as well as decreasing the extraordinary level of food insecurity that is prevalent throughout Zambézia Province should be implemented to help to reduce the prevalence of wasting and underweight. Future studies are needed to better explore local customs related to inter-household dietary diversity patterns, specifically focused on children under five years old. This study provided evidence that a combination of factors were associated with undernutrition. As such, use of multidimensional interventions should be considered to decrease undernutrition in children under five years old.


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Super Spending in the Super League

By Javan Latson

The People’s Republic of China is one of the world’s fastest growing economies. The rise of China has vaulted them onto the global stage and has made them a major player in global affairs. Although there is a heavy emphasis placed on manufacturing and being able to compete with other advanced nations in the economy, there is another area in which the PRC is trying to show its prowess – soccer. Having hosted the 2008 Summer Olympics and with the 2022 Winter Olympics on the way, the Chinese government has shown that they are capable of producing world class athletes. However, there is still a lot of room for improvement when it comes to their performance on the field.

President Xi Jinping is an avid fan of the sport and has laid out some pretty lofty goals for the nation’s soccer program. Unlike Brazil, Argentina or Germany, China doesn’t have any World Cup championships, or many high profile athletes competing in the top leagues. Whereas the women’s program has played in the World Cup six times, including a finals appearance in 1999, the men haven’t qualified since 2002.  In fact, the Chinese Men’s National Team is currently ranked a mediocre 86th behind countries like Belarus, Qatar, and Armenia. In an effort to improve China’s reputation, President Xi made a proclamation that he wanted to make his nation a major competitor by 2050. He aims to achieve this goal by investing heavily in infrastructure, developing domestic talent, and improving the quality of the nation’s professional league.

A similar initiative was proposed in the 1950s following the revolution that placed the communist government in power. Following the civil war, the plan was to use soccer to launch China onto the global scene. In order to achieve this goal, soccer became organized and financed by the government and what would eventually become the General Administration of Sport was founded. Under the oversight of the state, this government body helps regulate athletics, create standards of physical fitness, organize major international competitions, and encourage investment in the sports industry.

People in China are passionate fans and soccer is the most watched game in the entire country. More than 300 million people (about the population of the United States) tune in to watch English Premier League matches. In fact, demand is so high for these games that the league signed a three-year $700 million deal with the Chinese streaming site PPTV for broadcasting rights. To put things into perspective, NBC Universal paid $500 million to extend its contract with the league even though viewership in the US decreased by 17% last year. However, whereas there are many Chinese spectators, there are relatively few people that actually compete. According to the Chinese Football Association, there are only 7,000 players under 18 that are registered in the entire country.

To address the lack of soccer players President Xi plans to build at least 20,000 training centers and 70,000 soccer fields throughout the country by the end of the decade. Many people don’t play the game simply because they don’t have anywhere to compete, especially in rural areas. His goal is to increase the accessibility of citizens to high quality facilities and skills training. He wants every county to have two full sized fields and every residential area in larger cities to have at least one small sized court. In addition to building state of the art fields, billions of dollars will be spent on player development in the form of training programs or institutions. Children will be exposed to soccer as a part of their physical education curriculum, with the intention that students around the country will have the chance to become familiar with the game at an early age. This is important because when it comes to athletics, exposure at an early age plays a major role in future growth as a player.

By far the most spectacular example of China’s commitment to cultivating high quality prospects is the Evergrande Football School in Guangzhou. The building, which took ten months to build and cost $185 million, is the largest soccer school in the world. Although the primary focus is athletics, students also are taught the typical curriculum found at other schools (math, science, reading, etc.). The 2800 students at the school come from all around the country, including Tibet and the predominantly Muslim province of Xinjiang. They have access to more than 50 fields, special chefs, a library, swimming pools and a gym. The 160-acre campus is a testament to the enormous investment that the government is placing on the sport, which in the eyes of some plays a role in their nation’s prestige. Each week players are instructed in tactics and fundamentals by Chinese and Spanish coaches.

The European imports are the result of a strategic partnership with eleven time European champion Real Madrid. The aim of this partnership is to help develop quality Chinese players who, with the proper tutelage, will be able to compete for the top clubs of Spain, England, Germany and Italy. The opportunity to be taught by some of the world’s best is something that is highly desired by many players in the country, but it’s very hard to get into the school. It costs $9,200 a year for a child to attend Evergrande, which is more than the average yearly income for Chinese families. The more talented athletes are given scholarships to attend or are given financial assistance to help cover the cost of attendance. Thus, for the vast majority of children in China it’s highly unlikely that they’ll ever be able to attend this prestigious institution.

Exposure and access are two important things when trying to increase something’s popularity, but in the world of sports there must be opportunities for competition at the amateur and professional athletes. China’s goal isn’t simply to have more people playing, but to produce high-quality athletes that can go toe-to-toe with the world’s best. To solve this problem the government has begun a multimillion-dollar revamp of the Chinese Super League which is the country’s professional league. The CSL has 16 teams and is regulated by the Chinese Football Association. Chinese professional soccer has a rough history rife with mediocre teams, and corruption. In 2013, dozens of referees and former players were banned from soccer after an investigation into match fixing. The probe by the Chinese football association led to two high-ranking officials being arrested, the team Shanghai Shenhua vacating their 2003 championship.

