Key Determinants of High Fertility Rates in Rural Pakistan

The total fertility rate among women of childbearing age in rural Pakistan is very high at 5.6 births per women. When addressing this high fertility rate, it is important to determine causation.  In rural Pakistan, high fertility can be attributed to a variety of compounding determinants that relate to biological, social, environmental, economic, and political factors. 

Fertility in rural Pakistan is primarily effected by socioeconomic determinants.  Rural regions have a higher percentage of poverty compared to urban areas; 56% are in the lowest or second lowest wealth quintile (Pakistan).  Poverty has a positive association with fertility; as levels of poverty increase, so does the TFR.  Furthermore, women of the poorest fifth use contraception at a lower rate than women of the wealthiest fifth. Since the majority of women living in rural areas are poor, a high TFR would be expected. 

Women in rural Pakistan are also less likely to be educated, another key social determinant of fertility.  If a girl enrolls in secondary school and completes her education, she is likely to delay marriage and consequentially delay childbearing; if childbearing is delayed, a women will have less children. However, only 3.9% of girls in rural Pakistan receive secondary education and 68% receive no education (Pakistan). “Adolescent motherhood is widespread in rural areas among girls with little or no schooling, and among those with low socioeconomic status,” (Sultana).  Of those girls who attended 5-9 years of school, only 33% where married before 20 and of those girls who received no education, 68% where married (Sultana).  Marriage in Pakistan is usually immediately followed by pregnancy and, as a result, the average age at first childbirth is very young:  21 years.  

The cultural norms in conservative areas of rural pakistan make it acceptable and, in many cases, expected for a woman to bear many children.  There is also a difference between the number of children a women wants compared to the desire of her husband.  When compared, the desired number of children slightly higher among men; women desire 3.9 children whereas men desire 4.0 (Sultana). Furthermore, rural communities are primarily Islamic, which effects their attitude toward contraception and family size.  Contraception is not forbidden in Islam; only permanent methods, such as sterilization, are taboo.  Even still, conservative rural communities tend to also be wary of contraception; they see it as potentially promoting promiscuous sexual behavior.  However, cultural norms may not play as big a role as expected: “Due to modernization, the impact of culture and religion is fast disappearing from determining the demographic transitions taking place. It is clearly social and economic [factors that matter] and of course, at the top of it all, what public policies each country follows,” (Zuehlke).

Apart from cultural, social, and economic factors, another determinant of fertility for women in rural Pakistan is access.  There is almost no availability family planning and pre and post natal care due to their isolated location.  Lack of access to family planning means that modern contraception is used at a very low rate, only 17.7%, and there is a high unmet need at 31%. Contraception is “the most important intermediate fertility variable determining fertility levels,” (Davis). There is a negative association between contraceptive use and fertility; as contraceptive use increases, fertility decreases. Fertility also depends on the type of contraceptive that is used, as some methods are more effective than others.  

Lack of access to family planning services in rural Pakistan is primarily due to lack of effective government interventions. The Pakistani government has so far not implemented a successful family planning program (Karim). Any programs that have been implemented by the Pakistani government cannot be reached by the women in rural areas.  “In Pakistan, because there has not been an effective family planning program, only women who are living in urban areas, more educated, or coming from upper- or middle-class families are using contraceptives...” (Zuehlke).

Overall, high fertility rates in rural Pakistan can primarily be understood through examining their social, economic, and political environment.  Living in rural areas of Pakistan puts women at an inherent disadvantage when it comes to family planning; they are subject to more of the compounding key determinants that cause high fertility such as poverty, lack of education, and barriers to access.

p.s.- Dr. Crupain, here is my new problem definition: High fertility rates among women of childbearing age in rural Pakistan from 1970-2010. 

Do you think this sounds better? 

Also, are we able to include charts in our paper for clarification?

Works Cited:

"BBC - Religions - Islam: Contraception." BBC - Homepage. 07 Sept. 2009. <http://www.bbc.co.uk/religion/religions/islam/islamethics/contraception.shtml>. 

Davis and Blake 1956. “Social Structures and Fertility: An Analytic Framework” Econ. Dev and Cultural Change 4:211-235

"Population Dynamics - Countries of WOA!! Population Awareness." World Overpopulation Awareness. 27 Nov. 2010. <http://www.overpopulation.org/culture.html>. 

“Population & Economic Development Linkages 2007 Data Sheet.” Population Reference Bureau. 2006.

