At House Party on Health Care, the Diagnosis Is It’s Broken

Here's an excellent follow-up to my paper on "Healthcare, Culture, & The American Economy" from the NY Times.

“Instead of being able to focus on my health, I focused on insurance to cover the tests and treatments.”

The Organic Green Revolution

Christopher Bedford from the Center for Economic Security has given one of the best descriptions of our current state of affairs that I've seen in recent times. The Rodale Institute's "Organic Green Revolution" document, seems like a great resource. Here's his message:


Comfoodies and HENs,

What do next? Hank suggests that the change we seek has to rise up from thousands of local food system (let 10,000 flowers bloom) developments that inform, push, demand action from elected officials. I agree with that prescription for change with these substantive additions.

Those of you who have heard me speak know that I am enamored with the Bill McDonough lines, “If you want to go to Canada, but are driving towards Mexico at 100 miles an hour. Slowing down to 30 won’t help. You are still going the wrong direction.”

Many of the suggestions made in these last commentary strings around the appointment of Tom Vilsack as Secretary of Agriculture are the good intentioned equivalent of “slowing down to 30”.

Sure, it is important to have Obama appoint Under Secretaries of several federal departments who understand our concerns, who share parts or all of our agenda. But absent real change in corporate dominated agriculture and food power relationships in Washington politics, these “friendly appointments” may help us secure some grants for our institutions or some other helpful, marginal actions…but little more. (Not marginal if it is your institution, I know)

The change we are facing is real, profound, and potentially overwhelming because of…

…climate change and its impact on food production,

…the emerging ecological and economic limitations of the global industrial paradigm in agriculture and food production, (want a little melamine with that milk?)

…the growing health crisis produced by poor nutritional policies, (let them eat cheap food so we continue to increase the cost of health care)

…the economic and food security consequences of the rapid decline in petroleum availability for the US food system, (Peak Oil)

…a growing planet population with unequal access to food, energy, capital and information resources, (why would someone become a terrorist, anyway?)

…our continued reliance on new technological practices like GMOs and cloning to solve problems caused our lack of harmony with nature’s systems, (if brute force isn’t working, you aren’t using enough of it!)

…the relentless logic of greed by many in power when faced with future defined by new ecological limitations and scarcity, (the corporate patenting of genes, seeds and, indeed, now whole animals like pigs.)

…the growing use of corporate funded disinformation campaigns to slow the coalescence of voters and consumers around the need for fundamental change in our food and farming systems, (the Corn Processors’ HFCS campaign is just the latest example of a strategy that was first developed by the tobacco industry to slow the regulation of cigarettes.)

…the use of governmental actions and regulations to slow and stop the development of “local food systems and regenerative agriculture in every food shed in the United States” that kind Hank referred to in his earlier emails. (The Monsanto seed laws)

Does anyone on these lists seriously think I have exaggerated the scope and depth of the challenges that I have listed above? If, not, then we have to ask ourselves the question
”what do we really need to do to affect the change we seek?”

If you answer, “lobby Tom Vilsack”, then you should stop reading here. Tom Vilsack is a decent person. His wife, a more aware person, understands the importance of good food to our future. But Tom Vilsack won’t and can’t save us.

We must actually imagine what it means for us to “turn around and go in a new direction.”

Hank suggests that the “ten thousand flowers” of the local food revolution will create this change. I totally agree with him as far as he goes. Urgency is the question on my mind.

We don’t have time to fight a guerrilla war against the global industrial food system. Nature’s and history’s clock is ticking. Although, the local food revolution ultimately will be successful in replacing the global corporate industrial systems now in place, it could be a Pyrrhic victory if we have passed one or more of Nature’s tipping points (when decline is unstoppable) in the process.

I believe we need to demand fundamental change – the change presented in the Rodale Institute document “The Organic Green Revolution”. www.rodaleinstitute.org/files/GreenRevUP.pdf

In this new organic Green Revolution, industrial, petroleum based agriculture will become the niche (like arsenic sniffers of the 19th Century, a doomed and dying niche) and ecologically intelligent food and farming systems based on organic and permaculture growing principles will be the way we farm.

Now, anyone who speaks regularly to conventional farmers knows that such a suggestion is tantamount to treason. If you want to really make conventional farmers really angry just raise the issues surrounding “organic farming”.

But why such anger? If organic food production is just a niche, why does it arouse such powerful emotions?

The answer is, most farmers know deep in their hearts, that industrial agriculture is dying as an operational, viable paradigm. “Anger” is just one of the five Kubler-Ross stages in acceptance of this death. It is followed by “bargaining” (perhaps IPM and GMOs can be seen in this light) and “depression” (something working farmers are all too familiar with).

The final stage is acceptance, in this case, of a new way to farm, one that has the power to regenerate not just the health of the earth, but farmers’ economic, physical, and emotional health as well.

We must help conventional farmers through this transition and not let their “grieving” dictate the food policy for an entire nation.

Luckily, we have an example, a role model, for what we need to do. The WE Campaign, a project of the Alliance for Climate Protection, seeks “repower America with 100% of its electricity from clean energy sources within 10 years.”

That means no more carbon-based energy to produce electricity within a decade. A remarkable goal. A fundamental change of the same scale we seek.

The WE Campaign makes effective use of media to allow us to visualize this change. Their latest TV commercial depicts a working class guy recharging his pickup truck’s batteries from a wind-powered plug-in station. This is a brilliant commercial at many political levels.

The French anthropologist, Clause Levi-Strauss, says, in most cultures men must dream their children before they can conceive them. I believe this is true of the local food revolution as well.

Michael Pollan’s NY Times “Letter to the Farmer-in-Chief” is an example of creating a clear frame for our dream of regenerative, healthy food future. Every time a local TV station does a story about a chef using local food or a farm operating a CSA, our collective dream, necessary to imagine this change, is enriched.

But I believe we need to do more. We need to use the arguments and principles presented in “The Organic Green Revolution” to develop an effective national media effort to promote the ecologically intelligent values and community-based processes of the local food revolution that Hank wrote about.

In effect, we need our own “We” campaign to change the debate in the public square. In doing so, we will empower those ten thousand flowers of transformation, regeneration, and hope.

Does anyone want to join together to make this happen?

Peace and good food and Merry Christmas,

Chris Bedford

Op-Ed: Vision of a Grassroots, Grass-Fed Revolution

Here's an article I wrote for the NYU Steinhardt Public Health Student Group Fall 2008 Newsletter:

Op-Ed: Vision of a Grassroots, Grass-Fed Revolution
by Kelly Moltzen

Growing up, we were taught by the USDA that “all foods can fit,” that everything in moderation is good for us. We were taught that we needed dairy products in our diet in order to get calcium, otherwise we would develop osteoporosis. We were taught that we needed to get our protein from meat. But what if this were not the whole picture? Would the USDA actually hide information from us?

Unfortunately, yes. It seems as though Congress is more concerned about taking food industry lobbyists’ money than about giving the public scientifically sound advice, as Marion Nestle tells us in her book Food Politics. However disturbing this may sound, we cannot allow the food industry to dominate us, not when 63% of Americans are overweight or obese and children born in the year 2000 or after may be the first generation to die before their parents; not when animals are subjected to living on claustrophobic, unsanitary Concentrated Animal Feeding Operations (CAFO), force-fed corn and artificial substances that make them sick, necessitating the use of administering antibiotics before we buy and eat the omega-6 laden meat which makes us sick. Not when 25% of the foods we buy in the grocery store has some form of corn in them, and the ammonium nitrate left over from the production of explosives during World War II is used to fertilize crops – facts Michael Pollan shares with us in The Omnivore’s Dilemma.

This country needs a complete change of mindset, where we raise humanely treated omega-3 rich grass-fed animals and stop using additives and pesticides on our food. We need to craft a world that is not dominated by the need of the food industry to keep money in its wallet, but one that is driven by the need to keep real food on the table. A world where our children don’t need to learn how to read labels, but instead learn how to grow vegetables. A world where we get energy from the sun and wind, not coal and oil, and where we eat our food, not burn it as biofuel.

