Any given day, a billion people are vulnerable to be exploited due to a lack of food.

Following decades of improvements in access to food around the world, recent years have seen a reversal in progress, resulting in more than 820 million people going hungry in 2018, and of those 800 million being classified as chronically undernourished – costing the global economy an estimated $3.5 trillion per year (or $500 per individual). And this is not just a low-income country problem. Before the Covid-19 pandemic began, about 8% of the population in North America and Europe lacked regular access to nutritious and sufficient food. Sadly, access to food estimates show that food insecurity has likely doubled, if not tripled in some places around the world since the start of the global pandemic.
But it’s important to note that hunger isn't just going to bed one night with a stomach that growls. Lack of food determines how a child develops – physically, as well as mentally and emotionally. Lack of food determines the kinds of decisions that a parent must make – good and bad. Without knowing where meals on any given day or week will come from, families of all kinds are forced to make choices – and take risks – they otherwise would not.

According to Dr. Ambuj Jain (AJ), founder of Feed A Billion, “The key to any successful growth in society is empowering women and girls. But that cannot happen when they go hungry.” He points specifically to women and girls because of the vulnerability they face for exploitation. Adding, “The reasons that exploitation like trafficking happen is because of poverty and cultural issues, but the lack of consistent nutritious food is the core of poverty.”

What he paints is a picture that resonates with global health and medical experts as they face the Covid-19 pandemic. Not only are we dealing with the current challenges, but in fact, none of these challenges can be tackled when a most basic human need is not met. Further, the link between food security, fear and exploitation is such that one meal can remove uncertainty, changing the decisions made for an entire family, certainly keeping girls and women safer than without food.

​But when the world needs a billion meals, how do we scale during a pandemic?

The team at Feed A Billion believes they have a model that can be replicated and scaled. Although the organization is only four years old, the lessons learned are many, and both the positive and negative consequences of supplying food to girls have helped craft partnerships all over the world that manage to be structured, but adaptable to the demands of each geographic location, cultural norms and access to things like clean water. 

For example, one of their greatest successes is a partnership with YUWA in India, BlendHub and Happy Ratio. Essentially, this public-private partnership allows nutrition to be distributed faster, cheaper and use each dollar further upstream. Thus, instead of using funds to remove a child from forced labor, they are used to feed children so they are never sent away from their families to work in the first place. 

It’s a complementary system that piggybacks on current activities of trusted local organizations already in place. Essentially, Feed A Billion uses donations to leverage the strengths of others in the supply chain. In this partnership, Happy Ratio creates a protein-based formula that provides all the essential nutrients that a young person needs in a single serving. All the ingredients are blended and packaged by BlendHub, a food blending network with facilities all over the globe, who ensure the nutritional packets arrive to Feed A Billion’s local partners who meet girls where they are. In this case, YUWA distributes these meal replacement pouches to girls every morning when they play football (American soccer). 

According to the YUWA team, tens of thousands of girls (or more) may have been trafficked to date. They do however estimate that six in 10 girls have dropped out of school to become child brides. But the YUWA team claims that through their monitoring and evaluation metrics they have seen a complete turn-around in psychological and physical traits of the girls receiving nutrition regularly, and a trafficking rate of 0% in the 400+ girls they track.  

Franz Gastler, co-founder and Executive Director of YUWA asserts that by overcoming violence and exploitation, “Girls discover their self-worth. And when they do that, they are limitless.” Thus, his team is showing that access to nutrition leads not only to better physical development in girls, but subsequent improvements in schooling, social, emotional and mental health, and becomes a means of breaking generational poverty. 

The distribution model Feed A Billion uses in India can be replicated anywhere in the world with the right local partners AJ says. He cites the Feed A Billion work in Kenya and recent work in Atlanta – where they have already given over a million meals to Atlanta food banks.
In a time when the world is racing for a vaccine to fight a new virus, it’s clear that the solution to the public health and human rights crisis that is hunger is easily accessible, but ignored. Not only does a supply system like the one Feed A Billion and partners have crafted ease the issue of hunger, but it has the potential to do much more than that. When you pull the thread that connects vulnerability and exploitation, hunger is at the center.

“Nutritious food could just be the single most important factor for a better and healthy future for everyone, but particularly for girls and women around the world”, says AJ.