"Pakistan: DHS, 2006-07 - Final Report." Demographic and Health Surveys, 2006-2007.  

Sandra, Yin. "Pakistan Still Falls Short of Millennium Development Goals for Infant and Maternal Health - Population Reference Bureau." Home - Population Reference Bureau. Dec. 2007. <http://www.prb.org/Articles/2007/pakistan.aspx>. 

Sathar, Zeba, Christine Callum, and Shireen Jejeebhoy. "Gender, Region, Religion and Reproductive Behaviour in India and Pakistan." IUSSP. Rockefeller Foundation, 2001. <iussp.org>. 

Sultana, Munawar. "A Brief on Reproductive Health of Adolescents and Youth in Pakistan - Culture of Silence." The Population Council, Inc., 2005.

“World Population Prospects: The 2004 Revision.” United Nations. 2005.

Zuehlke, Eric. "Changes in Fertility Rates Among Muslims in India, Pakistan, and Bangladesh - Population Reference Bureau." Home - Population Reference Bureau. Apr. 2009. <http://www.prb.org/Articles/2009/karimpolicyseminar.aspx>. 

Lessons Learned in Public Health

My interest in public health began with a vague supposition: that, through public health, I could begin to understand the underlying problems facing the well being of populations.  Throughout the first half of this course, I have come to discover just this. Learning about epidemiology, chronic versus infectious diseases, nutrition, population growth, and other health determinants has expanded my interest and knowledge of public health.  I have come to learn that all health determinants inter-connectedly determine the health of populations. We have learned through many sources including lectures, readings, and our personal blogs.  Blogging has perhaps been the most beneficial learning tool, forcing me to think critically and to draw my own connections and conclusions about public health. 

Throughout this course, one question has become crucial to me: how exactly do I define quality health--by advancement of medical technology or by accessibility and affordability? Defining quality health is a difficult task, and to do so, it is important to consider care within a global context.  I have come to realize that, only through a comparison of public health in both developed and underdeveloped nations, can the U.S. system be analyzed accurately.  Through this comparison, one can begin to understand factors that comprise a good public health system which ultimately leads to the best outcome possible.

I have also come to realize the importance of population growth and, of all the lectures, I found this topic to be the most intriguing.  The lecture complimented another class of mine: Population Health and Development.  Both the lecture and this course emphasize how population growth is a determinant of public health.  Population growth effects all aspects of public health and the overall global health development.  Currently, health resources and infrastructure cannot compete with the population growth rate.  Thus, health is constantly lagging.  Global public health cannot improve until effective family planning programs are implemented, which will empower women, ensure the health of all citizens, and improve the success of development. 

Throughout this course, I have also come to appreciate the imperative importance of legislation for public health.  Legislation has the power to bring structural changes to shift our societal norms. Laws have brought about some of the greatest public health victories, as in the case of the ban on tobacco advertisements as a result of the fairness doctrine.  Hopefully, health can be further improved through future legislative changes.  For example, initiatives need to be taken in the public sector to combat obesity.  California is leading the way in such changes; under a new California law, McDonalds must meet certain nutritional standards before they can include a toy in their Happy Meals (http://www.cbsnews.com/8301-504763_162-20021901-10391704.html).  This law combats the advertising of unhealthy food to children, the most impressionable consumers.  The law also demonstrates how the public opinion has shifted enough to allow for such legislation to be passed. 

Ultimately, that is the goal of public health: shifting popular opinion to favor a sustainable lifestyle and making the path of least resistance a healthy one.  Public health aims to create a healthy environment for people to thrive; one free of infectious diseases, with minimal chronic disease, and access to care for all.  

Balancing the Rights of Individuals and the Community

The plight of the individual versus the well-being of society is a common conflict noted throughout history. It creates division among modern politics, inspires debate among great philosophers, and is even manifested in public health.  

In the case of KIRK v. WYMAN, the rights of the individual versus the community were brought to trial.  The jury weighed both sides of this debate, ultimately ruling in favor of the individual.  The plaintiff, Mary V. Kirk, was diagnosed with anaesthetic leprosy, which the Board of Health believed to be contagious and a threat to the community. They initially requested voluntary sequestration, but after her incompliance demanded compulsory isolation.  Even still, Mary Kirk refused to comply, arguing that her form of leprosy was not proven to be highly communicable and the environment of forced isolation was unhealthy and inhumane.  The Board of Health suggested an alternative location, only to be met with further resistance and an injunction by Ms. Kirk. Ultimately, they ruled in favor for the individual, arguing that isolation was unnecessary for her relatively non-communicable case.  The Board of Health unsuccessfully tried to appeal.  