Fortunately there is a revolution starting, as people have banned together for such programs as the Real Food Challenge and Slow Food Nation. Californians had an initiative on their ballot this November called “Proposition 2,” which was a huge breakthrough for humane farm animal treatment. It prohibits cruel and inhumane ways of confining animals in their cages. The USDA recently passed more rigorous regulations for organic food, prohibiting the existence of organic CAFOs. The list of 2010 Dietary Guidelines Advisory Committee appointees looks promising as well. Yet we need to continue supporting CSA communities, creating farm to school programs, and weakening the connection between food industry lobbyists and Washington, D.C. If we don’t do it, then who will?

Twitter

FYI. When I don't have enough time to do a full blog post, I sometimes post things on Twitter instead because it's easier. So go there sometimes :)

http://twitter.com/kellymoltzen

Healthcare, Culture, and the American Economy

And here's another paper. Only God knows how I managed to write all these in the past 2 weeks...

Kelly Moltzen
Community Health & Medical Care P.11.1830.002
Professor Soffel
December 18, 2008

Healthcare, Culture, and the American Economy

The United States spends 16% of its Gross Domestic Product on healthcare – more than any other developed country in the world – yet ranks poorly in comparison to other developed countries in terms of life expectancy. There are many contributors to this paradox, most of which have to do with the fundamental structure and culture of the US healthcare system. Money funneled into the healthcare system currently overemphasizes spending on long-term care for the elderly while inadequately funding public health programs and failing to account for behavioral determinants of health. It should be noted that “virtually no one in Canada or Western Europe views the U.S. health care system as a model to emulate” (Rodwin).

The first inefficiency of the US healthcare system is that it overemphasizes spending on long-term care for the elderly. Medicare and Medicaid together account for 19% of total US government spending, but the majority of this money goes towards a small number of beneficiaries. With the number of Americans over age 65 growing due to the aging of the baby boomer generation, the United States cannot afford to continue spending excessively on this population. In 2006, ten percent of Medicare beneficiaries accounted for more than two thirds of Medicare’s $374 billion budget, while 52% of beneficiaries accounted for only two percent of expenditures (Medicare: A Primer, 2007). And while the elderly and disabled comprise 25% of total Medicaid enrollees, they account for 70% of Medicaid’s $316 billion in expenditures, leaving only 30% of the funds for the other 75% – children, parents, and pregnant women (Medicaid: A Primer, 2007).

The majority of spending on healthcare for the elderly is on nursing home care, with 44% of Medicaid spending going towards nursing homes (Medicaid: A Primer, 2007). Yet nursing homes are not the most efficient way for the elderly to be cared for, as nursing homes are a very expensive business. In addition, they are generally understaffed, do not provide optimal care, and “many elders say they would rather die than live permanently in a nursing home” (Feldman, Nadash, & Gursen). Elderly people deserve to be treated with respect, and taking away their autonomy by forcing them to live in institutionalized settings denies their “right to take risks in order to lead a preferred lifestyle” (Feldman, Nadash, & Gursen). This “medicalization of everyday life” is not only draining the US budget, but is unfair to the elderly who normally prefer to live on their own as much as they can. Therefore, less costly ways to care for the elderly should be considered, such as in continuing care retirement communities and other residential alternatives (Feldman, Nadash, & Gursen). Consumers – no matter what their age – should have a say in what type of services they will receive through personally directed care. Many elders would prefer informal care while living at home or with family members, although this can be exhaustive and financially draining to their caregivers. By providing elders a specific allotment of funds for personally directed care, they could choose to hire who they saw fit. In any case, a primary goal should be ensuring that people die with dignity (Nuland, 1995).

A more humane future for America’s elderly can be expected to encounter various barriers, principally high costs of care, no matter what options are considered. The services Medicaid purchases for the elderly (i.e. nursing homes) are primarily provided by the private sector (Medicaid: A Primer, 2007), but if money were spent instead on purchasing care in public, non-for-profit institutions, or home-based care, it might cost less. However, many people may be concerned about quality assessment in home health care and assisted living facility settings (Feldman, Nadash, & Gursen). There needs to be a shift in the mindset of Americans and the culture of the healthcare system which currently seems to be more concerned with keeping people alive than ensuring the elderly can enjoy their life and maintain social relationships, which not surprisingly seem to have beneficial effects on health (House, Landis & Umberson, 1988). Yet getting Americans to change the way they conceptualize caring for the elderly will continue to be very challenging.

Another reason for the inordinate costs of healthcare in the United States is an inadequate funding of public health programs, with less than four percent of healthcare funds going towards public health (Hunt & Knickman). Although improvements in health have historically come from public health – not medical – interventions (Conrad & Schneider, 1992), the US healthcare system has become very focused on downstream interventions, which do not get to the root of the problem (McKinlay, 1974). These are extremely cost ineffective, and there are a “large number of unnecessary procedures” with “unexplained variations in practice patterns” and “unclear answers to rudimentary questions about which treatments [are] most cost-effective” (Light). Insurance providers and Medicare will pay for expensive end-stage medical procedures such as kidney transplants, dialysis, and amputations for diabetes patients, but will not pay for primary, population-based interventions that can prevent health problems, such as health education, public service announcements, and accessible healthy food. As McKinlay observes, “we long ago surrendered control of food…to private corporations…[which] have shaped the kinds of food we eat for their greater profits,” so much that “most people now eat more processed and synthetic foods than the real thing” (McKinlay, 1974).

The government needs to be much more stringent in enforcing restrictions on the advertising of unhealthy food products, as the food industry has a very influential voice in Congress due to the revolving door between Congressmen and lobbyists (Nestle, 2007). While a substantial amount of money has supposedly been set aside for public health interventions in the 2008 Farm Bill (Rush, 2008), the government needs to be sure this money goes towards interventions for those with the highest risk of disease (Leviton, Rhodes & Chang). More consideration should be given to efforts such as those that took place in post-war East Germany, where decentralization and prevention were emphasized, medical stations were put in places of work, and an extensive health education program was started in public schools (Light).

While it has historically been an American tradition to rely on non-profit organizations for public health interventions (Leviton, Rhodes & Chang), they can no longer support the country’s needs by themselves. The private sector’s contribution to health expenditures has unfortunately been declining since the 1960’s (Hunt & Knickman). Overall, the private sector needs to contribute more of its resources to public health interventions – particularly the food industry and the tobacco industry, as their products cause the most harm to human health.

Public health does not get the attention it deserves because it is largely invisible, avoiding problems rather than fixing them (Knickman & Kovner). Unfortunately, American culture and Western medicine in particular tend to err towards the side of wanting to see “something being done,” even if that “something” is inefficient and unproductive. In addition, the general public often may not understand what public health comprises, “often supposing it refers to programs for the poor” (Leviton, Rhodes & Chang). It is difficult to change the mindset of the American population, to whom health advertisements appear “boring” and “largely misdirected” (McKinlay, 1974). Very often people follow “quasi-health” fads that they believe are meant to improve their health, and “to request people to change or alter these behaviors is more or less to request abandonment of dominant culture” (McKinlay, 1974). Another challenge is trying to convince education officials of the value of investing time in teaching children more health and nutrition information during the school day, as school curricula already face difficult time constraints.

A third failure of the US healthcare system is the inadequate attention that has been paid to the behavioral determinants of health. While a growing number of Americans do not have health insurance, even those who are insured still experience barriers to accessing healthcare (Billings & Cantor). Families that are eligible for services such as Medicaid may not even know what they are eligible for or how to go about using the services. This could be because of language barriers, cultural barriers, a failure of health professionals to properly explain to them the necessary procedures and paperwork, or a combination of these factors. Many immigrants may be unfamiliar and skeptical of Western medicine and may not seek it out, even when ill. Immigrants may also have fears about immigration status. Individuals who have Medicaid may not use it because of a stigma attached to it or having to wait long periods of time.

Further, research shows that ethnic minority groups use healthcare services more, but the service they are provided is of lower quality (Gabe). This is particularly true for investor-owned hospitals that evidence shows spend less of their resources on uninsured patients than do voluntary hospitals (Relman, 1991). Individuals without private health insurance – such as the uninsured or those with Medicaid – may receive sub-par treatment from physicians who do not benefit from low reimbursement rates, or may even be outright rejected by some physicians and hospitals that avoid certain types of patients in order to maximize revenues (Relman, 1991; Billings & Cantor). The uninsured may be more likely to seek care in an emergency room, either because they waited until a late stage of disease progression, or thought they would eventually be noticed there. And even once they receive attention, limitations to functional health literacy may impede proper use of prescribed medication (Billings & Cantor).

