The World in 2050: The Future of Wellbeing by MG Publishing

THE WORLD IN 2050 THE FUTURE OF WELLBEING

A Bookazine Edition by

THE WORLD IN 2050 THE FUTURE OF WELLBEING ANA C. ROLD EDITOR

DIPLOMATIC COURIER | MEDAURAS GLOBAL WASHINGTON, DC

A Global Affairs Media Network

Editor-in-Chief Ana C. Rold

Editorial Board Andrew M. Beato Fumbi Chima Sir Ian Forbes Lisa Gable Mary D. Kane Greg Lebedev Anita McBride

Editors

Kathryn H. Floyd Michael Kofman Paul Nash

Creative Director Christian Gilliham

Photographers

Michelle Guillermin Sebastian Rich

Contributors

Nebeyou Abebe Amy Adkins Sangeeta Agrawal Akshan de Alwis Ellesse Balli Kathy Bates Roger N. Beachy Gwendolyn Beck Madeline Bielski Abhirup Bhunia Charles Crawford MarĂa de los Angeles Crummett Jordan Ernstsen Kathryn H. Floyd Judy Gibson Justin Goldman Epameinondas Gousopoulos Jim Harter David K. Hill Foluso Ishola Sarah Jones Linda P.B. Katehi

Elizabeth Maclean Paul Nash Arun S. Nair By Mario Ottiglio William Repicci Jennifer B. Rhodes Richard Rousseau Winona Roylance Jean-Claude Saada Augusta Smallwood Mary Utermohlen Dan Witters Molly Wheeler

Editorial Research Amar Kakirde Hannah Olivieri Yuki Preechabhan

1660 L Street, NW, #501 Washington, DC 20036 info@diplomaticourier.org

Copyright ÂŠ by Diplomatic Courier/Medauras Global Publishing 2006-2016 All rights reserved under International and Pan-American Copyright Conventions. First Published 2016. Published in the United States by Medauras Global and Diplomatic Courier. 1660 L Street, NW, Suite 501, Washington, D.C., 20036 www.medauras.com | www.diplomaticourier.com Library of Congress Cataloging-in-Publication Data Rold, Ana C 1980The World in 2050: The Future of Wellbeing / Ana C. Rold, Editor ISBN: 978-1-942772-07-1 (Digital) ISBN: 978-1-942772-06-4 (Print) 1. Rold, Ana, 1980-. 2. Megatrends. 3. Wellbeing. 4. Health. 5. Wellness. 6. Nutrition. 7. Title. NOTICE. No part of this book may be reproduced in any form, except brief excerpts for the purpose of review, without written consent from the publisher and author. Every effort has been made to ensure the accuracy of information in this publication; however, the author, Diplomatic Courier and Medauras Global make no warranties, express or implied, in regards to the information and disclaim all liability for any loss, damages, errors, or omissions. For permissions, email info@medauras.com. EDITORIAL. The articles in Diplomatic Courier both in print and online represent the views of their authors and do not reflect those of the editors and the publishers. While the editors assume responsibility for the selection of the articles, the authors are responsible for the facts and interpretations of their articles. Every effort has been made to ensure the accuracy of information in this publication, however, Medauras Global and the Diplomatic Courier make no warranties, express or implied in regards to the information, and disclaim all liability for any loss, damages, errors, or omissions. PERMISSIONS. None of the articles can be reproduced without their permission and that of the publishers. For permissions please email the editors at: info@medauras.com with your written request. 4 | THE WORLD IN 2050 ART | PHOTOGRAPHY. All images and photos by Bigstockphotos.

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THE FUTURE OF WELLBEING | 5

CONTENTS 009

INTRODUCTION By Ana C. Rold, Editor

012

IN PURSUIT OF LONGEVITY: LESSONS FROM NANA By Jean-Claude Saada

018

ESSENTIAL WELLNESS By Dr. David K. Hill

023

MOBILIZING EDUCATION FOR GLOBAL HEALTH By Constance St. Germain

027

SEX AND THE CITIES: THE IMPACT OF URBANISATION ON SEXUALLY TRANSMITTED DISEASE By Elizabeth Maclean

031

ENGAGED EMPLOYEES LESS LIKELY TO HAVE HEALTH PROBLEMS By Jim Harter and Amy Adkins