This case exemplifies the cruciality of this debate and both sides argue legitimate points.  The individualists view restriction by the government on the individual to infringe on personal freedom, thus contradicting the inalienable rights deemed in the Constitution.  However, protecting the community brings greater benefits for a larger amount of people: a seemingly utilitarian approach.  Furthermore, the individual has the potential to harm an entire community. As an ardent public health advocate, I support the rights of communities over those of the individuals in matters related to health.  Many personal behaviors effect the health of not only the individual, but also of those they encounter in the community.  This is exemplified in the case of communicable diseases, where people can easily infect those they encounter briefly and even indirectly.  To effectively protect the population, infected individuals must be either quarantined or isolated, restricting their rights in the process. In such cases, we are called to examine the ethics of the debate: is it moral to protect many individuals by sacrificing the freedom of one? 

The government is the entity responsible for defining instances where isolation and quarantine are ethical and should therefore enact laws to draw clear distinctions between the rights of individuals and those of the community in such instances. It is important when debating the issue of community versus individual in Public Health to differentiate between quarantine and isolation.  Quarantine is used when a person has been exposed to an illness and they have become susceptible to developing the illness.  Both share a common theme: ensuring the community remains unaffected by communicable diseases. However, forced quarantine or isolation should be a last resort.    Comfortable and humane living conditions must be provided for the patient, their pride and dignity cannot be sacrificed, and confidentiality must be maintained to avoid potential discrimination.

The individual will inevitably be connected to the community, and vice versa; but it is learning how to justly balance the rights of the two that will determine much of the future of public health. 

The Decline of Global Public Health

The article “The Challenges of Global Health,” published in Foreign Affairs, discusses the changes in development over the last century and the current state of global health.  Over the 20th century, aid has seen an increase in spending for health related programs. Increased spending on global health initiatives began with the HIV/AIDS epidemic, which revealed disparities in access to treatment for victims of low socioeconomic status. Healthcare professionals were appalled and caused an outcry, spearheading a, “larger global public health agenda.” Other recent incidences, such as the Avian Flu, have also increased funding for global epidemiological surveillance.  Furthermore, spending by wealthy nations has lead them to pressure developing nations do their share by allocating more of their national budget toward healthcare. The aid world is finally begging to realize that poor health impedes productivity and developmental growth.

Enormous sums of money are now given annually by private and government donators, each amount designated for a specific, narrow goal. This increase in donations has spurred an explosion of well-meaning NGOs dedicated to solving the world’s problems.  But, lack of coordination amongst these do-gooders may be doing more harm than good. The main problem facing health development is no longer lack of resources, but rather lack of coordination.  

Aid is ultimately failing because it is inefficient.  As money becomes tied up in bureaucracies and corruption, funds don’t end up supporting their intended purpose.  Inefficiency is also due to “stove-piping” funds by narrowing their focus to one specific disease or program.  Stove-piping reflects the priorities of donors, which is subject to their opinions, whims, and ideals. Improving efficiency can also be achieved by spending less on specific diseases prevention and more on improving the total health of the population, a more comprehensive approach. 

Donors and NGOs can even hinder the progress of global health with their well intended projects.  Spending by outside organizations and NGOs in developing nations can destabilize a nation’s economy by causing inflation and driving up costs of health higher than what people can afford.  This can only be avoided by the economic participation of local people. The article reaffirms this point stating, “If locals cannot profit, country will never be able to ween off its dependence of aid.” The donor system is also causing a “healthcare brain drain”--trained healthcare workers in developing nations are being lost to better funded projects or are practicing in wealthier nations where they can earn a better living.  In some cases, medical professionals are even being recruited by the very organizations who are trying to help. Ultimately, successful global health development will incorporate exit strategies and transfer control to local leadership.