Solutions to improving access to healthcare necessitate culturally sensitive interventions. By modeling Great Britain’s National Health System, walk-in clinics that are “accessible, convenient, and customer-focused” and address social issues of underprivileged populations could be put in place, such as a nurse-led phone help line and walk-in centers with accommodating evening and weekend hours (Gabe). Special outreach by non-profits and local governments may also be needed “to take preventive and therapeutic measures out of the hospitals, clinics, and emergency rooms and deliver them to the population at highest risk” (McCord & Freeman, 1990).

Other solutions may include setting up commonwealth funds for easier access to insurance, requiring employers to contribute to their employees’ insurance, subsidizing insurance through increased taxes on health-damaging products such as tobacco and junk food, and starting programs that teach people how to manage chronic diseases effectively (Billings & Cantor). Maine, Massachusetts, and Vermont – three states where these interventions were successful – started out with comparatively low rates of uninsured individuals. Barriers exist for other states, where employer mandates and taxes may work “against states’ economic development efforts to recruit and retain jobs within their boundaries” (Billings & Cantor). Mandating employer-sponsored insurance would likely meet fierce resistance from the business community. Capitated payments and publicly funded managed care can also be considered, although Medicaid managed care could create yet more barriers for low-income patients, as the enrollment process may be too confusing, the new site may be too far away, and continuity of care may be disrupted (Billings & Cantor).

Clearly, on many levels, today’s US healthcare system developed together with American culture, bringing the capitalistic mindset along with it. Resources are limited, however, and the United States must make much wiser choices with regard to how it utilizes those resources. At the same time, bringing some humanity into the information-dominant, depersonalized domain of medicine could go a long way in improving the health of all patients. It is possible for the US to simultaneously solve its health crisis and its economic crisis, but it may be that the underlying problem is American culture: “values shape financing. They have to change before financing can change” (Light).


References

Billings, J and Cantor, JC. “Access to Care.” In A. Kovner & J. Knickman (Eds.). (2008). Health Care Delivery in the United States (pp. 444-476). New York: Springer Publishing.

Conrad, P and Schneider, JW. (1992). “Professionalization, Monopoly, and the Structure of Medical Practice.” In: P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 170-176). New York: Worth Publishers.

Feldman, PH, Nadash, P, and Gursen, MD. “Long-Term Care.” In A. Kovner & J. Knickman (Eds.). (2008). Health Care Delivery in the United States (pp. 238-265). New York: Springer Publishing.

Gabe, J. “The British National Health Service: Continuity and Change.” In P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 522-539). New York: Worth Publishers.

House, JS, Landis, KR, and Umberson, D. (1988). “Social Relationships and Health.” In P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 74-82). New York: Worth Publishers.

Hunt, KA and Knickman, JR. “Financing Health Care.” In A. Kovner & J. Knickman (Eds.). (2008). Health Care Delivery in the United States (pp. 56-83). New York: Springer Publishing.

Knickman, JR and Kovner, AR. “Overview: The State of Health Care Delivery in the United States.” In A. Kovner & J. Knickman (Eds.). (2008). Health Care Delivery in the United States (pp. 2-11). New York: Springer Publishing.

Leviton, LC, Rhodes, SD, and Chang, CS. “Public Health: Policy, Practice and Perceptions.” In A. Kovner & J. Knickman (Eds.). (2008). Health Care Delivery in the United States (pp. 84-124). New York: Springer Publishing.

Light, DW. “Comparative Models of “Health Care” Systems.” In P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 500-515). New York: Worth Publishers.

McCord, C and Freeman, HP. (1990). “Excess Mortality in Harlem.” In P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 30-37). New York: Worth Publishers.

McKinlay, JB. (1974). “A Case for Refocusing Upstream: The Political Economy of Illness.” In P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 551-564). New York: Worth Publishers.

Medicaid: A Primer. (2007). Kaiser Family Foundation.

Medicare: A Primer. (2007). Kaiser Family Foundation.

Nestle, M. (2007). Food Politics. Berkeley, CA: University of California Press.

Nuland, SB. (1995). How We Die. New York: Random House, Inc.

Relman, AS. (1991). “The Health Care Industry: Where is it Taking Us?” In P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 268-274). New York: Worth Publishers.

Rodwin, VG. “Comparative Analysis of Health Systems Among Wealthy Nations.” In A. Kovner & J. Knickman (Eds.). (2008). Health Care Delivery in the United States (pp. 152-187). New York: Springer Publishing.

Rush, B. (2008). “Turning Urban Deserts into Urban Oases.” Retrieved October 10, 2008, from TheHill.com. Web site: http://thehill.com/op-eds/turning-urban-deserts-into-urban-oases-2008-06-10.html

Stunting in Uganda

Here's another term paper I just wrote:

Kelly Moltzen
Final Paper
E33.2314: International Health and Development
December 17, 2008

Political, Social, and Economic Contributors to Stunting in Uganda

The prevalence of stunted growth in Eastern Africa due to undernutrition is the highest in the world and has serious implications for maternal and child health (Black et al., 2008). In Uganda, where nearly half (49%) of the population is under the age of 15 (Bachou & Labadarios, 2002), the national average of stunting in children younger than five years old is 32% (UNICEF, 2008). Prevalence of stunting is generally highest for the poorest segments of the population (Black et al., 2008), with this number reaching up to 54% in the war-torn northeastern region of Karamoja (Africa News, 2007a). Stunting is associated with higher mortality and lower cognitive development. It therefore has widespread implications not just for an individual’s development, but also for the development of entire regions (Jilcott, Masso, Ickes, Myhre, & Myhre, 2007). Stunting has been found to be the best predictor of human capital, as “there is compelling evidence that malnourished children are unproductive as adults” (Africa News, 2008). Therefore, the prevention of stunting has the potential to bring about “important health, educational, and economic benefits” (Victora et al., 2008). The underlying causes of maternal and child mortality include poorly resourced health and nutrition services, food insecurity, and inadequate feeding practices, inadequate access to safe water and sanitation (UNICEF, 2008). However, there are even more basic social, economic, and political causes that contribute to the lack of capital necessary to prevent these underlying causes (Black et al., 2008). In Uganda, these include poverty, political unrest, misplaced policy decisions and interventions, and the discrimination and exclusion of mothers and children.

Stunting is defined as height-for-age less than -2 z-scores (Jilcott et al., 2007); the average Ugandan child falls one standard deviation below the international norms (Alderman, 2007). This restriction of a child’s potential growth is evidence of chronic undernutrition, leads to irreversible impairment, is associated with increased risk of death, and could potentially affect future generations. For instance, maternal short stature adversely affects pregnancy outcomes (Black et al., 2008). Research shows that it is much more efficient to prevent chronic undernutrition and its devastating effects than to attempt interventions later on in the lifecourse (Africa News, 2008), as the critical period of development occurs during the first two years of life. However, the Ministry of Health in Uganda has historically focused its childhood nutrition programs on children who are already underweight (Africa News, 2008), a misdirected intervention that has had serious consequences.

Northern Uganda is burdened with great deals of civil strife. Political instability in Uganda is associated with increased contributory factors to malnutrition, poor economic growth, worse health service delivery by government, local, and international agencies, and higher child mortality rates, as compared to times in the country’s history that saw more political stability. In a study of the Bundibugyo District of Uganda, where the stunting rate in children is 44.8%, students ranked last in recent secondary school standardized leaving exams (Jilcott et al., 2007). This rural, marginalized population is still recovering from Allied Democratic Force rebel attacks that occurred in the late 1990’s, during which people had to live in Internally Displaced People (IDP) camps. Malnutrition, malaria, tuberculosis, and sickle cell disease are common among children in Bundibugyo (Jilcott et al., 2007).

Social aspects such as gender inequality play a large role in health and stunting rates in Uganda. In a country where many families already struggle to get a meal on the table, women and children traditionally eat last in the household, after men (Nadakavukaren, 2006). “To reverse the trend of gender inequality, the United Nations Children’s Fund (UNICEF) recommends the empowering of women in politics, arguing this has the potential to change society” (Africa News, 2007c; UNICEF, 2008). UNICEF’s State of the World’s Children 2007 report said “women who have greater influence in decision-making can promote better healthcare practices for the family. Women's participation in household decisions decreases stunting among children and reduces child mortality” (Africa News, 2007c).