035

COMPANIES’ ROLE IN IMPROVING EMPLOYEE AND COMMUNITY HEALTH AND WELLBEING By Nebeyou Abebe

039

HOW MOBILE TECHNOLOGY CAN IMPROVE EMPLOYEES’ WELL-BEING By Dan Witters and Sangeeta Agrawal

043

SMART THINKING FOR HEALTHY LIFESTYLES By Mario Ottiglio

046

FIGHTING LYMPHEDEMIC CANCER AND BEYOND By William Repicci, Epameinondas Gousopoulos, and Kathy Bates

049

WE ARE ALL IN THIS TOGETHER By Maria de los Angeles Crummett and Judy Gibson

053

MIGRATION AND WOMEN’S HEALTH: A NEGLECTED ISSUE IN NEED OF ACTION By Elizabeth Maclean

THEWORLD WORLDININ2050 2050 66| |THE

CONTENTS 057

THE PARADOX OF EMPOWERMENT By Augusta Smallwood

061

THE FUTURE OF PREVENTIVE HEALTH AND WELLBEING By Foluso Ishola

064

RELATIONSHIPS MATTER MOST By Jennifer B. Rhodes

066

FINANCE AND AGING By Gwendolyn Beck

068

WHO ARE THE HAPPIEST PEOPLE IN THE WORLD? By Winona Roylance

071

THE PERFECT LAWN: CLIMATE CHANGE, NATIONAL SECURITY, AND DEATH By Kathryn H. Floyd

074

EGYPT’S HEALTHCARE REVIVAL By Dr. Paul Nash

078

THE FUTURE OF HUMAN LONGEVITY By Madeline Bielski

081

GLOBAL HEALTH VIS-À-VIS DIPLOMACY By Dr. Epameinondas Gousopoulos

085

POLIO’S BACKDOOR INTO CHINA By Dr. Paul Nash

089

WORLD ECONOMIC FORUM TECHNOLOGY PIONEERS DISRUPTING HEALTH By Jordan Ernstsen

093

CHINA AND INDIA’S GROWING INEQUITIES IN ACCESS TO HEALTH CARE By Abhirup Bhunia

THE THEFUTURE FUTUREOF OFWELLBEING WELLBEING| |77

CONTENTS 097

PRIVATE SECTOR SOLUTIONS IN FOOD SECURITY AND NUTRITION By Philip H. de Leon

101

BUILDING NEW MODELS TO NOURISH 7 BILLION By Dr. Klaus Kraemer

105

FEEDING THE PLANET; EMPOWERING WOMEN By Irene Khan

111

A SURPRISE LEADER IN FIGHTING HUNGER By Mohammad Ziauddin

115

FISHING FOR THE FUTURE By Madeline Bielski

119

RETHINKING EGYPTâ&#x20AC;&#x2122;S WHEAT BARNS By Dr. Paul Nash

123

UNIVERSITY-BUSINESS COLLABORATIONS KEY TO GLOBAL FOOD SECURITY By Roger N. Beachy

127

UPROOTED: THE FUTURE OF VERTICAL FARMS By Ellesse Balli and Molly Wheeler

131

FEEDING THE FUTURE By Linda P.B. Katehi

8 | THE WORLD IN 2050

INTRODUCTION BY ANA C. ROLD

ith the advent of new technologies such as artificial intelligence, sensors, robotics, 3D printing, big data, genomics, and stem cells there is no field more ripe for disruption today than the healthcare industry.

We live in an age of major disruption. According to the Ollin Business School, most of today’s Fortune 500 companies will be gone in the next decade. And there is no field more disrupted than healthcare. And that’s a good thing. Doctors spend $210 billion per year on procedures that aren’t based on patient need, but fear of liability. Americans spend, on average, $8,915 per person on healthcare – more than any other country on the planet. Prescription drugs cost around 50% more in the U.S. than in other industrialized countries. And at this rate, by 2025, nearly ¼ of the US GDP will be spent on healthcare. As you can see, healthcare is massively broken and entrepreneurs are finding new ways every day to make you the CEO of your own health and to replace (and even eliminate) doctors and hospitals. How? Think about what happened to the libraries in the age of Google; or taxis in the age of Uber; or long-distance calling in the age of Skype. The list goes on. The good news? We are on the cusp of witnessing the biggest breakthroughs humanity has ever seen. And everyone is in on it. THE FUTURE OF WELLBEING | 9