In spite of these major setbacks, the CSL has seen tremendous growth in recent years to a growing amount of investment from Chinese corporations. Firms like multibillion-dollar Alibaba  have begun purchasing stakes in professional clubs. Much like his other strategies, President Xi is setting the bar high for the country’s professional clubs and expects a few to be dominating Asian competition within a few years. To accomplish this, clubs in China have spent large sums of money to acquire some of the world’s top talent.

In December of 2016, Oscar dos Santos Emboaboa Junior left Chelsea FC for Shanghai SIPG in a deal worth 52 million pounds (over 64 million dollars). The team was shocked that one of their marquee players left a team that placed first in the English Premier League.The Brazilian silver medalist had been a part of their 2012 championship team and had only cost Chelsea 19 million pounds to acquire, but was paid more than twice his initial value. That same month, Argentinian footballer Carlos Tevez made the decision to take his talents to the Chinese team Shanghai Shenhua in a 70 million pound (87 million dollar) transaction. Tevez, who spent the majority of his career in the Premier League, now makes more than 745,000 dollars per week.

Tevez and Oscar are two members of a growing class of high-level players that are leaving Europe for China. During the January-February transfer period of 2016, CSL clubs spent $365 million on player acquisition. In comparison the English Premier League spent $275 million during that same two-month window. In addition, many reputable managers are also making the trek east. Alberto Zaccheroni, who led the Japanese national team to an AFC Asian Cup championship in 2011 and a berth in the 2014 World Cup, 2010 Japanese league manager of the year Dragan Stojkovic, and former coach of the Brazilian national team Mano Menzenes are some high profile hires that have been made by CLS clubs.

Speculators predict that by next year the CSL will become the world’s third most watched league behind the Premier League and  the German Bundesliga. The broadcasting rights within the span of one year increased from a value of $8.6 million in 2015 to $1.11 billion in 2016. In fact five-time league champion Guangzhou Evergrande is now estimated to be the world’s most valuable soccer team.

The rapid ascension and growth of Chinese soccer has caught the attention of many. European clubs are anxious about CSL clubs due to their incredible spending power. It was reported that four-time FIFA player of the year Cristiano Ronaldo was offered a huge contract by one Chinese team, but declined in order to stay with Real Madrid. There are others however, that are skeptical of this desperate spending. Critics claim these high level transactions are simply not sustainable over the long term. Others are more worried that much of the money is being spent on foreign players rather than Chinese athletes. In order to address the rampant spending, the Chinese government has begun to call for the creation of salary caps that limit the amount clubs can spend on players. There are also now rules that limit the amount of foreign players that can be on the field at one given time.

President Xi’s desire to build up his nation as a soccer powerhouse is quite impressive. However, the increased focused on athletics could all be a cover for something else. It is possible XI is using soccer to distract the people from the slowing economy or the human right’s abuses of the Communist Party. On the other hand, it could be a ploy to gain favor with other nations. There has been a history of China practicing “stadium diplomacy” with resource rich nations of Africa and Latin America. For example when Angola hosted the African Cup of Nations, China paid the bill for the construction of four new facilities. Following this act of “generosity” Angola has now become China’s second largest source of oil. China has the capabilities to excel on the world stage. It may not be long from now that we turn on our TVs and see a Chinese player as the star on Real Madrid or Manchester United, or a World Cup trophy being hoisted up in Beijing.

Using Mobile Technology to Promote HIV Self-Testing

By Dr. Nickolas Zaller 

Dr. Nickolas Zaller is an Associate Professor in the Department of Health Behavior and Health Education and Director of the Office of Global Health at the University of Arkansas for Medical Sciences. On November 7th he was in Nashville and gave a talk at the Vanderbilt Institute for Global Health weekly Grand Rounds.

Dr. Zaller’s talk focused on mHealth to promote HIV self-testing among men who have sex with men (MSM) in Hefei, Anhui Province, China. Interestingly, HIV started in China primarily with unsafe practices surrounding rural blood donations for money. Currently, HIV risk is highest among MSM in China with rates growing compared to other high-risk populations such as sex workers. This is compounded by low rates of HIV testing among MSM.

It is in this context that Dr. Zaller and his team hope to develop a mobile platform to promote self-testing among MSM as a potentially scalable model applicable in other locations. He sees this as breaking the cycle in which the stigma of even going to a testing site combined with the fear of a positive result prevent men from getting tested. By offering self-testing at home, there is no stigma associated with going to a testing location and the barrier to entry is lower.

The natural tradeoff that comes with self-testing is the inability to counsel patients during a clinic visit. Dr. Zaller hopes to preempt this with a mobile education platform to improve HIV knowledge. Taking into account local context, this platform will be built through WeChat. While not very common in the United States, WeChat is the most common messaging platform in the world, and 25% of adult Internet users report using it. It is also by far the most common in the region.

The ultimate goal is to push educational information directly to users’ phones to both promote testing and improve HIV knowledge in this high-risk group. Dr. Zaller plans to complete a randomized controlled trial among men over 18 who self-identify as MSM with some receiving the messages and others not. Testing rates as well as other metrics—such as high-risk behavior—will be compared between the two groups. Once the content has been refined, it is potentially scalable to other cities and contexts.