Alongside the Covid-19 pandemic and ongoing battles with cholera and measles, the Congo has now confirmed almost 80 new cases of Ebola. But what makes this 11th outbreak most frightening is the hotspots geographic proximity to Kinshasa, the Capitol of the country and home to more than 11 million people. The newest cases have been identified in Mbandaka (Équateur province), with an estimated 33 reported deaths in just the last few weeks.
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“The current Ebola outbreak is running into headwinds because cases are scattered across remote areas in dense rain forests. This makes for a costly response as ensuring that responders and supplies reach affected populations is extremely challenging,” explains WHO’s Regional Director for Africa Dr. Matshidiso Moeti. “Responding to Ebola in the midst of the ongoing Covid-19 pandemic is complex, but we must not let COVID-19 distract us from tackling other pressing health threats,” he warns.

However, with each day the likelihood Ebola will spread from one area to another, and internationally, grows. Not only because of continued violence in the region that has forced thousands to flee (often to other countries), but because of lack of access and reporting in remote regions. As the outbreak gains momentum, it has great potential to cross African borders like the Congo into Uganda, meaning further implications for other nations such as South Sudan and Rwanda cannot be ignored.

So what happens when a contagious disease with around a 50% fatality rate, incessant violence and distrust in the health system collide? The “perfect storm” for the spread of disease. Here’s what you need to know about the latest Ebola outbreak in the DRC and what the country’s Ministry of Health is dealing with to help prevent further spread of disease.

• There is a lack of trust in government that is driving unrest among the citizens and health care workers. Not only do many Congolese distrust their own government, but they distrust the health system associated with it, as well as the broader international organizations and NGOs. But this distrust, much like what the United States and other countries are seeing with Covid-19 misinformation and disinformation, has undermined local and international efforts to slow the spread.
• Like a growing number of viruses, Ebola is believed to cross from animals to humans, commonly affecting people and primates (monkeys, gorillas, and chimpanzees). Bats are believed to be the most likely source, carrying the virus and transmitting it to other animals, like monkeys and humans. Between humans, the virus spreads through direct contact with bodily fluids – both in those alive and from those who dead from the virus. 
• The incubation period for Ebola is between two and 21 days, with a mostly long incubation period. This means that those infected with Ebola might appear healthy during screening, and travel without knowledge of infection. As with any disease, tracking is near impossible when people do not stay in the same location, and likelihood of disease spread is greater – as is less interaction with health facilities and workers.
• The DRC has more than 500 “health zones,” difficult terrain, and extended areas without basic resources like clean water. The deadly virus can only be stopped if it’s properly tracked - meaning that those who are infected can be found, quarantined and even vaccinated. But given the extremely remote areas of the Congo without paved roads, the complications of so many disputed areas, limited electricity, and little contact with doctors, it can take days for people to come into contact with a health worker – and even longer to get any kind of necessary care. 
• However, the WHO contends almost 13,000 people have been vaccinated since the start of the 11th Ebola outbreak. According to new data, the experimental Ebola vaccines being used to try to contain the outbreak are protective 97.5% of the time. This gives great hope that with more funding and coordinated efforts (including rapid response testing and survivor research and support), the outbreak can be stopped before it resembles those of the past.
• According to the United Nations, more than 300,000 people have been displaced this month alone because of violence. There have also been hundreds of deaths and continued escalation of violence between groups that threated any health or diplomatic efforts.
• Violence against health workers has stymied efforts. Public Health efforts (usually through the work of community health workers) are vital for any success in the fight against Ebola. Health care workers throughout the region continue to face violence and infection, and have begun to demand security so they can do their jobs. Yet threats of strikes only seem to exacerbate fear, uncertainty and distrust in the system. Despite those challenges, community health workers have visited more than 40,000 households, and more than 273,000 people have been provided with health and safety information.
• While foreign aid is not the sole means of fighting this crisis, it has proven fundamental in assuring enough resources are available on the ground. Without additional resources, it’s impossible to have a steady supply of health care providers and equipment, keep vaccines in temperature-controlled environments, or get the needed people and necessities to the remote locations. On August 7th, the U.S. Agency for International Development (USAID) announced it is delivering $7.5 million in additional humanitarian assistance to the DRC for Ebola. However, the WHO is instrumental in directing the procurement and distribution of vaccines, testing facilities and on-the-ground expertise. And as of July 2020, President Trump notified the WHO that the U.S. would be withdrawing from membership.

