Alexander Zehnder is the Scientific Director of the Alberta Water Research Institute in Edmonton, Canada. A few weeks ago, he gave a lecture entitled “Water for Life, For How Many?”  at Nanyang Technological University in Singapore where I am currently Visiting Associate Professor. 

Zehnder listed 6 major challenges facing the world regarding water:

Good water for a growing population

Water induced disasters protection

3)   The water infrastructure for distribution and collection

4)   The distribution of water between humans and ecosystems

5)   Solutions for water conflicts and fair water share for all

6)   Enough food for all

There are 3 kinds of water, according to Zehnder: blue water, which lands in rivers and places from which we drink; green water, which lands on green spaces and vegetation, which uses it to grow and eventually evaporates or just sits there; and virtual water, which is the water that is turned into food that is traded and sold across communities and national borders.

Virtual water is very interesting and important since the vast majority of countries import it (in the form of food).   There are 5 countries on the planet that are by far the largest exporters of virtual water: USA, Australia, Argentina, France, and Canada.  These countries, according to Zehnder, feed the world.  Most countries of the world are food importers (including China and India) and this disparity will only increase as the populations of these countries also increase. Africa may suffer the most because of enormous population growth and world trade and financing policies that favor richer exporting countries.

The demand for water is increasing further as more Chinese and others move into middle class and are interested in eating more meat. The production of meat requires about 10 times more water than the production of non-meats. If we all became vegetarians, according the Zehnder’s data, we would have enough water to meet the growing demands. However, he is not advocating universal vegetarianism.  He loves a good steak.

Since water and food are so inexorably connected, Zehnder believes that efforts at turning millions of acres of corn or sugar into fuel is “the dumbest idea ever.” Instead, we need to use the water for food and solve our fuel problems with other strategies.

Since he did not specifically address conflicts over water during his talk, I decided to ask him about it when the floor was opened up for questions. He said that even though some are claiming that water will be the cause of future (if not present) global conflicts, he disagrees. In the short run, there are conflicts over water. However, over the long run, countries realize the interdependence of their water needs and that water will actually bring people closer together.  That may be hopeful but examples from Turkey and Egypt seem to confirm his hypothesis and the current water issues in Southeast Asia (between China, Vietnam, Laos, and Cambodia) may be a test of his theory.

In the end, Zehnder himself concludes four things: 1) The growing economic and political dependence on virtual water must be addressed, 2) Virtual water should be part of all water management decisions, 3) Economic power of the poor countries must be strengthened to cope with water instability, and this is a not just a responsibility of richer (water exporting) countries, but it is also in their own interests, and 4) geopolitical efforts are needed to abandon the myth of national food self-sufficiency.

So water should be used for people and food, not for fuel.

I finally gave in and saw a health provider for my painful upper back. It felt like a bad stiff neck that normally would go away in a couple of days. Only it didn’t go away.

I made an appointment with an orthopedist. He had a tiny two room office in a fancy medical center complex. There was no examining table in the room only a bench. He spent about 3 minutes asking me questions and said I needed an x-ray, which I got immediately by going down the hall to an imaging clinic.  I waited for the results and they gave me the x-rays to take back to the doctor.

Back in his office, the doctor said that my problem was inflammation. He recommended an injection of shincort and a course of the medication celebrex. I  had never heard of shincort and asked him if it was like cortisone. He said it was a new and improved version. I am never eager to get invasive treatments, but I was in pain and desperate to heal (I signed up for a 168km bike ride at the end of the month) so I agreed to the shot as well as the celebrex.  He said I would see improvement in 3 days.

Before leaving his office, I paid the bill, which amounted to $350 US dollars. I do have insurance but I am not sure what they will pay given that this is Singapore. The bill included no diagnosis and no codes which are usually required by my insurer.

I was no better after 3 days so I decided to find a physical therapist. I’ve had mostly positive experiences with PTs in the US (some of whom are my colleagues at the College). They usually give me ultra sound, nerve stimulation, and exercises.  Here they are called physiotherapists. They are quite common but I could find none in the vicinity in which I live.  So I picked one based its website and on the ease at which I could get there (about 45 minutes on the bus/train).