The group has already performed qualitative interviews with potential participants to begin getting feedback on self-testing and the learning platform. People generally thought the test was easy and reported that it afforded improved privacy over going to a testing center. Participants were concerned about the accuracy of home testing and stated there was an inherent loss of privacy in physically purchasing the test. While they acknowledged the potential to buy tests online, they had less faith in these tests because of the potential for fakes. For the learning platform, they emphasized the need for a mix of both formal educational materials and fresh content to keep people interested. They also emphasized the need for privacy when content is pushed to a person’s phone to make sure others would not see it.

In summary, Dr. Zaller and his team aim to improve testing coverage among MSM in a scalable model using a mobile learning platform and self-testing.

Nigeria: An African Giant Divided

Southern regions along with Abuja (FCT) have long been the economic hub while the north is generally viewed as being backward. (Credit GeoCurrents / CGIDD)
Southern regions along with Abuja (FCT) have long been the economic hub of the country. (Credit GeoCurrents / CGIDD)

By Aalok Joshi

On January 17th the Nigerian air force moved forward with operations in the northeastern Nigerian state of Borno, bombing what they thought was a Boko Haram hideout. However, this supposed hideout turned out to be a refugee camp hosting families who have been displaced by the radical Islamist group, Boko Haram, ravaging their country. Additionally, the refugee camp was also the temporary base of operations for members of the Red Cross and Doctors Without Borders working in the area. Borno state officials have put the death toll from this horrible miscue by the Nigerian armed forces at 100. Meanwhile the Red Cross has reported that 6 of their personnel were killed in the bombing.

This most recent blunder by the Nigerian armed forces has come at a time in which Boko Haram continues to be a festering sore for the African giant. Nigeria is the wealthiest African nation by GDP and has been blessed by ample natural resources in the oil rich southern region of the Niger delta. This combined with the fact that Nigeria has an expanding middle class gives  Nigeria the potential to be one of the world’s leading economies. Additionally, Nigeria has the largest population of any African nation. This puts Nigeria in the unique position of being the largest market on the continent and thus being able to dictate African demand for a variety of products. However, because of its exploitive colonial legacy and the influx of large multinational oil conglomerates into the southern half of Nigeria, the northern section of the country is relatively underdeveloped. Most of the wealth in the nation is centered around the capital of Abuja, the commercial hub of Lagos, and the petrodollar region of the Niger delta. All of these regions, relatively speaking, are in the southern half of the nation. This leaves much of the north poor, underdeveloped, and cut off from the center. The north has less educational facilities and almost completely lacks any foreign investment. While much of the north relies on subsistence farming and other agricultural pursuits, the south has a long history of foreign trade and bustling economic activity.

Along with this economic divide, Nigeria faces a cultural and religious divide within the nation. The north is largely Muslim while the south is mostly Christian. However, the Christian and Muslim populations are relatively equal, and there are enclaves of both Christians and Muslims in the north and south. This means that though the regions are culturally different Muslims and Christians generally get along with each other. The northern states practice sharia law while the southern states do not. This north-south tension has also taken on political undertones. Many national elections, issues, and geopolitical stances in Nigeria pit north against south because the two regions have completely different priorities and interests. While the North wants more economic investment and integration with the booming South, the South insists that it must pay attention to its own expanding economic aspirations before focusing on the North. Additionally, the rise of radical Islamic terror groups, specifically Boko Haram, in the North, has made Southern businesses and firms even more hesitant to invest in the area.

Boko Haram was founded in 2010 in the city of Maiduguri in the state of Borno. Borno, in the northeastern corner of the country, is bordered by the Sambisa forest near the country of Chad. This thick forest cover provides a base from which Boko Haram conducts its attacks on the surrounding towns, cities, and states. In the past seven years of the insurgency, Boko Haram has conducted attacks not only throughout the northern periphery, around Yobe, Kano, and Borno, but also as far south as the Niger state and the federal capital territory of Abuja. In fact, the capital of Abuja has been terrorized by multiple bombings and shootings throughout the city. Boko Haram’s attacks have killed and wounded both Muslims and Christians, and though Boko Haram claims an Islamic affiliation they seem to have no mercy toward any religion. Some of Boko Haram’s most infamous attacks include the 2011 attack on the U.N. building in Abuja, the Bauchi Prison break, and the abduction of almost 300 schoolgirls from the northeastern town of Chibok.

The Nigerian government, however, has been severely criticized for not taking the Boko Haram threat seriously enough. Most infamously, Nigerian president Buhari claimed that Boko Haram was “technically defeated” in late 2015 when in fact Boko Haram still regularly carries out attacks. Because of increasing international pressure, especially following the kidnapping of the Chibok girls, former Nigerian president Goodluck Jonathan, a Christian from the south, and current Nigerian president Muhammadu Buhari, a Muslim from the north, have ordered an offensive deep into Boko Haram controlled territory. In the past two years the Nigerian military has stepped up their military operations and have managed to contain Boko Haram within its northeastern core. However, this means that cities like Maiduguri still face attacks on a weekly basis. Many of these attacks are concentrated on public squares and markets where people – including women and children, gather daily. Such attacks have meant that businesses don’t feel safe and accessing basic commodities has become hard for many residents of Boko Haram’s northeastern core. The World Food Programme feeds around 4.4 million people in and around Boko Haram’s home state of Borno, and WFP estimates suggest as many as 1.8 million people are at risk of starvation because of food aid being disrupted by Boko Haram attacks.

