THE FOOD ISSUE: WHAT WE GROW • WHAT WE EAT • WHAT WE SEEK

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SPECIAL THE MAGAZINE OF THE JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH WWW.JHSPH.EDU ISSUE 2014

WHAT DO YOU THINK? We want to know. We’ll be asking many of you to take part in an online survey about the magazine this spring. Stay tuned. MAGAZINE IDEAS? SUGGESTIONS? Contact editor Brian W. Simpson: 50% Total Recycled Fiber [email protected] 20% Post-consumer Fiber

NEXT ISSUE TEAM TELOMERE Think plastic caps at the end of shoelaces, and you’ll get a sense of how telomeres protect the gene-containing parts of chromosomes. Elizabeth Platz, Alan Meeker and colleagues are teasing secrets from telomeres that may change FOOD the way we understand cancer. IMAGE: Carol & Mike Werner / Science Source STOP AND THINK FARM FORK

1 Open Mike 14 Twilight of Antibiotics? 22 After the Famine The Green Revolution saved a billion lives. In-Depth Indiscriminate use of medicines Essay How a $5 gift in 1972 changed my Now, we need another one. in animal feed may lead us into a post- life—and others’ lives as well. penicillin age. By Keith West 6 Paradise Lost Essay Nineteen years ago, I decided to fight 16 Planting Health 24 The Himalayas’ Hidden Hunger for clean air, clean water and healthy food. Special Report With garden projects, public Feature Nepal is a nation of farmers and By Terry Spence health rekindles humanity’s need for seed. undernourished children. Can a novel study By Leah Eskin help save its next generation? 8 Beyond Protein Factories By Cathy Shufro Feature Our taste for cheap animal protein 18 Investigations has hurt the environment and human health. Is Briefs Water farming, amazing maize and 30 A Consuming Controversy there a better way? the dangers of city soil. In-Depth Is it bad to ingest a few hormone- By Mat Edelson tickling chemicals like BPA? By Maryalice Yakutchik Contents FORK FURTHER

32 Rx for the Future 38 No Fries with That 50 Investigations Special Report David Paige’s idea for Essay My transformation from fatty and fried Briefs Caffeinated waffles, meatless Mondays “prescribing appropriate foods” in 1969 now to lean and green. and obese children. helps half of all U.S. infants. By Desmond Flagg Interview by Karen Kruse Thomas 52 Four Big Issues 40 Food in the Desert What you need to know about food 34 Investigations Feature In a city where the deep fryer is king, as a human right, food allergies, GMOs Briefs The right folate intake, a diet for flies, what does it take to sell yogurt and salad? and the end of cheap food. and why budget cuts aren’t a SNAP. By Michael Yockel 55 AfterWords 46 Anatomy of a Famine My brief life as a fry cook. In-Depth Why did 250,000 Somalis die in 2010 and 2011? 55 Letters By Ken Stier Lyme disease; fake drugs; a fitting tribute and Public Health and Surgery, Part II. 48 Free Range Talk 56 Just Desserts Special Report CLF experts dish on Not quite sated with this issue? the future of food. Enjoy a lite ending. Interview by Brian W. Simpson

Cover and contents illustrations: Alex Nabaum

JOHNS HOPKINS PUBLIC HEALTH / FOOD 2014 3 ORPER SUSCIPIT LOBORPER SUSCIPIT LOB ORPERWHAT SUSCIPIT WE LOBORPERGROW ORPER SUSCIPIT LOBORPER FACTORY FARMS, ANTIBIOTIC RESISTANCE, GARDEN PROJECTS, AQUACULTURE, URBAN SOIL, 4 JOHNS HOPKINS PUBLIC HEALTHFARM / SPECIAL FOOD ISSUE 2014 SUPER MAIZE A TEFF JOB UNDER THE WARM ETHIOPIAN SUN, DAY LABORERS HARVEST THE ANCIENT GRAIN KNOWN AS TEFF FROM A SMALL SCRAP OF LAND NEAR ADDIS ABABA. THE CROP WILL FETCH A GOOD PRICE, SAYS FARMER GIRMA SIDA, BUT HE WORRIES HOW PEOPLE WILL BE ABLE TO AFFORD IT. PRICES HAVE SOARED 70 PERCENT IN THREE YEARS. (PHOTO: DAVID COLWELL)

ORPERFARM SUSCIPIT STRONG LOBORPER THE GLOBALORPER FARM SUSCIPIT MONO-CROPPINGLOBORPER ORPEROUR SUSCIPITHISTORY LOBORPER GROWING BOUNTYORPER SUSCIPITSOARING LOBORPER NEED 60% of the global About 12% of the Since the 1900s, some Agriculture began Global agricultural To meet the estimated population depends world’s land area 75% of crop diversity about 10,000 to 15,000 production has grown demand in 2050, on agriculture for is used for crop has been lost from years ago along the by about 2-4% per global agricultural their livelihoods. production. farmers’ fields. Tigris and Euphrates year over the last production will have rivers. 50 years. to increase its 2005 FARM 5 levels by 60%. SOURCES: UNFAO, National Geographic, UN 6 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 Paradise Lost

Nineteen years ago, I decided to fight for clean air, clean water and healthy food.

BY TERRY SPENCE ILLUSTRATION BY JOEL NAKAMURA

I farm 400 acres in Putnam County, Missouri. After 64 years of corporation’s plans in 1994, I traveled to North Carolina, which mostly working and tending the land, and a little fishing and hunting, pioneered CAFOs. I saw what they did to rural communities and I have a personal relationship with every acre of its beautiful rolling became determined to hold the corporation accountable for its actions. hills. I raise beef cattle and harvest hay for winter forage. My wife That summer, our township adopted a zoning ordinance requiring Linda tends her flower gardens of roses, hydrangeas, mums, asters and the CAFO to have setbacks from residences and post a security bond 62 different kinds of day lilies. We raised our two children here and to ensure the township wouldn’t be stuck with cleanup costs should hope to turn the land over to them one day. the operation cease. Shortly after, the corporation filed a $7.9 million Our farm was a paradise until our new neighbors moved in— lawsuit against the 256 residents of Lincoln Township. On April 1, 80,000 hogs. 1995, Willie Nelson traveled to Lincoln Township for a Farm Aid rally Everything changed in 1995 when Premium Standard Farms to defy the company’s injustice to our community. After the negative arrived and started putting up 72 buildings that would house the press, Premium Standard Farms dropped the lawsuit. Despite endless swine. Back then, we had no idea what concentrated animal feeding legal battles, consent decrees and environmental fines, the CAFO is operations (CAFOs) would mean to a rural community. We soon still just over the ridge from my property. learned. It displaced area farmers with a corporation that controls The only good thing from this experience is the work I’ve done every aspect of animal production. It divided our community between helping others. Before, I didn’t have a fax or a computer or even those who saw economic benefit and those concerned about public talk on the phone much. I just tended my farm. Now I work with health and environmental degradation. community groups, speak before government committees and give Feces and urine from so many animals confined to such a small talks on college campuses. Since 1999, I’ve worked with the Socially space inevitably pollutes streambeds and kills fish, but in many ways, Responsible Agricultural Project assisting people throughout the U.S. the odor is the worst insult. in organizing and defending their communities against CAFOs. The odor comes and goes according to the weather and time We’ve had many victories over the years because people have become of day. As the sun comes up, the smell rises up out of the valleys. Linda educated and fought for their communities. says it’s like the Angel of Death moving through Egypt in the movie Consumers have the misconception that factory-farmed The Ten Commandments. It snakes along like that. At its worst, it’s products are cheaper than those that are sustainably raised, but they’re unbearable to be outside. The stench causes heaviness in my chest, not considering the true costs in terms of water and air pollution, headaches and foul sinus drainage that can linger for days. There are human health, transportation, infrastructure and taxpayers subsidies. over 160 compounds in the particulate matter that enters our lungs If all costs were calculated, sustainable production would be just as with every breath. Sooner or later, it’s going to have an effect on affordable as factory farmed. our health. The bottom line is that there are three elements of all life: clean People have asked me, why don’t you just move? Only other air, clean water and healthy food. Everyone should understand that farmers would understand. A farm becomes a part of your life, the CAFO model destroys all of these. a heritage of the past and the present, something you dedicate your Here’s what I advise: Find a farmer and buy locally. life to and steward for the future. My roots are embedded on this farm, just like the plants. Terry Spence is a fourth-generation farmer and a consultant for the Nineteen years ago, I chose to fight. After hearing about the Socially Responsible Agricultural Project.

FARM 7 8 JOHNS HOPKINSOne PUBLIC Straw H EALTHFarm’s / SJoanPECIAL Norman FOOD I SSUEand Andrew2014 Norman check on a couple of their swine. BEYOND PROTEIN FACTORIES

Our taste for cheap meat has industrialized agriculture, drained natural resources and hurt our health. Story by Mat Edelson There has to be a better way. Photography by Chris FARMHartlove 9 t the 172-acre, family-run One Our taste for meat is literally production, most administered through feed Straw Farm, they know their or water.) “The majority of the antibiotics changing the American land- animals by name. There’s Easy, sold for use in food animals are the same ones Athe world’s most energetic duck- scape. The farm belt is mostly we use in clinical medicine,” says researcher chasing Labrador; Houdini the Spanish corn and soybeans for animal Keeve Nachman, PhD ’06, MHS ’01. goat; and Carl the Berkshire pig. “That’s a big part of the worry.” Numerous Considering he’ll eventually be feed—reducing biodiversity investigations at the Bloomberg School and somebody’s bacon, Carl is living the swine and diminishing the soil, says elsewhere are looking at the effect of all equivalent of the life of Riley. No pens for CLF’s Robert Lawrence. these antibiotics and their impact on human Carl; instead he bunks down with 20 of his health. (See page 14.) piggy buddies in a converted hay-strewn CAFO, as defined by EPA, processes at least In addition, significant ethical issues greenhouse, where huge hay bales on three 2,500 swine, 1,000 head of cattle, 125,000 involving animal treatment exist. In many sides serve as windbreaks. There’s not a single chickens or 10,000 sheep or lambs. Many cases, the animals live and/or meet their antibiotic coursing through Carl’s body. CAFOs are much larger. (See page 7.) This demise in appalling conditions. An October His feed is completely free of genetically industrial revolution of farming, which 2013 Washington Post story, based on USDA modified organisms. Heck, he even gets an mostly has taken place since the 1970s, data, found that instead of being euthanized, occasional beer (a Corona last time, no lime) allows roughly 40 U.S. poultry companies “nearly a million chickens and turkeys are with his slop. Carl will spend his final weeks to process 9 billion broiler chickens annually. unintentionally boiled alive each year in U.S. living off acorns, foraging in the near wild It also has made the retail price of slaughterhouses.” in woods adjoining the northern Maryland meat more affordable. In 2005, Americans Equally disturbing are so-called farm. Seen through a meat eater’s lens, it’s spent 2.1 percent of their annual income on gestation crates, intended to manage conflict an idyllic setting, as humane as animal red meat and poultry—half of what they between sows in the crowded conditions of production gets. spent in 1970, according to the Livestock CAFOs and to protect piglets from being But it begs two questions: Is this a Marketing Information Center. Reduced crushed by the sow. The crates, which viable alternative to the modern approach to prices helped Americans increase their red tightly confine sows, limit movement and industrial food animal production? If not, meat and poultry consumption by almost 14 all normal behaviors. Though they’re being do we need to revisit the demand for meat? percent from 1970 to 2005. banned in many countries, University of Many would see more affordable meat Missouri researchers found in 2012 that, in he numbers tell the tale. Most as a good thing; however, public health U.S. CAFOs handling 1,000 or more sows, people choose to eat meat. In a 2010 researchers say IFAP has immense hidden more than 80 percent of pregnant sows were paper, economists estimated that 2 costs. Environmentally, animal waste effects put in gestation crates. A Humane Society of Tpercent of the U.K. population was are enormous. IFAP-confined animals the United States report found that pregnant vegetarian. In the U.S., a 2012 Gallup poll produce more than three times as much swine were so confined that they “could not found that roughly 5 percent of Americans waste annually—500 million tons—as turn around.” The result? Distress, disease were vegetarians. A 2008 report funded by humans, according to the 2008 Pew report. and deformities. the Pew Charitable Trusts found that the Most surface water and shallow ground- average American ate 221 pounds of red meat water pollution by IFAP is through spraying o, absolutely not.” and poultry in 2005. For many societies, the waste on fields and excess manure application Robert Lawrence, MD, growth in wealth is reflected in the amount to croplands. The waste can overwhelm soil director of the Bloom- of meat they consume: According to U.N. capacity for absorption, polluting waterways “Nberg School’s Center for a Food and Agriculture Organization data, and creating algal blooms that suck the Livable Future (CLF), doesn’t mince words China’s rising middle class has caused oxygen out of water and create fish-killing when asked if IFAP is sustainable or even more than a 22-fold increase in yearly meat “dead zones.” Air pollution by ammonia desirable. production since 1980. It’s not the One and hydrogen sulfide, as well as by danders, The economic, environmental and Straw Farms of the world that have made endotoxins and dried manure, is also a major health factors that go into the large-scale this protein-palooza possible. Instead, it’s problem. production of animal protein often live the rise of industrial food animal production CAFO waste and CAFO-produced under the public’s radar. Lawrence and 25 (IFAP). meat put humans at risk for antibiotic- fellow CLF faculty researchers, students and IFAP is the assembly-line organizing resistant infections and other serious staff delve into everything from massive use principle driving so-called Big Ag, medical issues. IFAPs use a tremendous of arsenic and antibiotics in the industry to particularly the growth of concentrated amount of antibiotics prophylactically at the amount of energy it takes to produce a animal feeding operations (CAFOs). Unlike sub-therapeutic doses. (Some 80 percent pound of beef. (Hint: It’s awfully high.) tiny One Straw Farm’s score of pigs, a large of antibiotics in the U.S. are used in animal They’re looking at both supply and demand,

10 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 Is there a truly viable alternative to industrial food animal production?