 
Global health challenges are directly linked to national security. While for many in the Western world the Congo seems a long way away, Covid-19 has shown just how quickly a virus can spread without proper attention and resources. It has also highlighted for many just how important and difficult building trust and fighting bad information can be as it pertains to infectious diseases. The DRC’s 11th Ebola outbreak is a wakeup call for us all, and a reminder that we, along with the rest of the world, must avoid complacency.

In 2018, around 11% of U.S. households reported they were food insecure at some point per the U.S. Department of Agriculture (USDA) – meaning they were without reliable access to a sufficient amount of quality food. The percentage of households as of April 2020 that are deemed food insecure has been estimated between 22-38%. Thus, at minimum, the number of households that lack the resources for a stable food supply has doubled, and possibly tripled. The rates of food insecurity at present are higher than at any point since data collection began. 
Even more unsettling, according to Brookings, one survey concluded that more than 17% of mothers with children 12 and under reported that since the Covid-19 pandemic started, “the children in my household were not eating enough because we just couldn’t afford enough food.” These findings are part of a multi-survey initiative the uses validated questions from the USDA to understand trends.
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But lack of resources isn’t just about food itself, it’s about all the other associated and underlying issues that pertain to how we access quality food and who can afford it. For example, food insecure households are 47% more likely to visit an emergency room, and be admitted. Lack of access to nutritious food has been proven to lead to obesity, high blood pressure, heart disease, diabetes, and a myriad of other health problems. 

Food insecurity is also emotional, and the source of a significant amount of familial stress. For both adults and children, the fear associated with not knowing where meals will come from takes a toll on mental health. This includes increased reports of depressions, anxiety, and suicidal ideation. All of which are health care issues – despite the fact that food itself is not often thought of as health care.

However, research has linked programs such as SNAP (Supplemental Nutrition Assistance Program) with improved health outcomes and lower health care costs. The same can be said for the second largest anti-hunger effort in the U.S., the National School Lunch Program (second only to SMAP) that feeds nearly 30 million children every day. Or did before the Covid-19 pandemic. Thus, current benefits addressing food needs of our most vulnerable are not able to meet demand under current circumstances.

The same can be said for food banks as they struggle with increased demand since the onset of the pandemic. According to National Institute for Health Care Management (NIHCM) Foundation, 98% of food banks in America are reporting increased demand, with about 40% reporting immediate critical funding shortfalls. Feeding Americaasserts that there is “soaring demand” and “plummeting supply” as a direct result of the pandemic. They also contend that almost 70% of food banks are accepting and in need of volunteers to help out.

Given the deep rooted and complex challenges associated with supply and distribution of food, there is no quick policy fix. If schools reopen and parents go back to work, some of the insecurity can be filled, but there is no guarantee. Benefits can certainly be increased and distribution chains can be made more efficient, but the food security traumas created during Covid-19 are going to be felt for some time. And possibly exacerbated by a second wave of shutdowns. 

Volunteers are needed. Donations are needed. Funding is needed. And, looking out for your neighbor is vital. There are no individual solutions to this growing problem. It will literally take the village.

To learn more about food insecurity in the U.S., in your state, congressional district, and county, visit: Map the Meal Gap by Feeding America.

And if you or someone you know is currently struggling to feed loved ones, here are some programs and agency efforts that can be of assistance:
Meals on Wheels
Feeding America
World Food Program
The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

Over the past two weeks people have increasingly spent time at home, often turning to television series and movies to distract themselves from being in the same place for days on end. But as the Netflix series dry up and the scary, pandemic-based movies run out, many are turning to books as a means of entertainment and education. 

And with the growing awareness of public health, global health, and diseases there has been an interest in learning more about the history and incredible stories associated with some of the world’s greatest challenges and most inspiring stories.

When it comes to infectious disease and public health efforts, real life is often stranger - and more entertaining - than fiction. 