Last year at the United Nations annual General Assembly meetings, the world’s nations adopted a new set of goals for humanity, the Sustainable Development Goals (SDGs). But the nations’ political leaders were not the only stakeholders—businesses, philanthropic institutions, media personalities, international NGOs, and a coalition of very diverse constituents have all vowed to pitch in to make it all happen. Goal 3 of the plan focuses on increasing life expectancy, reducing child and maternal mortality, increasing access to clean water and sanitation, and reducing the spread of diseases such as malaria, tuberculosis, and polio. The new Goal 3 aims to improve health systems, health research, and health financing. But there is more to health than the absence of disease. Some call it happiness. Others call it wellbeing. And others call it quality of life. And we all agree: this is not some elusive concept; it directly affects our performance at work. Having spent some time in the international policy arena as the editor-in-chief of Diplomatic Courier, the G7 and G20 Summit magazines, I have seen an interesting shift the past decade: world leaders have put at the top of policy agendas topics that used to be considered “soft”. These topics range from food security, nutrition, climate change, and education of girls, to healthcare and wellbeing. How did these issues top agendas that used to be riddled by “hard” geostrategic concerns? Having covered many of these meetings on the ground I have noted that increasingly, society at large now has a bigger voice and stake at these top-level summits. Importantly, this signals a new era for global engagement: the solutions to our world’s largest challenges will not come solely from the political sphere. Other actors are stepping in and in doing so they have filled leadership vacuums and created unprecedented opportunities for cross-sector collaboration. And we fundamentally agree: everyone wants to be happy. But what we have not figured out yet is how we should do it with policy, education, and community investment. When the discussion goes there, the question becomes: who will pay for all this innovation? My guess: probably not the consumer. Most likely it will be the insurance company, which makes a lot more money when we stay out of the hospital and live longer—so they can collect more fees and pay out less. But beyond the innovation, the future of health and wellbeing discussion centers on our elevated sense of purpose in life. Psycholo10 | THE WORLD IN 2050

gist have found that people who have this tend to live longer and experience less physical infirmity. This also resonates with a recent trend called “primordial prevention”. While our healthcare has focused thus far on primary prevention—intervening before a disease is developed—or secondary prevention—trying to prevent progression of a disease when people are already sick—primordial prevention looks at prevention of the risk factors in the first place. The best place to start is figuring out what allows people to attain and maintain health in the long term. And this is where wellbeing and happiness become the factor modern healthcare should begin with. Ana C. Rold, Editor Diplomatic Courier Washington, DC May 2016

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IN PURSUIT OF LONGEVITY LESSONS FROM NANA BY JEAN-CLAUDE SAADA

y family recently lost our matriarch–my grandmother, Nana, who was 102 years old. It was a sad event, but also cause for celebrating a life extraordinarily well lived.

For me, her passing prompted reflection about how her way of life can inform the development and support of longevityenhancing communities across the United States and around the world. You see, Nana truly LIVED her life. She was healthy and vibrant well past her 100th birthday. As her grandson, I hope robust genes played a role, but I know we owe her experience to more than just genes. Her longevity didn’t happen by chance, or by accident. Nana was mindful about everything. She was petite, with a fist half the size of mine. She used her fist to measure the meals she placed on her plate: a fistful of greens, vegetables, protein, whole grains, fruit. She knew portioning modest amounts of fresh, nutrient rich food was the healthiest way–and, better yet, the most flavorful and enjoyable way–to set her table. She spent much of her time outdoors, from Cairo where she raised her family, to the United States where she became a proud citizen, to the coastal regions and mountain villages of Lebanon where she lived her later years. In each of her homes around the globe, she was an enthusiastic member of tight-knit, supportive communities. She lived in the gardens, along the sidewalks, and in the green spaces and public places around the homes of her friends and neighbors. 12 | THE WORLD IN 2050