Looking at Nigeria from the outside it seems odd for an insurgency like Boko Haram to exist in this burgeoning African power. The McKinsey Global Institute (MGI) predicts that Nigeria is on pace to grow at a rate of 6% annually until 2030 and have a GDP of $1.6 trillion, putting it in the top twenty economies worldwide. Moreover, MGI estimates suggest that by 2030 Nigerian consumption could rise from $388 billion annually to $1.4 trillion. However, a cultural and socioeconomic divide between the increasingly unequal northern and southern regions of Nigeria has created a rift in this nation. The future of Nigeria will be decided by whether Abuja and the coastal economic hub will be able to address the lack of economic opportunity and upward mobility for the northern half of the country. Simultaneously, Nigeria will succeed if Muhammadu Buhari’s government can firmly stamp out Boko Haram and make northeast Nigeria suitable for business and development projects. It is very much within reach for Nigeria to have economic success relatively soon, however, if the festering sore that is Boko Haram is not handled soon it is unlikely that the economic wealth will be shared by all of Nigeria.

Zimbabwe – A Future Resurrection?

By Jackie Olson

About 20 miners a year die from the desperate efforts to find gold within the caverns in Johannesburg, South Africa. Called “Zama Zama” from the Zulu tribal phrase: ‘men who try to get something from nothing’ this group of Zimbabwe men travel to South Africa in a desperate attempt to find gold and to provide for their struggling families back in Zimbabwe. While the activity is illegal, the seriousness of their ‘illegal’ activity is certainly unequitable to the illegal activity of Zimbabwe’s 92-year-old president, Robert Mugabe.

Robert Mugabe took office in 1980 after a brutal civil war and was at first proclaimed as a leader who could positively impact Zimbabwe. Yet after nearing the end of his seventh-term in office, he is considered by the west as a leader of a regime that has invoked economic and political oppression on its people.

In 2009, Zimbabwe was infamously known for their massive hyper-inflated currency, which at one time hit over 231 million percent from a combination of a 50% shrinking economy, poor crops and public corruption in the midst of a political rebellion against Mugabe. In order to save Zimbabwe from utter economic destruction, Zimbabwe changed currencies and adapted the U.S. dollar for greater protection from internal insecurities.

Since 2016, rough estimates have placed Zimbabwe’s unemployment rate at 90%. With a failing agriculture and industry economy, Zimbabwe has had to increasingly rely on imports for products. As the economy is beginning to look similar to the one in 2008, the government has taken extra precautions in preserving the quantity of U.S. dollars in the treasury. This has resulted in the freezing of payments to many government workers such as teachers and civil servants and has also caused an increased amount of public demonstrations of unrest.

Yet, in order to combat activism on the streets, a local NGO has estimated that over 654 cases of political violence has come from government security officials, including police, military, and a secret service unit just from 2016 alone.  Reports have found that detainees have had to face sexual violence, were injected with mysterious substances and were hung over large pots of sulphuric acid to discourage them from more activism.

These troubling reports have certainly not helped Mr.Mugabe’s case in pressing the IMF for economic relief as the IMF has been reluctant in even providing support without any change in Zimbabwe’s governmental structure, especially the fact that 97% of all government spending is used to pay the governmental workforce. Zimbabwe has refused to make any spending cuts.

As a desperate-last ditch effort, President Mugabe on November 28 ordered to print a new currency, a Zimbabwean currency that looks almost identical to the note used during Zimbabwe’s hyper-inflated period in 2008-2009. Orders were then given to stock ATMs in millions of the new $2 and $5 note with the hopes that only larger bulk import purchases would need US Dollars for a transaction. The switch to Zimbabwean currency has caused civil anxiety and many people have rushed to banks to withdraw as many US dollars as possible resulting in long lines and unrest.

Many economists worry that Zimbabwe’s turn to an insulating currency will be highly detrimental to Zimbabwe’s economic health as foreign demand for the currency will be next to nothing.

For months the imminent disaster has led many Zimbabwean people to turn to plastic payment, either from debit card machines or services on a mobile phone. Services such as gambling, supermarket purchases and even donations to churches has been adapted to a plastic transaction as money has been so scarce. In rural villages where technology is not as prevalent, transactions have been left to bartering.

This vacuum of money has provided a perfect opportunity for a growth in inequality as only the wealthy has been able to open debit accounts. The poor are left to struggle without the basic tool to trade, money, and are forced to buy cell phones for access to a mobile banking service from individuals who realize the opportunity to make massive profits out of people’s desperations.

For example, take village trader, Fambai Mudzaniri who has been consistently making 500 dollars a month from the shortage. He goes into the town and buys $13 dollar phones and resells them to poor villagers for a goat or a few chickens. He then takes the livestock and sells them to restaurants for $50 dollars each.

Unfortunately, the troubling economic conditions and corrupt government will be unable to provide for the eventual widening of the inequity of Zimbabwe and the increased amount of civil unrest from droughts, a lack of food and opportunity. Fortunately, though, Robert Mugube is currently the world’s oldest leader and even though he is looking for ‘re-election’ in 2018, he has even acknowledged his own death in 2016 with the public statement: “Yes, I was dead-I resurrected.” Hopefully within the next decade Zimbabwe will resurrect too.

