What are the most pressing issues in global health?
October 15, 2017
Margaret Bentley, PhD
Carla Smith Chamblee Distinguished Professor of Global Nutrition
Associate Dean for Global Health
Associate director, UNC Institute for Global Health and Infectious Diseases
There are so many! Perhaps the best place to start is with the United Nations’ Sustainable Development Goals (tinyurl.com/UN-SDG). Officially titled “Transforming our World: the 2030 Agenda for Sustainable Development,” the document proposes a set of 17 global goals with 169 targets.
Many of the goals overlap with global health, including reducing poverty and increasing gender equality, quality education, climate action and economic development. Others clearly have global and public health significance for action, such as zero hunger, clean water and sanitation, and good health and well-being for all.
I’ll focus on two pressing issues that overlap with some of these goals and that have promising and feasible solutions – the convergence of infectious diseases and noncommunicable diseases, and food security, agriculture and malnutrition.
Q: What is the relationship between communicable and noncommunicable diseases (NCDs)?
A: Worldwide, NCDs are rising in low- and middle-income countries. These include rapid increases in diabetes, cardiovascular diseases (CVD), tobacco-related morbidities and mortality, and cancer – particularly cervical cancer.
Global mental health is at the top of the global burden of disease. Poor mental health can result from depression, stress and anxiety and can lead to substance abuse. Several Gillings School faculty members, including Drs. Brian Pence and Joanna Maselko (in epidemiology) and Dr. Rohit Ramaswamy (in the Public Health Leadership Program), work with students to grow our capacity for global mental health research.
In the same countries, communities and households, infectious disease prevalence remains high. HIV/AIDS, malaria, tuberculosis, diarrheal diseases, respiratory illness and emerging infectious diseases are among those old foes. Again, our School and University have great expertise in infectious diseases research and prevention, including Drs. Mike Cohen, Steve Meshnick, Ralph Baric, Audrey Pettifor and Jennifer Smith (in epidemiology), Drs. Suzanne Maman and Vivian Go (in health behavior) and many more.
This convergence of infectious diseases and NCDs is called the dual burden of disease, and it represents a great challenge to governments, programs and policy makers who must allocate resources for prevention and treatment. Many at the Gillings School focus on the dual burden of disease, including myself, Dr. Barry Popkin and his large team, Drs. Shu Wen Ng, Linda Adair, Amanda Thompson and others, all in nutrition.
Q: What can be done?
A: Research and programs focus upon a promising innovation – the integration of treatment and care of diabetes among HIV-positive individuals. The literature suggests that anti-retroviral (ARV) therapy adherence rises when we offer people diabetes management at the same point of health-care delivery.
Clare Bailey, a recent master’s degree and registered dietician (RD) alumna, studied diabetes clinical care during her degree training and now is project coordinator for a National Institutes of Health-funded study in Tanzania that aims to integrate diabetes management and HIV/AIDS care.
Dr. Jennifer S. Smith’s research in South Africa found that highly active antiretroviral therapy (HAART) helped to reduce the incidence of cervical precancerous lesions in HIV-positive women, compared to non-HAART users.
With colleagues at the University of San Francisco at Quito and the UNC Center for Galapagos Studies, Dr. Amanda Thompson (anthropology and nutrition), Dr. Jill Stewart (environmental sciences and engineering), and I are beginning interdisciplinary research in the Galápagos Islands.
Here, high rates of diabetes and obesity affect adults, and poor water quality causes high rates of diarrheal diseases, especially in children. There are also serious food security issues because of lack of agriculture, accessibility and price – leading to stress and anxiety among caregivers.
Our work in this World Heritage site will identify strategies for working with communities to prevent these problems – so we can ensure better health and well-being across the life cycle.
Q: How do we reconcile malnutrition and obesity?
A: Nutrition is a continuum. At one end is under-nutrition, which particularly affects children and women. Faculty members, including Drs. Linda Adair, Amanda Thompson, Penny Gordon-Larson and others, are at the forefront of this work on the developmental origins of disease related to under-nutrition.
At the other end is overweight and obesity, now a global epidemic. Dr. Barry Popkin published The World is Fat in 2009, and since then, the world has become fatter, even in very poor settings. This is related to over-consumption of highly processed foods and beverages that contain high levels of oils, sugar and salt – as well as more sedentary lifestyles.
More people in the world are now overweight and obese than are under-nourished. In India, more than half of all children are malnourished and stunted, but the prevalence of obesity, overweight and noncommunicable diseases is rising rapidly, even in rural areas. Alas, we have exported our western diets and lifestyles – a negative outcome of globalization.
Q: What can be done?
A: We know what should happen. Interventions to improve under-nutrition among children may include food and micronutrient supplements, improved breastfeeding and complementary feeding, and reduction of infectious diseases. Agriculture also has a key role in diversifying crops, improving yield and promoting home gardens and animal husbandry.
We have many examples of cutting-edge research conducted by our faculty. The Measure Evaluation project, which includes several Gillings School faculty members and has been funded by the U.S. Agency for International Development for nearly $600 million, examines how the “Feed the Future” program in Malawi can improve under-nutrition by integrating agriculture through more efficient value chains.
Individual behavior-change strategies can be successful in dealing with over-nutrition. Many of our faculty have demonstrated this in North Carolina and across the U.S., including Drs. Alice Ammerman, Dianne Ward, Deborah Tate, Leslie Lytle and others.
A major impact can be achieved through structural changes – e.g., tax policies and price increases to reduce demand and by making neighborhoods more conducive to active lifestyles. The most promising strategies should integrate these through interdisciplinary, team-based approaches with solid evaluation of “what works.”
Do what works. That applies to any pressing global health problem. We need to know what works and how, and then apply the solutions to scale. With the Gillings School’s strengths in implementation science, the solutions definitely are within view.
Carolina Public Health is a publication of the University of North Carolina at Chapel Hill Gillings School of Global Public Health. To view previous issues, please visit sph.unc.edu/cph.