She walked to local markets, selecting fresh produce and lean proteins from nearby farms, returning home with only as much as she could carry to serve that evening. That’s “Farm to Table” at its most effective. She remained engaged–always seeking new experiences and gathering generations of family around to draw strength from their energy and to share her wisdom from walking the earth for so many years. As she neared 100, she began a “romance” with an 85-year-old suitor. Talk about staying engaged! She prayed frequently, which both calmed and invigorated her. Whether one is religious or not, life must have purpose to be sustained. She knew that instinctively, and I learned it from her. Indeed, I’ve learned a lot about purpose. For nearly 30 years, my team has developed sophisticated medical facilities across the United States. Our intense and passionate focus on improving the human experience using real estate has helped people return to health faster than they otherwise would have. We’ve won 55 awards for that work, but more importantly, we’ve made a positive difference in many lives. But with Nana’s help, I learned that for all the good we do in healthcare, we’ve missed an opportunity to do more–to do better. I realized that healthCARE happens when HEALTH has failed. Many places around the world have failed to do the foundational work of illness prevention, which can reduce human suffering and avoid costs which can be so catastrophic to families, communities and economies. Consider that in the United States, 75% of the $3 trillion spent annually on healthcare goes to mitigate chronic, preventable ailments. Unhealthy weight and obesity, in particular–which plague two-thirds of adults and one-third of children–are linked to four out of the top five leading causes of death. The United States spends more than twice as much on healthcare as other developed nations, yet was dead last in a 2014 study measuring quality of care in 11 countries as defined by access, efficiency, equity, and healthy living. Scores were notably poor on infant mortality and productive years past age 60–two key “healthy living” indicators. Sadly–indeed, shockingly–public health experts now warn that failure to prevent illnesses associated with inactivity and food intake could make the current generation the first to live shorter lives than their parents. I can’t think of a statistic that demands action more urgently than that. Lest we think this problem is limited to developed countries, the World Health Organization reports that obesity has more than doubled worldwide since 1980 and that most of the world’s population currently live THE FUTURE OF WELLBEING | 13

in countries where obesity kills more people than undernourishment. National Institutes of Health Director Francis Collins has observed that chronic diseases are the fastest growing causes of death and disability around the globe and adds that urbanization can aggravate the problem; growth in personal purchasing power can enable the choices that raise the risk of chronic disease. Add to these lifestyle factors the results of scientific studies showing that a baby is born today with 250 potentially harmful chemicals in his bloodstream because of the air his mother breathes at home and work. Consider that we spend 90 percent of our time indoors, where air quality is up to five times worse than it is outside. Why? Less expensive building materials, which can be the most hazardous, are chosen all too often; and regulations haven’t kept up with materials that off-gas noxious chemicals. These materials, along with conditioned air, have done to our buildings what processed food and sugar have done to our bodies. They’ve made us sick. My purpose now is to use my firm’s resources and knowledge to keep people out of medical buildings–to use better practices in real estate development, construction and community engagement to do it; and to create more centenarians like Nana in the process. How? By providing a thriving mix of office, residential, retail and recreational uses; selecting healthier building materials; orienting buildings for health-enhancing light harvesting, and positioning them to encourage walking and cycling; supporting purveyors of fresh food; creating natural opportunities for exercise and engagement; and programming places and activities for interaction with nature and friends, colleagues and family. It’s a complicated and expensive form of real estate development–no question. But there are plenty of companies making the investment. The reasons are not entirely altruistic, nor can they be if this commitment is to be sustainable. These communities are in high demand in places where people can afford them, which can make them lucrative for developers. But if we develop them only for those who can afford high rents, we’ve missed the chance to spread health-enhancing benefits to all populations. On the civic side, forward-thinking city leaders know that the economic vibrancy of their communities is directly linked to the physical health of their citizens. Healthy people are the engines of financial growth, innovation, education and progress. That’s why some of the most exciting projects involve creative partnerships with cities contributing land in need of revitalization and offering incentives to private developers who, in turn, commit to including best urban planning and design practices in mixed-use neighborhoods that meet 14 | THE WORLD IN 2050