FARM 11 Top: A swine operation in Saskatchewan. Bottom: One Straw Farm’s pigs. Just 40 U.S. poultry companies process 9 billion broiler chickens annually.

as well as changing American attitudes It’s not surprising that the commission Health program, shares a breakdown of toward meat consumption. concluded that, given “the dependence some of the inefficiencies inherent in IFAP. Lawrence has few friends in the meat on chemical inputs, energy and water, “We have to start with producing the animal industry. “The Pork Council would call many IFAP systems are not sustainable feed. It takes about four and a half pounds of me a rabid vegetarian,” he says. Though environmentally or economically.” feed to produce a pound of chicken, nine and he does occasionally eat meat—he calls Things haven’t improved over the past a half pounds to get a pound of pork, and 25 himself a “flexitarian”—Lawrence comes by five years. If anything, it’s only more obvious pounds of feed to get a pound of beef,” she his opinions honestly. He spent two and a how our taste for meat is literally changing says. The feed requires fertilizer, and that, half years as co-principal investigator of the the American landscape, says Lawrence. too, is problematic. 2008 Pew report titled “Putting Meat on the “Because of the demands of concentrated “One important source of the yield Table: Industrial Farm Animal Production animal production, most of our farm belt increases we’ve had is from the affordable in America.” has turned into production for animal phosphorus we’ve been able to put into The report came up with some startling feed rather than feed for humans. The vast our fertilizer,” says Neff. “The supply is conclusions. The industry had exploded on majority of the corn and soy crop goes to now a serious concern. We get most of the back of cheap energy, low-cost/high- feed animals,” says Lawrence. “With that our phosphorous from mines in just a few yield animal feed crops (notably corn) and has come loss of biodiversity and reliance on countries, and we could hit peak phosphorus free-flowing water—none of which will unsustainable commodities such as synthetic production in the near future. That’s a real last forever. Intense confinement of large fertilizer and pesticides. The carbon content concern for future food security.” numbers of animals, necessary for fast, in the soil is going down, and the incredibly Neff and her colleagues are also troubled mass processing, makes the transmission of rich microbial environment of healthy soil by the human toll of IFAP, which takes disease a distinct possibility, even to human has diminished.” many forms. A controversial USDA proposal handlers. Then there’s the animal waste, CLF researches these and other hidden would increase line speeds at chicken and which has the very real potential to foul air, costs of CAFOs. Roni Neff, director of turkey processing plants by more than 20 land and water, and harm people. CLF’s Food System Sustainability and Public percent. The agency says the proposal is

12 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 aimed at lowering the risk of pathogens the FDA and two drug companies to pull small producers. (Solutions to the problem, including salmonella, though some food three arsenic-based drugs off the market. however, do exist. Some small producers safety advocates say the move is more about have partnered in developing mobile systems saving the industry money than safeguarding t’s a given that food systems are under that process meat on site.) the public’s health. In an industry that Neff tremendous pressure to increase Nor have the feds been much help. says has been notorious for a high-injury production. The planet’s population is The six priority recommendations listed rate among workers, the additional line Iexpected to jump past 9 billion people in the Pew report on IFAP have not been speed could also prove dangerous. “You’re by 2050. Can meat production keep up? embraced by the current administration. doing repetitive motions, in often too hot Can we meet increasing demand without At an October 2013 event at the National or too cold temperatures, it’s slippery, you’re sacrificing the public’s health? What’s the Press Club, Lawrence bluntly summarized using sharp tools. You’re already doing it best way forward—wholesale abandonment? government efforts by saying, “There has pretty fast [140 chickens per minute under Or moderation of our impulse to eat meat? been an appalling lack of progress. The current regulations]. Then picture doing it Tough questions with immense failure to act by the USDA and FDA, the even faster. The risk for injuries can really ramifications. Some experts argue that lack of action or concern by the Congress, escalate,” she says. industrialization is necessary to meet and continued intransigence of the animal Others say the concerns about industry demand, but IFAP needs tighter oversight to agriculture industry have made all of our practices extend far beyond the workplace. safeguard the public’s health. problems worse.” Antibiotic-resistant bacteria shed by chickens Lawrence argues we have little choice In addition, Big Meat has big money being trucked to processing plants have been but to change production and demand. It’s a pushing against change. “It’s very tough,” detected. hard sell, he knows, one in which a body of admits Lawrence. “There’s a disinformation And Jay Graham, PhD ’07, MPH, public health research must be painstakingly campaign that has Americans believing the MBA, now an assistant professor at the built before analyzing current public policy only source of protein is animals.” George Washington University School of and advocating for change. Still, Lawrence notes that as the body Public Health, discovered that flies outside “These are sloooow disasters, the of research grows, the public’s attitude about homes near poultry farms carried harm- unsustainability of the high meat diet as the meat production and consumption may ful bacteria, including antibiotic-resistant population grows and we diminish our soil indeed be changing. CLF’s partnership in enterococci and staphylococci, matching resources and rely on fossil fuels [for fertilizer the 10-year-old Meatless Monday campaign, those in poultry waste. production]. We’re at peak oil production, aimed at getting Americans to consume 15 Low-dose antibiotics are not the only and the prices are going to go up at some percent less meat (as recommended by a group of problematic drugs in the food point,” says Lawrence. Surgeon General’s report), is on the radar chain. CLF’s Keeve Nachman has been Then, of course, there are the serious of half of all Americans and has received looking at arsenicals, which allegedly impacts on human health. Recent data extensive media coverage. (See page 50.) In increase a bird’s ability to absorb feed from scientists at the Harvard School of the U.K., the “meat-free Mondays” idea is nutrients while protecting the bird’s GI tract Public Health and the Cleveland Clinic, also catching on, and Lawrence points to a against common parasites. among others, have shown the direct links recent report from a food trends agency that “On the human health risk assessment of high meat consumption and increased predicted that U.K. vegetable consumption side, I had learned to recognize arsenic as a cardiovascular disease, diabetes and some would rise by 10 percent over the next two potent human carcinogen, and the idea that cancers. years. “Not that any of us can predict the feeding even a different form of arsenic to “All of these things, the average person future, but this offers an encouraging view of something we intended to eat sounded crazy, really struggles to get their arms around,” [consumption of] less meat and more plant- so I pursued it, ” says Nachman. says Lawrence. based foods,” says Lawrence. Nachman’s work initially put him into Still, Lawrence says he sees a world more Domestically, there’s also a movement direct conflict with the FDA. According to in balance with nature and the environment, by some states to eliminate those gestation Nachman, the agency wouldn’t test chicken where a diminishing taste for animal protein crates: Colorado, California, Maine, muscle for arsenic, claiming, “‘Muscle tissue can be met by smaller, diversified farms that and Rhode Island passed bills that will is more difficult to test. It gums up our mass also grow vegetables (like One Straw Farm). eventually ban such crates. Similar bans spectrometers,’ which is not a very good But the USDA, for one, isn’t sure. A 2012 passed previously in Michigan and Oregon. defense.” USDA report found that small producers of Taken as a whole, Lawrence says, “the Nachman took up the challenge. His livestock are having great difficulties finding cracks are appearing in a lot of ways,” in study published in Environmental Health small rendering and processing plants to the current model of meat consumption Perspectives in May 2013 showing that the use handle their animals. The control of slaughter and production. Whether it’s protecting the of arsenicals increased levels of carcinogenic facilities by the vertically integrated heavy- health of our hearts, our planet or our wallets, inorganic arsenic in chicken breast meat led hitters like Smithfield and Tyson, shuts out he says, moderation may be inevitable.

FARM 13 TWILIGHT OF ANTIBIOTICS? Indiscriminate use of precious medicines in animal feed may lead us into a post-penicillin age

The outbreak was predictable but still of the dangers of mass use of antibiotics in 1928, antibiotics have heralded a new era in a shock. Salmonella infections emerged industrial food animal production. humanity’s war against pathogens. They also in California in March 2013, eventually Antibiotic resistance has become such a have been used extensively. An estimated 190 spreading to 23 states. Although none of the widespread threat that The Lancet Infectious million doses of antibiotics are given to people 430 infected victims died, the illness was Diseases Commission recently warned: “… every year in U.S. hospitals, according to the unusually severe. Nearly 40 percent of those we are at the dawn of the postantibiotic era.” American College of Physicians (ACP). And infected required hospitalization. In October, In the U.S. alone, at least 2 million people up to half of all courses of antibiotics are the likely source was traced to people who acquire serious resistant infections every unnecessary because the patient has a cold or had consumed Foster Farms chickens. When year leading to 23,000 deaths, according other viral infection, according to ACP. laboratory analysis discovered that strains to recent CDC estimates. This epidemic of Misuse of antibiotics in clinical settings causing the infections were resistant to drug resistance is happening as the pipeline plays a role in antibiotic resistance, but the several commonly prescribed antibiotics, the of new antibiotics is dwindling. far greater contributor to the problem is the outbreak was seen as another demonstration Since the discovery of penicillin in massive use of antibiotics in animal feed, says

14 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 Ellen Silbergeld, PhD ’72, who investigated “I bought 10-pound bags carrying broiler chickens. Johns Hopkins the issue for 12 years and is writing a book PhD candidate Joan Casey (with co- on industrial farm animal production. of penicillin and tetracy- authors Frank Curriero, PhD, MA; Sara E. Eighty percent of antibiotics produced cline. When I tell my clinical Cosgrove, MD, MS; Keeve E. Nachman, in the U.S. are used in industrial agriculture, friends [this story], they PhD ’06, MHS ’01; and Brian S. Schwartz, according to the FDA. The sub-therapeutic MD, MS) recently used a large database doses of multiple types of antibiotics given begin to understand the of health records from a major HMO and to cattle, swine and chickens are leading magnitude of the problem.” plotted the location of patients’ homes to to multidrug resistance, says Silbergeld, an show that people with more exposure to Environmental Health Sciences professor. —Ellen Silbergeld large animal operations were at greater “Scientists who have looked at this issue have attributed this glacial movement to the risk of methicillin-resistant Staphylococcus concluded that the major contribution to the combined influence of the agricultural and aureus (MRSA) infection than those with problem is from animals because of the sheer pharmaceutical lobbies. less exposure. And Silbergeld and colleagues amounts of antibiotics used in agriculture.” Some of their tactics remind Silbergeld at Johns Hopkins’ Homewood campus are Silbergeld has seen the quantities used of the lead industry in the 1980s challenging seeking grant funding to collect evidence of firsthand. Told by an FDA official seven public health researchers to “link” lead in the history of antibiotic use in Eastern Shore years ago that it wasn’t possible to buy large gasoline with lead poisoning in a specific poultry operations by digging core samples quantities of antibiotic feed additives, she child. “When the government actually of Pocomoke River sediment. went to a feed store on Maryland’s Eastern removed and then banned lead in gasoline,” While European countries have Shore, home to many large poultry-raising she says, “levels of lead in U.S. children already forced the industry to abandon operations. When she inquired about declined in direct proportion to the antibiotics as growth promoters, the FDA purchasing feed additive antibiotics, she reduction. Similar findings with respect to in the U.S. has yet to require industry to was offered several types—in 10-, 25- and antimicrobials and drug resistance have been take action. New FDA guidelines released 50-pound bags. “I bought 10-pound bags of reported in several EU countries following in December 2013 ask pharmaceutical penicillin and tetracycline. When I tell my bans on use in feeds.” companies to voluntarily revise their labels clinical friends [this story], they begin to Following European bans of antibiotic so that antimicrobial drugs are reserved for understand the magnitude of the problem.” use in animal feed more than a decade ago, disease prevention and treatment under the Robert Lawrence, MD, director of the for example, data collected by academic, supervision of a veterinarian rather than Bloomberg School’s Center for a Livable government and industry scientists in several growth promotion. The FDA argues that Future, also finds current practices to be EU countries showed that rates of antibiotic the voluntary guidelines, which include a a serious concern. Never “have such large resistance isolated from bacteria in humans, three-year transition phase, will avoid years quantities of antibiotics been routinely used animals and food items decreased. of litigation. David Kessler, a former FDA at doses destined to accelerate the emergence The U.S. could learn from the commissioner, told The New York Times: of resistance,” Lawrence says. Europeans, Silbergeld says. “We collect such “This is the first significant step in dealing Early in his medical career, he says he poor data, and industry and government have with this important public health concern in TWILIGHT OF ANTIBIOTICS? could never have imagined such antibiotic so successfully resisted legislation to improve 20 years.” profligacy. “As new antibiotics were data collection, that it is possible for [both To many in public health, however, introduced, it was common practice to government and industry] to continue their the voluntary effort seems a weak response. mandate an infectious disease consultation claims that absence of evidence is evidence of CLF researchers say the new FDA policy will before releasing the new drug from the absence. The other problem is that we don’t still allow industrial food animal producers hospital pharmacy … to preserve the do anything with the data we do have. This to use the same low doses of antibiotics in effectiveness of the new antibiotic as long as is stupidity in place of science.” feeds by simply claiming they are for disease possible,” Lawrence says. Investigators frequently find themselves prevention rather than growth promotion. Yet, the FDA took a different approach stymied by industrial producers who deny The new guidelines are not “much when it came to their use in agriculture and researchers access to farms and production of a step forward,” says Nachman, a began approving antibiotics as additives to data, a problem known as the “ag gag.” CLF scientist. “Voluntary measures from animal feeds in 1946, says Silbergeld. But researchers like Silbergeld have been regulatory agencies are rarely seen as a While several countries in Europe innovative. She and colleagues Ana Rule, successful vehicle for making change. I’m have reduced or banned the practice of PhD ’05, MHS ’98, and Sean Evans, a glad the agency is paying attention; I’m just using antibiotics as growth promoters, PhD candidate, followed trucks moving saddened that the nature of their attention is U.S. regulators have done little in the last poultry to processing plants and detected not really going to result in a whole lot.” 40 years—only recently adding voluntary drug-resistant bacteria on surfaces and in guidelines. Public health scientists generally the air inside cars traveling behind trucks Illustration by Harvey Chan

FARM 15 BY LEAH ESKIN PLANTING HEALTH PHOTOS BY XXXXXXXX

Above: Salena Gonzales and Vernon Tenorio work on their garden. Right: Michael Martinez with his fave veggies.