In a few days I was a patient at a clinic where Sylvia examined me.  I told her the diagnosis the doctor provided but she didn’t fully agree. She asked me to lie face down on the examining table and started massaging and pressing my neck area. It was painful, but she said the massage would help and I told her to proceed.

After 10 minutes, she checked my next tightness and pain. It was less tight, but not good enough for Sylvia, so she pressed more. After 4 times of massaging and checking, she said that was all my neck could take in one session. She gave me a heating pad for 10 minutes and told me to return in a few days.  When I left the office, I could actually move my neck to the right without pain for the first time in a month.

Every day, my neck improved a bit more. I returned to Sylvia for another treatment and it improved further. I was a happy and recovering patient. By the way, each treatment cost about $56 and I don’t know what insurance will cover.  Most of all, I liked the hands on treatment – no machines- and I felt better.

I wanted to learn more about Singapore’s health system, but I didn’t think I would do it from a patient’s perspective.  In 2000,  Singapore’s health system was ranked 6^th best in the world by the World Health Organization while the US was 37^th. Check out (http://www.photius.com/rankings/healthranks.html) or for a rock’n’roll version:http://www.youtube.com/watch?v=yVgOl3cETb4

 I can move my neck but I hope I can ride my bike for 168km.

Since the beginning of January, I have been living in Singapore. It is almost exactly halfway around the globe from my home in Ithaca. The plane from Newark that brought me here traveled due north to the North Pole, then due south to Singapore.   It is a mere 85 miles north of the equator. Ithaca, it is not.

If you twirl a globe or look at a world map you will notice that the equator traverses mostly water. Going west from Singapore, it crosses Maldives then Somalia, Kenya, Uganda, Congo, Sao Tome and Principe, and Gabon in sub-Saharan Africa .  It cuts across the Amazon in northern Brazil, Colombia, and Ecuador in South America. From there, it’s a long ocean passage west to Kiribati and Indonesia, with Singapore nearby.

This geographic location made me think about the health issues of people who live near the equator, where the weather is hot and sticky in some places, hot and dry in others, but always hot. Images of the equator conjure worries of insects with malaria and dengue fever,  jungles with snakes and spiders, or deserts with scorpion and drought.  The amount of sunlight and darkness hardly changes at all during the year at the equator.

Of the countries listed above through which the equator passes directly, most are poor with poor health data. For example, the life expectancy of Somalis is about 35 years, about 145 children out of 1000 die before the age of 5, and  they spend an average of $18 per person each year on health expenditures (of course it is hard to spend when one does not have). Ecuador, along with Brazil, have the most healthy overall populations on the Equator.  Ecuadorans live to about 73 years old, 24 children out of 1000 children die before the age of 5, and they spend about $297 per person each year on health expenditures.  The other  countries are somewhere in between according to the data from the WHO (http://www.who.int).

Singapore is quite a contrast. The average life expectancy is about 81 and only about 3 children out of 1000 die before the age of 5. These are among the best statistics in the world, significantly higher than the US even though Singapore spends only $1228 per person each year on health expenditures compared to about $6700 for the USA.

To explain this contrast could take awhile, but I will try to summarize here in two words: public health. Of course, it is more complicated than that. Singapore is a relatively new country forming in 1965 after a failed merger with Malaysia. (For an interest recent perspective on the current state of the country, try reading this piece from National Geographic:  http://ngm.nationalgeographic.com/2010/01/singapore/jacobson-text) 

Singapore is also a country that carefully controls its borders,  has low rates of unemployment and crime, high rates of home and apartment ownership in safe neighborhoods, integrates government ownership with private ownership of industry, and provides quality education. Most of which are strong determinants of health. The water is safe to drink and the island is malaria free (though dengue fever is a concern). To some, this has come at some cost such as the bulldozing of small (and less healthy) villages, severe criminal penalties for illegal drug use and trafficking, very high taxes on alcohol, and a government Health Promotions Board that enforces bans on smoking and spitting. It’s rare to walk more than a block without seeing some evidence of a health marketing campaign.  Yet from a public health perspective, the results are remarkable. 

Now that I am a resident, stay tuned for more comments about life and health in this part of the world.

 I cannot recount the number of times in the past few weeks friends, relatives, students, and strangers have asked me whether they should get the H1N1 vaccine.