With that in mind (and numerous requests for recommendations), We set out to make a list of the books that will entertain, educate, and open up an entirely new world for those without a background in public health or infectious disease. This list is certainly not all-inclusive, and can in no way be ranked. For your sanity, it does not include textbooks or medical literature. The books listed are both enjoyable to read and leave the reader feeling like they know more about the world around them. Many are inspiring, despite the harsh realities and inequalities they present. And all are true stories, as told by those in the fight for better health.

Here are our top 20 recommendations for infectious disease and public health books to read while surviving an infectious disease pandemic:  
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1. The Ghost Map: The Story of London's Most Terrifying Epidemic - And How It Changed Science, Cities, and the Modern World
   By Steven Johnson
2. Parasite Rex: Inside the Bizarre World of Nature's Most Dangerous Creatures
   By Carl Zimmer
3. Mirage Of Health
   By Rene Dubos 
4. Beating Back the Devil: On the Front Lines with the Disease Detectives of the Epidemic Intelligence Service
   By Maryn McKenna
5. House On Fire: The Fight To Eradicate Smallpox 
   By William H. Foege
6. The Great Influenza: The Story of the Deadliest Pandemic in History 
   By John M. Barry
7. Spillover: Animal Infections and the Next Human Pandemic 
   By David Quammen
8. The Spirit Catches You And Then You Fall Down 
   By Anne Fadiman
9. To Repair The World 
   By Paul Farmer
10. Pale Rider: The Spanish Flu of 1918 and How It Changed the World 
    By Laura Spinney
11. Guns, Germs & Steel 
    By Jared Diamond
12. Virus Hunter: Thirty Years of Battling Hot Viruses Around the World 
    By CJ Peters and Mark Olshaker 
13. The Strategy of Preventive Medicine 
    By Geoffrey Rose
14. A Planet of Viruses 
    By Carl Zimmer 
15. Mud Creek Medicine: The Life Of Eula Hall and the Fight for Appalachia 
    By Kiran Bhatraju
16. Polio: An American Story 
    By David Oshinsky
17. The Fever: How Malaria Has Ruled Humankind For 500,000 Years 
    By Sonia Shah  
18. Polio: The Odyssey Of Eradication 
    By Thomas Abraham
19. The Fears of the Rich, The Needs of the Poor: My Years at the CDC 
    By William H. Foege
20. Big Chicken: The Incredible Story of How Antibiotics Created Modern Agriculture and Changed the Way the World Eats 
    By Maryn McKenna
21. When Germs Travel: Six Major Epidemics That Have Invaded America and the Fears They Have Unleashed
    By Howard Markel
22. Typhoid Mary: Captive to the Public’s Health
    By Judith Walzer Leavitt​

​For good measure, We’ve also included a few “escapist reads” that are more story-telling than public health, but leave you with a better understanding of the world during difficult times in human history as we battle epidemics – and one coloring book for those who have a more visual learning style. 

• Arrowsmith 
  By Sinclair Lewis
• Ship Fever 
  By Andrea Barrett
• The Infectious Disease Colouring Book: A Gruesome Colouring Therapy Adventure 
  By MR Nicholas Wright

Multiple times a day, every day, for most of your life you performed the act of washing your hands. And if you are like 95% of Americans, you’ve been doing it wrong. According to Michigan State University, only 5% of people actually wash their hands correctly. During cold and flu season this is nothing to make light of. 

The average person touches their face anywhere from fifteen to twenty-three times per hour. And, on average, only washes their hands about 10 times per day. This leaves hundreds of opportunities daily to transfer bacteria and viruses from work surfaces, home surfaces, and the people in our lives directly to our nose and mouth.
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So before you find yourself taking sick days from work or spreading germs to your loved one during the holidays, here are some top tips for how to limit germ exposure – and most importantly, the right way to wash your hands.

STEP 1: Thoroughly wet your hands with clean, running water. Then turn off the tap and apply soap.
STEP 2: Lather all parts of your hands by rubbing them together with the soap. Don't miss any spots. Lather the backs of your hands, between your fingers, and under your nails.
STEP 3: Scrub your hands for at least 20 seconds. Darting in and out doesn’t cut it. Need a timer to know how long 20 seconds is? Hum the “Happy Birthday” song from beginning to end twice.
STEP 4: Rinse your hands well under clean, running water.
STEP 5: Dry your hands using a clean towel or air dry them. Paper towels are recommended because of the act of wiping away germs. 