With garden projects, public health rekindles humanity’s need for seed

Food grows in the ground. Yet it would dies. It’s something that resonates with the program called Edible School Garden, be easy to presume our meals spring from human spirit. It touches us deeply.” part of a larger nutrition program run by the grocery store, drive-through or quick And, Speakman hopes, gardens can CAIH under the guidance of “community mart. Can reconnecting with food at have a deep impact on communities that visioning” boards. For three years, students ground level improve public health? Can are returning, literally, to their roots. The have been working in the greenhouses, open- nurturing a garden also nurture healthy Santo Domingo Pueblo, who live along air classrooms and raised beds built into the habits in children, empower impoverished the Rio Grande in New Mexico, have a participating schools’ courtyards. They’re women and strengthen community bonds? long tradition of agriculture—one largely growing traditional crops including melon, Programs throughout the Bloomberg School abandoned to modern times, modern foods corn and chili peppers, and unfamiliar crops are finding out. and the modern epidemics of obesity and including okra, broccoli and spinach. “When you talk about gardens and diabetes. According to the CAIH, American “The goals are ultimately to reduce food, you touch a light in people, a hope, a Indian children have the highest rates of the incidence of obesity and diabetes,” says promise, a truth,” says Kristen Speakman, obesity and diabetes in the U.S. Speakman, who is based in Albuquerque. MA, MPH ’06, project manager at the Johns Now the Santo Domingo and two other “You have to start somewhere. This is Hopkins Center for American Indian Health Southwest tribal communities (the Navajo intuitive.” Though, in the public health (CAIH). “It’s the cycle of life. You start with Nation in Tuba City, Arizona, and the model, intuition isn’t sufficient. Indeed, a seed—like we all once were—you have to White Mountain Apache in eastern Arizona) it’s suspect. “So much harm has been done nourish it, then it sustains you, and then it are returning to that heritage through a with good intentions,” she says. “We want to

16 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 make sure this program is done right and is a stretch for congregations to say ‘this is effective.” important to us.’” Which is why the garden, with its Digging those values right into the science-based curriculum for third-, dirt is a way to get people to rethink the fourth- and fifth-graders and its component food they eat. “We hope what happens is of co-teaching by community elders, is that congregations and individuals become being rigorously evaluated before it can be better stewards of the earth, of food in “packaged” for other tribal communities. particular,” says Harris. Which might mean The team is looking for evidence of a congregation sponsors a CSA drop-off, improved knowledge about, attitude toward or an individual chooses locally grown, and behavior regarding healthy eating as well nutritious foods. as connection to traditional agriculture. “Gardens literally provide a source of Preliminary data looks promising. As food,” says CLF program officer Allison does the anecdotal. Some students have Last April, the students wanted to try Righter, MSPH ’12, RD. “But they also even transplanted their gardening skills growing cucumbers in socks tacked to connect people back to the process of from school to home. Kaitlin Mosley, senior walls. “It was desolate,” remembers Balch. growing food and caring for the land.” research program coordinator, says the “There were military helicopters overhead. In 2013 the program made 16 grants students seem more relaxed and attentive in We were surrounded by these beautiful to faith community gardens in Greater their outdoor classroom. “There was a boy at mountains. We’re filling socks with soil, and Baltimore, ranging from $122 to $750. Some one of the schools who was totally shut down, these women in burkas start making penis 40 gardens have flourished, including one at he wouldn’t talk to anyone,” says Speakman. jokes. There are some universal truths about the Weinberg Senior Village, where the beds “He came into the garden program and just women anywhere.” are raised to wheelchair-access height. Some blossomed. This program is healing work.” On the Darulaman Demonstration congregations shared their harvest with local Half a world away, in Kabul, Farm, Wilcox has carved out 100 plots. food banks. Afghanistan, public health workers are Once a week, 32 extension agents come One grant recipient is Epiphany healing the land itself. They’ve carved to learn drip irrigation, crop rotation, Episcopal Church, which sits on a winding out a 5,000-square-meter demonstration composting and other basic skills. Each takes street in suburban Timonium, Maryland. farm designed to grow one crop: women her lessons back to a Farmer Field School in At the far end of the parking lot, a statue extension agents. Participants in the Women an impoverished neighborhood, where she of Saint Francis of Assisi keeps watch over in Agriculture Training Center, part of the teaches 10 students. “They feel empowered,” a 40-by-20-foot garden plot. Here, members Afghanistan Agricultural Extension Project says Wilcox. “They’re not afraid to make an of the congregation—ages 2 to 82—spent funded by the USDA, in turn educate some extension visit and provide sound advice.” last summer tending tomatoes, green beans, of the country’s most vulnerable women. The Students in the Field Schools are now sunflowers and zucchini. program focuses on those who are widowed, tending their own kitchen gardens, growing The process was simple: “We digged divorced or abandoned with a goal of lettuce, tomatoes and beets in the walled the hole,” says 4-year-old Taryn Heist. “We improving food security, says Sophia Wilcox enclaves behind their homes. For women planted the seed and covered it up.” of the University of Maryland. Malnutrition who are often restricted from leaving home Then magic happened. Daycare is a severe problem in Afghanistan—one that and from marketing their crops, it’s a direct students watched over the sprouts during the afflicts 70 percent of the country’s children, route to improving family nutrition. And week. Sunday school students watered them she says. for those who can sell informally in the on weekends. One summer Sunday, in the The obstacles are formidable. The soil is neighborhood, it’s a way to earn money. middle of worship, a 7-year-old burst into the clay-heavy and nutrient-poor. Clean water is Gardens are sprouting up closer to sanctuary lugging a huge yellow squash. Rev. scarce. Many of the students cannot read or Baltimore as well. The Center for a Livable Kristofer Lindh-Payne paused to set the prize count. But they are eager to learn. Future (CLF) is in its fifth year of seeding on the altar. “We used games and activities that are gardens through the Baltimore Food and “It gave our congregation the very visual, no written words,” says Christie Faith Project. opportunity to grow together,” says Balch, an MPH student at the Bloomberg “In faith groups pretty much across Lindh-Payne. “To literally grow food and School who has taught gardening on three the board—whether it be Christian, Jewish, to grow in relationship with each other and trips to Afghanistan. “They loved it. In the Muslim or Buddhist—care for the earth, care with God.” final test they had to teach a lesson to the rest for your neighbor is going to be included,” of the group. They rocked it.” says Darriel Harris, program officer for the By Leah Eskin Some lessons easily crossed borders. Baltimore Food and Faith Project. “It’s not Photos by Kaitlin Mosley

FARM 17 FARM INVESTIGATIONS

Water Farming From Staple to Lifesaver If Dave Love has his way, we’ll all be eating He also has been working with PhD From breakfast porridge to nshima at Swiss chard and cucumbers fertilized by fish candidate and CLF Lerner Fellow Ben Davis dinner, the typical Zambian family meal rather than by synthetic chemicals. on a project that examines the relationship often includes maize. In the summer of 2012, Love, PhD, between land use, water quality and oyster Now, Bloomberg School researchers are an assistant scientist in the Bloomberg food safety in the Chesapeake Bay. Davis, investigating how to turn this staple into a School’s Center for a Livable Future, finished the recipient of the first Aquaculture, Public lifesaver. They are exploring the efficacy of a constructing an experimental aquaponics Health and the Environment Research Grant new type of maize bred to provide as much greenhouse at Baltimore’s Cylburn from CLF, has been collecting data on water as 15 times the vitamin A found in standard Arboretum. It uses a combination of contaminants, oyster diseases and land use varieties grown in Zambia today. aquaculture (fish farming) and hydroponics throughout the Bay to create an accessible Earlier studies pioneered by Dean (soilless plant farming). The project geographic information system (GIS). Emeritus Alfred Sommer, MD, MHS ’73, demonstrates how such a system could be As more aquaculture businesses sprout and colleagues at the School have established employed for raising crops and fish in an along the Bay, the water quality where that this one nutrient, vitamin A, could economically and ecologically sound way. aquafarms are sited becomes an issue that reduce childhood mortality in at-risk In the 1,200-square-foot greenhouse, could affect public health. “The reason we’re populations by 23 to 34 percent and prevent tilapia swim in fish tanks while edible interested in food safety from an ecological afflictions like xerophthalmia, which can plants are raised hydroponically in nearby respect is that oysters filter the water and lead to blindness. tanks. The 4,000-gallon system circulates store what they filter,” says Davis, who The new variety is known as orange water from tilapia, to plants and back. The notes that elevated levels of bacteria, like maize for the distinct hue of its kernels—a plants scrub excess nutrients from the water, fecal coliform from farm runoff, have been departure from the white or yellow familiar cleaning it for the fish. measured in some areas of the Chesapeake. to most. This new maize is not genetically “Aquaponics combines multiple species “If there’s anything we don’t want to have in modified, however, but rather biofortified—a at different levels of the food chain, and that’s the water, we probably don’t want it in the hybrid carefully crossbred to maximize each really exciting,” says Love, whose team sells oysters.” kernel’s pro-vitamin A carotenoids, which whatever it harvests through city farmers’ “Scientists have long studied the can be converted to vitamin A in the body. markets. “That’s how I think agriculture epidemiology of oyster-borne diseases,” says (Genetically modified foods are banned in should work. It’s mimicking natural systems, Love, “but Ben brings a new perspective and many countries.) and if we can replicate that in a controlled mapping tools to answer the question: What The study included approximately environment—the greenhouse—then we’re makes an oyster safe to farm and eat?” 1,000 Zambian children ages 5 to 8 years doing a good thing.” —Joe Sugarman split into two groups. One group received

18 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 FARM INVESTIGATIONS

From Staple to Lifesaver Growing Food in City Soil regular meals of biofortified maize. The It’s an increasingly common sight in In Baltimore and other urban settings, second received conventional white maize. neighborhoods in Baltimore, Detroit and the most notorious soil contaminant is lead. The study was conducted in the central other American cities: Residents have But that is only the beginning: Arsenic, agricultural district of Mkushi, where maize reclaimed abandoned lots by planting cadmium, cleaning solvents and many other is the primary energy source for children. gardens. Those projects have been praised contaminants have been found in soil in The researchers measured blood levels of for building social solidarity and improving various parts of the city. CLF’s Maryland vitamin A to assess the efficacy of the maize. local access to fresh produce, among other Food System Map team collaborated with With the data-gathering phases complete, benefits. the study authors on an online map of the team hopes to publish results soon. But planting urban gardens is not environmental hotspots in Baltimore. “Maize is the dominant staple in without risks. Today’s vacant lot may have Unfortunately for community gar- Zambia, especially among the rural poor. been yesterday’s dry-cleaning operation, deners, soil tests can be limited in scope. It’s a perfect delivery mechanism for vitamin aluminum factory or bus depot. “Gardeners “The tests that are typically available only A,” says Amanda Palmer, PhD ’11, MHS may not know what sorts of contaminants include a few chemicals and may not tell the ’06, an assistant scientist at the Bloomberg are there or how to test for them,” says Brent whole story,” says Keeve E. Nachman, PhD School who is overseeing field operations of F. Kim, MHS ’08, a program officer at the ’06, MHS ’01, director of the CLF’s Food the study. The study’s principal investigator Center for a Livable Future (CLF). With Production and Public Health Program and is Keith P. West Jr., DrPH ’87, MPH ’79, colleagues from the School and Baltimore’s principal investigator on the project. director of the Center for Human Nutrition Community Greening Resource Network, While the researchers note that the risks at the School. Kim recently conducted a study of what of contaminated soils should not be taken In Zambia, existing vitamin A community gardeners know and believe lightly, they emphasize the importance of not supplementation efforts include capsules about the risks of planting in urban soil. They deterring people from gardening. “Overall, given twice a year and fortified sugar. found that gardeners have some awareness participating in community gardening is a The capsule form, however, does little to of specific dangers, but often have a spotty very healthy activity, one that benefits not address the underlying dietary inadequacy. understanding of how to reduce exposure. just gardeners but their neighborhoods and Meanwhile, less than 20 percent of sugar Many overestimate the effectiveness of the city as well,” says Melissa N. Poulsen, in rural homes is properly fortified. Orange using raised beds, for example, and may be MPH, a PhD candidate at the Bloomberg maize would complement both of these unaware of important practices such as not School and co-author on the study. “We strategies. planting next to buildings that may shed want to encourage people to garden. We just “Orange maize could really transform old paint. The study was published in PLOS want them to do so safely.” lives,” Palmer says. —Andrew Myers ONE in February. —David Glenn

FARM 1919 what ORPER SUSCIPIT LOBORPER SUSCIPIT LOB WHATORPER WE SUSCIPIT EAT LOBORPER ORPER SUSCIPIT LOBORPER AFTER FAMINE, HIMALAYAN HUNGER, ENDOCRINE DISRUPTERS, WIC STARTER, A FLY DIET, FOLATE FOR ALL 20 JOHNS HOPKINS PUBLIC HEALTHFORK / SPECIAL FOOD ISSUE 2014 UGALI, YUM! IT’S TIME TO EAT AT ST. MONICA LODWAR GIRLS PRIMARY SCHOOL IN TURKANA PROVINCE, KENYA. THE GIRLS ARE SEEKING BOWLS OF UGALI, A MAIZE PORRIDGE THAT IS A STAPLE FOOD IN MANY AFRICAN COUNTRIES WHERE IT IS KNOWN AS POSHO, NSHIMA AND BY OTHER NAMES. (PHOTO: SHEHZAD NOORANI)

ORPERACRES SUSCIPIT OF PIZZA LOBORPER VITAMIN POWERORPER SUSCIPIT HUNGERLOBORPER KILLS ORPERHUNGRY SUSCIPIT WORLD LOBORPER FOODBORNEORPER ILLNESS SUSCIPITGLOBAL GAINS Americans eat ap- E.V. McCollum, a fac- Poor nutrition causes 842 million people in Each year, about 48 Number of over- proximately 100 acres ulty member from 1917 nearly half of deaths the world do not have million Americans weight/obese adults of pizza each day, or to 1944, discovered in children under 5— enough to eat. This get sick, 128,000 are in developing nations 350 slices per second. vitamins A and D. 3.1 million children number has fallen by hospitalized, and rose from 250 million each year. 17 percent since 1990. 3,000 die of foodborne in 1980 to 904 million FORK 21 diseases. in 2008. SOURCES: WFP, Agriculture Council of America, CDC, WHO, ODI 22 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 After the Famine

How a $5 gift in 1972 changed my life— and others’ lives as well

BY KEITH WEST ILLUSTRATION BY JOEL NAKAMURA

Human history is full of famine. Bangladesh aligned with our military’s expanding role to help solve The Irish famine, the Ukraine famine, the Chinese famines… nutrition problems around the world. countless famines over the millennia. Yet, when I landed in Bangladesh What I encountered in Bangladesh changed my views about in December 1974 and saw people starving to death, it was surreal. nutrition and my life. I visited Concern’s feeding and food-for-work This was not how human society is supposed to be. programs in vast encampments near Dhaka. I saw people eat famine I was, at the time, a U.S. Army major and registered dietitian on foods—roots, barks, plants, flowers and leaves—and spent time with a brief leave to work with Concern. I knew about food, nutrition and amputees as they prepared meals at the Sher E Bangla Hospital. I left health, and could surely help, I thought. Then I realized how very with a question pounding at me: Now that I’ve seen it, what do I do little I knew. about it? I finished my tour of duty and joined Concern in Bangladesh Modern famines are complex and related to a host of interlocking to do surveys, train staff and set up food-for-work programs that events like crop failures, food system and market failures, civil brought dignity with critical sustenance. disruption, unaccountable governance and conflict—all superimposed I’ve been going to Bangladesh ever since. The country has on already fragile states. Many people perish but some actually benefit. changed in many ways for the better. The nutrition priorities have The poor sell everything they have cheap. The rich buy, cheap. also evolved. The Hopkins-Bangladeshi research project JiVitA, Prior to my 1974 arrival in Dhaka, rumors that the rice crop begun in 2000, now focuses on quality of diet, food security and would fail had set off speculative hoarding. This caused soaring food protecting each generation’s “human capital.” For example, a poor prices and, for the poorest masses, starvation and migration. That quality diet can lead to micronutrient deficiencies that thwart health crop did not fail, but by the time I arrived the damage was done. I was in pregnancy, impair child growth and development, and potentially not prepared for what I saw: a mass of humanity, outside the plane, increase risks of chronic disease. Through our rural research network inside the airport, on the grounds everywhere. They had no reason to of 800 staff covering more than 600,000 people, we work with be there other than to escape hell. I made my way slowly along streets Bangladeshi institutions to develop and test locally produced food teeming with people to the Concern house in Dhaka. supplements as well as assess cognitive capacity and disorders that Unprepared as I was, I knew I was meant to be there. As a child, may have nutritional underpinnings. We keep the next generation in I had pondered over maps while my mom would sigh, “Thursday’s mind, knowing that women need good nutrition not only when they child has far to go.” are pregnant, but even before they start to conceive children, as they I gravitated to nutrition at Drexel University because my older go through puberty. brother had studied it and then joined the Army because a recruiter That seemingly insignificant $5 check I sent off in 1972 had been looking for food and nutrition majors. turned out to be a rich investment in my future and my ability to While based at Fort Dix’s Walson Army Hospital, I was moved work at improving sustenance in a country to which I am forever by a short news article about amputee freedom fighters in Dhaka indebted. being retrained for careers in food service. So I sent a $5 donation to Concern and received an invitation to visit. Knowing I had to make Keith P. West Jr., DrPH ’86, MPH ’79, RD, the George G. Graham that journey someday, I took a posting on Okinawa to get nearer to Professor of Infant and Child Nutrition, directs JiVitA, a collaborative my destination. Finally, I convinced my commanding officer that research project on maternal and child micronutrient deficiency attending a dairy conference in India and working with Concern in prevention in northeastern Bangladesh.