The impact of poverty in Uganda is profoundly felt through a lack of funds and resources to buy livestock. “Animal-source foods…are an important component of children’s diets, as a major source of protein and micronutrients” (Black et al., 2008). Yet in Uganda, many families can only afford meat once a year, if that (Tuller, 2007). This excludes them from access to adequate sources of protein and iron in the diet – key nutrients in preventing maternal and child mortality. Low intake of meat, fish, and/or poultry is associated with iron-deficiency anemia in mothers, which is an important contributor to maternal mortality as it increases the risk of dying with blood loss during delivery (Black et al., 2008). Mothers who die while the child is still an infant poses additional risks for newborns, as they no longer have their mothers to breastfeed them. Grandparents, particularly grandmothers, are left to care for 50% of orphans in Uganda (Africa News, 2007c); however, milk production of grandmothers is not nearly as sufficient as would be necessary for the child to thrive. If women were empowered within the household and within the government, they could push for better access to livestock which could drastically improve the nutritional and economic situations of many Ugandans.

The importance of farming and agriculture to nutritional status, as well as the social and economic development of Uganda, cannot be overstated. Farming is a critical aspect of the economy of Uganda; one women professed that “African business is agriculture” (Stuart, 2007). However, the current cropping systems in Uganda are leading to nutritional deficiencies and are also threatened by climate change. Uganda would do well to consider alternative agricultural strategies; over the past few years, the National Academies released a series of books entitled “The Lost Crops of Africa,” which enforces the promise of many crops that are native to Africa, but are not currently widely harvested (The National Academies Press, 2006).

There are currently two main cropping systems in Uganda: a grain-based system in the northern and western regions, and a banana-based one in the central, southern, and eastern regions (McIntyre, Bouldin, Urey, & Kizito, 2001). Since livestock farming is not a large contributor to nutrient intake in Uganda, this leads to low protein intake in the banana farming areas, as the banana-based system has been found to be associated with nutritional deficits of protein in addition to calcium, iron, and zinc. Zinc deficiency is associated with stunting prevalence, and both iron and zinc deficiencies have both been shown to be associated with increased cognitive impairment among children (Black et al., 2008). A different study found that the local variety of bananas is low in iron, iodine, and Vitamin A (Eliot, 2008) – the three micronutrients that are most deficient in Ugandans’ diets (Bachou & Labadarios, 2002).

In addition, diminished crop yields due to seasonal variation and crop infestation compromises the nutritional quality of bananas (Stuart, 2007). Addressing banana stem infestations is one solution, as weevil and nematode infestations in the roots of banana plants lead to a decreased absorbance of vitamins, minerals, and water by the plant (Stuart, 2007). Drought and soil degradation may compound the effects of the diseased stems, leading to lower yields and quality of bananas. Using tissue-cultured banana plants with endophytes (good microbes) reintroduced to the plant at an early stage would help to increase the plant’s natural defenses before it is planted in the field. A sensitization campaign was supposedly started in 2008 to educate Ugandans on the adoption of growing tissue-cultured banana plants – something that has already been started in Kenya (Stuart, 2007). Another potential solution is genetically modified bananas, which have been developed in Australia and are currently undergoing field testing in Uganda (Eliot, 2008).

Strategies have also been proposed to alter the land area’s crop selection. Initiatives which set out to introduce new crops to farmers and broaden the range of crops planted may hold promise in improving the diet quality of Ugandans; the Uganda Bean Program is one such example of success (McIntyre et al., 2001). The Vice President of Uganda discusses the role of maize flour in the diet as contributing to stunting, as its high phytate content contributes to zinc malabsorption, and “zinc deficiency contributes significantly to stunting and impaired cognitive development” (Africa News, 2007b). He offers the suggestion of providing children with more “millet, soya, and sorghum, which are easily available in Uganda” (Africa News, 2007b). The Ugandan government could be instrumental in providing aid to the development and implementation of alternative agricultural strategies, as well as facilitating the distribution of higher nutritional quality food.

Agriculture is inextricably linked with the HIV/AIDS epidemic, as the practice makes available food and nutrition that are of critical importance in fighting the disease (Africa News, 2008; Tuller, 2007). David Tuller, a graduate student from the University of California, San Francisco, spent five months in Uganda investigating whether “food insecurity…undermines the effectiveness of HIV treatment” (Tuller, 2007). Far too often, parents must choose between feeding their children and selling their crops to make the money needed for the “monthly clinic trip for the medication that keeps them alive” – a trip that also means a missed opportunity for gardening or other work (Tuller, 2007). Compounding the issue of food insecurity among people with HIV/AIDS is the issue of power struggles between men and women. Hunger and food insecurity put women at the mercy of their husbands, who will oftentimes demand unprotected sex in exchange for bringing food home (Tuller, 2007). In this way poverty, food insecurity, and gender disparities interact to prolong the HIV epidemic and continue the plight of the disenfranchised.

The government has a role to play in improving food security in urbanized areas as well. Although stunting is twice as prevalent in rural areas as urban ones, people are moving to urban slums in greater numbers, leading to higher rates of stunting in urban areas (Bachou & Labadarios, 2002). Malnutrition in urban areas is a very real issue, but strategies such as urban agriculture could help curb food insecurity. Urban agriculture has traditionally formed an informal safety net for buffering the impact of economic hardship and the cutbacks of urban subsidies and formal safety nets. However, urban farming is currently not endorsed by the government and is actually illegal, despite its positive association with decreased rates of stunting (Maxwell, Levin, & Csete, 1998). Officials of local and national governments do not recognize benefits that urban farming could have on health; they actually consider it a threat to public health and generally overlook or even discourage it (Maxwell et al., 1998). There is plenty of idle land available in cities that could easily be used for urban farming if policymakers recognized its importance in enhancing food security and made the legal framework more conducive to informal livelihood strategies.

Perhaps the most important thing the government could do to increase food security and improve its country’s maternal and child health is to form community partnerships (UNICEF, 2008). Engaging the community in the promotion of its own health is critical to the success of any intervention, as it builds capacity and empowers its members. Governments should engage in intersectoral collaboration and work cooperatively on community, district, and national levels to include all members of a community in policy and decision-making processes, particularly women. By including women in policy and decision-making, this may help change the ethos of gender discrimination and ultimately lead to improved diets and access to healthy environments for women and children. As UNICEF posits, “the ultimate responsibility for ensuring children’s rights to health and nutrition lies with national governments in partnership with civil society” (UNICEF, 2008).

Local authorities, research establishments, and development agencies should “work with the urban poor to understand and develop other urban food and livelihood security strategies” (Maxwell et al., 1998). A key facet of community partnerships involves community growth promotion, or the recruitment of community health workers to bring health education to the communities door-to-door. This may include educating caregivers on the importance of exclusive breastfeeding, health, nutrition, numeracy, and literacy, and improving the capacity of women in a community to recognize malnutrition (Alderman, 2007). Rates of exclusive breastfeeding are declining throughout the world, which is problematic because there is a higher risk of morbidity and mortality from suboptimum breastfeeding (Black et al., 2008). Similarly, “suboptimum complementary feeding is clearly a determinant of stunting” (Black et al., 2008). Infectious diseases, particularly those that result in diarrhea, reduce intestinal absorption of nutrients and thereby are large contributors to stunting (Black et al., 2008). Educating women on these health issues could not only lead to lower stunting rates and improved health outcomes for children, but could also improve capacity, decrease dependence, and even improve the economy.

Farming and community growth promotion are both associated with decreased prevalence of stunting in children. One study found significantly less stunting in children from farming households than children from non-farming households (Maxwell et al., 1998). Also, there are more moderately and severely undernourished children in non-farming households than in farming households among lower socio-economic households (Maxwell et al., 1998). Farming has been proposed as a good female income-generating activity, and allows mothers to spend more time caring for their children (Maxwell et al., 1998). Evidence shows that community growth promotion, including education and skills training on early childhood development, can have an impact on children’s diets in Uganda. In a longitudinal intervention study, training focused on breastfeeding, complementary feeding at time of weaning, and diet diversification (Alderman, 2007). Improvements were seen in children’s diets in their first year or two of life with long-term intervention exposure, which is significant because the first two years of life are the most critical in a child’s physical and cognitive development (Africa News, 2008).

