Healthy people need healthy microbiomes from an early age.
- 30 million children worldwide suffer from moderate acute malnutrition.
- Lifelong problems from undernourishment include increased risks of diabetes and heart problems.
- New research shows that targeting the microbiome could help malnourished children grow up healthy.
According to the United Nations Food and Agriculture Organization, an estimated 815 million people — nearly 11 percent of the global population — suffer from chronic undernourishment. While the predominant number of them live in poor countries, some 11 million live in more developed nations. As the pandemic rages on and the effects of climate change continue, those numbers will continue to increase if there are no interventions.
A new study, published in The New England Journal of Medicine by an international team of researchers, investigates one potential solution that could address the 30 million children suffering from moderate acute malnutrition: target the microbiome.
Childhood undernourishment results in a variety of crippling lifelong effects: wasting and stunting (impaired growth and development), immune and metabolic dysfunction, and central nervous system problems top the list. With the pandemic predicted to increase childhood deaths from wasting by 20 percent, the team expresses urgency for this chronic problem.
Feeding the microbiota
For this randomized, controlled study, researchers recruited 118 children between the ages of 12 to 18 months. They split the recruits into two groups: 59 children were given an experimental diet (which they called microbiota-directed complementary food prototype, or MDCF-2), and the other 59 were given a control diet (which was ready-to-use supplementary food, or RUSF). All children lived in Mirpur, an impoverished region of Dhaka, Bangladesh.
Supplementation was given for three months followed by one month of monitoring. The team measured a total of 4,977 proteins and 209 bacterial taxa in fecal samples over the course of the project. Because they had previously observed that malnourished children have less advanced microbiome profiles than healthy children, the goal was to feed and encourage the growth of the bacterial community associated with normal childhood development.
During the first month, mothers brought their children to a regional healthcare center to feed them two daily servings of either MDCF-2 or RUSF. During the second month, one of those two feedings happened at home. By the third month, the children were fed at home. After three months, the children returned to their normal feeding routines and were tested one month later.
The group given MDCF-2 saw improvements in two of four key measurements: weight-for-length and weight-for-age. They also found an important improvement in terms of bodily inflammation. The authors wrote:
"By the end of MDCF-2 supplementation, children in the upper quartile had the largest increases in mediators of bone growth and CNS development and the largest decreases in effectors of inflammation. Together, these results provide evidence that mediators of bone growth, neurodevelopment, and inflammation distinguished the effects of the MDCF-2 nutritional intervention from that of RUSF."
Undernourishment often results in metabolic reprogramming that predisposes children to develop cardiovascular issues, diabetes, and hypertension later in life. This is, in part, why they're seeking early interventions focused on creating healthy microbial communities before such metabolic changes occur.
Stay in touch with Derek on Twitter and Facebook. His most recent book is "Hero's Dose: The Case For Psychedelics in Ritual and Therapy."
Global inequality takes many forms, including who has lost the most children
- A first-of-its-kind study examines the number of mothers who have lost a child around the world.
- The number is related to infant mortality rates in a country but is not identical to it.
- The lack of information on the topic leaves a lot of room for future research.
Among the best indicators of societal progress over the last few decades has been the remarkable decline in infant and child mortality rates worldwide. In the early sixties, a staggering 1 in 4 children around the world died. Today, that rate has fallen to fewer than 1 in 10. The continued efforts of several organizations will help that number to fall even further.
However, like many other kinds of progress, the blessings of these advances have been shared unequally. Child mortality rates are much higher in some parts of the world than in others. Additionally, measuring infant mortality by itself doesn't tell the whole story. While conditions are improving, the legacy of high child mortality rates endures.
In hopes of shedding light on both issues, a first-of-its-kind study suggests that mothers in some parts of the world remain astronomically more likely to lose a child than others.
Bereavement around the world
An international team of researchers led by Dr. Emily Smith-Greenaway examined data from 170 countries. By combining information on child mortality, maternal life expectancy, the fertility rate, and the proportion of women in the country who have children, among other statistics, the researchers were able to create indices of the number of mothers per thousand who lost a child either before the age of one or five, or ever, for nearly every country in the world.