Peace Deals and Populism in Colombia

By Adithya Sivakumar

2016, regardless of its flaws, was a reactionary year. However, the interesting component of decisions made throughout this cycle has been that populism, not necessarily politicians, have fueled these choices. From Trump to Brexit, voters have signalled a wakeup call to the establishment, letting them know their voices are loud and present. Colombia, a nation in the upper region of South America, was one of the countries to fall victim to the incendiary political forces of this wild year, where a peace deal between the country and an rebel group was put up to the scrutiny of the nation’s voters, leading to a surprising result.

Created in response to perceived government neglect, the Revolutionary Armed Forces of Colombia (FARC) was first a group that protected rural communities from government attacks, but soon developed into a group that participated in kidnapping and drug trafficking to pay for their expenses. Despite a peace deal in the 1980’s, conflict between the government and FARC continued, with major crackdowns by the government and renewed attacks by the group leading to further violence. After years of war between the Colombian government and FARC, both sides finally sat down and hammered out a peace agreement earlier this year, under the watchful eyes of various other countries and organizations, including the Roman Catholic Church and Cuba.

For the peace agreement to be put into effect, however, the Colombian people needed to ratify it. In Colombia, just like other nations around the globe, a choice with wide-ranging implications was to be made by its population.To an outsider, the decision may seem simple. Peace seems the safest way to proceed, and could heal the divide caused by years of war. It seems like a no-brainer, right?

The Colombian people, however, did not think so.

In a decision that shocked the world, the peace deal was rejected in a razor-thin margin, with 50.2% saying “No” to ratifying the peace deal. Despite backing from the Prime Minister of Colombia and various members of the United Nations, the deal failed to be enacted by less than 54,000 votes. The voting turnout was low, which may have contributed to the decision, but many were confused as to why this rejection had occurred in the first place. Were those who voted against the deal less willing to compromise with FARC, or less affected by the conflict than those who voted yes to the deal? Or, as seen with Brexit and Trump’s win in the United States, was this simply a rejection of the establishment’s position on a certain position?

Turns out, it was a mixture of some of these factors. Many who voted “no” did not necessarily reject peace, but rather rejected some of the terms laid out in the deal, which were viewed as too lenient in some views. For example, provisions that allowed those who confessed to war crimes more lenient sentences and gave a monthly stipend to demobilized rebels were seen as too much for some citizens. Additionally, these voters may have been distrustful of FARC due to its violation of ceasefires in the past. Alvaro Uribe, the primary opponent of the peace deal and also a President of Colombia during a crackdown on FARC, insisted that he wanted peace, but wanted, among other stipulations, that those convicted of crimes were to be barred from political office and FARC leaders spend time in prison.

However, unlike many populist movements around the world, the decision in Colombia was unique in that it demonstrated a urban-rural divide in terms of the vote. Urban areas, which had been shielded by the conflict, primarily voted no, while rural areas, who were experiencing the brunt of the conflict, voted yes. Therefore, the vote did not seem strictly defined by populist sentiment, but rather various other factors that may in fact indicate an elitist sentiment among those who voted no.
With these factors in mind, both the Colombian government and FARC sat back down at the negotiating table to create another settlement, one that would take the concerns of the voters into consideration. More severe restrictions were imposed on rebel movements, while rebels would also be required to reveal drug-trafficking routes to the government. After these changes were sown into the deal, the Colombian Congress approved the deal unanimously, bypassing the will of the voters and leading to a new peace in the Colombian nation. Although the deal was approved, the nation will have to deal with the lasting after-effects from the war, in which more than 260,000 have died, at 79,000 have gone missing, 30,000 have been kidnapped, and 7 million have been displaced. The new outcome gives a wider berth for hope in Colombia’s future, and it is up to the government, FARC, and the people of Colombia to actively participate in the next steps of the reconciliation process in the region’s longest-running conflict.

Electronic Medical Record for Clinic Growth in Rural Guatemala

By Benjamin Li, MD/MBA expected 2018

Purpose: Describe the Primeros Pasos clinic and provide context for its current growth strategy: developing an electronic medical record system.

In 2004, a Vanderbilt medical student founded a non-profit primary care clinic to address health disparities in his home country, Guatemala. Like many developing countries, Guatemala struggled to provide access to health care throughout many parts of the country, especially rural areas. Located outside of Quetzaltenango (the second largest city in Guatemala), the Palajunoj Valley is an agricultural community of 18,000 inhabitants. Though situated in a beautiful landscape, it struggles with no access to clean water, heavy ash from the nearby active volcano (volcán Santa María), and poor education and nutrition. The Primeros Pasos Clinic provides care for this population.

Each year, Primeros Pasos has continued to grow through the collaboration of medical students, volunteers, and professionals. In its inception, the clinic served children from local schools. It expanded to include adult services in 2007, laboratory services in 2009, dental care in 2010, and a nutrition program for health and education in 2012. It is currently staffed with a clinic coordinator, a dentist, a pathologist, two Guatemalan physicians, six to eight rotating Guatemalan medical students, and a host of international medical volunteers who come and go throughout the year, usually one to three months at a time. It has established several partners, including local businesses, Spanish schools that provide education and lodging for volunteers, and global health alliances. The clinic treats four main conditions: intestinal parasites, respiratory illnesses, skin lesions, and malnutrition.