In the north, political upheaval compromises the social capital and economic potential of certain populations residing in Uganda, making self-sufficiency more difficult. Rebel groups in northern Uganda pose a serious threat to the health and well-being of the population. Northern Uganda is plagued by the Lord’s Resistance Army’s terrorist activities, which makes access to food difficult and takes children out of school. This is especially true in Karamoja, where fewer than twenty percent of children attend school because they must help out with the farming at home (Grainger, 2007). To make matters worse, droughts are drastically reducing the amount of crops to harvest, and two-thirds of the region is dependent on foreign food aid such as from the World Food Programme (Africa News, 2007a; Grainger, 2007).

In addition, northern Uganda is home to a significant number of refugees relocating to Uganda from neighboring countries. In 2005, there were nearly 188,000 refugees in Uganda from Sudan alone (Kaiser, 2005). Although the majority of refugees currently in Uganda have been there since the 1980’s and 1990’s, the government of Uganda has outright rejected the notion for permanent integration of refugees into the Ugandan population (Kaiser, 2005). Yet refugees are not even granted the right to freedom of movement, and experience insecurity, deprivation, and political repression in the north (Kaiser, 2005).

Refugees in Uganda have consistently been the victims of social exclusion, defined by Manuel Castells as “the process by which certain individuals and groups are systemically barred from access to positions that would enable them to an autonomous livelihood within the social standards framed by institutions and values in a given context” (Castells, 2000). The Ugandan government has attempted to implement the “Self-Reliance Strategy” (SRS) to provide services to refugees in such a way that it would improve the socioeconomic development of both the refugees and their Ugandan hosts. The idea was for services for refugees to be integrated into regular government structures and policies. It was envisioned that refugees would be able to grow or buy their own food, access and pay for basic services, and maintain self-sustaining community structures (Kaiser, 2005). While the SRS program was successful in one region that had considerable political stability, in most other areas refugees were often relocated from one unsafe area to another, not informed of what was going on, and regularly denied access to a range of economic activities. In attempting to fulfill the material needs of the refugee population, their legal and political rights have not been maintained. As a result of this social exclusion, the building of capacity, self-esteem, and social resources has been hindered, consequently undermining the goals of the program (Kaiser, 2005). This has implications for nutrition outcomes in that the crux of a successful, sustainable public health intervention relies on a community’s social capital and solidarity.

There is much evidence of the negative impact of political activities on nutritional status. Granaries have been abandoned in the north due to increased political insecurity, which adds to the problem of recurrent drought and seasonal variation that threaten household food security (Bachou & Labadarios, 2002). Political insecurity has also made the delivery of health-promotion services in these areas more difficult (Bachou & Labadarios, 2002). There was a statistical difference in stunting prevalence in sub-counties depending on distance to the health center, with populations who lived further away experiencing greater rates of stunting (Jilcott et al., 2007). This underlines the significance of lack of access to health-promoting resources, as management of malnutrition is primarily facility-based in Uganda (Jilcott et al., 2007). In addition, for those in the areas with the worst malnutrition, such as Karamoja, the health and therapeutic feeding centers are regularly overcrowded, which raises the risk of cross-infections and hypothermia from sleeping on the floor (Africa News, 2007a). Indeed, as UNICEF puts it, “cultural and climatic factors as well as endemic conflict combine to create cyclic humanitarian crises of a disastrous scale and complexity” (Africa News, 2007a).

While the intentions of programs such as the SRS are noteworthy, their implementation and outcomes have not been quite as stellar. The government must be sure to be sensitive to the realities of life when developing intervention programs. It must balance its own interests with its citizens, and those of the refugees in the north, in order to mitigate the detrimental effects of conflict on both populations. Chen and Berlinguer state that “good health is the cornerstone of economic progress, a multiplier of society’s human resources, and, indeed, the primary objective of development” (Chen & Berlinguer, 2001). Therefore, vesting more interest in the rights of refugees in terms of the SRS would allow these individuals more autonomy and access to health-promoting resources, ultimately benefitting the country of Uganda as a whole.

One intervention that has been moderately successful but has encountered some difficulties is the distribution of Vitamin A supplements. Vitamin A deficiencies have been common in Uganda, and while the vitamin is fat-soluble, Ugandans’ main source of Vitamin A is green leafy vegetables (Bachou & Labadarios, 2002). Ugandans’ diets are low in fat, especially as a result of the insufficient contribution of animal sources to their diet. Inadequate quantities of Vitamin A in mothers’ diets lead to Vitamin A deficient breastmilk (Black et al., 2008). The Ministry of Health’s national protocol for Vitamin A supplementation for postpartum mothers has been moderately successful at reducing Vitamin A deficiencies in Uganda, with a current coverage rate of 78% in children 6-59 months old (UNICEF, 2008). However, there are many barriers to the success of supplement distribution in Uganda. The country lacks a well-defined system for the distribution of the capsules, as they are only readily accessible to mothers who use health facilities (Bachou & Labadarios, 2002). In addition, capsule supplementation may not be ideal in the north due to the political instability, and in many of the isolated, rural areas of the country, as serious barriers may be encountered in attempting to distribute supplements to both of these populations. Additionally, supplementation is not a sustainable solution, but a downstream intervention that does not get to the root of the problem of inadequate Vitamin A in the food that is consumed. Micronutrient supplementation may be successful in improving child health outcomes in the short term, but in order to “eliminate stunting in the longer term, these interventions should be supplemented by improvements in the underlying determinants of undernutrition, such as poverty, poor education, disease burden, and lack of women's empowerment” (Bhutta et al., 2008).

Community partnerships have proven successful in decreasing rates of stunting in India (UNICEF, 2008), and will likewise be critical to successful public health interventions as Uganda moves forward. The government’s first priority should be inclusion of women in decision and policymaking, and building intersectoral collaboration. These collaborations should then prioritize nutrition issues, improving food security in Uganda such as through supporting alternative cropping strategies and changing its stance on urban agriculture. At the same time, it should support education on breastfeeding and complementary feeding practices through community growth promotion. In the Lancet’s 2008 series on Maternal and Child Undernutrition, Bhutta et. al concluded that “in populations with sufficient food, education about complementary feeding increased height-for-age Z score by 0.25…, whereas provision of food supplements (with or without education) in populations with insufficient food increased the height-for-age Z score by 0.41” (Bhutta et al., 2008). Stunting is inextricably tied to social, economic and political issues, so in order to decrease its prevalence, improve maternal and child health, and improve the future development of Uganda, the role of policy and community partnerships should be seriously considered.