Cumulative prevalence of infant mortality for mothers age 20–44. Notice the groupings of countries at both the high and low ends of the scale. (scale is per thousand) USC Dornsife College of Letters, Arts and Sciences
The results are quite shocking.
As seen in the above map, the countries with the highest maternal bereavement rates are clustered in sub-Saharan Africa and the Middle East. Hong Kong has the lowest maternal bereavement rate of any measured locale in the world at 2.8 per 1000, while Sierra Leone has the highest at 303.3 per 1000, nearly 1 in 3. A mother in Sierra Leone is 108 times more likely to have lost a child than a mother in Hong Kong.
This difference is far larger than that of infant mortality alone. There are many possible reasons for this, including factors which directly impact child mortality. Because of the number of factors involved, there are countries where the infant mortality rate remains stubbornly high but where maternal bereavement is rather low, such as the Philippines, and countries where a low mortality rate hides a high bereavement rate, such as Peru.
The differences between countries continue to exist when age is accounted for. While rates are worse everywhere when looking only at older mothers, the difference between Hong Kong, which remains the best, and Liberia, which becomes the worst, is still a factor of 70.
Cumulative prevalence of infant mortality for mothers age 45–49. Notice the similarities with the above map. (scale is per thousand) USC Dornsife College of Letters, Arts and Sciences
The mental and physical toll of losing a child
The authors of the study suggest that these numbers demonstrate the existence of a previously hidden element of global health and the inequality between nations. Their work shows that the maternal cumulative prevalence of infant mortality is not identical to the infant mortality rate, though it is related. They also warn that their estimates are probably conservative due to the likelihood of unreported infant deaths.
The toll of losing a child on a mother's mental and physical health is considerable. However, much of the research on this topic ignores the possible effects on other family members. The authors note that what information does exist suggests it can be equally as damaging to them. Additionally, they state that their research focused on national rates but that similar issues may exist within nations where demographic differences in infant mortality and parental bereavement rates exist. They encourage further study into this matter.
Dr. Smith-Greenaway explained the authors' hopes for the study and the new area of research it identifies:
"We hope that this work will emphasize that further efforts to lower child deaths will not only improve the quality and length of life for children across the globe, but will also fundamentally improve the lives of parents."
First drawn in 1935, Hu Line illustrates persistent demographic split – how Beijing deals with it will determine the country's future.
- In 1935, demographer Hu Huanyong drew a line across a map of China.
- The 'Hu Line' illustrated a remarkable divide in China's population distribution.
- That divide remains relevant, not just for China's present but also for its future.
A bather in Blagoveshchensk, on the Russian bank of the Amur. Across the river: the Chinese city of Heihe.
Credit: Dimitar Dilkoff/AFP via Getty Images
The Hu Line is arguably the most consequential feature of China's geography, with demographic, economic, cultural, and political implications for the country's past, present, and future. Yet you won't find it on any official map of China, nor on the actual terrain of the People's Republic itself.
There are no monuments at its endpoints: not in Heihe in the north, just an icy swim across the Amur from Blagoveshchensk, in Russia's Far East; nor in Tengchong, the subtropical southern city set among the hills rolling into Myanmar. Nor indeed anywhere on the 2,330-mile (3,750-km) diagonal that connects both dots. The Hu Line is as invisible as it is imaginary.
Yet the point that the Hu Line makes is as relevant as when it was first imagined. Back in 1935, a Chinese demographer called Hu Huanyong used a hand-drawn map of the line to illustrate his article on 'The Distribution of China's Population' in the Chinese Journal of Geography.
The point of the article, and of the map: China's population is distributed unevenly, and not just a little, but a lot. Like, a lot.
- The area to the west of the line comprised 64 percent of China's territory but contained only 4 percent of the country's population.
- Inversely, 96 percent of the Chinese lived east of the 'geo-demographic demarcation line', as Hu called it, on just 36 percent of the land.
Much has changed in China in the intervening near-century. The weak post-imperial republic is now a highly centralized world power. Its population has nearly tripled, from around 500 million to almost 1.4 billion. But the fundamentals of the imbalance have remained virtually the same.