Like many developing clinics in poor regions, Primeros Pasos provides most of its care at low or no cost, so it relies heavily on outside funding. The clinic coordinator is responsible for applying for numerous outside grants throughout the year. In addition, each international volunteer is expected to fundraise $300 for the clinic. Vanderbilt Medical School organized a “Miss America” style event called the “Dr. Vanderbilt Pageant” to fundraise $2000 for the clinic in 2016. The clinic currently hopes to use this funding to acquire a new electronic medical record system (EMRS).

The new system, OpenMRS Software, is an open source EMRS platform commonly used to improve health care delivery in the developing world. It is designed to be adaptable for different sites, languages, and types of diseases. First implemented in Kenya and Rwanda in 2006, it is now used throughout the world.

As the clinic coordinator explained, this new system would open a whole new pathway for Primeros Pasos. Currently, the clinic operates with a handwritten paper/Microsoft Excel hybrid system in which patient records are kept in color-coded folders (pink for females, blue for males) stored alphabetically in three large filing cabinets in the clinic. The new system improves difficulties that range from illegible handwriting to providing unique patient identifiers (many people in the valley share identical names), and creates an organized way to streamline care, track patients, and collect information. Improving efficiency allows the clinic to see higher volumes of patients. This will encourage patients to return to the clinic for routine healthy check-ups, instead of just when they are ill.

On a significant note, the new EMRS opens avenues for greater funding. Many large grants require data and metrics to support program efficacy. Primeros Pasos will be able to use OpenMRS to collect, centralize, and report patient data (health demographics, diseases, treatment, outcomes, and more), allowing it to access this pool of funding. Furthermore, statistical reports can be used to evaluate and improve medical program design, approach, and policies to most effectively optimize patient care and outreach.

The steps towards this growth would not have been made possible without the interest and contribution of student volunteers and Global Health programs. Though short-term visits may appear to offer limited impact, Primeros Pasos is an example of a clinic that has benefited steadily through the years with continued support. A key component to its success has been establishing a long-term vision and a diverse board of members to oversee its growth and operations. Particular credit should be given to the clinic coordinator, who has been able to track the progress of the clinic, develop partnerships, spearhead finances, and update goals and initiatives while managing its volunteers. The clinic imparts a lasting impression on its volunteers, which serves as a testament of its collaborative success.

Systems-Based Healthcare in Lwala

By Chinonso Opara

Being a Nigerian-born American, I have grown to understand that the benefit of living and working in a first world country is not necessarily lifestyle and “Western amenities”. Nor is it the people or culture. I have come to see that the benefit of living in the United States or any other developed country is the relatively available access to healthcare. You can almost bet that when a medical emergency knocks at your door, there will be services to help meet your newly acquired needs. Through a partnership between Vanderbilt and Lwala Community Alliance (Lwala), I was immersed in the Kenyan healthcare system and was able to draw comparisons between Kenyan healthcare and that in the US. I was placed at Lwala’s hospital and observed care provided in this semi-private facility as well as the care provided through government hospitals in the area. I realized more and more that Kenya, and Africa in general, are relatively young countries – only being about half-a-century old. I realized that while Kenya still has a long way to go, it has come far and has potential to grow even more in terms of improving access to adequate healthcare. I had the opportunity to be exposed to the National Health Insurance Fund. I also had the privilege of contributing to the improvement of the KenyaEMR (electronic medical record) system at Lwala, which was originally designed for the care of HIV patients.

One dismaying thing I saw about healthcare in Kenya is that it is based too much on one’s ability to pay. If you come to the emergency room with a medical emergency, such as acute appendicitis, some hospitals will require you to pay first before they touch you, even though your life is in grave danger. While Lwala provides subsidized and free care, patients that are referred to other facilities for acute conditions face cost barriers. At least in the United States, the ER will see you, even though they’ll hand you a hefty bill later.

One particular patient I remember was a young adult with a past medical history of Hepatitis B, undergoing treatment with tenofovir and lamivudine, and who developed cirrhosis of unspecified etiology complicated by a large hepatic mass seen on ultrasound. He had no other known risk factors: no hepatitis C, no smoking, no drinking, one sexual encounter 5 months prior with a condom, no known family history of abdominal disease. The next step in the workup was to refer the patient to another facility for a CT scan, which will cost his family 7 to 9 thousand shillings ($70-$90). This is a hefty price! Especially considering the median income in Kenya is a little above KSh6000/month ($60), and in village life, it is likely much less than this. They will need help from family and good friends in order to come up with the money.

On another day, we had a patient come in with bowel obstruction. She had initially been diagnosed with bowel obstruction secondary to colon cancer in one of the main government referral hospitals. However, her family could not come up with the necessary funds for further workup and therefore took her home. At home her cancer metastasized systemically and she deteriorated. She was brought by her family to Lwala. However, because she required specified diagnostic tests that Lwala’s hospital does not have, we had to tell the family that we could not do much for her. This is another example of how a family’s limited immediate financial resources hinders even the workup of a life-altering disease.