municipal goals: things like mixed-income housing and lower priced office environments to encourage entrepreneurialism and innovation; sustainable building and site practices to reduce natural resource depletion and dependency on overburdened city services; and public spaces for art, culture and recreation–all of which enhance the overall health and well-being of every society. This work requires visionary leadership and passionate execution from all players. The Urban Land Institute has been studying and promoting the design of healthy places and working to improve health along busy corridors like the one that borders one of our projects in Nashville, Tennessee. On a global scale, the United Nations in 2015 recognized the importance of equitable, nutritious and healthy community development as the top three of its 17 Sustainable Development Goals. We need every commercial developer, municipality, nonprofit and NGO involved in community development to work on these issues. In doing our part, we’re focusing on cleaning up indoor environments and making the lifestyle changes that can end chronic disease easier than the alternative choices. We believe that is the only way to catalyze the knowledge most people already have, but many have not acted upon. Namely, that we need to eat better and move more. We are inspired to do this work by our “Nanas”–our grandparents and parents–and we’re called to do it for our kids and grandkids. Because every generation deserves to live longer than the one that came before. That’s what human advancement is all about–it’s who we are, and it’s why we are here. About the author: Jean-Claude Saada is Chairman and CEO of Cambridge Holdings.

THE FUTURE OF WELLBEING | 15

ESSENTIAL WELLNESS BY DR. DAVID HILL

lug the search term “essential oils” into the PubMed health database and the results are staggering. Nearly 10,000 peer-reviewed and evidence-based studies have been published in scientific journals within the last decade. Essential oils are being used in the world’s top medical facilities and elite universities have made them one of the hottest topics of health research, but what exactly are they? An essential oil is the essence of a plant, a lipophilic liquid containing aromatic compounds extracted from the leaves, roots, seeds, peels, and bark. An essential oil is why a rose smells like a rose and why a grapefruit has that amazingly uplifting aroma. These gifts of the Earth are precious. It takes approximately 60,000 roses to produce a single ounce of rose oil, and the quality and efficacy of an essential oil are greatly determined by where, when, and under what conditions it is harvested. There is evidence that ancient Egyptians used cedar and juniper essential oil. Ayurvedic health care systems have included them as a core element for over four millennia. In Haiti, natives have used vetiver as a panacea for centuries. Modern aromatherapy was born in 1937 when French chemist Rene-Maurice Gattefosse discovered, by pure accident, that lavender oil soothed the hand that he had badly burned in a lab accident. For the next few decades, essential oil knowledge was based on tradition and its use viewed as unconventional…at best. Recently, modern medicine has begun to embrace essential oils. Essential wellness, the movement toward optimal health through lifestyle habits such as informed use of essential oils, is the future. The fact that essential oils are becoming more widely accepted by modern medicine comes as no surprise as they are simply natures’ conglomeration of chemical constituents, many of which have formed the basis of modern medicines and wellness products. Thus, menthol, the primary constituent of peppermint essential oil, is a featured active ingredient of common household products with a cooling and soothing sensation, including lip balm, aftershave, mouthwash, toothpaste, and brand name products such as IcyHot and VapoRub. Alpha Pinene, found in high concentrations in frankincense and eucalyptus, is com18 | THE WORLD IN 2050