Even if China's territory has not: in 1946, China recognized the independence of Mongolia, shrinking the area west of the Hu Line. Still, in 2015, the distribution was as follows:
- West of the line, 6 percent of the population on 57 percent of the territory (average population density: 39.6 inhabitants per square mile (15.3/km2).
- East of the line, 94 percent of the population on 43 percent of the territory (average population density: 815.3 inhabitants per square mile (314.8/km2).
Hu Huanyong's original hand-drawn map of China, showing population density and the now-famous line (enhanced for visibility).
Credit: Chinese Journal of Geography (1935) – public domain.
Why is this demographic dichotomy so persistent? In two words: climate and terrain. East of the line, the land is flatter and wetter, meaning it's easier to farm, hence easier to produce enough food for an ever-larger population. West of the line: deserts, mountains, and plateaus. Much harsher terrain with a drier climate to boot, making it much harder to sustain large amounts of people.
And where the people are, all the rest follows. East of the line is virtually all of China's infrastructure and economy. At night, satellites see the area to the east twinkle with lantern-like strings of light, while the west is a blanket of near total darkness, only occasionally pierced by signs of life. In China's 'Wild West', per-capita GDP is 15 percent lower on average than in the industrious east.
An additional factor typifies China's population divide: while the country overall is ethnically very homogenous – 92 percent are Han Chinese – most of the 8 percent that make up China's ethnic minorities live west of the line. This is notably the case in Tibet and Xinjiang, two nominally autonomous regions with non-Han ethnic majorities.
This combination of economic and ethnic imbalances means the Hu Line is not just a persistent quirk, but a potential problem – at least from Beijing's perspective. Culturally and geographically distant from the country's east, Tibetans and Uyghurs have registered strong opposition to China's centralizing tendencies, often resulting in heavy-handed repression.
Street view in Tengchong, on China's border with Myanmar.
Credit: China Photos/Getty Images
But repression is not the central government's long-term strategy. Its plan is to pacify by progress. China's 'Manifest Destiny' has a name. In 1999, Jiang Zemin, then Secretary-General of the Chinese Communist Party, launched the 'Develop the West' campaign. The idea behind the slogan retains its political currency. In the last decade, Chinese Premier Li Keqiang has repeatedly urged the country to "break through" the Hu Line, in order to modernize China's western half.
The development strategy has an economic angle – adding industry and infrastructure to raise the region's per-capita GDP to the nation's average. But the locals fear that progress will bring population change: an influx of enough internal migrants from the east to tip the local ethnic balance to their disadvantage.
China's ethnic minorities are officially recognized and enjoy certain rights; however, if they become minorities in their own regions, those will mean little more than the right to perform folklore songs and dances. The Soviets were past masters in this technique.
Will China follow the same path? That question will be answered if and when the Hu Line fades from relevance, by how much of the west's ethnic diversity will have been sacrificed for economic progress.
Strange Maps #1071
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Pandemics have historically given way to social revolution. What will the post-COVID revolution be?
- The US is approaching 500,000 COVID-19 deaths. What can we learn from one year of loss and chaos?
- The lessons are clear. Among them are realizing our fragility as a species, our codependence as humans, and the urgent need to move beyond social injustice and inequity.
- As with the Renaissance following the Black Plague of the 14th century and the explosive creativity of the 1920s post Spanish influenza, this is our turn to redefine the course of history. Let's not mess this up.
It's been almost a year now since COVID-19 brought the world to a halt. Everyone has been affected, to a degree that varies from the no-so-much to the profoundly tragic. In March 2020, a few weeks into the pandemic, I wrote an opinion piece for CNN where I advanced a few ideas about what changes could unfold due to the challenges ahead. Now that we are well into this mess, and with the growing hope of stepping out of it within the next few months, it's time to reconsider some of these ideas.
First, some facts.
This is the biggest existential threat of our generation. We didn't face the tragedy of two world wars and, so far, escaped the ongoing threat of nuclear warfare. It's important to compare the tragedy that we are going through now with the devastation of the Spanish Influenza of 1918, with numbers that seem almost incomprehensible. It is estimated that about 500 million people, some one-third of the world's population then, were infected by the virus. Of those, 50 million—10 percent—died worldwide, 675,000 of which were in the US. In today's numbers, this would mean that about 2.4 billion people would be infected, and 240 million would die. At the time of writing, there have been about 109 million confirmed infections (surely an underestimate) and 2.4 million deaths. While the numbers are much better worldwide this time around, this data doesn't make us feel any better. We are approaching half a million deaths in the US, another incomprehensible number, getting closer to the number of US losses during the Spanish flu. Denial, the lack of federal leadership, the top-down silencing of scientific evidence and support, complacency, science denial—these are all to blame.
