This dissertation is a collection of three separate essays on the health of women and children. In the first essay, I along with my co-authors, analyzed the impact of two large, national-level health policies (the Janani Suraksha Yojana (JSY) and the National Rural Health Mission (NRHM)) on maternal health outcomes (proportion of institutional deliveries) in India. We used data from the India Human Development Survey (IHDS) and found that the JSY and the NRHM had a greater impact on institutional deliveries in high-focus states. We also found that the conditions of the public health facilities, did not change after the implementation of the JSY and the NRHM. Finally, we found that adequacy of health facilities was not associated with the likelihood of mothers in high-focus states having an institutional delivery. In the second essay, I examined whether a key social determinant of health in South Asia- gender inequality, is associated with physical health outcomes among Indian women. I found that the gender inequality expressed as the gendered household practice of seclusion was negatively associated with body weight of Indian women. Further, I found that participation in all household decisions by women of the household was generally not associated with body weight outcomes. The association between gendered household practices and women’s body weight outcomes was generally similar among rural and urban Indian women. In the final essay, I examined whether perinatal food environments (FE), maternal gestational weight gain (GWG) and early childhood weight (ECW) outcomes are associated. I used data on mother-children dyads from the Early Childhood Longitudinal Study – Birth cohort (ECLS-B), Area Resource Files (ARF) and Current Business Practices (CBP). I found that maternal GWG was associated with ECW outcomes. I also found that measures of food environment were associated with ECW outcomes. Specifically, I found that having an additional full-service restaurant per one thousand population in the maternal perinatal county of residence was associated with lower Body Mass Index (BMI) among children at age two years. Finally, I found that GWG did not mediate the association between food environment and ECW outcomes.

Despite the benefits of antiretroviral therapy in treating HIV/AIDS, government responses have varied substantially, from provisions guaranteeing nearly universal access to insufficient provisions providing almost no access. This research seeks to specifically examine primary explanations, such as economic capacity, and emerging explanations, such as the role of electoral accountability and the presence of stigma, and the coordination between the epistemic community and political leadership as potential causes for the variance in the government provision. By controlling for state economic capacity, this research furthers the importance of examining other explanations for state response in light of a public health crisis. While electoral accountability and the role of stigma had marginal impacts, the level of scientific coordination and understanding among the states political leadership had perceptible impacts. This research also tests broader aspects of the political economy such as the role of state capacity and subsequent government crisis response.

Following the Second World War, the Food and Agriculture Organization (FAO) and the World Health Organization (WHO) teamed up to construct an international Codex Alimentarius (or “food code”) in 1962. Inspired by the work of its European predecessor, the Codex Europaeus, these two UN agencies assembled teams of health professionals, government civil servants, medical and scientific experts to draft food standards. Once ratified, the standards were distributed to governments for voluntary adoption and implementation. By the mid-1990s, the World Trade Organization (WTO) identified the Codex as a key reference point for scientific food standards. The role of science within this highly political and economic organization poses interesting questions about the process of knowledge production and the scientific expertise underpinning the food standards. Standards were constructed and contested according to the Codex twin goals of: (1) protecting public health, and (2) facilitating trade. One recent criticism of Codex is that these two aims are opposed, or that one is given primacy over the other, which results in protectionism. Bearing these themes in mind, in this dissertation I examine the relationship between the scientific and the ‘social’ elements embodied by the Codex food standards since its inception after the Second World War. I argue that these attempts to reach scientific standards represent an example of coproduction– one in which the natural and social orders are produced alongside each other. What follows from this central claim is an attempt to characterize the pre-WTO years of the Codex through a case study approach. The narrative begins with a description of the predecessor regional group the Codex europaeus, and then proceeds to key areas affecting human health: 1) food additives, 2) food hygiene, and 3) pesticides residues.

Though Argentine women have made marked advancements in terms of equality since the Latin American country’s return to democracy in the 1980s, they still face barriers to the full exercise of their sexual and reproductive rights in a number of arenas. For low-income women, the added dimension of poverty further erodes the ability to seek necessary services to maintain sexual and reproductive health. As a result, high rates of maternal mortality and adolescent pregnancy persist. Given the broad socioeconomic inequality among Argentine provinces, the policies created by Argentina’s government to address sexual and reproductive health lack widespread implementation and oversight. Furthermore, a strong opposition to these policies is in place, promoted by the heavy presence of the Catholic Church in Argentine institutions and society as well as deeply entrenched perceptions of motherhood. This study identifies the social, economic, legal, cultural, and political challenges that face the sexual and reproductive autonomy of Argentine women, evaluates the current policies in place to address them, and projects potential solutions for Argentina’s government, women’s movement, and NGOs.