FORK 23 24 JOHNS HTerracedOPKINS P UBLICrice fields HEALTH feed / S PECIALthe people FOOD of I SSUESitapur 2014 and nearby villages in the hills of midwestern Nepal. Planting begins when the monsoon rains arrive. THE HIMALAYAS’ HIDDEN HUNGER

In a nation of farmers, undernutrition leaves children

stunted and at lifelong risk. Can a novel study Story and Photography Terraced rice fields feed the people of Sitapur and nearby villages in the hills of midwestern Nepal. Planting begins when the monsoon rains arrive. help save Nepal’s next generation? by Cathy Shufro FORK 25 The country cut both child and maternal border, in small towns in the hills (including mortality in half in the past 10 years despite Sitapur) and in high-altitude villages near ranking 157th out of 187 countries in the UN Mount Everest—one of them was a five-day Human Development Index, and despite trek from the nearest road. enduring a decade of political upheaval “It’s a little breathtaking,” says Keith that only ended in 2006. This nation of 30 West, DrPH ’86, MPH ’79, RD, director of million also is a global model for preventing the Bloomberg School’s Center for Human child deaths and blindness by giving vitamin Nutrition. West is the School’s principal A supplements to preschool children. investigator for the study, called PoSHAN, So why has undernutrition proved an acronym that means “good nutrition” so intractable here? Why aren’t people in Nepali. The $15 million, five-year chool has let out for the day in the well fed in a country where 70 percent of USAID grant is led by PoSHAN principal Himalayan hill town of Sitapur. the workforce is engaged in farming—in investigator Patrick Webb, PhD, of Tufts. Children in blue-and-white growing food? The aim of the Bloomberg School’s team Suniforms flood out of the school To answer that question, researchers is to apply public health methodologies to courtyard onto the only road running from the Bloomberg School and Tufts mapping the complex interactions between through this town in midwestern Nepal. A University’s Friedman School of Nutrition nourishment and what’s grown, what’s boy runs joyously, his backpack bouncing. A have launched an ambitious nationwide eaten and what efforts have been made to girl with black braids leads her little brother study that pays attention not only to diet improve nutrition, health and farming. The up the steep path to the neighboring village. but also to a broad range of other factors Tufts team, meanwhile, is analyzing how A few boys send a volleyball back and forth that influence nourishment, including well policies and programs for improving over a net strung to a house. The children’s agriculture. agriculture and nutrition translate into voices overlay the faint shouts of men calling In May 2013, 66 interviewers and action as they move from Kathmandu to to their oxen in emerald rice fields in the 30 supervisors and research assistants towns and villages. valley far below. completed the first of three annual surveys. The interdisciplinary focus of the These schoolchildren look like kids In 60 representative towns and villages and research makes the study unusual, according anywhere exulting in release from the three neighborhoods in the Nepali capital to West. “There’s a deep sense that agriculture classroom. But on this July afternoon, their of Kathmandu, interviewers talked to any and nutrition have not talked to each other familiar exuberance deceives. It’s likely woman who had a child under 5 or who had over the decades, and the centuries,” he says. that nearly half these children have already recently married. They also interviewed the Governments, nonprofits and suffered irreparable harm. head of each woman’s household (generally community groups have repeatedly tried The cause is chronic malnutrition. her husband or father-in-law). to address malnutrition by improving Some 41 percent of Nepali children In 4,288 households across Nepal, farming. And yet no one really knows what, under 5 are moderately or severely stunted, interviewers asked a broad range of questions if anything, has worked. When Webb and a according to Nepal’s 2011 national health about factors that can affect nutrition colleague studied 10 reviews that had closely survey. Long-term undernutrition coupled for young children and their pregnant or examined 250 of the strongest studies, they with recurrent infections and other nursing mothers: what children and their found all 10 reviews concluded that the consequences of poverty has caused them mothers eat, and whether they have enough; studies provided little or no evidence that to be stunted—that is, markedly shorter which foods families grow, and which agricultural interventions improve nutrition. than well-nourished children of the same they buy. When an interviewer asked, for The reviewers found that most of the studies age. Short stature is only the outward instance, how much rice a mother and her were badly designed or poorly analyzed. manifestation of how malnutrition damages children under 5 ate during the past week, “There are decades of claims that children. Long-standing undernutrition the interviewer also asked if the household say, ‘Do this, and we’ll improve nutrition,’ thwarts the development of their brains grew rice, if they owned the land where it was but actually very, very few studies have and bodies, undermining their chances to grown, and whether they ever got so hungry succeeded in documenting it,” says Webb. prosper as adults. that they ate seeds intended for planting the “It’s astonishing.” There’s no reason to think that the next crop. The stakes are high. Globally, children of Sitapur have fared any better. The survey teams raced to finish undernutrition means death for 3.1 million data collection before the midsummer children younger than 5 every year. It caused HUNGER IN A NATION OF FARMS monsoons made travel difficult. They visited 45 percent of all child deaths in 2011. Nepal’s slow progress against stunting communities in all three ecological zones— Yet the factors affecting nutrition contrasts with other health advances. in the southern plains near the Indian are numerous and difficult to isolate. For

26 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 Undernutrition causes stunting and increases the risk of death.

FORK 27 A girl in the village of Durkatta lingers outside while a PoSHAN enumerator talks with the head of the household. Stunting is an intergenerational issue.

Peeking from the doorway, a child listens in on Sabina Maharjan’s PoSHAN interview.

instance, a family might provide more protein project scientist Swetha Manohar, MSPH ironically, of being overweight; genes are for their children if they raised chickens. But ’11, RD, and colleagues had begun analyzing made “thriftier” by long-standing privation that gain would be undermined if chicken the data. so that the body maximizes fat storage. droppings caused recurrent diarrhea in the In part, they were looking for stunting. The 1,000 days that begin with children. Or, consider a family that chose Everywhere they’d gone, the survey teams conception are the most crucial: By age 2, to raise poultry rather than plant a garden. had weighed and measured children, and stunting is largely irreversible. After that age, They would not have their own vegetables to those numbers would show the prevalence of children can’t catch up, says International eat but they might make enough money by stunting. Health Professor Robert E. Black, MD, selling eggs or meat to buy a mobile phone Stunting signals trouble: It results MPH, a veteran health and nutrition that would make a family business more from poor nutrition over the long term, researcher who directs the Institute for competitive, increase income and allow them not just small setbacks caused by a recent International Programs. to buy vegetables. The linkages are complex. food shortage or a child’s transient illness. And stunting is insidious. In societies With this study, says West, “we’re Stunting embodies chronic gaps between where stunting is pervasive, it may go embracing the complexity.” nutrition and agriculture. It is also important unnoticed, says Black, adding “everyone because it costs a child so much. For children looks small, so it looks normal. It’s the usual SHORTER STATURE, SHORTER LIVES who survive, the deprivations and insults that pattern of growth.” Though it may appear By September 2013, piles of completed cause stunting not only hinder physical and to be the norm, it substantially increases the surveys were stacked, waist-high, in an office intellectual development but also increase risk of death. Nearly 15 percent of under-5 in Kathmandu. There, Bloomberg School the lifetime risk of degenerative diseases and, deaths stem from stunting.

28 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 Damage can begin at conception if the outdoors near the house, in an open field, in mother herself is stunted or underweight. She a river? Do animals live inside the house? is more likely to give birth to a baby that is After answering a few questions, the small for its gestational age. Restricted fetal man darts inside the house and returns with growth accounts for 20 percent of stunting a topi, a traditional cloth hat commonly worldwide. If a stunted child is a girl, she will worn by older Nepali men. Donning the hat be more likely to give birth, in turn, to an suggests that he takes the interview seriously, underweight baby. but he laughs as he does so, making fun of “It’s an intergenerational issue,” says his own self-consciousness. Manohar. A few minutes later, his older son Although stunting has declined appears at the top of the trail, bent over, a worldwide by one-third since 1990, it still tumpline across his forehead to support the affected 165 million children in 2011, 69 weight of the grasses he’s cut for the family’s million of them living in south-central Asia. two water buffalos. By this time, Maharjan The individual impairments that stunting is asking a long series of questions about time to find the kernels of information that causes, multiplied by these millions, affect farming: Which of 22 crops does the family are probably important.” national economies: pervasive stunting in a grow during the wet season? And which ones Maharjan is asking about household population reduces gross domestic product during the dry season? What crops did they finances when the man’s teenage daughter by an estimated 8 percent. eat themselves, and what did they sell? She brings out rice with milk, breakfast for her “Stunting is a reflection of loss in asks which animals they keep, from bees to 4-year-old brother and a visiting child. The human capital,” says Keith West. “And pigeons to pigs. She asks if they vaccinated boys attack the rice, then tip up their bowls that human capital develops early in life. their buffalos. and contentedly slurp the milk. A typical So preventing stunting is a metaphor for To do this job, Maharjan attended six meal in Nepal consists of a mound of rice improving capacity.” weeks of training in Kathmandu. All 66 and a dish of dal (lentil gravy), and perhaps “enumerators” were women because of the a few tablespoons of vegetable curry. The FINDING THE RIGHT KERNELS intimate questions they would ask mothers diet tends to be low in micronutrients and Sabina Maharjan is out of breath when she and mothers-to-be. Each trainee had to in protein. Stunting is an intergenerational issue. arrives at a sturdy stone-and-mud house on master a 180-page manual. By the time Maharjan asks her last a narrow terrace high above Sitapur. She has “There was a lot to digest,” says Swetha question, it’s mid-morning. She will return been climbing for half an hour to reach this Manohar, who oversaw the training. “She the following day to interview the man’s place, one of 38 scattered homesteads that has to understand what crop rotation is, but wife, who has by now departed for the rice make up the roadless village of Durkatta. she also needs to know what a micronutrient fields. Maharjan will record what the woman Maharjan has scheduled this interview for supplement is. She has to know what contour has eaten in the past week, ticking off a list early on this summer morning, before the lateral irrigation is, versus pipe-based of 49 foods that begins with rice and ends family’s workday has begun in earnest. irrigation.” with Wai-Wai, packaged fried noodles that She greets the head of the household, a Maharjan and the others also had to are popular in Nepal. She will ask how much relatively prosperous farmer in his mid-40s. learn how to standardize data so similar the woman knows about keeping children He and his wife have four children. Maharjan responses given to interviewers in the healthy. What would she feed a child who perches on a shaded wooden veranda in front mountains and the plains would be marked was sick? When should she wash her hands? of the two-story house, and the man faces the same. For instance, how would “two oxen Maharjan will also ask about the woman’s her on a woven bamboo stool. Maharjan can plow my land” translate into hectares? If power within the family. Who decides asks him the first in a series of questions and a girl was promised to a man at age 12 but whether to use contraception? Who decides follow-up questions that will require two moved in with him at 18, how long has she when the woman can visit her mother? hours to complete. Does he own this house? been married? Then Maharjan will weigh and measure Does it have electricity? How many fans are Choosing survey questions required the woman and her 4-year-old son. If the in the house? Radios? Bicycles? restraint. For the people interviewed, taking mother was randomly selected to give a blood She marks answers on a form fastened several hours to answer questions is, as sample, to measure hemoglobin, Maharjan to a clipboard. West puts it, “expensive.” Participants lose will take a few drops. How does the family treat its water: time from gathering wood, mending roofs, simply allowing sediment to settle, boiling, cutting fodder. Even in urban Kathmandu, NO TIME TO WASTE adding chlorine? Who fetches the water, and many people have to fetch water from rivers Enumerators will return to Sitapur and the how long does that take? Where do children or haul it up from wells. “The poor don’t other 62 communities in spring 2014 and under 5 defecate? In a household toilet, have time,” says West, “so we’ve spent a lot of again in spring 2015. To track seasonal (Continued on page 54) FORK 29 A CONSUMING CONTROVERSY Is it bad to ingest a few hormone-tickling chemicals like BPA?