Science is essential.
A global pandemic of this magnitude is first and foremost a public health issue and the first line of defense is through science and public policy working in tandem. The fact that we are faring comparatively better than in 1918 speaks to the power of medicine to save lives: ventilators, antiviral drugs, better sanitation, better understanding of how this virus operates. The numbers could have been much better if health policy measures had not become politically weaponized and added to the current ideological divide with tragic consequences. The fact that we now have extremely effective vaccines, some using entirely novel technologies, speaks again to the power of science to save lives. This is a moment to celebrate science in service of humanity's greater good.
We need to rethink who we are.
Earth has existed for 4.5 billion years; our species, Homo sapiens, has existed for about 200,000 years.
Credit: desdemona72 via Adobe Stock
The pandemic has exposed our perennial fragility as a species. Nature operates under rules that don't include compassion for loss of life. We are not above nature. Technology may give us the impression that we can control the ways of the world, but we are still very much part of the process of natural selection, getting ill as mutant forms of this virus and others create new public health challenges. Natural selection is an endless battle for survival. We cannot trick it into a permanent stop, only into momentary halts. Indeed, as the environment changes, new forms of life emerge and not all of them will be beneficial to us. The melting of the permafrost is bringing up diseases that hit our distant ancestors and against which we are defenseless. Rethinking who we are calls for humility. Humility in the face of our limited resources, humility in the face of forces that are much more powerful than we are. We can dig deep holes and tunnels through mountains, cut down forests and make oceans retreat. But every one of these actions has a profound environmental impact that costs us dearly. Rethinking who we are calls for a reframing of our relationship to the planet. Earth has existed for 4.5 billion years; our species, Homo sapiens, has existed for about 200,000 years. We have just arrived here. Earth will continue without us. We can't continue without it, space exploration notwithstanding. The future of our project of civilization depends on our rethinking of our planetary role.
We are a human hive.
The pandemic has given us ample proof of our codependence. We need each other at all levels; the first responders, the farmers and drivers, the supermarket workers bringing food to our tables. It is said that the stability of society is nine meals away. If we don't eat for 3 days, society unravels. And we need energy, supplies, banking systems, clear roads, clean cities, political stability, news, and fast internet. In a beehive, all workers contribute to the survival of the hive as a whole, every job is important. We are a human hive, and must respect all labor, and ensure that all workers are properly compensated. To live with dignity is not a luxury, it is a right.
We must rethink social structure and inequality.
The uneven toll of the pandemic has exposed systemic racism and social injustice to levels that can no longer be tolerated or overlooked by anyone, and certainly by those in power. Since at least the origins of agrarian civilization, our ancestors divided into tribes so as to guarantee social cohesion against battling economies. Defined mostly by religious beliefs and social exclusion, such tribal walls have been the signpost of cultures across the globe. We now have a different view of humanity's place on this planet, our togetherness exposed to us in ways that many dislike. A virus doesn't care what you believe in, the color of your skin or how much money you have in the bank. It will attack opportunistically and hijack your cellular material to reproduce. But the extent to which people can protect themselves against such attacks does reveal societal inequities in transparent ways. If you share an apartment with eight people and must go to work every day, taking public transportation to get there, you will be walking into the war zone without a weapon or shelter.
We need to rethink how we work.
With fast internet, it's abundantly clear that much of the dislocations to and from work, or frequent trips to distant places for meetings, is unnecessary, costly, and detrimental to the environment. Huge expenses with business real estate can be avoided, and funneled into higher compensation for workers and better computer and connectivity equipment. The notion of a downtown where people go to do business is quickly becoming obsolete. Travel will be mostly for fun and adventure. However, for this to become the new normal, fast connectivity and better equipment must be accessible to all, like electricity and clean water (there's some work still to be done here for sure.) Otherwise, we will be creating another tribal divide (it's here already), between those who have fast access to information and resources and those who don't.