Teaching in the field of public health needs to employ a global perspective to account for the fact that public health problems and solutions have global determinants and implications as well. International university partnerships can promote such a perspective through the strengthening of cooperation, exchange, and communication between academic institutions across national boundaries. As an example for such an academic network in the field of public health, we introduce the International Public Health Partnership—a collaboration between a university in Germany and universities in India, Turkey, and Nigeria. Formed in 2005, it facilitated the exchange of information, fostered discussion about the transferability of public health concepts, contributed to the structural development of the universities involved, and promoted an intercultural dialog through a combination of local and distance learning activities. Although well accepted by students and staff, different obstacles were encountered; these included limited external funding, scarce own financial, time and personnel resources, and diverging regulations and structures of degree programs at the partnership sites. In the present article, we share several lessons that we learned during our joint collaboration and provide recommendations for other universities that are involved in partnerships with institutions of higher education or are interested to initiate such collaborations.

Dyslipidemia is increasing among U.S. children, and the prevalence is highest among children with diabetes and obesity. Recently, vitamin D deficiency has been suggested as a possible dietary risk factor for dyslipidemia. Despite the high prevalence of vitamin D deficiency amongst children, virtually no studies have evaluated the association between vitamin D and dyslipidemia among children. We evaluated the vitamin D and dyslipidemia relationship among 240 children and adolescents aged 2 through 21 years who were outpatients of a pediatric endocrinology unit at a large tertiary care facility in Western Massachusetts from April 2008 to April 2010. Eligible children were those with either obesity and/or type 1 or 2 diabetes mellitus. A total of 17.4% of children had severe (<15.0 ng/ml) vitamin D deficiency, 19.2% had moderate (15.0-19.9 ng/ml) deficiency, 36.3% were insufficient (20.0-29.9 ng/ml), and 27.1% had normal (≥30.0 ng/ml) levels. A total of 28.8% of children had high total cholesterol (TC ≥180 mg/dL), 19.6% had high triglycerides (TG; <10years: ≥110 mg/dL, ≥10years: ≥130 mg/dL), 21.3% had low high density lipoprotein (HDL <40 mg/dL), and 6.7% had high low density lipoprotein (LDL ≥130 mg/dL). Moderate vitamin D deficiency was associated with increased risk of high TC (adjusted odds ratio [OR adj] = 2.9, 95% confidence interval (CI): 1.0, 8.8) compared to children with normal vitamin D levels. Severe vitamin D deficiency was associated with an increased risk of low HDL (OR adj = 3.5, 95% CI: 1.0-12.3) and high TG (OR adj = 11.7, 95% CI: 1.9, 70.3) compared to children with normal vitamin D levels. Children with moderate vitamin D deficiency had approximately 3-fold increased risk of high TC compared to children with normal vitamin D levels. In comparison to children with normal vitamin D levels, severe vitamin D deficiency was associated with a strong and significant increased risk of low HDL and high TG; with a significant dose-response relationship. Additionally, in linear regression analyses, we found that an increase in vitamin D deficiency was associated with a significant mean increase in all four measures of dyslipidemia. Vitamin D adequacy may reduce the risk of dyslipidemia in children.

<p>Malnutrition and Anemia in children continue to be major public health challenges in most developing countries, particularly in Africa. Malnutrition and Anemia pervade all aspects of their health, growth, cognitive and social development. They lead to irreversible and lifelong effects that prevent children from realising their full potential. This study was designed to examine the prevalence and determinants of malnutrition and anemia in children under 5 years of age in the Ghanaian population. This research is based on data from the Ghana Demographic and Health Survey (GDHS) 2008, obtained from the Ghana Statistical Service (GSS). The survey is an extensive survey conducted using a stratified, two-stage cluster sampling design. The GDHS data contains a wealth of information on health, demographic, as well as socio-economic factors but is underutilised due to the complexity of the survey data. This study therefore stands out as one of the few that use the GDHS to investigate aspects of child health in Ghana. In this study, we perform subgroup analysis by disaggregating the data by age and gender specific subgroups and then by place of residence and region. This was in order to identify sub level estimates as national estimates have a high tendency of concealing true values and deviations from general trends. Also, subgroup analysis is very significant especially for resource allocation so as to minimize the likelihood of missing the target populations. We investigated associations between the three measurements of malnutrition; stunting, underweight and wasting and anemia (assessed by haemoglobin concentration) and the various risk factors using chi-square test to examine bivariate associations and chi-square trend test to examine linear trends in association. We identified the following variables to be significantly associated with all forms of malnutrition and/or anemia: age of child, mother’s education, financial status and place of residence. Other factors that were identified to be associated with some form of malnutrition and/or anemia include duration of breastfeeding, source of drinking water, mother’s occupation and currently breastfeeding. In view of the high rate of malnutrition, approximately 36% (33.6−37.6) and the alarming prevalence of anemia, 78% (76.7 − 80.2) in children in Ghana, particularly among those less than 2 years old, and the grave consequences on their cognitive and behavioral development even in later years, there is an urgent need for effective and efficient public health interventions.</p> / Master of Science (MSc)