Two rates that can be used as markers of healthcare development: reduced maternal mortality and increased life expectancy, trends that show an overall improvement in the health of populations.  It is more beneficial to focus on these factors rather than improvement of mortality rates by specific diseases.  Death rates from specific diseases will will only show narrow progress, because diseases can be controlled independently of the nation’s general health, as in the case of HIV.  Furthermore, life expectancy also incorporates death by preventable diseases, thus broadening the focus of aid efforts.  Diseases and causes of death are interconnected, demanding a comprehensive approach that addresses them all simultaneously. Integrated efforts that deal with many variables at once through interconnected, community based interventions will be more effective than tackling each problem individually.  The article discusses the importance of maternal mortality and life expectancy, claiming “If mothers thrive, it means the health-care system is working, and the opposite is true,” and “life expectancy is a good surrogate for child survival and essential public health services”  

The efforts of donors and NGOs are also unintentionally worsening the state of certain illnesses, such as AIDS and Multi Drug Resistant Tuberculosis (MDRTB).  Many developing nations don’t have sufficient healthcare infrastructure in place and are not equipped to effectively battle AIDS and other infectious disease.  Having multiple donor groups is resulting in uneven distribution of aid and incoordination between efforts.  This has lead to many bad effects, such as the failed recognition of connection between AIDS, malaria and MDRTB.  Ultimately, lack of coordination amongst donors results in repetition of interventions.  The state of global health can be improved through dialogue and coordination between organizations and donors who are focusing on the same goals.  Coordination needs to be lead by a visionary leader, something which global health is currently lacking.

Immunity at Risk

American children and parents in the 21st century are naive to many infectious diseases.  Thanks to vaccinations, populations have seemingly forgotten about smallpox, measles, polio, pertussis, and many others.  This lack of knowledge and recognition of diseases has left us vulnerable to these reemerging illnesses.  Pertussis (aka Whooping Cough) is reemerging in California, as described in the article, “Whooping Cough Makes a Comeback,” featured in the Washington Post. 

Bordetella Pertussis is the bacteria responsible for Whooping Cough.  There are two vaccines currently available for Pertussis: whole cell (deactivated pertussis bacteria) and acellular (purified pertussis proteins).  Since the 1940s, the whole cell vaccine has decreased the pertussis infection rate by 99%. In the 1970s, the vaccine shifted to acellular, due to rare but severe side effects from the whole cell.  This change, along with three other factors have lead to the reemergence of pertussis: bacteria are mutating, effectiveness of vaccines are in dispute, and parents are opting to refuse vaccination. 

Fear is the main factor compromising immunity.  Parents are opting out of vaccination due to popular misunderstandings concerning vaccines, as they are uninformed and fall susceptible to rumors (i.e. the MMR vaccine causes autism).  Scarred parents then rely on herd immunity to protect their vulnerable children from infectious diseases. Herd immunity is the concept that not every person needs to be immunized for a population to be protected from a disease. When the majority of a population is protected, an illness’ infectivity deceases, lessening the opportunities for the bacteria or virus.  Thus, even those not inoculated are inadvertently protected. 

However, when too many parents rely on this theory, herd immunity fails.  If too few children are vaccinated, the threshold drops bellow effective levels, allowing the bacteria or virus to spread rapidly through a population.  This trend is observable in many wealthy communities, where parents are less likely to subject kids to vaccines due to a false sense of security. Consequences of this decision can be detrimental, causing an upsurge in cases and increasing risk for immunodifficient children.  Despite all the popular beliefs, there is one truth: benefits of vaccination far outweigh the potential risks.  

Fearful parents are not the only obstacles, as physicians, pharmaceutical companies, and the healthcare system share the blame.  Health care providers need to inform their patients of the actual risks of vaccines, correcting any preconceived beliefs. Pharmaceutical companies are becoming reluctant to developing vaccines because they face legal implications over risks associated with vaccines.  Furthermore, there is only a small return on investment, so vaccines are not profitable for the company to continue to produce and innovate.  Finally, due to access disparities in healthcare, children of lower socioeconomic status tend to have lower rates of vaccination.  Only through eliminating this access disparity and by inoculating these children can any population be effectively protected against infectious disease.  

There are many approaches the public health sector can take to tackle the reemergence of Whooping Cough: mandating boosters to ensure continued immunity, screening those who are at highest risk, educating the community about the truth of vaccination, providing children with equal access, and incentivizing the pharmaceutical sector to continue production of vaccines.  Appropriate public policy must be implemented to ensure these changes. 

