Children's health
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Mustafa is a Research Data Analyst at the Center on Food Security and the Environment, where he supports Marshall Burke's work on estimating the impacts of environmental degradation on social and health outcomes. He has previously led a research project investigating the impact of Cleft Lip and Palate and CLP surgeries on the life outcomes of adolescent patients in India. Most recently, he worked as a Data Analyst on projects surrounding Medicare delivery. He holds a BA in International Studies and an MS in International and Development Economics from the University of San Francisco.

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Estimation of pollution impacts on health is critical for guiding policy to improve health outcomes. Estimation is challenging, however, because economic activity can worsen pollution but also independently improve health outcomes, confounding pollution–health estimates. We leverage variation in exposure to local particulate matter of diameter <2.5 μm (PM2.5) across Sub-Saharan Africa driven by distant dust export from the Sahara, a source uncorrelated with local economic activity. Combining data on a million births with local-level estimates of aerosol particulate matter, we find that an increase of 10 μg m3 in local annual mean PM2.5 concentrations causes a 24% increase in infant mortality across our sample (95% confidence interval: 10–35%), similar to estimates from wealthier countries. We show that future climate change driven changes in Saharan rainfall—a control on dust export—could generate large child health impacts, and that seemingly exotic proposals to pump and apply groundwater to Saharan locations to reduce dust emission could be cost competitive with leading child health interventions.

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Nature Sustainability
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Marshall Burke
Sam Heft-Neal
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Experts gathered to discuss the linkages between climate change and health at a Stanford-led event at the Global Climate Action Summit.

When it comes to food security, health and poverty, the impacts of climate change already are evident. That’s the message FSE Fellows David Lobell and Marshall Burke delivered last week at Global Climate Action Summit events held by Stanford in San Francisco. Attendees from across the globe gathered at the summit aimed to mobilize commitments and action from local governments, corporations and NGO’s to mitigate climate change and reach the goals of the Paris Agreement. 

Lobell and Burke – a professor and assistant professor (respectively) in Earth system science in Stanford’s School of Earth, Energy & Environmental Sciences participated in the Stanford Woods Institute for the Environment sponsored panel on Sept. 14  “The 2009 EPA ENDANGERMENT FINDING: EVEN STRONGER EVIDENCE in 2018.” Moderated by Stanford Woods Institute Director Chris Field, the panel examined how new research bolsters the original report’s findings that greenhouse gases pose a threat to human health and welfare.

Read the full story.

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More children die from the indirect impact of armed conflict in Africa than those killed in the crossfire and on the battlefields, according to a new study by Stanford researchers. 

The study is the first comprehensive analysis of the large and lingering effects of armed conflicts — civil wars, rebellions and interstate conflicts — on the health of noncombatants.

The numbers are sobering: 3.1 to 3.5 million infants born within 30 miles of armed conflict died from indirect consequences of battle zones between 1995 and 2005. That number jumps to 5 million deaths of children under 5 in those same conflict zones.

“The indirect effects on children are so much greater than the direct deaths from conflict,” said Stanford Health Policy's Eran Bendavid, senior author of the study published today in The Lancet.

The authors also found evidence of increased mortality risk from armed conflict as far as 60 miles away and for eight years after conflicts. Being born in the same year as a nearby armed conflict is riskiest for young infants, the authors found, with the lingering effects raising the risk of death for infants by over 30 percent.

On the entire continent, the authors wrote, the number of infant deaths related to conflict from 1995 to 2015 were more than three times the number of direct deaths from armed conflict. Further, they demonstrated a strong and stable increase of 7.7 percent in the risk of dying before age 1 among babies born within 30 miles of an armed conflict.

The authors recognize it is not surprising that African children are vulnerable to nearby armed conflict. But they show that this burden is substantially higher than previously indicated. 

“We wanted to understands the effects of war and conflict, and discovered that this was surprisingly poorly understood,” said Bendavid, an associate professor of medicine at Stanford Medicine.  “The most authoritative source, the Global Burden of Disease, only counts the direct deaths from conflict, and those estimates suggest that conflicts are a minuscule cause of death.”