monly found in cold and respiratory ointments. Terpinen-4-ol, a component of melaleuca (tea tree), is found in many topical applications due to its ability to protect against seasonal threats. The synergism of these thousands of hydrocarbons and oxygenated compounds, combined precisely by nature, result in substances whose benefits we are just beginning to understand. So where do essential oils fit in the ever-changing health paradigm? We’ve all benefitted from the remarkable advances in modern medicine and the ready availability of this knowledge. A few clicks of a mouse provide access to the breadth of history’s health and medical research. With rates of infectious disease rapidly declining, thanks primarily to these medical advancements, our new world’s greatest health adversaries are those primarily tied to lifestyle behaviors. The components of essential wellness—better nutrition, more physical activity, and informed self-care—are the answers. Informed self-care is where all-natural, certified pure therapeutic grade essential oils are best utilized. Until the last several years, essential oils were promoted as an alternative to modern medicine. Essential oil and other natural product users were sometimes regarded as nonconformist, eschewing the modern advancements of pharmacology for little bottles of aromatic lipids that they smelled, applied topically, and consumed in effort to ease health maladies. Without accepted standards for quality or purity for and a lack of available knowledge on essential oils, consumers looking to be proactive about their health by using essential oils truly had no idea what was inside that bottle or how to properly use it. With a new dedication to hard science, improved standards, and increased accessibility of information, this is all changing. Essential oils are beginning to take their rightful place as a tool for informed self-care and as a compliment to modern medicine. Those “nonconformists” are now joined by your next-door neighbors who are concerned about the effect of seasonal threats on their children, their grandparents’ achy joints, and their ability to get a good night’s rest. Your family physician may now be recommending essential oils as all-natural support for a number of their patients’ body systems. This changing landscape has empowered millions to take a proactive approach to their health and the health of those around them. The next step is to figure out how to responsibly disperse this knowledge and these compounds to all corners of the globe. With this growing body of knowledge comes responsibility, both from the industry and the consumer. The essential wellness movement has begun. Our progressively healthconscious global population is creating opportunities for themselves and taking responsibility for their own well-being. With a continued focus on science, improved industry standards, and a dedication to working with modern medicine, essential oils are progressively becoming a more vital ingredient in the recipe for optimal health. About the author: Dr. David K. Hill is the Chief Medical Officer and Chairman of the Scientific Advisory Board at doTerra. THE FUTURE OF WELLBEING | 19

MOBILIZING EDUCATION FOR GLOBAL HEALTH BY DR. CONSTANCE ST. GERMAIN

ducation is a fundamental right for everyone, yet lack of access to education continues to be a core driver in the global health epidemic. Across the world, 59 million children and 65 million adolescents are out of school and more than 120 million children do not complete primary education.

Education is often referred to as the great equalizer and is critical to improving socio-economic conditions. It opens doors to better employment, access to healthcare and ultimately the ability to support a family. When families are educated, healthy and self-sufficient, they can strengthen their communities. Increasing access to education and the skills needed to participate fully in society would boost the economy by an average 28% per year in lowerincome countries and 16% per year in high-income countries for the next 80 years, further solidifying the direct and indisputable link between access to quality education and economic and social development. This data has inspired policy makers, public health professionals, educators, and other community stakeholders to develop strategies for mobilizing support that would provide greater access to education, and ultimately improve global health. While strides have been made that show determination and concentrated efforts can deliver results, there is still work to be done.

THE FUTURE OF WELLBEING | 21

CREATE A SHARED UNDERSTANDING To unlock the barriers to global health, we must understand the connections between social and physical environments and the implications on one’s access to education. Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, and worship that affect a wide range of health, functioning, and quality-of-life outcomes and risks. If we understand this, strategic partnerships and policies can be made that address the specific challenges that sustain positive and lasting changes to local, state, national, and global systems and environments. WORKING THROUGH THE PROCESS Like with any planning effort, thinking through the details of the process before beginning is a vital part of determining a successful outcome. To ensure efforts towards mobilizing education is valued in the community, it’s critical to consider the stakeholders involved. The most essential stakeholder group to education are government policy-makers (80%). While collaborating with other governments to adopt policies is the easiest way to enable access to education worldwide, the current state of the world economy, budget cuts, and a shift in priorities have governments spending less. It will become increasingly important for the private sector to step up, get involved, and advocate for improvements to education in the United States and in other countries. Currently the private sector is contributing more than $683 million a year to the United States and developing countries. Looking forward, it is critical that the private sector, which benefits from an educated skilled workforce, look for constructive ways to improve the quality of education worldwide. Finally, parent and teacher associations, educators, non-profits as well as civil-society organizations have a unique opportunity to convene to address the most challenging global education issues. Together, we need to intensify efforts to bring the poorest and hardest to reach children access to quality education and the opportunity at a better quality-of-life. REIMAGINING GLOBAL HEALTH THROUGH EDUCATION Compared to a decade ago, the challenge to mobilize education for global health is different. We’ve made a lot of progress, successes have been achieved, and many partners have joined the global effort to improve education access. This includes the technology sector. 22 | THE WORLD IN 2050

Through collaboration, knowledge sharing, and access to education, sustainable solutions are empowering communities worldwide to transform their own health. For example, advances in science, technology, and health care delivery are helping the United Nations (UN) Millennium Development Goals catalyze a new global focus on ending preventable maternal and child deaths. This alone highlights the unprecedented opportunity that exists to transform health through access to education and fostering innovation. We have the potential to solve the global education crisis and contribute to sustainable economic growth and equity in health, making it more accessible and adaptable to people worldwide. This is a call to action for governments, the private sector, health professionals, educators, and other stakeholders around the world to work together to mobilize education, and ensure we continue to improve global health. About the author: Constance St. Germain, Ed.D., J.D., is the Executive Dean of Colleges of Humanities and Sciences and Social Sciences at the University of Phoenix.