The Innocent Victims of Second-Hand Smoke

Both of my parents grew up in the houses of heavy smokers.  The daily exposure to cigarette smoke compromised their household environment and long term health.  Even today, they continue to feel the consequences of long term exposure to smoke.  Exposure to second hand smoke is serious, as it effects innocent nonparticipants including family, friends, and any one who breathes the same air.  A study, “Non smoking wives of heavy smokers have a higher risk of lung cancer: a study from Japan.” revealed just how serious passive exposure to smoke truly is. 

The study focussed on the effects of second hand smoke on the wives of smoking husbands.  However, the wives themselves were nonsmokers. It was found that the rate of lung cancer increases with an increase in exposure to passive smoke, so that women in the first group had the highest rates of lung cancer. No correlation between passive smoking and other forms of cancer, such as cervical, breast, or stomach was found.  

The study also compared those living in urban versus rural areas and found that, surprisingly, those living on farms hard a higher rate of lung cancer.  It was deduced that this was probably a result of exposure; wives in urban settings on average spend less time with their husbands than do wives in rural areas.  Therefore, the latter group has greater exposure time to cigarette smoke, thus increasing their chance for lung cancer. 

This study was conducted as a cohort study, which provided it with many advantages.  Researchers were able to observe the development of its subjects over an extended period of time, thus better controlling for outside variables. Bias in studies sometimes cause a miscorrelation between association and causation.  However, this study minimized its bias by controlling for as many factors as possible.   Occupation, age, alcohol consumption and marital status were all considered during the study.  How heavy the husband smoked was also considered, so the subjects were divided accordingly into three groups: wives of heavy, moderate, or light/ex smokers.  They were then considered within the context of these groups.  Small sample size can also occasionally skew results, but this study avoided the problem by following a large group of women.  The results of this study can be confidently cleared of any suspicions of bias to ultimately reveal that second hand smoke is a cause of lung cancer.

Carcinogens from cigarette smoke in the air, present at any level in the environment, creates a risk for everyone.  Since clean air is a fundamental concern of environmental health, this poses a major concern. Of course, risk increases as exposure increases, so strict regulations must be established to decrease exposure and risk.  Smoking causes risk for not only those who are directly involved, but for everyone who breathes common air, which causes many innocent victims of lung cancer every year.  Toxins in the air from cigarette smoke can only be reduced through public health efforts, policy implications, and structural societal changes.  Only then will innocent victims, such as the Japanese wives, be spared from an unnecessary death from lung cancer. 

Globalization: The Connections of Disease

Globalization: connecting our world for better and for worse. 

Pros: improves economies, reveals similarities between cultures, and connects humanity. 

Cons: diminishes individual cultures, increases gap between social classes, and shares diseases.  

Prior to globalization, there existed a clear distinction between the illnesses of developed versus developing nations.  The wealthy were effected by noncommunicable diseases of “affluence”, typically obesity, whereas the third world suffered from infectious diseases related to poverty, such as cholera.  Globalization has since diminished these differences.  Now, noncommunicable diseases pervade all nations, rich and poor, and are the leading causes of death throughout the world.  This international shift in illness to preventable, noncommunicable diseases is discussed in the article “Global Noncommunicable Diseases - Where Worlds Meet,” published by The New England Journal of Medicine. 

The article attributes the changing health problems as a side effect of the increasingly globalized market, which has brought us mass production of cheap synthetic foods and the influence of media on impressionable consumers.  It has also brought us an unprecedented problem: for the first time in history, it is more affordable and accessible to purchase junk food than whole foods. These factors, as well as others, have made unhealthy lifestyles more acceptable, and in some cases the norm, in almost all regions of the world. 

High and low income nations share not only an unhealthy lifestyle and the same chronic diseases, but also the same risk factors. Almost all risk factors overlap between high, middle, and low income countries.  The most shared components include: high blood pressure, tobacco use, physical inactivity, high blood glucose levels, and high cholesterol levels.  Obviously, this overlap was brought about by globalization and its many facets.

The article not only discusses implications of noncommunicable diseases on health, but also on economic development.  Chronic disease will effect the prosperity of nations, as it reduces the productivity of its people on a long term scale.  And, since economic growth of a nation inherently depends on the health of its people, these persistent disease will result in economic decline.  The nations suggests that nations should unite in their common interest, prosperity, to recognize their common problems and solve them, This, combined with “levels of policy, health care delivery, health communication, and education,” are the only ways the public health crisis of noncommunicable can be overcome. 