These five steps may seem simple enough, but 95% of people don’t thoroughly cover their hands in soap and don’t wash long enough to effectively kill germs. It’s important to wash all of your hands and spend at least 20 seconds on the task. But in addition, here are a few more tips and tricks for staying healthy.

• Stop Touching Yourself. It can be hard to break habits, but as often as you can try not to put your hands on your face. This will limit the opportunities you have for transferring bacteria and viruses to your nose and mouth.
• Hot water or cold water? According to the Food and Drug Administration it doesn’t matter. Water that is hot enough for us to handle isn’t hot enough to kill bacteria, so there is no benefit to using hot water over lukewarm or cold water. 
• Is hand sanitizer just as good? No. Soap and water is best. However, hand sanitizer is a decent alternative under certain circumstances when you don’t have soap and water available. 
• Hand Sanitizer has its own rules. Since it doesn't require water, it is an acceptable alternative when soap and water aren't available. But make sure your hand sanitizer contains at least 60% alcohol. Then Rub the gel over all the surfaces of your hands and fingers until your hands are dry.
• Don’t have soap or sanitizer? Wet wipes can be an alternative when you’re on the go. Winter is an ideal time to keep a pack with you for convenience. They can also be used to wipe surfaces you may touch or rest your things on.
• Always wash your hands BEFORE: Preparing food or eating, treating wounds or caring for a sick person, or inserting or removing contact lenses.
  
• Always wash your hands AFTER: Preparing food, using the toilet, changing a diaper or cleaning up a child who has used the toilet, touching an animal, animal feed or animal waste, blowing your nose, coughing or sneezing, treating wounds or caring for a sick person, handling garbage, and handling pet food or pet treats.

August is National Immunization Awareness Month. An annual observance held to highlight the importance of vaccinations for people of all ages. However, this year it feels a bit like an oxymoron, as certain high-income areas of the United States have vaccination rates on par with low-income countries around the world.

For example, until 2015 parents in California could elect to not vaccinate their children through what are called Non-medical Exemptions or Personal Belief Exemptions, whereby parents could be exempted from the traditional medical recommendations because of what they philosophically believe. Despite state-level changes, reports suggest parents in California are still opting at twice the rate as previous years from getting their children vaccinated. This has led to immunization rates in places like Santa Monica and Beverly Hills that are as low as the country of Chad and South Sudan.

According to the American Academy of Family Physicians, “The number of philosophical exemptions to vaccination has increased in two-thirds of the states that allow such exemptions. As a result, researchers suggest that these areas are becoming increasingly vulnerable to vaccine-preventable disease outbreaks.”

What this means is that Measles outbreaks and Whooping Cough, long eradicated from the U.S., are back. Clearly signaling a public health crisis.

Why Are Vaccination Rates Low?

Many point to the anti-vaxx movement in the U.S. and around the world for declining vaccination rates. And parents within that movement often note autism as the reason for avoiding vaccines for their children. However, this is despite study after study around the world, as well as statements by the CDC, indicating that vaccinations have no impact on developing autism.

That said, vaccinations are not perfect, and they sometimes do result in side effects like muscle pain, headaches, and in very rare cases allergic reactions. All of which need to be properly addressed by the medical community.

But the anti-vaxx movement is not the only thing at play when it comes to declining rates of immunity in the US. For example, the number of vaccines recommended by the CDC’s schedule for children entering school, has nearly tripled in the last decade. What that means is that the number of vaccines – often monovalent – or single doses that children need has increased. Consequently, the number of visits for parents, the number of shots, and therefore the costs have also increased. All making it more difficult to complete that schedule.

At the same time, providing vaccinations doesn’t pay well. Despite myths about doctors making money to push immunization shots on patients, on the doctor side of the equation providers have very little incentive to make vaccines a priority for their medical practices.
All these factors in tandem mean that we find ourselves in a public health crisis as we enter National Immunization Awareness Month in 2019. And the only way to solve this crisis is to use local, state and federal solutions together. As well as ensure that educational campaigns inform parents about the risks of not vaccinating.

At the end of the day, we all have to come together to get vaccination rates in the United States above 90%, in which herd immunity can protect children.
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• You can view, download, or print CDC resources to learn more about immunizations and vaccine-preventable diseases here.
• For parents wanting information or to make decisions on vaccinating their baby, please visit the American Academy of Pediatrics website.
• For the CDC’s child, adolescent and adult immunization schedules, go here.