References

Africa News. (2007a, September 27). Uganda: Malnutrition the Main Challenge in Karamoja's Chronic Emergency. Africa News: UN Integrated Regional Information Networks.
Africa News. (2007b, February 3). Uganda: The Hidden Brain Hunger. Africa News: The Monitor.
Africa News. (2007c, March 8). Women and Gender: UN - Women Still Play Second Fiddle. Africa News: The East African Standard.
Africa News. (2008, April 30). Uganda: Early Prevention is Best, Says Child Malnutrition Study. Africa News: The Monitor.
Alderman, H. (2007). Improving Nutrition Through Community Growth Promotion: Longitudinal Study of the Nutrition and Early Child Development Program in Uganda. World Development, 35(8), 1376-1389.
Bachou, H., & Labadarios, D. (2002). The Nutrition Situation in Uganda. Nutrition, 18(4), 356-358.
Bhutta, Z. A., Ahmed, T., Black, R. E., Cousens, S., Dewey, K., Giugliani, E., et al. (2008). What Works: Interventions for Maternal and Child Undernutrition and Survival. The Lancet, 371(9610), 417-440.
Black, R. E., Allen, L. H., Bhutta, Z. A., Caulfield, L. E., de Onis, M., Ezzati, M., et al. (2008). Maternal and Child Undernutrition: Global and Regional Exposures and Health Consequences. The Lancet, 371(9608), 243-260.
Castells, M. (2000). The Rise of the Fourth World. In D. Held, & A. McGrew (Eds.), The Global Transformations Reader: An Introduction to the Globalization Debate (pp. 348). Cambridge: Polity Press.
Chen, L., & Berlinguer, G. (2001). Health Equity in a Globalizing World. In T. e. a. Evans (Ed.), Challenging Inequities in Health: From Ethics to Action (pp. 34). Oxford: Oxford University Press.
Eliot, J. (2008, March 5). Uganda Health Gets Hand. The Cairns Post (Australia), pp. 31.
Grainger, S. (2007, 19 January). Surviving Uganda's Cattle Wars. BBC News.
Jilcott, S. B., Masso, K. L., Ickes, S. B., Myhre, S. D., & Myhre, J. A. (2007). Surviving But Not Quite Thriving: Anthropometric Survey of Children Aged 6 to 59 Months in a Rural Western Uganda District. Journal of the American Dietetic Association, 107(11), 1983-1988.
Kaiser, T. (2005). Participating in Development? Refugee Protection, Politics and Developmental Approaches to Refugee Management in Uganda. Third World Quarterly, 26(2), 351-367.
Maxwell, D., Levin, C., & Csete, J. (1998). Does Urban Agriculture Help Prevent Malnutrition? Evidence from Kampala. Food Policy, 23(5), 411-424.
McIntyre, B. D., Bouldin, D. R., Urey, G. H., & Kizito, F. (2001). Modeling Cropping Strategies to Improve Human Nutrition in Uganda. Agricultural Systems, 67(2), 105-120.
Nadakavukaren, A. (2006). Our Global Environment, A Health Perspective (6th ed.). Long Grove, IL: Waveland Press, Inc.
Stuart, P. (2007, Bananas--Science Comes to the Rescue. African Business, 332, 58.
The National Academies Press. (2006). Lost Crops of Africa: Volume II: Vegetables. Washington, D.C.: The National Academies Press.
Tuller, D. (2007, December 25). Food Scarcity and H.I.V. Interwoven in Uganda. The New York Times, pp. 6.
UNICEF. (2008). The State of the World's Children.
Victora, C. G., Adair, L., Fall, C., Hallal, P. C., Martorell, R., Richter, L., et al. (2008). Maternal and Child Undernutrition: Consequences for Adult Health and Human Capital. The Lancet, 371(9609), 340-357.

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Term paper on food deserts and obesity

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The Urban Environment’s Role in the Formation of Food Deserts as a Sociological Contributor to Obesity

Kelly Moltzen

Social and Behavioral Determinants of Health E.33.2355 – Fall 2008

December 11, 2008

Final term paper

Introduction

Obesity is an epidemic in many developed countries, notably the United States, where more than 30 percent of Americans are classified as obese 1,2. Obesity occurs more often in urban areas than in rural areas 3. At the same time, more and more cities around the world are becoming urbanized, with half of the world’s population now living in urban areas 1,2,4. Due to the forces of globalization, obesity is becoming a pandemic as fast food companies expand their empire in developed as well as developing countries through the process of “Americanization,” so much so that one billion adults in the world are overweight 2. Overweight is defined as having a Body Mass Index (BMI) of >24.9 kg/m2, and obesity is defined as having a BMI of >29.9 kg/m2. Obesity is a risk factor for other debilitating diseases, such as diabetes and cardiovascular disease, which decrease quality of life and lead to skyrocketing healthcare costs. For these reasons, it is of crucial importance to examine the characteristics of urban environments in terms of how they contribute to obesity. In this paper, the role of the urban environment in affecting living conditions that contribute to obesity will be examined, with a particular focus on food deserts in cities in developed countries such as New York.

The urban environment is a broad term encompassing urban planning, urban development, and urban zoning. These factors affect living conditions such as “housing, employment, education, equality, quality of living environment, social support, and health services” 4. The built environment encompasses the transportation system and land use patterns, which together influence opportunities for healthy eating and physical activity 5. In densely populated urban spaces, public transportation can allow for easier mobility, thereby increasing access to stores that sell healthy food, health services, education, and employment 4. How unevenly quality of housing is distributed within a city affects health, and so does poor transportation, which makes access to health services and employment more difficult 4. Land use patterns can affect the existence of food deserts in an area, where communities’ access to healthy food options is limited. Insufficient access to healthy food translates into less healthy diets, which translates into higher rates of obesity – especially without adequate access to physical activity-friendly environments. This is particularly relevant in low-income neighborhoods, where not only are food deserts more likely to exist, but poor people are more likely to be uninsured and therefore more apt to let their health go unchecked until they have already developed a chronic illness such as obesity and/or diabetes 6.

There are several other characteristics of the urban environment that can affect health 4. The social environment can play a key role in health maintenance in urban environments. Social support can mitigate the impact of stressors and enable access to goods or services, and organizations that work to improve living conditions can have a positive influence on the social environment 4. Availability and access to health and social services are important determinants of health, as are demographic characteristics such as race. Risk of obesity in urban areas is affected by such living conditions as “housing, employment, education, equality, quality of living environment, social support, and health services” 4.

Municipal level determinants such as government, markets and civil society are noteworthy contributors to health as well. Governance can influence many sectors of health. Markets can act positively on health – such as the existence of farmers’ markets – but they can also be very detrimental to health, such as through the fast food market. In the urban setting, the availability of supermarkets is particularly salient. Civic society, which Vlahov et al. defines as “the space not controlled by government or the market where residents interact to achieve common goals,” can work to improve social capital (social support, community capacity) 4. Government, markets, and civic society can work independently as well as collaboratively to critically influence an urban community’s risk for obesity, and these relationships will be explored further in this paper.

Methods

I have compiled a wide array of research by using various methods. I conducted literature searches of peer-reviewed journals through NYU Library’s electronic journals and database search engines, finding articles in World Development, Nutrition Reviews, and Environment & Urbanization, to name a few. I informally asked my network of professionals in the field for their expertise on food deserts, particularly through the American Dietetic Association’s Hunger & Environmental Nutrition Dietetic Practice Group’s list-serve. In this way I found out about many resources that I would not have otherwise known about. Through my network, I also found out about and attended various nutrition and food security related meetings and conferences in New York City, of which I attended a Food Systems Network of New York City (FSNYC) meeting, a NYC Nutrition Education Network (NYCNEN) meeting, and a Manhattan Borough President Politics of Food Steering Committee meeting. I was unable to make it to the Politics of Food Conference that was organized by the Borough President’s Steering Committee because it conflicted with the NYCNEN meeting, but many of the speeches are available online, so I was able to watch them on my own.

At the FSNYC meeting on November 11, 2008, Geri Henchy from the Food Research and Action Center gave an overview of the Women, Infants and Children Supplemental Nutrition Program (WIC) changes, and Bob Lewis of NYS Dept of Agriculture and Markets led a discussion on the impact of these changes on our local Farmers' Markets 7. At the NYCNEN meeting, the New York City Department of Health and Mental Hygiene’s (NYC DOHMH) new Green Cart initiative 8 was discussed 9. Manhattan Borough President Scott Springer has a Politics of Food Steering Committee, which organized a Politics of Food Conference that had speeches by Mayor Bloomberg, the President of the United Nations General Assembly Miguel d’Escoto, and Maya Wiley, the Director of the Center for Social Inclusion 10. Additionally, the conference had the following breakout sessions: “From Field to Market: A Blueprint for Food Distribution in New York City;” “Finding Healthy Food: Supermarkets, Farmers’ Markets, Community Supported Agriculture (CSAs) and Food Deserts;” “The Importance of Nutrition Education; Urban Farming: What Does It Look Like? What Makes It Work?;” “How Schools, Hospitals, and Other Institutions Can Serve Healthier Meals;” “Recession's Consequences for the Food Safety Net;” and “The Urban Food Agenda: Shaping City, State, and Federal Policy.”