As part of our daily diet, most of us one side of a debate about whether EDCs are mother she sought out and used baby bottles unwittingly consume a cornucopia of contributing to obesity, heart disease, cancer made of polycarbonate (which contains BPA, endocrine disrupting chemicals (EDCs). and other public health problems. Her a substance that manufacturers voluntarily These compounds—you’ve likely heard of systematic reviews of published research— stopped using even prior to a government bisphenol A (BPA) for example—interfere she works full time as an industry consultant ban). with normal hormone function. They are in evaluating health risks from chemicals in “I need to walk the walk,” Goodman many fertilizers and pesticides and often in consumer products and the environment— explains, “if I believe in my own scientific the linings of cans, on the nonstick surfaces indicate that low exposures to BPA are a conclusions.” of pots and pans, and in beverage bottles. nonissue. Other scientists hold different No problem, says Julie Goodman—at She has testified to that fact before state conclusions. Investigated for decades by least not with BPA. Not even for infants or legislative committees considering potential researchers focused on reproductive and pregnant moms. restrictions on BPA. And, to address any developmental effects, BPA is one of about Goodman, PhD ’02, ScM ’00, represents suspicions of bias, consider that as a new 800 chemicals known or suspected to

30 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 be capable of interfering with hormone A comprehensive study in Sciences. An immunologist and expert in function. Endocrine disruption, a mounting the emerging science of sex differences, concern since the 1980s, has been blamed for preschool-aged children sug- Fairweather is looking at EDCs through declining fertility rates as well for increasing gested that dietary sources a new prism that’s decidedly different rates of the endocrine-associated cancers, from any that toxicologists traditionally namely breast and prostate. constitute 99 percent of BPA use. She’s exploring the effects of BPA in a “The multiplicative effects of many exposure. mouse model of myocarditis (inflammation chemicals on the endocrine system are of the heart), a male-dominant disease difficult to predict,” says prostate cancer and Translational Toxicology Program, that’s driven by sex hormones. Females are researcher Terry Brown, PhD, a professor in is working with Thomas Hartung, MD, protected against heart disease by estrogen. Biochemistry and Molecular Biology. PhD, the Doerenkamp-Zbinden Endowed Fairweather’s female mice are protected Brown represents that camp of scientists Chair for Evidence-Based Toxicology. too—unless they sip water treated with low who contend that “dose” doesn’t matter Using a human cell culture model, they doses of BPA, which renders them male-like, because hormone receptors are exquisitely are employing mass spectrometry to detect immunologically speaking. sensitive at critical times of human cellular metabolites whose levels are altered When exposed to coxsackievirus (the development. by low concentrations of BPA and other most common agent for myocarditis in the Goodman’s not buying it. She attributes EDC chemicals. U.S.), they developed severe heart disease the BPA fervor to scientific cherry picking. Hartung aligns with the faction that much more frequently than females who What’s missing, she contends, are consistent, doubts the relevance of EDC contamination weren’t ingesting levels of BPA equal to replicable results that indicate evidence of on human health. But it’s an exceedingly “high human-relevant” doses. adverse effects on human health. People are complex issue, concedes the director of the A bit of BPA alone doesn’t cause heart exposed to much lower levels than are used Center for Alternatives to Animal Testing. It inflammation in mice. But in tandem with in most experimental studies, she points out. requires a whole new method of investigation. a common virus, it alters a once-protective “One study looks at the effect of BPA on “In a situation of controversy, we need signal and leads more often to a worse disease 30 things in live animals, and finds an effect data,” Hartung says. He’s developing a new state. on prostate weight but no effect on anything endocrine disruptor screening paradigm “BPA can act as a co-factor; alone else,” Goodman says. “Another study looks because, he says, the current toolbox (which it would probably never do this,” at 30 things in live animals and doesn’t find relies largely on animal testing) is too costly, Fairweather says, crediting PhD candidate an effect on the prostate, but finds an effect time-consuming and crude. Katelyn Ann Stafford with that finding. on mammary glands. The media interprets His strategy is to use emerging “Receptors activated by the virus and sex this as: Bisphenol A causes effects on prostate technologies to better understand the hormone receptors work together to drive and mammary glands. That’s not solid mechanism. This involves developing high- inflammation in the heart. BPA alters that science. That’s a whole bunch of studies that throughput human cell-based assays that process, allowing a heightened inflammatory find one effect here, one effect there. But are show not just what binds to what receptor response.” the effects because of bisphenol or statistical but also the results of that binding, the so- Fairweather, like Brown, argues that any A CONSUMING CONTROVERSY anomaly, or poor methodology or something called downstream effects. interference with hormones is disruption, and else? You can’t ignore that question.” When we rush to get rid of substances that’s likely to have negative consequences, if The human body naturally has high like BPA, they are likely to be replaced with not right away, then sometime in the future. levels of hormones, she reasons. If you new compounds that have not been tested Meanwhile, toxicologists like Goodman compare the potency of bisphenol exposure as much, or at all, Hartung cautions. Case and Hartung bristle at what they see as an from water bottles or canned tomatoes, in point: One replacement for BPA is BPS, inherent inaccuracy in the popular moniker versus natural estrogen in a person, “it’s like another bisphenol compound. Some think “endocrine disrupting chemical,” preferring nothing,” she says. “It’s like a grain of sand it’s not a great choice given its tendency to instead the more neutral endocrine-active on a beach.” leach out of the plastic (though less than chemical. These substances might act like Goodman’s former PhD advisor, BPA) and its staying power (greater than hormones without actually disrupting or James D. Yager, PhD, the Edyth H. BPA). A recent Environmental Health interfering with anything, they say. Schoenrich Professor in Preventive Perspectives study showed that very low Goodman says she will change her Medicine, describes her as “brilliant” and levels of BPS interfere with normal hormone mind if persuasive data emerges. “But,” she her analyses as sophisticated. Meanwhile, he activity in animal cells. adds, “that hasn’t happened yet.” is collaborating on research to determine the In addition to his work with Hartung, effect of endocrine disruptors—beginning Yager is collaborating on a grant for a BPA with BPA—on signaling and metabolic project with DeLisa Fairweather, PhD, By Maryalice Yakutchik pathways. Yager, director of the Molecular associate professor, Environmental Health Illustration by Harvey Chan

FORK 31 DAVID PAIGE’S IDEA FOR “PRESCRIBING APPROPRIATE FOODS” IN 1969 LED TO THE FEDERAL PROGRAM THAT NOW HELPS HALF OF ALL INFANTS IN THE U.S.

INTERVIEW BY KAREN KRUSE THOMAS

PHOTO BY CHRIS HARTLOVE RX FOR THE FUTURE THE RX FOR

32 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 As a pediatric resident at Johns foods?” That was really the data on heights, weights and section of Maryland], where Hopkins Hospital and an MPH dawning of the WIC issue for blood characteristics and resistance from health officers student in the late 1960s, David me. That clinical recognition of noted a very high percentage was strongest. Fortunately, as a Paige was frustrated. Iron- the futility in treating case after of undergrown children, below Hopkins pediatric resident I had deficient infants with stunted case. the third percentile. Of course, traveled throughout the state growth routinely arrived at In the School of Hygiene, a high percentage of low birth and down to the Eastern Shore. the Harriet Lane emergency I was taking a course on weights. The early data on The health officers finally room—many so sick they population statistics with the benefits of supplementing accepted the IFIF program required hospitalization. At Matthew Tayback [ScD ’53], maternal and infant diets gave when I agreed to continue to the time, breastfeeding was an assistant commissioner in us courage to try to expand to a cover their pediatric clinics once rapidly declining in favor of the Baltimore City Health larger population. a month. evaporated milk formula, which Department. Dr. Tayback INTERVIEW BY poor families frequently would headed a task force trying to EXPANSION. We received a grant GOING NATIONAL. CSA liked KAREN KRUSE THOMAS dilute with water to make it increase enrollment in the federal from the federal Community the IFIF program very much, last. Some mothers gave infants free school lunch program and Services Administration to and they began to spread the PHOTO BY cow’s milk, which often led to asked me, as a student—and this launch a statewide voucher word on a national level, that CHRIS HARTLOVE gastrointestinal blood loss. is the greatness of Hopkins—if program enabling Maryland Maryland and Baltimore and The solution pioneered I would be a working member. mothers to purchase formula Paige and the Maryland Food by Paige, MD, MPH ’69, and It gave me the opportunity to and nutritious food. My research Committee were the go-to colleagues evolved into the marry the clinical issues and the confirmed that providing people for nutrition intervention federal Women, Infants and public health perspective. fortified formula to infants in in the community, and that, Children (WIC) nutrition low-income families reduced obviously, they had funded us. It program. WIC is the third-largest THE REAL WORK. The school their risk of iron deficiency and suddenly became bidirectional: federal nutritional assistance lunch program was a good way undernutrition. Our appeal and our funding program (after food stamps to assure appropriate nutrition I wanted to demonstrate unleashed interest on the part of and school lunches). Designed and maximize the educational that the problems we were the feds, such as the Food and to prevent the serious health experience for disadvantaged dealing with at Hopkins weren’t Nutrition Service in the USDA. consequences of malnutrition, children, but the negative specific to Baltimore City, that WIC has emerged as an it provides nutritious foods, impact on cognition had already malnutrition existed anywhere important national program. nutrition education and taken place. The real work had poverty existed. When we The School and I can justly revel referrals to health care and to be directed at pregnancy and submitted the grant, we coined in its success—we didn’t build it social services. Today, almost the early years of life. “IFIF” as the acronym for alone, but we were important half of all U.S. infants and one- To pursue that goal, the Iron-Fortified Infant Formula architects for the program. quarter of children aged 1 to 4 school lunch committee led Program. Our internal participate in the program. to creating the permanent conversation was, “If we get the LONG-TERM IMPACT. WIC has The affable and energetic Maryland Food Committee money, if we can convince the been very successful in lowering professor of Population, Fam- [now the Maryland Food Bank]. health officers,” so everything the incidence of low birthweight ily and Reproductive Health Along with the committee, was if-if, and it seemed like an and pre-term birth, which in recently talked about WIC’s my colleagues and I tried to appropriate acronym. turn effectively reduces infant origins and impact with think through how to develop mortality and developmental Bloomberg School historian a prescriptive approach to early RESISTANCE. We had con- disabilities. Studies by the CDC Karen Kruse Thomas, PhD. infant feeding and pregnancy. siderable resistance from found that WIC preschoolers We started to provide iron- many of the rural counties, show improved weight gain fortified formula to newborns where health officers had been and overall health, as well as a POWER OF PREVENTION. In my at the newborn clinic in Cherry disappointed by previous sharp reduction in anemia. At public health courses, we learned Hill, a poor neighborhood, federal programs that came and the same time, WIC has been that you prevent disease. You principally African American. went. The food vouchers were extraordinarily cost-effective. don’t wait to treat it. I was really I should say that it wasn’t until unfamiliar and untested, and Even reducing one or two annoyed. I said, “I’m writing the 1980s that WIC began to no one knew if the merchants nights in the neonatal intensive prescriptions for everything. promote breastfeeding. would accept them. Many of care unit or an extra day of a Why don’t we treat iron It was really a mom-and-pop the people who most needed the woman’s hospital stay will more deficiency and undernutrition operation, I was doing almost all program lived on the Eastern than compensate for the cost of by prescribing appropriate the work. We started collecting Shore [the poorest, most rural WIC benefits.

FORK 33 FORK INVESTIGATIONS

Optimizing Folate Intake The Fly Diet “Folate is good stuff,” says Xiaobin Wang, acid supplements have indeed been shown It’s well known that a woman’s diet can affect MD, ScD, MPH. Just how good, however, to slow the progress of atherosclerosis and her baby. But ongoing research by Daniela has been a matter of some debate— reduce the risk of cardiovascular disease. Drummond-Barbosa, PhD, suggests that until now. For Wang, the takeaway is simple: Folate is diet might determine whether she can When mothers consume it through a useful tool, but “it’s only good when people produce one in the first place. fortified foods and folic acid supplements, need it.” For the past decade, Drummond- prenatal folate prevents neural tube defects Most recently, Wang, who is director Barbosa, an associate professor of such as anencephaly and spina bifida. Folate of the Center on the Early Life Origins of Biochemistry and Molecular Biology, has and other B vitamins, such as B6 and B12, Disease and the Zanvyl Krieger Professor explored how diet regulates ovarian cells in also regulate blood levels of homocysteine, in Child Health, found that optimal folate Drosophila melanogaster, the common fruit an amino acid that promotes atherosclerosis status at preconception is not only important fly. By manipulating Drosophila’s genes, and increases the risk of heart attack and in itself but may also counteract the adverse Drummond-Barbosa and her colleagues stroke when produced in excess. But for effect of DDT on early pregnancy loss have identified several nutrient-sensitive many years, clinical studies failed to show in a Chinese preconception cohort. She pathways that influence the ovarian stem that reducing elevated homocysteine levels also discovered high rates of elevated cells that make egg production possible. through folic acid supplementation improved homocysteine levels in Chinese children (Adult humans appear to lack ovarian stem patient outcomes. and adolescents. cells, but our embryonic germ cells play a Wang and her colleagues have produced Wang believes these results argue for B similar role in utero, eventually developing a series of papers (including one published vitamin supplementation across the lifespan into eggs.) They’ve also demonstrated in The Lancet) demonstrating that those to improve pregnancy outcomes and head that the same pathways affect the ovarian disappointing results arose from studies off adult diseases in populations that lack microenvironment. That microenvironment, conducted in the U.S. and Canada, where fortification. Ultimately, Wang hopes that or “niche,” sustains the stem cells, as well as mandatory fortification of grains and cereals her work will encourage national fortification their daughter cells (specific cell types they with folic acid ensures that most people programs abroad. produce through division, which go on already get enough of the stuff. “Additional research is needed to to form eggs). For example, Drummond- By contrast, studies conducted in determine optimal dosage and combination Barbosa discovered that insulin levels— China—a country where there is no national of B-vitamin intake that is tailored to increased by carbohydrate intake— fortification program, genetic mutations tied individual life stage and health needs and influence the rate at which ovarian stem cells to elevated homocysteine levels are common, avoids potential adverse health effects of proliferate, while diet-related changes to the and rates of hypertension and stroke are excessive B-vitamin intake,” Wang says. ovarian niche affect the numbers that are high—paint a different picture. There, folic —Alexander Gelfand maintained.