Paul Wise, a professor of pediatrics at Stanford Medicine and a senior fellow at the Freeman Spogli Institute for International Studies, has long argued that lack of health care, vaccines, food, water and shelter kills more civilians than combatants from bombs and bullets. 

This study has now put data behind the theory when it comes to children.

“We hope to redefine what conflict means for civilian populations by showing how enduring and how far-reaching the destructive effects of conflict have on child health,” said Bendavid, an infectious disease physician whose co-authors include Marshall Burke, PhD, an assistant professor of earth systems science and fellow at the Center on Food Security and the Environment.

“Lack of access to key health services or to adequate nutrition are the standard explanations for stubbornly high infant mortality rates in parts of Africa,” said Burke. “But our data suggest that conflict can itself be a key driver of these outcomes, affecting health services and nutritional outcomes hundreds of kilometers away and for nearly a decade after the conflict event”. 

The results suggest efforts to reduce conflict could lead to large health benefits for children.

The Data

The authors matched data on 15,441 armed-conflict events with data on 1.99 million births and subsequent child survival across 35 African countries. Their primary conflict data came from the Uppsala Conflict Data Program Georeferenced Events Dataset, which includes detailed information about the time, location, type and intensity of conflict events from 1946 to 2016. 

The researchers also used all available data from the Demographic and Health Surveys conducted in 35 African countries from 1995 to 2015 as the primary data sources on child mortality in their analysis.

The data, they said, shows that the indirect toll of armed conflict among children is three-to-five times greater than the estimated number of direct casualties in conflict. The indirect toll is likely even higher when considering the effects on women and other vulnerable populations.

Zachary Wagner, a health economist at RAND Corporation and first author of the study, said he knows few are surprised that conflict is bad for child health.

“However, this work shows that the relationship between conflict and child mortality is stronger than previously thought and children in conflict zones remain at risk for many years after the conflict ends.” 

He notes that nearly 7 percent of child deaths in Africa are related to conflict and reiterated the grim fact that child deaths greatly outnumber direct combatant deaths.

“We hope our findings lead to enhanced efforts to reach children in conflict zones with humanitarian interventions,” Wagner said. “But we need more research that studies the reasons for why children in conflict zones have worse outcomes in order to effectively intervene.” 

Another author, Sam Heft-Neal, PhD, is a research fellow at the Center for Food Security and the Environment and in the Department of Earth Systems Science. He, Burke and Bendavid have been working together to identify the impacts of extreme climate events on infant mortality in Africa.

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Poor air quality is thought to be an important mortality risk factor globally1,2,3, but there is little direct evidence from the developing world on how mortality risk varies with changing exposure to ambient particulate matter. Current global estimates apply exposure–response relationships that have been derived mostly from wealthy, mid-latitude countries to spatial population data4, and these estimates remain unvalidated across large portions of the globe. Here we combine household survey-based information on the location and timing of nearly 1 million births across sub-Saharan Africa with satellite-based estimates5 of exposure to ambient respirable particulate matter with an aerodynamic diameter less than 2.5 μm (PM2.5) to estimate the impact of air quality on mortality rates among infants in Africa. We find that a 10 μg m−3 increase in PM2.5 concentration is associated with a 9% (95% confidence interval, 4–14%) rise in infant mortality across the dataset. This effect has not declined over the last 15 years and does not diminish with higher levels of household wealth. Our estimates suggest that PM2.5 concentrations above minimum exposure levels were responsible for 22% (95% confidence interval, 9–35%) of infant deaths in our 30 study countries and led to 449,000 (95% confidence interval, 194,000–709,000) additional deaths of infants in 2015, an estimate that is more than three times higher than existing estimates that attribute death of infants to poor air quality for these countries2,6. Upward revision of disease-burden estimates in the studied countries in Africa alone would result in a doubling of current estimates of global deaths of infants that are associated with air pollution, and modest reductions in African PM2.5 exposures are predicted to have health benefits to infants that are larger than most known health interventions.