The Steering Committee has had one follow-up meeting so far after the conference, where Scott Springer discussed the potential for introducing a bill to the city council for a new “Department of Food” in New York City 11. He has already developed the “Go Green East Harlem” Cookbook, an initiative developed by his steering committee in January 2008 12,13. [Note: document since published: Food in the Public Interest]

Results

There is much evidence that living in urban areas is associated with a greater prevalence of obesity, both in developed and developing countries. People in urban areas consume foods higher in fat, more animal products, more sugar, more food prepared away from the home, and more processed foods 3. In addition, urbanicity is traditionally associated with more service sectors jobs than agricultural jobs, and generally a more sedentary lifestyle. The urban effect exists even when income, food prices, and various other sociodemographic variables are controlled for, as found during a study in China 3. Kjellstrom and Mercado confirm this with the statement “urbanization itself is a determinant of health” 2. There are multiple reasons for this, including the interplay of the existence of food deserts, facets of the urban environment – such as urban planning, urban zoning and urban development – and racial discrimination. While urbanization and economic growth have generally gone hand in hand since the Industrial Revolution, they “give every sign of becoming dissociated” 3, leading more people to experience the urban health penalty than the urban advantage. This may be partially due to the unfortunate effect of decades of fighting poverty and working to increase fat consumption, which “led to an entrenched bureaucracy trained to encourage such activities” 3.

Another observation is that although the average income in urban areas is generally higher than the average income in rural areas, this difference can be misleading, as a majority of the wealth is concentrated in the hands of the few urban elite 2. In addition, the cost of living is much higher in urban areas – especially New York City – than in rural areas. This lack of finance leads to more food insecurity and poor nutrition status in developing countries as well as developed countries 2.

Land use and transportation, the components of the built environment, can significantly affect urban health. While land use and transportation systems should ideally work together to bring the most benefit to an area’s residents, in the United States they are structurally part of different levels of government: land use patterns are set by local governments and private developers, while transportation is run by the federal government. Therefore, increased coordination between these agencies is key to producing healthier environments 5.

Neighborhood design shapes “how people get from place to place (e.g., roads, transportation systems, bicycle and walking paths)…, where they exercise…, and the social norms and perceptions that impact how people use their neighborhoods (e.g., crime,…social capital)” 1. Decreased opportunities for physical activity contribute to the sedentary lifestyle that is found in individuals of lower socioeconomic status. Likewise, fear of crime and violence may decrease the likelihood of seeking outdoor physical activity in a neighborhood, especially for children whose parents perceive the area as dangerous 1.

The growth and expansion of highways by transportation authorities has pushed aside consideration for pedestrians and bicycle riders 5. However with the passage of the Intermodal Surface Transportation Efficiency Act (ISTEA), more pedestrian- and biker-friendly programs are being implemented, including providing over $400 for pedestrian and bicycle facilities, hiring a bicycle-pedestrian coordinator in each state, starting a $612 million Safe Routes to School program, as well as several other programs 5. Maryland has begun providing incentives for employees to live closer to work; London has implemented a “congestion pricing” program to discourage people from driving into certain areas at certain times by charging a fee; and “Location Efficient Mortgages” incentivize living in areas that are conducive to active travel instead of driving 5. Another idea is implementing voluntary travel reduction programs to educate residents on how to save time and money by cutting down on driving 5.

Most cities have high rates of inequality 4, and therefore in order to reduce the risk of widening disparities, community-specific inequalities must be accounted for. For example, there are neighborhood disparities in terms of obesity prevalence, with black neighborhoods having higher rates of obesity than white neighborhoods 1. African Americans are less likely to own a car in comparison to other races 6, which puts them at a disadvantage in terms of availability of transportation to get to healthy food vendors. Also, immigrants in a city like New York who move to the United States with the goal of making money to send back to their families, often start out with an economic disadvantage, and therefore cannot afford to buy healthy food for their families. They must buy what the food industry in the United States makes inexpensive – namely, unhealthy food. For these reasons, minorities have higher rates of obesity 14 and are therefore more prone to the urban health penalty as a contributor to obesity than whites.

According to Maya Wiley from the Center for Social Inclusion, urban zoning shows signs of segregation by race, especially in New York15. Out of the fifty largest metropolitan areas in the country, New York is the 4th most segregated. The top 5% of earners make 52 times the income of the lowest fifth, making the income disparity comparable to that in Namibia. Additionally, only the highest earning professionals can afford to live in Manhattan. Housing construction occurs much more often in wealthy areas of the City, with very limited construction in low-income neighborhoods 15. In addition, Blacks, Latinos and Asians are consistently victims of the illegal practices of “redlining” neighborhoods not considered loan worthy, and “steering” buyers to certain neighborhoods based on their race or ethnicity 15. Mandatory inclusionary zoning would incentivize developers to sell or rent a percentage of new units to low and moderate-income families at an affordable price 15, which would thereby work to decrease segregation.

While zoning ordinances of land use were originally established to improve public health by separating industrial activities from residential areas, the concern of property rights and separation of land usages eventually took over, leading to a separation of non-industrial establishments – such as stores and schools – from residential areas 5. The greater distances between destinations in a community, the less likely people are to walk or bike to get there, thus contributing to obesity through decreased physical activity. Yet “fast food restaurants aren’t usually labeled undesirable as a land use,” which means that they are allowed in low-income neighborhoods which have less restrictive zoning policies 5.

These policies brought about the existence of food deserts. Food deserts are areas “where access to healthy foods such as fresh fruits and vegetables is either limited, too expensive, or nonexistent. Inhabitants must opt for cheap and unhealthy foods based on whatever is available” 16. Food deserts exist both in rural areas – where the nearest supermarket may be miles and miles away – and in urban areas, where the number of fast food options far outweigh the number of supermarkets stocked with healthy choices, and the fast food choices are much more affordable than healthy foods. Urban areas are often characterized by a preponderance of corner stores which may not be adequately equipped with refrigerators, shelving, or advertisement messages for fresh fruits and vegetables; additionally, fresh fruits and vegetables may not be affordable or available 16.

The close proximity of fast-food and bodegas or convenience stores compounds the problem of increased distances to supermarkets that have affordable, healthy food. This is especially problematic for residents of low-income neighborhoods who are less likely to possess a car 17, as people who live far away from grocery stores and who do not have access to cars are less likely to travel distances to shop at them 6. In addition, fast food restaurants tend to be located around schools so that they can target their products to children and adolescents 5. Children in urban environments may be more likely to buy food at these establishments and bodegas on their way to and from school instead of eating a healthy breakfast in the morning, bringing lunch with them to school, or purchasing food from the school’s breakfast or lunch program offerings.

Meanwhile, “more affluent neighborhoods tend to restrict the number and location of [fast food] outlets through the formal land use planning process” 5, leading to even more health disparities between high and low-income neighborhoods. This is yet another contributor to the fact that areas with lower socioeconomic status have been shown to have less access to stores selling healthy food such as low-fat milk, high-fiber bread, fresh fruits, and vegetables 1.

Large chain supermarkets have the benefit of being able to offer lower prices and higher quality food options, but these benefits cancel out and contribute to health disparities if they are not accessible to low-income communities. Over the past 30 years, grocery stores have followed the white flight out of urban areas and established themselves in suburban areas, leading to an “urban grocery store gap” 18. They find it more economical to cut costs by buying in bulk and using large warehouses, which is easier to do in suburban areas 6. Research conducted by the University of Connecticut’s Food Marketing Policy Center found that for 21 cities across the US, there were 30 percent fewer supermarkets in low-income areas than in high-income areas 17. Data from research in Chicago suggests that the race of a neighborhood may be a deciding factor in whether large chain grocery stores come to an area or not 6,19. In addition, this study found that low-income neighborhoods that had no or distant grocery stores (but nearby fast food restaurants instead) had higher rates of premature death and chronic health conditions. Similar findings have been found in Philadelphia, where 70 new supermarkets would be needed in order to erase food deserts 6,20.

In order decrease the prevalence of food deserts in low-income communities, several interventions could be considered. These could include limiting the number of fast food stores and other vendors of unhealthy food by setting stricter zoning regulations, as well as giving incentives to supermarkets to locate in urban neighborhoods such as tax breaks and streamlined processes for obtaining permits 5. The development of public/private partnerships between governments and grocery stores could also be considered 17. However, adding more supermarkets to low-income neighborhoods in cities does not address the entire problem of food deserts, as will be discussed further on the following pages.

While large supermarket chains can successfully cut costs and consequently make foods cheaper, they have disadvantages as well. Food sold in large supermarkets that is shipped long distances has a diminished nutritional value, and there are high monetary and environmental costs of shipping, processing, and packaging 6. Also, supermarkets were designed for people with cars who could load up their cars with several days’ worth of groceries. They are not ideal for urban residents who have to worry about transporting the food items home.