Globalization cannot account for the prevalence of all noncommunicable diseases in developing and developed nations. Certain shared chronic diseases predate the our modern globalized society.  For instance, mental health illness (i.e. bipolar disorder) is a naturally caused occurrence and an inherent problem for all of humanity, superseding culture and effecting all communities.  However, what does vary is the culturally specific attitude towards these illnesses; some cultures hold a stigma regarding mental health problems, whereas others are more understanding.  For public health initiatives regarding mental health to be effective, they must be culturally specific, as an understanding of varying attitudes is integral. Once the culture is understood, the three levels of prevention can be implemented:

• Primary: educating communities about changing the pervading mindsets on mental health issues. 
• Secondary: providing those with predisposition to resources and teaching them to control their symptoms.  
• Tertiary: treating and counseling those individuals who are effected.  

Once policies are implemented, communities are educated, and the ill are treated, changes in mental health can occur. 

Medicine's Intelligent Brother

Public health is medicine’s introverted twin brother.  By nature, it remains unseen, flying under the radar to vigilantly maintain and raise our standards of living.  It does this all without our knowledge, for when we don’t see it, it is working most efficiently.  Public health is truly the unsung hero of the 20th century, singlehandedly saving countless of lives by sanitizing our water, vaccinating our children, and improving our health.  Here are a list of its greatest achievements of the last century, compliments of the CDC.  This list was included in the article, “Ten Great Public Health Achievements--United States, 1900 to 1999.” Count how many you take for granted: 

o    Vaccination

o    Motor-vehicle safety

o    Safer workplaces

o    Control of infectious diseases 

o    Decline in deaths from coronary heart disease and stroke

o    Safer and healthier foods

o    Healthier mothers and babies

o    Family planning

o    Fluoridation of drinking water 

o    Recognition of tobacco use as a health hazard

I know how many I take for granted: all ten.  However, some accomplishments are easier to ignore than others.  For instance, safer foods and healthier mothers and babies.  


While eating, we rarely stop to contemplate the safety of what we are ingesting. Eating is such a routine part of our schedule that it never receives much thought until it gives us problems.  I recall one interesting fact that our professor, Dr. Alexander, shared with us: people who are ill are better able to remember what they recently ate than people who are healthy.  This is because food has suddenly become more important to them, as it could be the reason behind their illness. 


Food safety began receiving attention with the publication of Upton Sinclair’s The Jungle, which revealed the unsanitary conditions of the meat packing industry.  His book lead to public outcry and subsequential public health initiatives. We owe Sinclair many thanks for this.  Without him, we would still be eating sausage imbedded with rat droppings and salmonella among other surprises for breakfast. 


As a woman, maternal and neonatal health hold particular importance to me.  I am grateful for the tremendous initiatives taken to improve maternal health over the 20th century--mortality rates of pregnant women has decreased by 99% and infant mortality by 90% in the US.  Even still, half a million women die every year as a result of complications related to pregnancy and birthing.  Although I see maternal health and food safety to be of particular importance, I recognize a myriad of other health concerns waiting to be praised.


The CDC may provide us with a comprehensive list, but it is in no way complete.  Acknowledging all of the public health accomplishments is a difficult task because we take most of them for granted. Simpler initiatives, such as iodizing salt, deserve more recognition.  Because we have iodized salt in the US, we have improved our metabolism, strengthened our bodies, and even raised our IQ levels by 10 points each!  


Number 11 on the CDC list should be environmental improvements. On the global scale, environmentalism has become a facet of the public health initiative.  By seeking greener models for sustainable development, we have inadvertently created a more livable society that keep us healthy. Environmental change and health are undeniably connected and an integral aspect to the ever-increasing successes of public health. Indeed, public health is also medicine’s more intelligent brother. 

America's Preventable Epidemic

Contrary to most developing nations, America has public health problems of opulence; we can afford to eat richer foods, and more of them.  This not only affords us a comfortable lifestyle, but also the highest rate of childhood obesity.  For the past few decades, this rate has continued to increase at an alarming rate -- the number has tripled since the 1980s!  WHO has some interesting, and alarming, statistics.  The rate of obesity is increasing in both boys (up from 5% to 13%) and girls (up from 5% to 9%). 22 million in the world under 5 are overweight.  Of those, the majority are American.  

Obesity brings many related health problems, both physical and mental, including type II diabetes, high blood pressure and cholesterol, poor self esteem and even depression.  Public health can prevent obesity before these related medical issues need to be addressed.  In fact, public health initiatives will be the only effective form of intervention because obesity is a public health issue; it results from the unhealthy habits of a population as a whole.  But, the difficulty is figuring out the most effective solution to address the problem.  