34 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 FORK INVESTIGATIONS

The Fly Diet Budget Cuts Aren’t a SNAP But in a complex living organism, many Cuts to the federal Supplemental Nutritional “We see $15 billion in potential different organs and tissues will respond Assistance Program (SNAP) could backfire diabetes-related costs, which would really to the nutrients they encounter, and any by actually increasing federal health offset many of the savings that they’re of those responses could conceivably affect spending, according to a recent analysis by considering in Congress,” Pollack says. Her the ovaries and their contents. As a result, a team of scholars including Keshia Pollack, analysis was conducted with colleagues at Drummond-Barbosa recently decided to PhD ’06, MPH, an associate professor in the Health Impact Project, a Washington- explore how diet-driven signals from fat cells, Health Policy and Management. based nonprofit collaboration between the which play an important role in regulating When millions of Americans found Robert Wood Johnson Foundation and the appetite, metabolism and insulin sensitivity themselves newly unemployed after the Great Pew Charitable Trusts. throughout the body, might influence Recession, many turned to SNAP (the federal John T. Cook, PhD, an associate ovarian stem cells and their environment. In Food Stamp program). Its budget more than professor of pediatrics at Boston University a series of as-yet-unpublished experiments, doubled between 2007 and 2011—drawing who was not involved in Pollack’s study, Drummond-Barbosa and postdoctoral attention from congressional budget-cutters. says: “Our studies have consistently shown fellow Alissa Armstrong, PhD, found that On February 4, the Senate passed the long- that children in SNAP households are the presence of diet-related substances such delayed Farm Bill cutting SNAP’s budget significantly more likely to have their as insulin and amino acids causes fat cells by $8 billion over 10 years. At press time, health reported as ‘good’ or ‘excellent’ than to release biochemical signals that trigger President Obama was expected to sign the children in otherwise-similar families that “really specific effects” in ovarian stem cells, bill into law. don’t receive SNAP benefits. their niches and their daughter cells. Those proposed cuts could prove to “And that, in turn, means that they’re If further research reveals that the be a serious mistake, even from a fiscal less likely to need hospitalization or relationships between fat cells and ovarian perspective, according to Pollack (above, at ambulatory-care services,” he says. stem cells in Drosophila also apply to human the Maryland Food Bank). If SNAP’s budget Pollack emphasizes that her team’s embryonic germ cells, Drummond-Barbosa’s falls too far, she says, we can expect increases report does not make recommendations work could shed new light on how diet affects in spending on Medicaid and other health about whether SNAP benefits should be cut. the early stages of ovarian cell development programs. As low-income Americans lose “We simply want policymakers to be aware in people—and, hence, their ability to secure access to nutritious food, Pollack says, of the potential population-health effects produce offspring. Additionally, clarifying they will be more likely to need expensive and distribution of those effects within a how fat cells and stem cells interact could health treatments for diet-related diseases population,” she says, “and to start thinking help explain the link between obesity and such as diabetes. Families may also be more about ways to mitigate the adverse effects various diseases, including cancer. likely to forgo preventive health care as their and optimize the beneficial ones.” —Alexander Gelfand food budgets tighten. —David Glenn

FORK 35 what WHAT WE SEEK HEALTHY CITY FOOD, BETTER FAMINE WARNINGS, FREE RANGE TALK, 36 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 MEATLESS MONDAYS, FURTHER REASONS FOR OBESITY MICRO LOAN, MACRO CHANGE AFTER SHE RECEIVED A MICRO LOAN FOR HER VEG- ETABLE STAND IN LAHORE, PAKISTAN, BILQUES DOST MOHAMMAD WAS ABLE TO BUY PRODUCE FROM A WHOLESALE MARKET AND AVOID DAILY LOANS FROM A MIDDLEMAN. WITH THE PROF- ITS, SHE PLANS TO SEND HER YOUNGEST SON TO SCHOOL. (PHOTO: SHEHZAD NOORANI)

WHAT WE SEEK CHEAP EATS BAD ADS AND THE GOOD NEWS FOOD CHAIN STARVING CLIMATE FEMALE FARMERS HEALTHY CITY FOOD, Americans spend The U.S. fast food Total calories in fast “You are what you By 2050, climate If women farmers had 10 percent of their industry spent $4.6 food ads viewed by eat eats.” change and erratic the same access to BETTER FAMINE WARNINGS, incomes on food—the billion in 2012 on teens went down by at —Michael Pollan weather could push resources as men, the FREE RANGE TALK, lowest of any country. advertising. least 11 percent from another 24 million world’s hungry could 2009 to 2012 children into hunger. be reduced by up to MEATLESS MONDAYS, FURTHER 37 150 million. REASONS FOR OBESITY SOURCES: Yale Rudd Center for Food Policy & Obesity, Consumer Affairs, UNFAO 38 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 No Fries with That

From fatty and fried to lean and green—how I transformed my relationship with food BY DESMOND FLAGG ILLUSTRATION BY JOEL NAKAMURA

Salt, fat and sugar. vegan and vegetarian, farmers markets, ethnic restaurants of all As a young boy in Atlanta, the unhealthy but tasty combination kinds—narrowed considerably. The bodegas and corner stores amounted to a major food group in my diet. limited residents to the familiar high-fat and processed foods of my Fatback, deep-fried pork rinds and fried chicken were menu childhood. staples at home. Eating out was usually a trip to the six-dollar, all- The experience sparked my interest in public health, specifically you-can-eat buffet, where second and third helpings ensured that our in the areas of obesity risk and improving urban food environments. plates were never empty. So I returned to school to learn about food disparity as a social It was hard to avoid the Southern fried food culture, but family justice issue. I earned my MPH at Hunter College, and now my dynamic also figures in my food narrative. My mother was a single PhD dissertation examines the role that father involvement plays in parent, raising two boys, working and going to school for a master’s determining a child’s risk for obesity, focusing on Black and Hispanic in social work. She didn’t have much time for home cooking. With non-resident fathers. The issue has particular resonance for me, as the no full-service grocery close by, fast food and pizza were cheap and father of a 4-year-old girl. easy options. Having been overweight as a child, I’m committed to making Over time, the fat- and sugar-laden diet was a recipe for disaster. I sure that Emma grows up with healthy, fresh food on the table. I don’t grew into a fat kid and an easy target for schoolyard jokes. (“Better not keep soda, candy or cookies in the house. For snacks, there’s fruit— mess with him; he’ll sit on you!”) Our inner-city apartment complex and the occasional granola bar. was far from parks and playgrounds, so we didn’t get much running- Emma also knows that I’m serious about staying fit. My football around time. And my mother, worried about our safety, told us to stay days are over. Now bodybuilding is my sport of choice, and I’ve inside until she returned home from work or school. actually won a couple of competitions. I launched a website—Dads Bring on the television and potato chips. of Steel—as a resource for fathers, with workouts, healthy recipes and When I was 10, everything changed. We moved to Ann Arbor parenting tips. so my mother could pursue further graduate work at the University of I put a lot of effort and passion into living a healthy life—and it Michigan. We lived in student housing in a neighborhood where kids works. However, it’s not a regimen that we can expect most people to threw the Frisbee after school or played basketball at a nearby park. adopt. With more than two-thirds of U.S. adults overweight or obese At our public middle school, phys ed was mandatory, the cafeteria and 18 percent of children classified as obese, this epidemic needs had a salad bar, and there was a strong extracurricular sports program. bold initiatives from public health officials, educators and researchers. Soon, the pounds started to come off. I hope to play a role in the research or policy arena to tackle I was exposed to new foods (artichokes!). We learned that chronic obesity with the same urgency that informed anti-tobacco baked could taste as good as fried. I played high school football and and clean air campaigns. began to make the connection between healthy eating and improved Every child deserves more than a steady diet of Happy Meals. performance—on the field and off. After I graduated from Columbia University and took a job as a social worker in the South Bronx, I began to think about food on a deeper level. Desmond Flagg is a PhD student in Health Policy and Management and The endless eating options I had enjoyed as a college student— a C. Sylvia and Eddie C. Brown Community Health Scholar.

FURTHER 39 40 JOHNS HOPKINSTheodora PUBLIC and H EALTHEugene / SMorrisPECIAL (marriedFOOD ISSUE for 2014 45 years) discuss the bell peppers with Food Depot produce manager Dominic Wilson. FOOD IN THE DESERT

In a city where the deep-fryer is king,

what does it take to sell yogurt, Story by Michael Yockel Theodora and Eugene Morris (married for 45 years) discuss the bell peppers with Food Depot produce manager Dominic Wilson. salad and wraps? Photography by Christopher FURTHER Myers 41 (CLF), the city teems with 440 such corner launched three programs to increase access stores and 709 carryouts, while boasting just to healthy foods: B’more Healthy: Retail 47 supermarkets. Rewards; B’more Healthy: Communities for “If you went outside this building Kids; and Baltimore Healthy Carryouts. [in East Baltimore] and spun around in a Conducted in 2011, Healthy Carryouts circle and walked in whatever direction you worked with eight West Baltimore shops wanted, you would probably have to walk a located in food deserts: four, including mile or more before you hit a supermarket— Shareef’s Grill, emphasized healthy items; probably two miles,” notes Joel Gittelsohn, four others were left untouched, says former PhD, MS, with both the Center for Human program coordinator Seung Hee Lee, PhD Nutrition and the Global Center for ’13. The “healthy” carryouts redesigned uring the lunch-hour peak at Childhood Obesity. “But if you walk a block menus and signage; promoted bottled water, Shareef’s Grill in West Baltimore, a or two, you’re going to hit a corner store or a juices, salads and yogurt; and offered new tightly packed line stretches all the carryout or both.” combo meals like a grilled chicken sandwich, Dway from the Plexiglas-enclosed The stakes are significant: The high- baked chips and bottled water that were sold counter straight out the front door. sugar, high-fat, low-fiber diet commonly at a discount. Hungry customers chat in the 15-by-20- consumed in poor communities is linked to “In Baltimore City carryouts, the deep- foot shop as they wait for the usual carryout elevated rates of obesity, which in turn raises fryer is king,” Gittelsohn notes. “Many of fare of wings and fries, steak sandwich and the risk for diabetes, heart disease and some these places do not even have a grill or a way Pepsi, as well as the not-so-usual: a hot kinds of cancer. to cook food in a low-fat way.” To alleviate veggie wrap, a turkey wrap, corn chowder, Gittelsohn has spent the past 10 years that problem, the program provided one of 100-percent juices and other healthy items. exploring the relationship among low- the shops with a George Foreman grill. Also atypical for an urban carryout are signs income minority populations, food access Sales of healthy foods at the intervention on the walls that declare, “We only use and health via the Baltimore Healthy Stores shops went up dramatically—even after just peanut oil when frying foods,” and “Shareef initiative. He’s identified barriers to healthy the menus and signage were changed, says Sorbet: all natural, no high fructose corn eating in the city and fashioned strategies to Lee, now an Epidemic Intelligence Service syrup, pounds of fruit in every batch,” and increase access to a nutritionally adequate officer with the CDC. The final numbers “One of Baltimore’s Healthy Carryouts.” diet, improve food security and reduce the showed a 100 percent sales increase for But then Shareef’s, located in the risk of diet-related chronic diseases. healthy options and an overall increase economically depressed Harlem Park “It’s a supply-and-demand issue,” he in gross receipts; meanwhile, the control neighborhood, defies convention. The explains. “We work with local food suppliers carryouts experienced an overall decrease in beneficiary of an initiative called Baltimore to increase the supply of healthy foods, and gross sales during the same time period. Healthy Carryouts led by the Bloomberg we work with local consumers to increase the Additionally, pre-intervention versus School’s Center for Human Nutrition, demand for those foods, because you can’t post-intervention customer surveys indicated Shareef’s encourages its clientele to make have one sustainably without the other.” a behavioral change. “We noticed that those better food choices. The project is just one Typically, corner stores and carryouts who recognized the Baltimore Healthy way in which researchers, policymakers offer few, if any, options like whole wheat Carryouts intervention materials were more and others are making strides toward bread, fruits and vegetables, and low-fat likely to buy healthier items—and a greater understanding “food deserts” and their toll milk. Instead, they sell a cornucopia of high- variety of healthier items,” Lee points out. on low-income urban populations. fat, high-sodium and high-sugar foods. Count Tina Jackson among them. The Characterized by areas where the “Most of the people in these comm- Shareef’s Grill customer took notice of the distance to a supermarket is more than unities say that they would love to eat green-leaf-flagged hot jumbo lump crab one-quarter mile and where more than 40 healthier foods,” Gittelsohn notes, “but they wrap filled with broccoli before placing her percent of households do not have access to a cost too much or they’re of poor quality or order. “I’m trying to be more conscious about vehicle, food deserts commonly plague large they are just not available.” Residents have eating heart-healthy foods,” she explains. American cities like Baltimore, where one in a “relatively good concept” of what healthy “I like when food is healthy but still tastes five people lives in one. foods—and unhealthy ones—mean. Fruits good.” Then she jokes, “Make me at least feel With supermarkets out of easy reach, and veggies: good. Sugary sodas: bad. “It’s like I’m not eating healthy.” Baltimoreans living in food deserts often not so much of a knowledge-gap issue,” he For his part, Gittelsohn expresses rely on corner stores and carryouts for their says. optimism in what the Healthy Carryouts meals. According to 2012 data compiled Following research and feasibility study demonstrated: Not only did healthy by the School’s Center for a Livable Future studies, Gittelsohn’s Healthy Stores has food sales improve in the intervention

42 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 Bringing healthy food to the city means working the angles of supply and demand.

FURTHER 43 Hold the deep fryer: Shareef’s cook Baseem Wilson stir-fries some veggies. new options and creating nutritious combo meals. “The markets’ management now prioritizes and understands the dire need to have more healthy food venues,” says Freishtat. In formulating food-access policy, BFPI has also successfully tapped into CLF’s food-mapping project (mdfoodsystemmap .org), which graphically depicts Maryland’s food system, including farms, processors, distributors and retail food outlets. Its Baltimore City map effectively portrays the city’s urgent need for solutions. “[The map Can a supermarket’s is] very good at targeting where need exists, how many people live in a food desert and what a food desert looks like,” she says. environment help Using CLF’s map, BFPI worked with the USDA to revamp its own food desert map and how a food desert is defined. That resulted in increased federal Healthy Food consumers make financing that is used to develop and equip grocery stores, small retailers, corner stores and farmers markets selling healthy food in healthy decisions? underserved areas.

Barbara Countee scrutinizes the cabbage at Food Depot. THE SUPERMARKET AS LAB Not long after his wholesale/retail-food carryouts, people also bought fewer “Some of the markets are more like company bought a Southwest Baltimore unhealthy items. “Sometimes you worry food courts,” says Holly Freishtat, the city’s grocery store in 2008, CEO Benjy Green about these interventions in that you could food policy director and head of BFPI—an roamed its aisles, discreetly noting his just get people to eat more healthy foods, but amalgam of city departments that seeks to customers’ purchases. they will keep eating doughnuts and high- increase access to healthy food. “They were filling their carts primarily sugar cereals at the same time,” he says. While serving an internship with BFPI with unhealthy stuff,” he recalls, “and I For now, the four healthy carryouts “are in 2011 and 2012, Seung Hee Lee worked couldn’t stand seeing what people were on their own,” he adds. “However, many with its then healthy food coordinator, buying. I really felt like I needed to give back more carryouts will be part of the B’more Rachel Yong, MSPH ’13, to analyze a CLF [to the community]. I thought, ‘What can Healthy: Communities for Kids trial, which food assessment survey of the markets. I do?’” starts in spring 2014.” They found that four lie in food deserts, The community can use the help. Food and 70 percent of vendors in all six markets Depot serves a racially mixed, economically AN A-HA! MOMENT IN CITY MARKETS operate as traditional carryouts—in effect, challenged neighborhood vexed by a Baltimore Healthy Carryouts may have implicating the city itself in Baltimore’s high incidence of obesity, diabetes and started a ripple effect. In 2012, the city paucity of healthy food. hypertension. The neighborhood’s average government’s Baltimore Food Policy “That was an a-ha! moment,” admits life expectancy of 65 is one the lowest in the Initiative (BFPI) adopted the program’s Freishtat. city. basic model and introduced it to carryouts Subsequently, BFPI worked with 30 Wanting to understand his customers’ operating in two of the six city-owned public vendors in the Lexington and Northeast shopping habits and help change their markets. First established in the mid-18th markets, both located in food deserts, to behavior, he contacted the CLF in 2010, century, the markets sold fresh produce, implement Gittelsohn’s multifaceted Healthy suggesting collaboration: “I said, ‘There’s a meats and dairy products for more than 200 Carryouts strategy, dubbing its initiative Get need here. Use us as a lab.’” years, but over the past several decades they Fresh Baltimore. That meant designing new CLF accepted Green’s challenge. “It transitioned into offering mostly prepared green-leaf-highlighted menus to emphasize was a researcher’s dream,” says Anne Palmer, meals. the existing healthy choices, introducing MAIA, program director of CLF’s Food