 Some are concerned about the side effects or wonder whether the vaccine has been tested. Parents are worried for their young children.  They are concerned about the claims of links between vaccines and autism even if they know that there has never been a credible study demonstrating it.  Some of my students say that the flu sucks, but it isn’t bad enough to get a vaccine.  They ask: Is it effective? Will the vaccine make me sick?

 Let me be clear: I am neither a physician nor a scientist.  On the other hand, many don’t seem to trust physicians or scientists who claim the benefits of the vaccine with near unanimity even while some admit that we really will not know how effective the vaccine is until H1N1 has run its course.  So when people ask for vaccine advice (or any medical advice for that matter), I hesitate to tell them what I think.  I can only tell them what I would do.

 I would vaccinate. And I will vaccinate after they cover all those who are most at risk.  Why, you might ask.  There are two major reasons for vaccinating. One is self-interest. Who wants to be sick? Second, I don’t want to infect anyone else.

 Most of us don’t think of the second reason, especially in the U.S.A.  In many parts of Asia, for example, the culture of community responsibility is embedded (admittedly, it is also mandated in some places). Living in Singapore in 2003, residents would wear masks if they had symptoms to prevent the spread of infection. And that was BEFORE the SARS epidemic.

 Luckily, I am a generally healthy 50+ year old. Thus, I am low on the priority list for the H1N1 vaccine.  But when I am called, I will be vaccinated.  I hate being sick, but I also don’t want to infect pregnant women, young children, or anyone else who might be at higher risk than I. 

 For anyone who is wavering, think of it as giving a gift to those around you who will NOT be infected because you vaccinated. 

 What we really need is health reform, not just health insurance reform.

 Interesting, exciting, confusing, frustrating, and disappointing are just few of the more generous terms I can use to describe the current state of what is being called the “health reform” debate in the U.S. 

 I pose a few basic questions and respond based on what the likely outcome appears to be: an private insurance-based system with no “public option”.

 Is it really “health reform”? 

Hardly.  Let’s call it “health insurance reform.” It’s about removing one major barrier for those without health insurance: money. However, providers of care – hospitals, physicians, and others- do not have to accept whatever payment system will be in place. So access may still be limited. For example, in the Ithaca area where I live only about half the physicians are currently accepting new Medicare and Medicaid patients. Will they accept new patients in the future?

 Health insurance reform will not likely diminish the inequalities that exist due to factors such as race, gender, sexual preference, geography, education, and social status.

 What would “health” reform look like? 

There are two ways to answer this. 

First, we would have to change the mechanism and culture of medical care.  A “health” system that focuses on keeping people healthy instead of rewarding the treatment of the ill would prevent problems and likely save an enormous amount of money over the long run. Initial investments in changing our system will be costly, but will be worth it.

For example, we pay cardiologists in the thousand of dollars for performing 60 minute procedures in their offices or outpatient clinics. However, we pay them much much less for spending 60 minutes with their patients discussing ways to improve or maintain their health status such a nutrition, stress reduction, and physical activity. What do you think most doctors decide to do?

 Second, let us consider the areas know as the social determinants of health. 

We know that “health” is far more than access to medical treatment.  Consider the “choices” one has for purchasing healthy food on a low fixed income, for example.  What food stores are available in their neighborhood? What parks or recreation opportunities are available? Is their neighborhood safe?  Therefore, “health” reform means doing something to increase and improve the choices one has where they live.

Here are other social determinants of health:

race, education, housing, employment and occupation, and stress.  We rarely consider these when discussing “health insurance reform.”  

So we need to change the terms of the debate.

If the goal of reform is to improve health status for as many people as possible, then removing financial barriers to care is only one way. Investing in better housing, wider access to education (not just health education), healthier neighborhoods, food policies with consumer health as a priority, healthier workplaces, and acknowledgement of racial inequalities in health would mean real health reform.

Here are a few sources to check out:

Reaching for a Healthier Life: Facts on Socioeconomic Status and Health in the U.S. (This is a clear and concise explanation of the social determinants of health.)

www.macses.ucsf.edu/.../Reaching%20for%20a%20Healthier%20Life.pdf

Unnatural Causes: Is Inequality Making Us Sick?