The Black Death of the 14th century helped usher in the Renaissance, a spectacular blossoming of human creativity. The Spanish influenza was followed by the Roaring Twenties, an era of explosive cultural dynamism that brought us jazz, Art Deco, and a renewal of our capacity to celebrate life and be productive: automobiles, telephones, aviation, the film industry, electrical appliances, rapid industrial growth. What will be our post-pandemic revolution? The old ways are about to go; they are going already. There is a new world order emerging, the signs are everywhere. Not everyone is willing to see them, or to embark into this new venture. But I hope that those who do will inspire many to follow them. All this loss has to swing around and usher a new page in human history.
Want to tell someone's future in the US? You don't need a crystal ball, just their zip code.
- Social determinants of health, such as income and access to healthy food, affect well-being long before people may enter medical facilities.
- They're one reason neighborhoods in the same city can maintain life expectancy gaps larger than a decade.
- With growing awareness of how societal ills determine health, medical professionals and their partners are devising more holistic approaches to health.
New York City is a vibrant, vivacious city. No one knows this better than the people who live on its Upper East Side. Residents of this Manhattan neighborhood enjoy easy access to Central Park, a panoply of top-tier restaurants and markets, and some of the country's most renowned museums and cultural venues. But the real perk to calling the Upper East Side home is measured in years.
Upper East Side residents maintain an average life expectancy of 86.4 years, a number on par with the most peaceful, prosperous countries in the world. For a population to enjoy so many precious years represents historic achievements in education, infrastructure, and health care. Yet these hard-won achievements have not been distributed equally. A mere 15 miles away, in the Brooklyn neighborhood of Brownsville, the average life expectancy is a full decade shorter.
Just 15 miles from Brownsville, Brooklyn, residents of the Upper East Side in Manhattan have an average life expectancy of 86.4 years.
Source: NYC DOHMH; Bureau of Vital Statistics, 2006-2015
Such life-expectancy gaps are common across the United States. Residents of Chicago's Streeterville neighborhood can rest easy knowing they will live to be, on average, 90 years old. Chicago's Englewood neighborhood, however, maintains a life expectancy of around 60 years. That's ten years lower than the world average—in the world's most affluent country. The phenomenon is not just an urban affliction. On the whole, rural community members have lower life expectancies as they become more likely to die from these five leading causes than their city-dwelling peers.
While it may be tempting to write off these life gaps as the result of lifestyle choices or bad luck, they aren't. They are the consequences of a complex intersection between social, environmental, and cultural conditions that fall under 'social determinants of health.'
You can have the best treatments, the best physicians, the best facilities, but unless a patient's non-clinical needs are addressed, none of it will make a difference.
The 80/20 rule of health
Social determinants of health are those conditions in a person's life and environment that can either aid or degrade their health. They include employment, education, food availability, living conditions, communal support, neighborhood quality, socioeconomic status, and the wider systems that surround these conditions. When such determinants aren't wholesome, they erode health long before someone enters a hospital—at which point, health professionals may have only minutes to turn the tide of years of eroded health.
As Udai Tambar, vice president for community health at Northwell Health, said, "You can't medicate for social issues, and that's, in a way, the system we have developed. We're trying to medicate for social risks and social factors. You can have the best treatments, the best physicians, the best facilities, but unless a patient's non-clinical needs are addressed, none of it will make a difference."
Today, experts generally agree that 20 percent of health outcomes are derived from the care received at medical facilities, 80 percent from the non-clinical care attributed to one's lifestyle, environment, and social circumstances.
The data bear this out. U.S. health-care spending has nearly quadrupled since 1980, and the country has invested that bankroll heavily in hospitals, nursing facilities, prescription drug development, and medical specialist training. Each is valuable in its own right, yet as a systematic whole, this massive, decades-long investment has not netted proportionate health dividends. In addition to country-wide life gaps, the U.S. has one of the lowest life expectancies, the highest suicide rate, the highest chronic disease burden, and the highest obesity rate when compared to other major OECD nations.