44 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 Communities and Public Health Program “They were filling their carts WHY IT’S HARD TO EAT HEALTHY (FCPHP), which launched a two-year primarily with unhealthy stuff. The battle against food deserts may never campaign in 2011 called Eat Right Live end, but City food policy director Freishtat Well (ERLW). The campaign sought to And I couldn’t stand seeing what thinks they can be eliminated in some areas answer a simple question: Can changing people were buying. I thought, and at least reduced in others. a supermarket’s environment induce For her, the most imposing obstacle its shoppers to become more healthful ‘What can I do?’” to that goal resides in Washington, not consumers? —Benjy Green, Food Depot Baltimore: decreasing funds for SNAP First, investigators quizzed Food benefits. In January 2014, the House of Depot customers to explore how their Representatives passed a Farm Bill cutting limited financial resources influenced their when possible and started making low-fat the federal food stamp budget by $8 billion purchases. More than 70 percent receive prepared foods. over 10 years. (Initially House leaders had federal Supplemental Nutrition Assistance “It’s unique in terms of a supermarket sought to cut $40 billion from the SNAP Program [SNAP] benefits, the formal in a low-income neighborhood,” says Palmer, budget, which had doubled in size during name for food stamps. They also asked “both visually and display-wise.” the national recession.) On February 4, shoppers how the store’s layout affected On a recent December morning, the Senate passed the bill. At press time, their decisions to buy nutritious items and Theodora Morris was perusing the President Obama was expected to sign the solicited suggestions on how to promote augmented produce section, with her bill into law. more healthful purchases. husband, Eugene, following attentively. She “We cannot forget that SNAP is an Just as Gittelsohn contends, the results was shopping for the two of them, their three economic driver in our city—$422 million indicated that low-income residents know children and one grandson. “I like to shop annually is spent on SNAP in the city and healthy from unhealthy. “They have thought healthfully,” notes Morris, placing two bags surrounding areas,” says Freishtat. “Retailers about it significantly,” Palmer observes, of mini carrots in her cart. “The vegetables are impacted by any fluctuations to the SNAP “and they’re making very rational choices of here are good, and they have better prices.” budget, as are the individual residents.” what’s available to them.” Barbara Countee, at the store to buy Depending on how the SNAP That includes looking elsewhere for salmon, is also price conscious. “Healthy reductions affect people and retailers, more healthy food. “People cannot purchase what choices can be very expensive,” she says. food deserts could appear in Baltimore and is not accessible,” explains Joyce Smith, Still, she prefers fresh vegetables—“cabbage, other cities. who works with Palmer as a community lettuce, greens, broccoli”—to frozen ones, Anticipating additional cuts in SNAP liaison coordinator in Southwest Baltimore. and she avoids the canned variety entirely. funds, Food Depot’s Green expects to see “[When feasible] they travel to other Meanwhile, over in the store’s dairy shopping patterns change at his store as communities—some beyond city limits— section, Teshea Jackson—shopping for customers choose cheaper, unhealthful where better supermarkets are located.” herself, her daughter, her fiancé and his items over more expensive, healthy ones. He In cooperation with Green, the FCPHP daughter—hauls a gallon of 1 percent cites processed white bread instead of whole team moved into intervention mode in 2012. milk out of a chilled case. In an effort to wheat as an example. They reduced healthful foods’ prices and consume less fat, “I made the change from Palmer believes that knowledge still gave in-store tests, moved healthy choices [whole milk] about a year ago,” she relates. holds the key to reducing food deserts. to eye level, displayed signage encouraging But like Morris and Countee, she considers “We want to provide qualitative research to the purchase of low-fat, low-sodium and price extremely important; she cuts costs by the public and academia that gives a better low-sugar options, set up end-of-cap aisles choosing canned fruit over fresh. understanding of how hard it is for people and register racks featuring healthy grab-n- It’s too soon to say if the two-year to eat healthfully,” she says. “So often we go items and suggested recipes to customers. program made a difference. Pam Surkan, want to say, ‘Oh, those poor people living The team also worked with store employees PhD, ScD, the project’s principal investigator in those neighborhoods,’ or we victimize on how to better promote healthier food and an assistant professor in International them—we do them a disservice, as if they choices and collaborated with a staff dietitian Health, is still analyzing the data. don’t understand or haven’t thought about hired by Green. From a business point of view, it’s “an choosing and eating healthful foods. By the time the intervention concluded, uphill battle,” says Green. “People make “We need to turn that on its head and Food Depot had been transformed. Green their own choices; we can’t tell them how say, ‘Why do we make it so hard for people replaced its warehouse-like sensibility with to act. And we can’t simply stop selling the to eat healthfully?’ We need to convey how a warmer, more inviting atmosphere, hired stuff that may not be very good for them— difficult it is to do what we’re asking people more staff, improved the variety of produce we’re in business,” he says. “So we have to do, and really respect that they understand (adding yucca, boniato, chayote squash the good and the bad stuff and everything their circumstances way better than we ever and tomatillos), began buying locally in between.” could. They are partners in this.”

FURTHER 4545 ANATOMY OF A FAMINE Why did 250,000 Somalis die in 2010 and 2011?

When the worst drought in 50 years struck in but Al-Shabaab has made Somalia the most just the very point when we should have 2010 and threatened its people with famine, dangerous country in the world for aid been focused on this, other things were Somalia, the world’s most failed state, was workers—two-thirds of those killed in 2008 happening, the Arab Spring and other big in no position to handle the crisis on its worldwide died in Somalia. The World Food news events,” explains Courtland Robinson, own. The country hasn’t had a functioning Programme pulled out. PhD ’04, associate professor in International central government since 1991, and much of Chronic hunger conditions deteriorated. Health and deputy director of the Center for its territory is under capricious warlord rule, As a tell-tale torrent of desperately Refugee and Disaster Response. including by the Islamist militant group, the hungry people moved to refugee camps The result was that the global relief Al-Qaeda affiliate Al-Shabaab. in neighboring countries, there were more community failed to act promptly, leading Effectively a ward of the international than the usual complicating circumstances. to a largely avoidable tragedy. Robinson and humanitarian community, the desperately “There was a kind of perfect storm of a London-based colleague have studied the underdeveloped country has received very bad conditions—climactic, political consequences of that failure, and the results periodic emergency food aid in the past, and security and many other things—at are a stunning indictment: an estimated

46 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 258,000 lives were lost, a figure that at least “There was a kind of perfect when famine level has been reached, insists equals the toll from the last famine Somalia a declaration could not have been made suffered more than 20 years ago. “An storm of very bad condi- earlier in this instance. But he quickly adds: estimated 4.6 percent of the total population tions—at just the very point “A response to an emergency like this should and 10 percent of children under 5 died in when we should have been not require a declaration famine. If you southern and central Somalia,” noted the wait until a famine declaration to respond, May 2013 report. focused on this.” you will always be late—food insecurity “The numbers that we found were —Courtland Robinson deteriorates over time and you have got to beyond what anybody had predicted,” says respond earlier on.” Robinson. Previous estimates were orders of ground assessments (down to current market Just why this happened is not clear and magnitude smaller, in the tens of thousands. prices of red sorghum) to help spot probable was probably due to a complex convergence But this study found that the famine, at conditions three to six months ahead. of factors. The global economy was still its most savage peak, was claiming 20,000 The increasingly sophisticated mon- in recession. The Arab Spring and the “excess deaths” each month—above and itoring networks (Famine Early Warning Japanese earthquake/tsunami were grabbing beyond an already high baseline mortality Network and FAO’s Food Security and headlines. “Somalia fatigue” and concern rate. Nutrition Analysis Unit for Somalia) about running afoul of U.S. anti-terrorism “That the needless hemorrhage of worked as intended. Beginning in August statutes likely played a role as well. human lives took place again in the Horn of 2010, their technical experts started issuing But there is also a nagging sense that, Africa in 2011, in spite of all our knowledge warnings that grave conditions were as Robinson says, “we took our eye off the and all our experience, is an outrage,” said Jan worsening. Some relief efforts got under ball.” That has practitioners on the front Egeland, UN emergency relief coordinator way but were hampered by local conflicts line calling for reforms that will further 2003–2006, echoing the sentiments of and uncertainty about the severity of food depoliticize the process and secure more many. insecurity, according to Robinson. After a upfront donor aid commitments that can be Robinson, who has researched other famine was officially declared in July 2011, tapped without waiting for key capitals to famines, including in North Korea (where the international community’s ensuing deliberate each time there is a crisis. official denial of famine is still intact), operations were impressively effective and Luca Alinovi, a leading Somalia expert, primarily worked out the demographic helped to save many. By the time, the famine has suggested (along with FAO colleagues) denominators for the study—that is, the was declared over in April 2012 a quarter- that major donors and UN agencies total population of Somalis (non-displaced, million Somalis had perished. should agree to “Ulysses Pacts” that would internally displaced and refugees in other Exactly why that happened continues to irrevocably bind major donors to future countries) exposed to famine mortality risk. haunt those who take seriously the wealthy assistance to help vulnerable populations. This complemented the work of the study’s world’s obligation to help their fellow humans Key aid personnel, he adds, should be main author, Franchesco Checchi, at the to avoid the age-old curse of starvation, and accountable for achieving measurable results time in the London School of Hygiene and the myriad diseases that opportunistically with a “specific measure of recourse” for Tropical Medicine (now at the Save the ride on top of such blows. Some criticize failures, including being dismissed from ANATOMY OF A FAMINE Children, UK), who processed data from the process of determining a famine that is their posts. hundreds of surveys to calculate baseline occurring as too technical—not sufficiently It seems unclear—perhaps unlikely— and excess mortality rates for the different open to strong, earlier anecdotal evidence— that the big power players are going to sign populations of displaced and non-displaced and flawed by relying on some lagging up for this. “I am not that optimistic that Somali populations. The study, released in indicators, such as mortality, that take we will never again have a famine as severe May (which made headlines in Europe but months to show up in the data. “I think we as this, with the kind of mortality that we barely a blip in the U.S.), has helped fuel need a different metric because mortality believe occurred, that we’ll fix this for the anger and frustration among humanitarian doesn’t always happen early, and it’s hard to next time—there are just too many factors professionals trying to understand how they measure quickly enough,” says Robinson. that will conspire against this, again possibly, failed—once again. Others insist the process—which sadly, even in Somalia,” says Robinson. After decades working in this region, relies on the Integrated Food Security Still, he hopes the study might help the international relief community is in Phase Classification (IPC) scale—is still promote a better understanding of what a position to do far better. A key part of the best now available means of achieving happened in Somalia and forge a new its extensive infrastructure are two early an internationally accepted determination international resolve of “never again!” warning systems, set up almost 30 years of famine, which should then galvanize ago, by USAID and the UN’s Food and unreserved global action. Agriculture Organisation (FAO). The Chris Hillbruner, one of the key By Ken Stier monitoring systems offer detailed on-the- technical experts involved in determining Illustration by Harvey Chan

FURTHER 47 FREE RANGE TALK INTERVIEW BY BRIAN W. SIMPSON CLF experts dish on the future of food PHOTOS BY CHRISTOPHER MYERS

ON A SNOWY SATURDAY, CENTER FOR A LIVABLE FUTURE FACULTY GATHERED AT BALTIMORE’S LIQUID EARTH CAFÉ FOR LUNCH AND CONVERSATION

Can the poor afford good quality, healthy food? Lawrence: The foodies are exploring; they’re trying new things. Robert Lawrence: It depends on what you mean by affordable. I’m And then other people eventually adopt those innovations. [But] reminded of the car mechanic: you either pay now or you pay later. unintended negative consequences are always a real problem. So think The externalized cost to health and to the environment of the current of quinoa. Quinoa was really introduced to consumers by a few people American diet really makes it unaffordable to all of us. Low-income who discovered its nutritional benefit, the taste. Some of the low- people get a special hit, however, because they end up buying more income people in the Andes, however, are actually no longer able to processed food because of the low retail cost but with the high content afford quinoa because, as a cash crop, its export value is much greater. of cheap inputs—fats, sugars, salt. Several researchers told me there’s a real chasm between nutrition Anne Palmer: Price is obviously a factor. If it’s going to be affordable and agriculture. and healthy, it’s going to be mostly raw products that you’re working Keeve Nachman: I think the nutrition and food systems communities with and not prepared foods. You need skills, kitchen equipment and are after the same set of goals. I think nutrition is just one way that knowledge about how to prepare it. the food system influences health. It benefits both of us to pursue a common ground where the recommendations that are made on the Has the foodie movement helped drive awareness of food quality and nutrition front could also guide people in making decisions on the sustainability? other aspects of the food system. Roni Neff: Absolutely, it’s made a huge difference. There’s now an ever-expanding market for the kinds of sustainably produced foods Is it possible to have healthy, fresh food that’s fast and easy as well? that we’d like to see more of. And the more market there is, the more Palmer: I don’t feel like we’ve really answered that question. If we’re production there is. being honest: Do I go home and cook a meal every night? Heck no, I don’t have time. So what do I do? We throw things together, we try and make it work. You try and make things as healthy as possible.

48 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 People are more inter- Food and food systems The long-term outlook Evidence about nutri- ested now than ever in have become a legiti- for a healthier, more tion and environmental where food comes from mate part of environ- nutritious, more sustain- impact is converging. and what goes into mental health sciences. ably produced diet for That provides further producing it. It’s really great to see the U.S. is optimistic. pressure for a healthier Keeve Nachman, PhD ’06, MHS ’01 that change. Robert Lawrence, MD and more sustainable Anne Palmer, MAIA food system. Roni Neff, PhD ’06, MS

Bob, what’s been CLF’s greatest epidemics of foodborne disease. Palmer: I’m naively optimistic Nachman: I’m going to give success—and its biggest So there’s a general uneasiness but I do feel like the entrenched you two. The first is, I wish failure? in the American public about business interests have thwarted that food packaging indicated Lawrence: The great success the safety of our food. But the a lot of substantial change for the external costs associated INTERVIEW BY BRIAN W. SIMPSON has been that discussion of connection between [that] and so long that it’s really going to with that particular food item. PHOTOS BY CHRISTOPHER MYERS the food system, and its role the fact that in a generation be tough. And that makes it I think if folks had a better as an important part of the and a half, we have totally sometimes feel a little bit really understanding of the health, public health agenda, has transformed the way in which we long-term, you know, when are environmental and ecological ON A SNOWY SATURDAY, CENTER FOR A LIVABLE FUTURE FACULTY GATHERED AT BALTIMORE’S LIQUID EARTH CAFÉ FOR LUNCH AND CONVERSATION been advanced tremendously produce food—especially food we going to reach that critical costs associated with what they by faculty, staff and students, animals with all the attendant tipping point where we see some choose to purchase and eat, through our innovation grants public health consequences and transformational change? the diet would change. And program, our fellowship pro- environmental consequences—I the other, as a parent of young gram, the courses that we don’t think the average person Nachman: I’m cautiously children, I’ve been disgusted offer, and our collaboration has made that connection yet. optimistic. I think we’ve seen by the marketing of processed with the Meatless Monday It’s literally out of sight, out of the groundswell really, really foods to children in schools. campaign. The biggest failure, mind. increasing. And I think the rate And I would be in favor of strict I would say, is that despite of that increase has ramped up regulation prohibiting that. some extraordinarily valuable So where are we headed? over the last few years. contributions to the knowledge Neff: It has been a slow-moving Lawrence: I would change base, the policy domain for the catastrophe, but there’s every If you could change one thing all of the policies that have U.S. food system remains highly indication that we could hit about the American diet, what promoted an inexpensive to resistant to evidence-based some real serious bumps. In the would that be? the consumer but very costly interventions. meantime, there have been a Neff: I would address the fact to the environment, high-meat lot of small, incremental efforts that in the U.S., we waste 30 diet: the subsidies for corn and What will it take to actually and policy changes. Many of to 40 percent of all food that’s soybeans, which mostly go to change the food system in the those could lay the framework produced throughout the feed animals instead of people; U.S.? for what we need in the face food system. That’s not just [and] the lax interpretation of Lawrence: The problem with of a really serious catastrophe. at the consumer level. That’s the Clean Air and Clean Water our food system is that it’s But we need to invest now in throughout, from production Acts that allows polluting to go a slow-rolling catastrophe. ramping them up. through consumption. on that is a central underpinning There are these episodic major of factory farming.