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SEX AND THE CITIES

THE IMPACT OF URBANIZATION ON SEXUALLY TRANSMITTED DISEASE BY ELIZABETH MACLEAN

ast civilisations could have scarcely imagined the bustling metropolises in which we now live. The ever increasing urbanisation of the planet has already changed the social and environmental dynamics of every continent across the globe and will continue to do so in the future. For the first time in history over half of the worldâ&#x20AC;&#x2122;s population lives in towns or cities and by 2030 the urban population will reach almost five billion. Rural to urban migration has become the common global phenomenon which has propelled the 21st century into the age of the city. But as it does so, new (and old) health problems are emerging including the increased spread of sexually transmitted infections (STIs). At the start of the previous century, in 1900, only 13% of the worldâ&#x20AC;&#x2122;s populations lived in urban areas and London was the largest city in the world. Today London scarcely compares; it has been grossly outpaced by urban growth in the developing world. In Africa, for example, the urban population is expected to triple in the coming years. Indeed, there are now over 30 mega-cities across the globe each populated by more than 10 million inhabitants. From Lagos to Mumbai ever more centers are gaining the title of mega-cities, the largest of which, Tokyo, hosts almost 38 million inhabitants. These mega-cities are continually growing - almost 200,000 people become new urban residents each day, with strong trends in rural to urban migration being increasingly evident. In China approximately 250 million rural migrants have moved from the countryside provinces to cities looking for better working and living conditions. Large population movements are also happening from city to city: in Sao Paulo, Brazil, a third of all population growth can be attributed to migration from

THE FUTURE OF WELLBEING | 25

other cities. These huge movements of people are changing the demographic makeup of cities, with inevitable health impacts. Urbanization typically comes hand in hand with economic growth and the health benefits that are reaped from this. Cities generally experience better child survival rates and longer life expectancies. However, the hurried evolution of cities into mega-cities in many cases has not been structured. Large slum areas trace the outskirts of cities like Sau Paulo and in Lagos, Nigeria, urban development/planning has utterly failed to keep pace with their population growth. Indeed in some countries over 90% of urban residents now find themselves living in shanty towns and slums and by 2030 the number of people living in such places globally will reach almost 2 billion. These urban poor are always at risk of disease. Conditions in slums are often squalid, with open sewage and overcrowded housing. With such conditions disease is easily spread. Tuberculosis thrives in overcrowded, poorly ventilated places and without proper sewage systems cholera becomes a major concern. Research from the University of Otago, New Zealand, has already shown that every 1% increase in overcrowding can lead to an 8% increase in TB incidence in that housing block. Without proper planning and infrastructure cities quickly become the epicentres of disease. In an increasingly globalised society diseases now have potential to rapidly propagate from city to city with tourism and migration. Our knowledge of sexual and reproductive health in mega-cities is slowly increasing and a clearer picture of the impact mass urbanisation has on sexually transmitted disease has now come to light. The results are not particularly promising; urban poverty has been linked to high rates of unintended pregnancies as well as STIs and HIV has boomed in urban centres. In some cities HIV rates are so extreme that they compare to the national HIV figures of some countries. Although the situation varies from country to country, data has shown that even in countries that are still mostly rural, cities tend to have a disproportionately high prevalence of HIV. The city of Monrovia in Liberia is home to 80% of the people living with HIV nationally. Young urban dwellers are particularly at risk. In Kampala, Uganda, a recent study showed that 20% of girls and 13% of boys were infected with at least one sexually transmitted disease. Furthermore city environments can put young women at risk of sexual abuse and violence. In Tanzania, for one fifth of girls in urban centres their first sexual experience was forced, and as a result HIV rates for girls were double that of their peers in the countryside (UNFPA 2012). Cities can also acts as hubs for the sex trade. Young people frequently move to the city to provide income for their family; if they donâ&#x20AC;&#x2122;t find work, they can be drawn into commercial sex as a way of making money. Far 26 | THE WORLD IN 2050