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Nature
Authors
Sam Heft-Neal
Jennifer Burney
Eran Bendavid
Eran Bendavid
Marshall Burke
Marshall Burke (198750)
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Women empowerment (WE) is increasingly viewed as an important strategy to reduce maternal and child undernutrition,13 which continues to be a major health burden in low- and middle-income countries causing 3.5 million preventable maternal and child deaths, 35% of the disease burden in children younger than 5 years, and 11% of total global disability-adjusted life years.4,5Global data show that one of the worst affected regions is sub-Saharan Africa (SSA), where about 20% of children are malnourished.6,7 Benin is no exception, as the prevalence of stunting, wasting, and underweight was 37%, 5%, and 17%, respectively, among children aged 6 to 59 months in the 2006 Benin Demographic and Health Survey (DHS),8 while 9% of women had chronic energy deficiency in the 2012 DHS.9 Greater rates were observed in rural areas where stunting was found in 40% of children, underweight in 19%, and wasting in 5%, while 10% of women had chronic energy deficiency.8,9 Additionally, Beninese women and children have a limited dietary diversity score (DDS), with diets predominately composed of starchy staples with little or no animal products and few fresh fruits and vegetables.10,11 Government, United Nation agencies, and nongovernmental organizations in Benin recognize that the state of maternal and child undernutrition requires multiple types of interventions.12

However, women’s low empowerment status in Benin can hinder the improvement in women’s and children’s undernutrition. Indeed, although females accounted for 47% of the economically active population in 2014,13 social and civil legislation is strongly influenced by tradition and customs, as women continue to be required to seek their husband’s authorization in certain areas such as family planning or health services.14 Rural women provided labor to the families’ commercial plots, were responsible for household food production and processing, and also had to work in the cooperative structures set up by the state in addition to their household tasks.14 In a more recent study of productivity differences by gender in central Benin, researchers noted that female rice farmers are particularly discriminated against with regard to access to land and equipment, resulting in significant negative impacts on their productivity and income.15 As in other areas of West Africa, women also have the responsibility of caring for children and preparing food for the household,16 but they may be vulnerable to food insecurity owing to unequal intrahousehold food distribution and their willingness to forego meals in favor of children during times of scarcity.17 Finally, no study to date has examined links between women’s empowerment and nutrition in Benin.

In addition, the evidence backing the effect of women’s empowerment on maternal and child undernutrition is inconsistent.18 Using the Women’s Empowerment in Agriculture Index (WEAI), Malapit et al19 reported positive and significant association between women’s group (WG) membership, control over income, overall empowerment, and women’s health (as measured by body mass index [BMI] and DDS) in Nepal. However, in Ghana, women’s aggregate empowerment and participation in credit decisions were positively correlated with women’s DDS, but not BMI.20 Mixed findings were also observed between women’s empowerment and child anthropometry. Moestue et al21 found a positive association between maternal involvement in social groups and length-for-age z score of 1-year-old children, but De Silva and Harpham22showed a negative association in 6- to 18-month-old children. Shroff et al23 found positive association between decision-making and child weight-for-age z score (WAZ), but Begum and Sen’s24 analysis of Bangladesh DHS data did not reveal any significant associations. Therefore, information about which domains of WE are associated with nutritional status is limited,20 and this lack of knowledge constrains the set of policy options that can be used to empower women and improve nutrition.

In addition to a limited set of studies in SSA, examinations of the effects of WE on nutrition outcomes are constrained due to interstudy differences in population characteristics, settings, or methods/conceptualizations of WE.2527 For example, despite recognition of the complex, multidimensional, and culturally defined nature and influence of empowerment on nutrition,20,26,28,29 only a few studies considered the multidimensional structure of empowerment domains in Africa or examined the varied relationships between each measure of WE and maternal and child nutrition status.30,31 Furthermore, in 2012, the International Food Policy Research Institute developed WEAI constructed from 5 prespecified domains of empowerment,32which may not be equally relevant in all areas. In contrast, in 2015, the United Nations adopted the Sustainable Development Goals (SDG), but the specific indicators for the SDG empowerment targets are largely equality metrics.33 To address the need for multidimensional and contextual examinations of WE and its influence on maternal and child health outcomes, we draw from the concepts put forward in the WEAI and the SDGs but took an approach more along the lines of the World Bank which gathers indicators, both equity and empowerment related, that can be used in contextually appropriate ways.34 The aims of this study were therefore to first explore the structure and domains of WE in Kalalé district of northern Benin and then to examine the effects of these constructs on nutritional status of women and their children in the region.