These other OECD countries don't spend more on health than the United States. In terms of absolute dollars, the U.S. handily outspends these countries. Instead, these countries spend a larger portion of their GDP on social services, helping to mitigate deleterious social determinants long before a hospital visit. By one estimate, other major OECD countries allot, on average, $1.70 for social spending for every dollar on health. The U.S. system is almost the inverse, spending .56 cents on social services for every dollar on health.
"You need social equity to get health equity," Tambar added.
There’s no pill to cure poverty
This pattern of spending is one reason for the U.S. health-wealth divide, a pernicious and destructive social determinant of health. We've seen this divide's handiwork in the life expectancy differences between the Upper East Side and Brownsville, but those are samples of a whole. According to a 2017 paper in The Lancet, the "life expectancy of the wealthiest Americans now exceeds that of the poorest by 10-15 years." And these life-gap metrics signal the end consequences of a myriad of unmet social needs.
Consider the health barriers common in impoverished areas, where residents lack access to healthy, affordable food. Limited funds make it impossible to update or maintain safe housing without mold or lead-contaminated paint or water pipes. Narrow or nonexistent transportation options cut off residents from employment opportunities or health-care access. And being surrounded by street crime, unsafe public spaces or no greenways generates sustained high stress, which research shows grinds away at our physical health as fiercely as it does our mental wellbeing.
Each of these conditions is bitter in and of itself, but these social determinants often come packaged as part of a social circuit that magnifies the effects of each.
Unfortunately, dietary fads and the U.S.'s rugged individualism have loudly espoused health to be the culmination of lifestyle choices (for some, even moral rectitude). While lifestyle and choice certainly have their role, an understanding of these social determinants shows how inextricably tied our choices are to our social conditions. As Tambar points out, a person can be well-versed in nutrition, but if their neighborhood is a food desert, their choices are constrained. Social circumstances can limit or adversely influence health in inimical ways.
As Dr. Mary Travis Bassett, Director of the FXB Center for Health and Human Rights at Harvard University, told Big Think: "Nobody picks a substandard building to live in with terrible issues of rodent infestation and indoor allergens that trigger asthma. That's not a lifestyle choice. […] It's not about choice; it's about the fact that people don't have enough choice."
Going to the source
Credit: Getty Images
Negative social determinants of health provide a massive challenge to the health-care community, but experts and medical professionals aren't powerless to meet it. As Michael Dowling, CEO of Northwell Health, writes in his book "Health Care Reboot":
This trend toward greater awareness of the social determinants of health is one of the most encouraging developments in health care, for it creates greater awareness among providers of the whole patient, including all of the various elements—most of them outside what might be considered strictly medical issues—that affect an individual's overall health and wellbeing.
An outgrowth of this growing trend goes by the name "upstreamism." Upstreamist practitioners don't only focus on the patient's downstream symptoms; instead, they also turn their attention upstream to incorporate the patient's social determinants of health in their diagnosis. Dowling illustrates this paradigm with an example of a patient with chronic, life-interrupting headaches. Her upstreamist doctor provided her the usual medication but added the unusual prescription of a visit by a community health worker. The health worker found the patient's apartment walls to be infested with high levels of mold. The doctor and health worker told the patient to have her landlord fix the problem and provided the number for a public-interest attorney should the landlord fail to comply.
Dowling's story shows the holistic approach of upstreamism: to take into account all the determinants of health, not only those found within hospital walls. Sometimes, Dowling notes, that will require medical professionals to take the lead. But other times, when there are extra-symptomatic drivers of health, it will mean partnering with or supporting social service workers, law enforcement, or legal minds to secure a combination of services to heal the whole person.
It's for these reasons that many health-care organizations are spearheading initiatives and outreach programs to directly target social determinants of health before they become medical issues. Examples include Northwell's first-of-its-kind gun-violence screening program and the American Academy of Pediatrics' fight for food security for U.S. children.
As Tambar points out, this holistic outlook means changing our approach to more than just medicine. It will require many aspects of our society to adopt a multi-lens approach, one that adds an interdisciplinary depth to social problems beyond a solitary profession's expertise. He concluded, "What people are realizing is to holistically serve someone, it's not about you doing it all. It's about partnering with the best person who can do something you can't do."