Although arsenic is naturally present in the environment, 99% of human exposure to arsenic is through ingestion. Throughout history, arsenic is known as “the king of poisons”; it is mutagenic, carcinogenic, and teratogenic. Even in smaller concentrations, it accumulates in the body and takes decades before any physical symptoms of arsenic poisoning shows. According to the World Health Organization (WHO), the safe concentration of arsenic in drinking water is 10 µg/L. However, this limit is often times ignored until it is decades too late and people begin showing symptoms of having been poisoned. This is the current situation for Vietnam, whose legal arsenic concentration limit is 50 µg/L, five times higher than the WHO guidelines. Groundwater in Vietnam was already naturally high in arsenic due to arsenic-rich soils releasing arsenic into groundwater. Then, in the past half century, with the use of arsenic-laden herbicides dispersed during the Vietnam War and subsequent industrial developments, the levels of bio-available arsenicals has dangerously spiked. With the proliferation of government-subsidized shallow tube-wells in the past two decades, shallow groundwater has become the primary source for drinking and irrigation water in Vietnam. This is a frightening trend, because this groundwater has arsenic concentrations up to 3050 µg/L, primarily in the +3 and +5 oxidation states, the most readily available oxidation states for bioaccumulation. This thesis argues that measures must be taken immediately to remedy the high concentration of arsenic in groundwater, which in Vietnam is the primary and, in some cases, the sole source of water for domestic consumption and agricultural production. Although there are numerous technologies available for treating arsenic in groundwater, not all of them are suited for Vietnam. By analyzing the historical, cultural, economic, and political parameters of Vietnam, several optimal treatments of groundwater for drinking water emerged as most recommended, a classification that is based on their local suitability, social acceptability, financial feasibility, and governmental support. Further research on irrigation water treatment is proposed due to the need for sustainable crop production, the safe ingestion of rice and vegetables, and the continued growth of Vietnam’s economy, which is heavily dependent on agriculture.

The purpose of this thesis is to prove the existence of the right to adequate healthcare through a critical analysis of the law of obligations, constitutional law and international law framed in the wider focal point of South African medical law. The Constitution only makes provision for the right to access to health care. Conclusively this thesis will have to establish a link between a minimum standard in health care and the Constitution. It is submitted that the most efficacious method of establishing this link is with the duty of care, which is intrinsically linked to the doctor-patient relationship. If a critical analysis of the doctor-patient relationship can establish a clear link between the duty of care and state liability then such a link can successfully be applied to the Constitution. If this link is transposed onto the Constitution, a critical evaluation of the rights in the Bill of Rights will then reveal the most applicable right that can house the right to an adequate standard of health care. Such an analysis is only part of the solution however. In order to make this right effective, the international body of medical laws must be critically analysed and juxtaposed against this adequate standard. This carries the dual purpose of adding normative content as well as determining the current state of South Africa’s obligations under international human rights law, and to what extent those obligations have been discharged. Finally, and most significantly, the right to adequate healthcare, as it was forged in the international legal analysis, will be transposed onto the current South African jurisprudence of socio-economic rights. This practical application will then be reflected onto the new National Health Care Insurance to show conclusively that the current governmental approach of effecting health care is wholly inoperable and will ultimately result in significant harm and extensive human rights violations. This is based on the government only considering access to health care sufficient to discharge its duties and being totally incapable of effectively managing its resources. The core outcome for this thesis is to prove the existence of the right to adequate healthcare. Secondary outcomes are tracing the history of medicine to illustrate the creation and evolution of the doctor-patient relationship, a critical analysis of the application of medical ethics to South African law of obligations, a critical analysis of the Constitution and its fundamentals, an exhaustive evaluation of South Africa’s duties and accomplishments under its international obligations and effectively applying the right to adequate healthcare which is diametrically opposed to the current course South Africa is taking to provide health care. / Dissertation (LLM)--University of Pretoria, 2012. / Public Law / unrestricted

Current research shows moderate alcohol consumption is associated with decreased risk of diabetes and excessive consumption or binge drinking can cause insulin resistance and diabetes. In 2010, diabetes was the seventh leading cause of death in the United Statesand was responsible for significant health complications: blindness, kidney failure, and limb amputations, and is a large national economic burden. Fasting blood glucose (FBG) is a tool used to help diagnose diabetes. Abnormally high FBG, ≥100 mg/dl, is indicative of diabetes and pre-diabetes. Few studies have observed diabetic prevalence among young adults or college students. Studying young adults can help provide added information about early risk factors for diabetes and pre-diabetes, facilitating public health efforts to stem the rising tide of the diabetes epidemic. This study aimed to research the associations between alcohol consumption (numbers of days alcohol consumed in the past month and binge alcohol consumption in the past month) and FBG in a college population as part of the FLASH cohort study. FBG levels were measured in 141 young adult participants and alcohol consumption was determined by self report. Other individual-level characteristics and potential confounding variables were also collected. The association between alcohol consumption and FBG followed a J-shaped curve whereby students who reported drinking 6-8 days within the last 30 days showed significantly lower FBG levels than those who did not drink and those who consumed alcohol on nine or more days (p=0.04). Binge drinking did not have a significant association with FBG (p=0.4). Sex and body mass index were also significantly associated with FBG. In conclusion, moderate frequency of alcohol consumption is found to have an inverse relationship with FBG and excessive drinking can reverse these effects.