However, we had another patient during rounds who was HIV-positive with nevirapine-induced dermatitis and hepatitis, requiring further workup, including LFTs, and kidney function tests. The difference here is she had health insurance through the National Hospital Insurance Fund in Kenya, and she could therefore afford the further workup of her condition.

The National Hospital Insurance Fund, established in Kenya in 1966, was designed to make access to adequate healthcare more feasible for families, similar to health insurance companies in the US. It is the oldest such insurance scheme in Africa and the pride of the Ministry of Health. It requires a minimum income of KSh1000/month just to enroll and the individual contribution is based on one’s monthly salary. For instance, the following income brackets of KSh1000 – KSh5999 and KSh6000 – KSh7900 must contribute KSh150/month and KSh300/month, respectively. And anyone who is self-employed must contribute KSh500/month. Considering the median Kenyan income of around KSh6000 this is expensive for the most vulnerable Kenyans.

Because of the very vulnerable population Lwala serves, very few patients are enrolled in NHIF.

In fact, in my whole time in Lwala, I only saw one person who had NHIF and that was the patient described above. Even one of the clinical officers, in his whole time in Lwala has only seen three patients with NHIF in Lwala

Lwala provides free services to pregnant mothers, children under 5 and people living with HIV as well as subsidized services to the general population. However, patients needing specialized care above the services provided at Lwala, must navigate the public system.

Lwala is in the process of registering for NHIF and aims to be a full participant in the program in 2017. Once registered, Lwala will begin an ambitious campaign to enroll its population into the insurance scheme. This will mean increased sustainability of the hospital as it receives reimbursement for the free care it provides as well as fuller coverage for patients when they are referred for higher levels of care.

My hope is that the NHIF expands in Kenya to increase coverage for and access to healthcare, but that it does so in a way that retains quality, as is the hope for any health insurance program.

Highlighting VUMC Research on TB/HIV Co-infection

Tuberculosis (TB) is the leading cause of death among people living with HIV. In 2015, there were 1.2 million people living with HIV estimated to have fallen ill with TB, and 390,000 people who died from HIV-associated TB. To control TB in high HIV-prevalence settings, it is imperative to coordinate efforts for TB and HIV control. Vanderbilt collaborates with international organizations and performs studies in population-based cohorts to identify ways to reduce the burden of TB among persons living with HIV.


William Wester, M.D., M.P.H. leads a large CDC-PEPFAR-funded initiative in Mozambique entitled, “Avante Zambézia” (“Go forward” Zambézia province) where the Vanderbilt University Medical Center (VUMC)/Friends in Global Health (FGH) team provides technical assistance supporting the scale-up of comprehensive HIV and TB services, including the provision of antiretroviral therapy (ART). Currently beginning year 5 of their initial 5-year cooperative agreement plus beginning year 1 of 5 of a new grant award, the VUMC/FGH team is making great strides in the area of service expansion, as they now support ART services in 112 health facilities across 14 out of 23 districts within Zambézia province; with plans to expand into a 15th district, namely the province’s most populous district (Quelimane) beginning in January 2017.  During the recently completed year 4 of the initial grant award (9/30/15-9/20/16), 5,224 new TB patients registered in the program and 92% of eligible HIV/TB co-infected persons initiated ART. During this current funding year, the VU/FGH team plans to specifically focus on improving the timeliness of TB diagnosis via the wide-scale implementation of the Gene Xpert diagnostic test, as well as improve TB infection control via site refurbishment to improve patient flow and air flow/ventilation.



April Pettit, M.D., M.P.H. studies the epidemiology and outcomes of those co-infected with TB and HIV via datasets from large HIV cohort collaborations. Results of an International Epidemiologic Databases to Evaluate AIDS (IeDEA) study examining mortality due to non-AIDS defining events in HIV patients on ART were presented at the International Workshop on HIV Observational Databases (IWHOD) in March 2015. Another IeDEA study led by Pediatric Infectious Diseases Fellow James Carlucci, M.D., looked at TB treatment outcomes in HIV/TB co-infected children in resource limited settings, results were presented at CROI in February 2016. Additionally, Dr. Pettit is involved in clinical studies of TB infection and disease via the Tuberculosis Epidemiologic Studies Consortium and the Tuberculosis Trials Consortium, funded by the Centers for Disease Control and Prevention.


The Caribbean, Central, and South America Network (CCASAnet) for HIV epidemiology, a network of IeDEA and led by Catherine McGowan, M.D., collects and synthesizes data through the Vanderbilt Data Coordinating Center (VDCC). CCASAnet has created a shared repository of HIV patient data that has been merged from 10 sites throughout Latin America. This dataset has allowed high-quality analyses of HIV and TB. The most recent project is evaluating TB treatment intermittency in the continuation phase and associated mortality; preliminary results will be presented at CROI in February 2017.


A newly funded NIH R01 project led by Timothy Sterling, M.D. aims to optimize the treatment of HIV-related TB in a large, genetically diverse cohort in Brazil. Treatment of TB/HIV is complicated by drug-drug interactions and increased drug toxicity risk. The current guidelines recommend a standard 6-month based regimen regardless of HIV status, but recent studies suggest that TB failure and relapse is increased in HIV-infected persons. Pharmacogenomic predictors of TB failure and relapse could help optimize treatment. This project builds on the previously established Regional Prospective Observational Research on TB (RePORT)-Brazil cohort which is enrolling patients from 5 sites in Rio de Janeiro, Salvador and Manaus.