When thinking about traumatic brain injuries (TBI), most people immediately conjure images of NFL players, car accidents or nasty falls. But there is a global public health epidemic  going completely unrecognized – and untreated: intimate partner violence (IPV). In fact, IPV is the most common form of violence against women in the world, with nearly 1 in 3 women age 15 or older experiencing physical or sexual IPV. And it occurs in all settings, amongst all socioeconomic, religious and cultural groups.

Shockingly, up to 90% of injuries sustained in IPV are to the head, face, and neck. And research has shown that 75% of women with a history of IPV sustained at least one partner-related TBI and nearly 50% sustained repetitive TBIs. Thus, it is sadly not surprising that the women who experience IPV report symptoms consistent with those who have sustained TBIs, such as problems with, “concentration, memory, headaches, depression, anxiety, fatigue, and sleep.”

According to Eve Valera, Ph.D., “The number of women sustaining IPV-related TBIs dwarf the combined number of military and NFL TBIs or concussions reported. Using annual estimates of severe physical violence (totaling 3,200,000 women), about 1,600,000 women are estimated to sustain repetitive IPV-related TBIs in comparison to the total annual numbers of TBIs reported for the military and NFL (18,000 and 281, respectively).” While she suggests that we need to learn more about all of these cohorts, she points out that there are only two IPV/TBI imaging studies published, compared to the growing body of literature on TBI in athletes and military populations. And she should know, because both of those studies are hers.

But what makes this epidemic so difficult to understand, is much greater than just a lack of research on brain injuries. The truth is, there are a number of confounding factors at play including a general lack of research on women, and thus extreme underrepresentation of sex and gender differences that exist in brain injury. Add in that women who suffer from IPV are often unable to join research studies either due to fear of their partner, societal stigma associated with domestic violence, or simply a lack of resources in their daily lives.

While IPV affects all socioeconomic strata, according to the Prevention Institute there is a multifaceted set of risk factors including, poverty, social marginalization, weak social support networks, gender and cultural norms that promote harming others that frequently accompany IPV – making resources and access to care and research extremely limited. Additionally, because domestic violence happens behind closed doors, many individuals are unwilling to get involved in what happens in other people’s homes.

"If brain injury is the “invisible illness” of our time, then within this invisible injury, women have been the invisible patients,” says Katherine Snedaker, Founder and Executive Director of PINK Concussions. And the data support Snedaker’s statement. Even if some estimates were overstated, and as few as half (50%) of women who are exposed to IPV suffer TBIs, that would still be one in every eight women – the same statistic as breast cancer. Yet we have very little existing knowledge and research exploring this intersection.

Although very little research has been done on the repetitive damage of IPV and TBI, the number of research faculty around the world is growing. And like Lin Haag and Dr. Valera, their voices are gaining volume and their body of work is growing. There is also a growing awareness amongst the general population that invisible injuries – whether sustained on the battlefield or the sport field – are real and dangerous. And they can be life changing due to the cognitive, emotional and physical challenges associated with a TBI.  The next step is making this same realization for women survivors of IPV-related TBI.

Improvements in combating stigma and shame associated with IPV are also making small strides in communities of every religion, race and socioeconomic strata, as mental health efforts grow in number. This also includes training community workers, shelter employees and medical staff to recognize the signs of TBI earlier – and be looking for it in women who present with complaints about cognitive troubles or behavior associated with trauma. Attempting to do just that, Lin Haag, Dr. Colantonio and their team, are just completing a web-based toolkit educating frontline workers about TBI in women exposed to IPV. And, as Dr. Valera hopes, that the education of police forces and judges will make a significant difference in the lives of women and their children. “As first responders and judicial personnel learn to ask about and recognize IPV-related TBI, women’s behaviors may be interpreted in the context of a TBI that occurred behind closed doors rather than simply ‘strange’ or ‘uncooperative’. This interpretation will ultimately help women receive appropriate care and legal decisions.”
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All the women in this article are open to being contacted by those with questions about IPV, TBI or how to get involved in their research. If you’re a survivor of intimate partner violence, there is a 24/7 hotline and online resource where you can get help here.