 

 

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Food and Nutrition Bulletin
Authors
Halimatou Alaofe
Min Zhu
Jennifer Burney
Jennifer Burney
Rosamond L. Naylor
Rosamond L. Naylor
Taren Douglas
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Objective: To identify the magnitude of anaemia and deficiencies of Fe (ID) and vitamin A (VAD) and their associated factors among rural women and children.

Design: Cross-sectional, comprising a household, health and nutrition survey and determination of Hb, biochemical (serum concentrations of ferritin, retinol, C-reactive protein and α1-acid glycoprotein) and anthropometric parameters. Multivariate logistic regression examined associations of various factors with anaemia and micronutrient deficiencies.

Setting: Kalalé district, northern Benin. Subjects: Mother–child pairs (n 767): non-pregnant women of reproductive age (15–49 years) and children 6–59 months old.

Results: In women, the overall prevalence of anaemia, ID, Fe-deficiency anaemia (IDA) and VAD was 47·7, 18·3, 11·3 and 17·7%, respectively. A similar pattern for anaemia (82·4 %), ID (23·6%) and IDA (21·2%) was observed among children, while VAD was greater at 33·6%. Greater risk of anaemia, ID and VAD was found for low maternal education, maternal farming activity, maternal health status, low food diversity, lack of fruits and vegetables consumption, low protein foods consumption, high infection, anthropometric deficits, large family size, poor sanitary conditions and low socio-economic status. Strong differences were also observed by ethnicity, women’s group participation and source of information. Finally, age had a significant effect in children, with those aged 6–23 months having the highest risk for anaemia and those aged 12–23 months at risk for ID and IDA.

Conclusions: Anaemia, ID and VAD were high among rural women and their children in northern Benin, although ID accounted for a small proportion of anaemia. Multicentre studies in various parts of the country are needed to substantiate the present results, so that appropriate and beneficial strategies for micronutrient supplementation and interventions to improve food diversity and quality can be planned.

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Public Health Nutrition
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Jennifer Burney
Jennifer Burney
Rosamond L. Naylor
Rosamond L. Naylor
Halimatou Alaofè, Douglas Taren
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The ongoing decline in under-5 mortality ranks among the most significant public and population health successes of the past 30 years. Deaths of children under the age of 5 years have fallen from nearly 13 million per year in 1990 to less than 6 million per year in 2015, even as the world's under-5 population grew by nearly 100 million children. However, the amount of variability underlying this broad global progress is substantial. On a regional level, east Asia and the Pacific have surpassed the Millennium Development Goal target of a two-thirds reduction in under-5 mortality rate between 1990 and 2015, whereas sub-Saharan Africa has had only a 24% decline over the same period. Large differences in progress are also evident within sub-Saharan Africa, where mortality rates have declined by more than 70% from 1990 to 2015 in some countries and increased in others; in 2015, the mortality rate in some countries was more than three times that in others.

What explains this remarkable variation in progress against under-5 mortality? Answering this question requires understanding of where the main sources of variation in mortality lie. One view that is implicit in the way that mortality rates are tracked and targeted is that national policies and conditions drive first-order changes in under-5 mortality. This country-level focus is justified by research that emphasises the role of institutional factors in explaining variation in mortality—factors such as universal health coverage, women's education, and the effectiveness of national health systems. It is argued that these factors, which vary measurably at the country level, fundamentally shape the ability of individuals and communities to affect more proximate causes of child death such as malaria and diarrhoeal disease.

An alternate view has focused on exploring the importance of subnational variation in the distribution of disease. In the USA, studies on the geographical distribution of health care and mortality have been influential for targeting of resources and policy design. Similar studies in developing regions have shown the substantial variability in the distribution and changes of important health outcomes such HIV, malaria, and schistosomiasis—information that can then be used to improve the targeting of interventions. Nevertheless, the relative contribution of within-country and between-country differences in explaining under-5 mortality remains unknown. Improved understanding of the relative contribution of national and sub-national factors could provide insight into the drivers of mortality levels and declines in mortality, as well as improve the targeting of interventions to the areas where they are most needed.

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The Lancet Global Health
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Marshall Burke
Sam Heft-Neal
Eran Bendavid
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New spatial analysis shows that progress in combating child mortality has been highly uneven, even within countries where overall declines are substantial.