In addition, supermarkets often run smaller stores out of business 6. Small stores are more likely to be near a community’s residential area, and therefore are more convenient for people who don’t own a car, can’t get a ride, can’t rely on public transportation, and can’t walk far distances. Single parents, people with disabilities, and the elderly all fall into this category 6. Yet, small grocers encounter a number of problems which makes it more difficult for them to provide fresh, healthy food. For instance, small grocers do not have the space or equipment needed to offer fresh produce regularly, normally do not carry a wide variety of produce, cannot buy in bulk quantities, and as a result must charge higher prices than chain supermarkets – up to 76 percent more 17.

The upshot is that cities should enable local citizens to obtain locally produced food. This can be done with urban agriculture, a phenomenon that is not new but was reintroduced to modern culture in the 1970’s when residents of New York’s East Village decided to clean up abandoned lots and plant gardens 6. Urban gardens require very little land and resources but can have a large output, increase a city’s green space, optimize production of unused land, and improve the quality of food (as it is produced closer to its eventual market and therefore does not need to be genetically modified) 6. Gardens can even have a huge environmental impact, as food miles – or, the distance food is transported from its production site to its distribution site – will be drastically reduced.

There is substantial evidence regarding the promise of urban gardens, and “the importance of urban and peri-urban agriculture and livestock keeping in sustaining the urban poor is being recognized globally” 2. Commercial food production relies on monocultures of crops that can prove devastating if the climate produces a poor harvest, as costs skyrocket with a decrease in supply. Urban agriculture can improve food security by increasing the stability of the nation’s food supply, as it decentralizes the food system and makes food available locally. It also drastically cuts down on food miles, improves the preservation of green space, and can benefit communities in terms of economic development 6. In addition, “micro-farming provides healthier produce” 6 and the nutritional quality does not decline with days of being transported from far distances.

Urban agriculture can be started in a number of ways. It can take the form of school gardens, where they can be used to educate children on skills that will last them for a lifetime. It can be entrepreneurial, where the food grown can be sold at local farmers’ markets. Community gardens are another idea, where the community members take charge through leadership and community organization. This can increase social capital, can have physical and psychological benefits, and can motivate youth and senior citizens to take a part in their communities 6.

Micro-farming has been used to boost the economy throughout United States history, such as via “Victory Gardens” during World Wars I and II. During this time, 40% of the nation’s food supply was grown by gardeners 6. Urban and community gardens represent a type of food sovereignty: “the right of peoples, communities, and countries to define their own agricultural, labor, fishing, food, and land policies which are ecologically, socially, economically, and culturally appropriate to their unique circumstances” 21. It “introduces a complete integration of social justice ideals,” where community based organizations can aid in achieving the local economy goals, community members can be hired to work on the farm sites, and the produce can be sold at local farmers’ markets and at neighborhood corner grocery stores 21. One example of a contribution to the community effort took place in Chicago, where good-quality compost was purchased by the truckload from a local urban farmer who collects vegetable waste from local restaurants and turns it into compost 21. University resources should also be utilized when developing urban farms, such as a local Cooperative Extension office that could be used to help identify suitable plant varieties. By taking a food systems approach and involving every aspect of the community, urban farming can allow a community to take advantage of the “urban advantage” and not have to suffer from the “urban health penalty.”

While access to healthy foods in low-income communities is essential to improving the obesity situation, it is not the only necessary component. Several generations of lacking access to healthy foods has led to a dearth of knowledge about how to prepare healthy foods, even when they do have access to them. Therefore, health education programs must be implemented in communities while simultaneously increasing access to healthy foods. There are various health-based efforts to shape the built environment, such as the World Health Organization’s Healthy Cities program to build relationships between public health officials, local planners and others; the Active Living by Design program to promote physical activity; Health Impact Assessments which state and federal governments could require for land use and transportation planning, and statewide health plans supported by the Centers for Disease Control and Prevention’s Nutrition and Physical Activity Program to Prevent Obesity and Other Chronic Diseases 5. However, there are still many communities that have not been reached and still suffer from the problem of food deserts 6. National governments must adequately equip local governments “with the mandate, powers, jurisdiction, responsibilities, resources and capacity to undertake ‘healthy urban governance’” 2.

One way they could do this is by subsidizing seed programs to jump-start food sovereignty-based programs in low-income communities, such as the proposed Urban Agriculture and Education Center to be located in the center city of Indianapolis 6. This site will be a place where nutrition and culinary classes can take place, food can be grown and sold, and social networks can be strengthened. It has been modeled off of successful combinatory farmers’ markets and community centers, such as the City Market in Kansas City and Santa Caterina Market in Barcelona, Spain. Similarly, community-initiated development corporations can “compete for public funding opportunities to attract needed businesses to low-income communities, develop affordable housing, or provide education and skills opportunities to residents” 5.

Another promise for creating more equitable opportunities in the urban setting is to use financing schemes such as conditional cash transfers 2 and social welfare programs like the Supplemental Nutrition Assistance Program, which now allows users to shop at farmers’ markets 22. NYC DOHMH has come out with a Health Bucks Program where one Health Buck coupon will be given to each customer for every five dollars spent using food stamps 23. The Health Bucks can be used at farmers’ markets. This is promising because vouchers for fresh fruits and vegetables have been shown to increase consumption of produce in the past, as was shown in a study of the WIC program in Los Angeles, California 24. The Health Bucks Program is in addition to the DOHMH’s Green Carts Program, which has increased the number of fruit and vegetable vendors in New York City by 500 in 2008 and will increase it by another 500 in 2009 8. There are also new changes happening to the WIC Supplemental Nutrition Program, which will provide healthier food options starting in 2009 7. Vertical farming, a concept developed by Dickson Despommier at Columbia University, may hold potential for the future as well 25.

Discussion

While this paper set out to examine the research linking obesity to urban environments in developed countries, the majority of studies I found were based in the United States. This is not necessarily a bad thing, as public health interventions are best examined within the context of a particular community. Another limitation is while I originally set out to focus on the factors of the “urban environment” – urban planning, zoning, and development – the majority of the research focused on effects of urban planning and zoning in terms of placement of food vendors, and only a small amount of research was found on zoning of residential areas. Perhaps this is because it is easier to develop policies regarding where food stores can and should be located than to focus on altering residential patterns, which touches on the effects of urban renewal and redevelopment issues.

From the research, it is clear that there is indeed an urban health penalty felt by low-income communities across the United States which leads to increased rates of obesity. In many areas this impact is felt the strongest by African Americans, as they are the minority group that has been here the longest. Besides generations of outright discrimination in employment and being put at an economic disadvantage, they have been the victims of discriminatory zoning practices in cities. They also must have had the most generations suffer from lack of access to healthy foods and the concurrent loss of a knowledge and skill set on how to prepare healthy foods.

There are many interventions which can be considered when determining how to best decrease the effect of the urban health penalty and its associated risk for obesity among low-income communities. Changes can be made at the governmental level, such as: regulating where fast food restaurants are allowed to exist; working with the Department of Transportation and each state’s bicycle-pedestrian coordinator to expand and improve bicycle routes and pedestrian walkways; giving subsidies to vendors and community organizations that are willing to move into an area to sell healthy foods and educate residents on nutrition and cooking skills; and using social welfare programs to encourage low-income communities to purchase fresh fruits and vegetables. Governments can also take an even more radical step and develop a “Department of Food,” as is being considered in New York City. Many governmental interventions are best implemented at the local level, however, because the community must have the capacity to carry out the program.

It is also important to focus on community-level interventions because they help build social cohesion, which can go a long way in terms of actually bringing about change to a community. For instance, involving community members in the growing and selling of the foods they eat can give people a sense of pride and accomplishment while simultaneously improving their economic development opportunities, thereby increasing the chances that the program will be successful in the long term. Fortunately, there will be funding available for new interventions in the coming years in the U.S., as the 2008 Farm Bill has allotted $10.4 billion for urban agriculture and nutrition, aid for Historically Black Colleges and Universities, and a Healthy Urban Food Enterprise Development Program that will provide grants and technical assistance to communities to link farmers and grocery stores 26. One can only hope that this money will be used wisely by all parties involved.

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