The Vanderbilt Tuberculosis Center (VTC) is a focal point for collaborative efforts in TB research that contribute to a reduction in the burden of TB/HIV globally, including Tennessee and Nashville. The VTC also provides technical assistance to local and global service programs engaged in TB control including the Metro Nashville Public Health Department and the Tennessee Department of Health.

Costa Rica: Renewable Energy’s Success Story

By Derek Brody

Costa Rica is a Central American nation known primarily for its lush rainforests and booming tourism industry, but this year it is attempting to make another claim to notoriety as the first country to last an entire year running on only green energy.

The country has become a pioneer in renewable energy, and has spent the last 5 months subsisting solely on green energy sources, rather than fossil fuel. Twenty fifteen was a landmark year in the push for green energy in Costa Rica, as the country spent 285 days powered entirely by renewable energy sources according to the Costa Rican Electricity Institute, also referred to as ICE. The country has not been powered by fossil fuels since June 17 of this year, meaning they are almost halfway to their goal of an entire 12-month cycle. In fact, ICE announced in April that they “now consider fossil fuels a backup energy generation source.”

In the place of fossil fuels, Costa Rica uses a mixture of hydro, wind, geothermal, and solar energy. Hydropower provides the majority of their energy, greater than 80%, with geothermal plants providing 12.6%, wind turbines providing 7.1%, and solar energy providing 0.01%. The country has been able to utilize its climate and terrain, using its large river system and heavy tropical rainfalls to create large amounts of hydropower. The nation has been lucky in 2016 because of the heavy rainfalls near the country’s four hydroelectric power facilities. Carlos Manuel Obregon, the executive president of ICE, noted that Costa Rica will soon turn on its Reventazon hydroelectric project, which is massive in size and scope. According to the Tico Times, the dam’s five turbines will have a generating capacity of 305.5 megawatts, or enough power for an estimated 525,000 homes.

Costa Rica is also not alone in its quest to reduce dependence on fossil fuels, and a number of European countries have been reasonably successful in their attempts to make greater use of green energy sources. Sweden, for example, draws approximately half of its power from renewable sources, as Prime Minister Stefan Lofven announced that the country will work toward becoming the “first fossil fuel-free” nation in the world in a speech to the UN General Assembly earlier this year. In September, his government announced it would allocate 4.5 billion kronor (approximately $521 million) to green infrastructure, funding projects like the production of more solar panels, wind turbines, and a cleaner public transport and energy grid.

Denmark has also made major steps toward reducing dependence on fossil fuels, and currently ranks as the world leader in energy sourced from wind. In fact, nearly 40 percent of the nation’s electricity came from its wind turbines in 2014. Even Portugal, a nation not well-known for its commitment to renewable energy, ran for 107 straight days without using any fossil fuel-based sources earlier this year.

That is not to say, however, that Costa Rica’s success comes without challenges and obstacles. In fact, it can be argued that their overwhelming reliance on hydropower is actually harmful to the environment, according to Gary Wockner of “Save the Colorado.” In August, Wockner warned against the dangers of hydropower when he said, “Hydropower has been called a ‘methane factory’ and ‘methane bomb’ that is just beginning to rear its ugly head as a major source of greenhouse gas emissions that have so-far been unaccounted for in climate change discussions and analysis.” Additionally, rainfall can be fickle at times and long periods of drought result in countries having to resort back to the use of fossil fuels.

It is also incorrect to assume that Costa Rica’s success is easily transferrable to other countries. The country has only 4.9 million inhabitants, and the Economic Commission for Latin America and the Caribbean estimated they used about 10,713 gigawatt-hours of electricity in 2015. In contrast, the United States generated about 373 times more electricity in 2015, with roughly 4 million gigawatt-hours of total generation.

Recent actions taken by the United States, however, suggest that the U.S. is not as committed to green energy as it could be. In mid-August, the state of Wyoming declared that the state itself owns the wind. This measure, passed by the state legislature, allows the state to increase taxes on energy produced by wind turbines from $1 per megawatt hour to $12 per megawatt hour. This legislation has been criticized for its deleterious effects. Matt Agorist of the Free Thought Process noted that, “This move by the state is not in the interest of the people, nor it is even in the interest of raising funds for the government. In the four years that it’s been law, the state has only raised $15 million from taxing the wind. This move is purely retaliatory and meant to stifle new businesses who threaten the dinosaur coal and fossil fuel industry’s grip on energy production.”

Nevada also passed legislation designed to suppress green energy production, hiking its tax on solar power by 40 percent in January of this year. To make matters worse, the tax increase was applied retroactively, effectively squashing investments in the growing solar industry. Former SolarCity CEO Lyndon Rive expressed his displeasure at the increase, saying, “It will destroy the rooftop solar industry in one of the states with the most sunshine. There is so much wrong with the decision. The one beneficiary of this decision would be NV Energy, whose monopoly will have been protected.”

Despite the challenges put forth by certain state legislatures, the planet as a whole has made large strides away from dependence on fossil fuels and toward a more sustainable future. Leading the charge, perhaps unexpectedly, is a tiny Central American country who may just make history this year.