Stanford researchers have determined that more than 15 million children are living in high-mortality hotspots across 28 Sub-Saharan African countries, where death rates remain stubbornly high despite progress elsewhere within those countries.

The study, published online Oct. 25 in The Lancet Global Health, is the first to record and analyze local-level mortality variations across a large swath of Sub-Saharan Africa.

These hotspots may remain hidden even as many countries are on track to achieve one of the U.N. Sustainable Development Goals: reducing the mortality rate of children under 5 to 25 per 1,000 by 2030. National averages are typically used for tracking child mortality trends, allowing left-behind regions within countries to remain out of sight — until now.

The senior author of the study is Eran Bendavid, MD, MS, an assistant professor of medicine and core faculty member at Stanford Health Policy. The lead author is Marshall Burke, PhD, an assistant professor of Earth System Science and a fellow at the Freeman Spogli Institute’s Center on Food Security and the Environment.

Decline in under-5 mortality rate

The authors note that the ongoing decline in under-5 mortality worldwide ranks among the most significant public and population health successes of the past 30 years. Deaths of children under the age of 5 years have fallen from nearly 13 million a year in 1990 to fewer than 6 million a year in 2015, even as the world’s under-5 population grew by nearly 100 million children, according to the Institute for Health Metrics and Evaluation.

“However, the amount of variability underlying this broad global progress is substantial,” the authors wrote.

“Mortality numbers are typically tracked at the national level, with the assumption that national differences between countries, such as government spending on health, are what determine progress against mortality,” Bendavid said. “The goal of our work was to understand whether national-level mortality statistics were hiding important variation at the more local level — and then to use this information to shed light on broader mortality trends.”

The authors used data from 82 U.S. Agency for International Development surveys in 28 Sub-Saharan African countries, including information on the location and timing of 3.24 million births and 393,685 deaths of children under 5, to develop high-resolution spatial maps of under-5 mortality from the 1980s through the 2000s.

Using this database, the authors found that local-level factors, such as climate and malaria exposure, were predictive of overall patterns, while national-level factors were relatively poor predictors of child mortality.

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Temperature, malaria exposure, civil conflict

“We didn’t see jumps in mortality at country borders, which is what you’d expect if national differences really determined mortality,” said co-author Sam Heft-Neal, PhD, a postdoctoral scholar in Earth System Science. “But we saw a strong relationship between local-level factors and mortality.”

For example, he said, one standard deviation increase in temperature above the local average was related to a 16-percent higher child mortality rate. Local malaria exposure and recent civil conflict were also predictive of mortality.

The authors found that 23 percent of the children in their study countries live in mortality hotspots — places where mortality rates are not declining fast enough to meet the targets of the U.N. Sustainable Development Goals. The majority of these live in just two countries: Nigeria and the Democratic Republic of Congo. In only three countries do fewer than 5 percent of children live in hotspots: Benin, Namibia and Tanzania.

As part of the research, the authors have established a high-resolution mortality database with local-level mortality data spanning the last three decades to provide “new opportunities for a deeper understanding of the role that environmental, economic, or political conditions play in shaping mortality outcomes.”  The database, available at http://fsedata.stanford.edu, is an open-source tool for health and environmental researchers, child-health experts and policymakers.

“Our hope is that the creation of a high-resolution mortality database will provide other researchers new opportunities for deeper understanding of the role that environmental, economic or political conditions play in shaping mortality outcomes,” said Bendavid.  “These data could also improve the targeting of aid to areas where it is most needed.”

The research was supported by a grant from the Stanford Woods Institute for the Environment

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Sam Heft-Neal is a research fellow at the Center on Food Security and the Environment and in the Department of Earth System Science. Sam is working with Marshall Burke to identify the impacts of extreme climate events on food availability and childhood nutrition in Africa. Specifically, they are examining the impacts of climate induced food shocks on child health measures including child mortality rates. Sam’s previous work examined the non-linear relationship between agricultural productivity and the environment and its effects on human health and the economy. Sam holds a Ph.D. in Agricultural and Resource Economics from the University of California, Berkeley and a B.A. in Statistics and Economics from the same institution.

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