FURTHER 49 FURTHER INVESTIGATIONS

Caffeinated Waffles and the Law Make Your Mondays Meatless People have been drinking coffee and tea for Caffeine has crept into The Center for a Livable Future (CLF) this a caffeinated boost for centuries, but in the past fall celebrated 10 years of supporting the last few years the stimulant has crept into everything from “Wired” Meatless Monday campaign to encourage everything from “Wired” breakfast waffles breakfast waffles to Americans to eat meat-free one day a week. to “Perky” beef jerky to a new line of Cracker “Perky” beef jerky. The In 2003, advertising executive turned public Jacks called “Cracker Jack’d.” health advocate Sid Lerner teamed up with It’s a trend that caught the attention of trend caught the attention CLF to give the campaign a strong technical Stephen Teret, JD, MPH ’79, founder of the of Stephen Teret. assistance and scientific advisory resource. Johns Hopkins Clinic for Public Health Law Since then, Meatless Monday has spread to and Policy and a professor of Health Policy of elevated sodium levels in food served at 30 countries around the world. and Management. senior living facilities. In recognition of Lerner’s vision and “I wasn’t focused on the health effects They also made a video presentation to leadership to create a healthier America, of the caffeine per se, but if you start feeling Maryland Secretary of Health and Mental the School awarded him the Dean’s Medal, really good from the waffles because of the Hygiene Joshua Sharfstein, who later called its highest honor, at a scientific symposium caffeine, maybe you’re going to eat more for public comment on proposed regulations on the Meatless Monday anniversary of them than you normally would,” says based on the students’ work. This year’s in October 2013. “Sid took this idea Teret, who compares the practice to cigarette students presented the issue of caffeinated introduced during both world wars and manufacturers adding nicotine to cigarettes food products to Michael Taylor, FDA deputy turned it into an innovative public health to addict consumers. “It’s the sugar for some commissioner for food policy, explaining campaign, encouraging people to go without of these products or the salt or the fat that why the agency should be paying attention meat one day per week to improve not just will ultimately give you health problems, not to it. “It was just a fantastic opportunity for their personal health, but also the health the caffeine, but, like nicotine, the caffeine students because they have the ability to of the environment,” says Allison Righter, is what is habituating you. … I thought actually make change by talking to someone MSPH ’12, RD, a program officer at CLF. that there’s something the FDA ought to be who is in the position to affect the regulatory “It’s grown tremendously despite no paid doing about it.” structure of food in the United States,” says advertising budget.” In other words, the issue was ripe Teret. “And that’s exactly what the clinic was Meatless Monday participation has for study by Teret’s health law and policy designed to do.” increased dramatically, Righter says. clinic, which he began in 2012 as a way for This spring his clinic plans to address Celebrities like Oprah Winfrey and students to gain hands-on experience solving the issue of states experimenting with drugs Gwyneth Paltrow have joined the campaign, public health problems. In the clinic’s first to be used as lethal injections when executing as have universities, food bloggers and high- year, Teret’s students examined the issue death-row prisoners. —Joe Sugarman end New York restaurants. Thanks to these

50 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 FURTHER INVESTIGATIONS

Make Your Mondays Meatless A Wider Search for Obesity efforts, nearly half of all Americans are Over the last two decades, the soaring care provider; the study includes more than now aware of Meatless Monday, according prevalence of childhood obesity has alarmed 164,000 children in some 1,300 communities to a 2012 national survey, and many are and perplexed the public health community. in almost 40 counties in central and changing their behaviors as a result. Yet, there has been a precious little northeastern Pennsylvania. Longitudinal Changing your behavior just one day per understanding of the complex interplay of aspects will evaluate how body mass index week might not sound significant, but small environmental factors that influence obesity. trajectories and community contexts such changes may kick start larger behavioral Now, a team of Bloomberg School as population density, socioeconomic status shifts—both personally and culturally. researchers has begun a massive, first-of- and distance to food sources have changed CLF scientists backed up this concept with its-kind study to explore the community since 2001. literature reviews that documented the dynamics of childhood obesity. The multi- Among its more intriguing aspects, the efficacy of periodic prompts in changing component study, led by Thomas A. Glass, study will also measure DNA methylation—a behavior and Monday’s cultural significance PhD, MA, and Brian S. Schwartz, MD, biochemical process by which genes are and usefulness in health promotion. MS, who are part of the Johns Hopkins turned on and off in cells—to assess how Building on the success of Meatless Global Center on Childhood Obesity, will community environments potentially alter Monday, The Monday Campaigns look at numerous community factors that gene expression and influence obesity. organization has expanded into other contribute to childhood obesity, including “This will be among the first studies “Healthy Monday” ideas, such as quitting land use and food environments, as well as of community factors, childhood obesity smoking, encouraging kids to cook and physical activity settings and social contexts. and DNA methylation, which is thought hitting the gym. Scientists from the “This will provide an unprecedented and to play a role in stress, appetite control and Department of Health, Behavior and richly detailed view of childhood obesity,” inflammation systems,” Schwartz says. “This Society published a study in October 2013 says Glass, an Epidemiology professor. may tell us how a variety of community in JAMA showing that people are most likely “This study is about big data and big factors like neighborhood design, food to consider quitting smoking on a Monday. epidemiology,” says Schwartz, a professor of proximity and walkability literally ‘get under Their analysis of Google searches in six Environmental Health Sciences. “We will the skin’ to influence health.” different languages found that people were have longitudinal data on both risk factors He adds: “We’re still early in the study, most likely to search Google for information affecting obesity and height and weight but we already know how several individual on quitting smoking on Mondays. measurements throughout childhood, health factors—family socioeconomic status, “Mondays are a chance to start fresh, something few if any prior studies have child diagnoses, child medications and which encourages people to make positive used.” community deprivation—are influencing changes for their health,” Righter says. Health data will be drawn from the body mass index growth in early, middle and —Carrie Arnold electronic health records of a large health late childhood.” —Andrew Myers

FURTHER 51 FOUR BIG ISSUES

Are GMOs a good idea? Is food a human right?

People want to know: Are genetically modified organisms (GMOs) All citizens of the world have a right to food. causing diseases? Are they bad for my health? The science isn’t really Under UN guidelines, the right to adequate food is everything settled on those questions. It’s not clear if there are direct negative from nutritional quality to sufficient calories, so food adequacy is this health effects from consuming GMOs. broad concept of good, healthy, safe and culturally appropriate food. But to really evaluate GMOs from a public health perspective, Globally about 2.5 billion people lack food security. Almost a we need to look beyond food consumption. Food production affects billion are malnourished. Policy changes are needed to support small the environment, populations in surrounding communities and farmers in low-income countries with better seeds and fertilizer, people working throughout the food system. better use of water, access to markets and protection from subsidized The two most widely used GMO crops in the U.S. are corn and commodities from high-income countries. soy designed to withstand a specific herbicide. Monsanto sells both When you look at the statistics in the U.S., 15 percent of the the GMO seeds and the herbicide, known as Roundup. Over the population lives in poverty. Even with SNAP (the Supplemental years, Roundup-treated weeds have become tolerant to the herbicide, Nutrition Assistance Program), many people run out of benefits leading to increasing doses and runoff, resulting in growing risks to halfway through the month and turn to cheap, high-calorie, public health and the environment. processed food because it’s available in low-income neighborhoods. The latest chapter of the GMO story is the development of That is a failure of the federal government to fulfill the right to GM salmon for human consumption. GM animals produced for nutritious, affordable food. And it’s a factor in the 600,000 premature direct human consumption is something we’ve never seen, and FDA deaths in the U.S. that are the result of a poor diet. officials evaluating its safety are relying on data from the company If we could ensure food security tomorrow to the 18 million seeking approval. people in the U.S. who don’t have access to enough food—or the right Overall, the use of GMOs to date has been a negative for the food kinds of food—the number of premature deaths would plummet. system and for public health because of increased use of chemicals As public health people, through our training and research and and other issues. It’s conceivable that genetically modified food could knowledge, we have the duty to work more effectively for better food be used in a positive manner, but many factors need to be considered policies and for greater access to healthy foods. in addition to dietary intake risks. Robert S. Lawrence, MD, is director of the Center for a Livable Future. Jillian Fry, PhD ’12, MPH, is project director for Public Health and Sustainable Aquaculture at the Center for a Livable Future.

52 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 FOUR BIG ISSUES

ILLUSTRATION BY DUNG HOANG

Are we reaching the end Why are there so many of cheap food? food allergies now?

It’s difficult to predict the future. But I really do think we cannot It’s likely that many things have changed in the environment, in our continue long-term with the availability of cheap food—and in diets and in child-rearing practices that have led to an increase in saying this, I should note that for many, it already seems anything food allergies in the past 20 years. but cheap. One of the most popular theories is the hygiene hypothesis. If We’re not paying the full cost of the food, which includes the the developing immune system is not exposed to enough levels and overuse of natural resources, the contaminants we’re putting out types of germs and bacteria, its focus may shift, leading to allergies or there and the fact that food system workers often don’t earn a living autoimmune diseases. Worldwide, there’s a lot of evidence to support wage. Someday those costs will show up in our food prices. this, as food allergies are much more common in developed countries. With a global population that’s expected to hit 9 billion by 2050, But the hygiene theory does not seem to be the most important factor the UN predicts we’d have to expand food production by 70 percent. in developed countries. Higher rates of food allergies in inner-city But environmental threats are going to make it challenging even to populations contradict the hypothesis. maintain current levels. It’s hard to imagine that technological fixes In terms of nutrient-related allergy causes, two theories have are going to solve these problems. some evidence to support them: vitamin D deficiency and excess I don’t say it’s impossible, but I think it will require some folate. Compared to two decades ago, there’s a much higher rate of big changes. We could feed a lot more people by reducing meat vitamin D deficiency—especially in northern climates. This may be consumption because it’s so inefficient to produce. And cutting into diet-related, but it’s also because most of us spend more time indoors. food waste is critical: Thirty to forty percent of all the food that’s And about 20 years ago, women who were pregnant began taking produced is wasted—in fields, during storage and transport, and by supplements with high levels of folic acid to prevent birth defects. So retail, restaurants and consumers. there’s been a major change in developing infants’ exposure to folic We eventually will have to move into more sustainable types of acid. food production and distribution systems. It’s happening now, but I think we’re going to learn that there are quite a few more not even close to the scale that’s needed. contributors to food allergies. Some are under investigation; some we haven’t thought of yet. Roni Neff, PhD ’06, MS, is director of Food System Sustainability and Public Health Program at the Center for a Livable Future. Robert A. Wood, MD, is chief of Allergy and Immunology, Johns Hopkins Children’s Center; and professor of International Health.

FURTHER 53 (Continued from page 29) fluctuations in nutrition, they will also longer-term view. This will help us find ways likens noodle manufacturers to American conduct surveys each September (after to guide programs toward greater impact, to tobacco companies because they are pushing the monsoons) and each January in three favor the good influences while always trying harmful products, “deteriorating the health representative “sentinel” communities—one to lower costs.” status of our children.” in the mountains, one in the plains and one Nepal’s Ministry of Health would Pokharel looks forward to finding out in the hills (in Sitapur, in fact). value that kind of recommendation, says Raj what the PoSHAN household surveys show For Sitapur and other hill communities, Kumar Pokharel, MPH, chief of the child about what people actually eat, day to day. preliminary results are in: 36 percent of nutrition section. “Experts come and give The government will use that information children under 5 are moderately or severely ideas, for example, small fish farming or a to advocate for crops that will support or stunted. That’s slightly better than the sweet potato hybrid,” says Pokharel. “Some improve diets in the various ecological zones, national average of 41 percent. say, ‘Oh, golden rice is a very good source and to fine-tune programs that educate Analyzing the data further will allow the of vitamin A and micronutrients.’ We don’t people about what to grow and what to eat. PoSHAN researchers to look for associations know what to adopt. … The agricultural Declines in stunting will signal success. between good nutrition and the many factors sector wants to increase productivity and There’s no time to waste, says Pokharel. that affect it. For instance, perhaps the variety. But it’s dietary diversity within the Nepal did manage to reduce stunting by 8 surveys will show that families have fewer household that we want to cultivate.” percentage points between 2006 and 2011. stunted children if they build toilets or have That applies to both the poor and the But at that rate, it will take a generation to cleaner sources of drinking water. Perhaps (relatively) rich: Not only were 81 percent bring it below 5 percent. it will show that one program promoting of Nepal’s poorest children stunted in “Stunting reduces IQ levels and the hygiene and sanitation was associated with 2011, but so were 32 percent of the richest. capacity of the brain,” says Pokharel. “If you improved nutrition, while another was not. Pokharel blames poor nutrition partly on fast can calculate it in terms of daily losses, in “We get at least a snapshot of these foods like the instant noodles whose bright terms of how much we are losing every day, kinds of patterns,” says West, “ and returning packages occupy the front racks in urban every minute, every month and every year, next spring to the same homes will give us a food shops and village markets alike. He we cannot wait.”

Left: Project scientist Swetha Manohar supervises as two enumerators measure a toddler’s upper-arm circumference. 54 JOHNS HOPKINS PUBLIC HEALTH / SPECIAL FOOD ISSUE 2014 Right: A schoolgirl washes clothes at a community pump in Durkatta.