A recent study, published in the New York Times, researched a solution to curtail this huge problem.  The idea was simple, yet ingenious: “school based health intervention” they call it.  The interventions teach kids healthy habits, increase their physical activity, and improve lunch options in the cafeteria.  This gives kids not only awareness, but also access, to healthy eating. 

To test the effectiveness of these interventions, a cohort study was used to follow over 4,500 students, split equally into two groups: one participating in a school health program, the other acting as a control.  The students were followed for the duration of middle school.  By eight grade, the rate of obesity declined significantly in the children participating in the health program -- by a full 24.6 percent.  But, surprisingly, the control group dropped by even more -- 26.6 percent.  So, what exactly does this suggest?  

The researches believe this indicates a much larger trend--a nationwide decrease in childhood obesity.  They see outside factors as contributing to the decrease in obesity rates of the control group as well as the experimental group.  However, I remain a little skeptical of this conclusion.  Unable to pinpoint exactly what these outside factors may be, the researchers seem uncertain.  Furthermore, the results do not seem to correlate.  Why would the control group have a higher decrease in obesity than the group with the health interventions?  If the same outside factors were influencing both groups, the experimental group should still have a larger percentage decrease because they also received further health interventions.  

The inconsistent results could also mean that the intervention was ineffective and obesity decreased due solely to other factors.  Or, it may indicate some selection bias within the study.  (i.e. could more children in the control group come from wealthier families, who can afford healthier, organic foods?)  Either way, potential biases of the study could possibly undermine its validity.  By controlling for these factors, the study could be strengthened.   

Despite these apparent weaknesses, I still find the school based health intervention approach to be innovative.  I think that, with further studies, this sort of approach will be confirmed as helpful.  If implemented in all public schools, I see it as having great potential to halt the nation’s most serious, yet preventable, epidemic: obesity. 

Closing the Gap

Welcome!  This blog will cover my intellectual journey through the many layers of public health.  My name is Anna Wherry, and this journey begins as a freshman at Johns Hopkins University.

As a college student, I am frequently asked the classic question, “What’s your major?”  Whether asked by an adult or a fellow student, the reaction to my response is usually the same: How did you become interested? What exactly is public health? 

The answers to these questions are not so simple.  

Public health first captured my interest here in Baltimore.  It was the summer between my sophomore and junior year in high school.  Insisting I not waste the summer in our comfortable suburban neighborhood, my mom dragged me to the uncomfortable world of East Baltimore.  

My task was daunting: to survey refugee patients at a local community health center.  Concerned about cultural and language barriers, I approached the opportunity apprehensively.  

But, I was also excited.  I thought people who had experienced health care in developing counties could provide me with a window for evaluating health care in this country.  During the surveys, it was startling to hear that some refugees thought they received the same or better quality health care in their home country. The basis of this perception may lie with their definition of quality health care. To them, quality was a matter of simplicity, accessibility, and affordability.  Once in the United States, refugees face the same healthcare barriers as we do.

Talking with refugees also gave me insight into their cultural views of healthcare.  These views had an obvious influence over their perception of westernized health and made me realize the importance of cultural dialogue in healthcare.  

At the time, I couldn’t come up with a logical explanation for these findings from the survey on my own, but realized I could come to understand them through studying public health.  

I am just beginning to fully grasp its complex layers -- which include public policy, medicine, environment, and philanthropy -- through my Intro to Public Health class.  I am learning that public health is a broad term.  This term isn’t always understood by communities, yet these people are exactly who public health effects.  

It is a discipline dedicated to the health of the public as a whole.  This is how public health differs from traditional medicine.  Doctors treat individual patients.  Public health officials strive to improve living qualities and the health of an entire population.  They focus on preventive measures, including health education, policy initiatives, sanitation, and structural and environmental changes.  

Because preventive measures usually aren’t enough (people are bound to get sick), public health officials also work to increase access to medical care.  For people like the refugee patients, this means all the difference.  They defined quality care to me using terms such as “easy” and “cheap”; their concerns were accessibility and affordability rather than quality.  Public health addresses these concerns to make sure that even newly arrived refugees have access to quality care. 

From discussions with refugees to lectures in class, I have come to realize the cause that I am dedicating my life to: closing the gap! 

Anna