from their homes, migrant workers can feel isolated and become vulnerable to risk behaviours like unprotected sex with multiple partners- several papers have indicated that China’s millions of rural-urban migrants are contributing to the country’s AIDS epidemic. Some cities have also developed reputations for “sex tourism”; Bangkok is infamous for its brothels and sex workers there are known to have high rates of HIV. Bangkok is also a major destination for sex trafficking. Women and children are regularly taken from rural areas and trafficked into the urban sex trade, where exploitation and abuse are rife - in Southeast Asia as many as 250,000 women are thought to be trafficked each year. Many come from poor villages and are lured with promises of a good job in the city. The risk of STIs, including HIV is extremely high among trafficked women, since many are forced to have unprotected sex with many customers and are especially vulnerable to violence and rape. In Cambodia, the United Nations Development Program found that over 70% of trafficking survivors had a sexually transmitted infection. Trafficked women are furthermore extremely difficult to access with reproductive health care and education programs. They are often marginalised within communities and are given little access to outside health care by their exploiters. In general knowledge of STIs and sexual health tends to be higher in cities than in rural areas and people use condoms more frequently. Urban residents are more exposed to advertising campaigns for disease prevention and health clinics are more local. There are therefore clear opportunities for prevention in urban areas which are simply not possible in rural areas. However, there are strong disparities between richer and poorer urban areas when it comes to reproductive health. In India, contraception use has been shown to be far lower in slums compared to other urban districts. It is these areas that are in the greatest need of public health interventions and disease education and far more must be done to reach these marginalized communities. The huge expansion in urbanisation has changed the face of everyday living and will continue impacting on the health profiles of urban inhabitants. Sexual health needs to become a major consideration for town counsels to prevent more infections in the future. About the author: Elizabeth Maclean is a Research Officer at the International Centre for Migration Health and Development in Geneva, Switzerland.

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ENGAGED EMPLOYEES LESS LIKELY TO HAVE HEALTH PROBLEMS BY JIM HARTER AND AMY ADKINS

S employees who are actively disengaged at work are more likely than their engaged peers to say they experience health issues ranging from physical pain to depression.

Actively disengaged employees also report more “unhealthy” days, or days in which health issues limited their activity. On a monthly basis, actively disengaged employees have 2.17 unhealthy days, compared with 1.25 unhealthy days for engaged employees. Gallup categorizes workers’ engagement based on their ratings of key workplace elements that predict important organizational performance outcomes. Engaged employees are involved in, enthusiastic about, and committed to their work. Actively disengaged employees are not just unhappy at work; they are busy acting out their unhappiness. Every day, these workers undermine what their engaged coworkers accomplish. Gallup’s extensive research shows that employee engagement strongly connects to business outcomes essential to an organization’s financial success, such as productivity, profitability, and customer engagement. These findings, collected as part of the Gallup Employee Engagement tracking series and Gallup-Healthways Well-Being Index from January 2014 through September 2015, are statistically controlled for other demographic differences, including respondents’ age. These results do not necessarily indicate that engagement causes better health, but they do show that there is a strong relationship between levels of engagement at work and health.

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HEALTH IS AS MUCH ABOUT ENGAGEMENT AS IT IS ABOUT AGE Young workers who are actively disengaged report more unhealthy days than older but engaged employees do. On average, actively disengaged employees aged 20 to 29 have 1.82 unhealthy days per month. This number is higher than it is for engaged employees in all older age groups. For example, engaged employees aged 40 to 49 experience 1.28 unhealthy days per month, and engaged employees aged 50 to 59 experience 1.57 unhealthy days. Gallup has found similar relationships between work engagement by age and other health issues, including physical pain and stress. While just 16% of engaged employees aged 50 to 59 say they experienced physical pain “yesterday,” 23% of actively disengaged employees aged 30 to 39 say the same. And 33% of engaged employees aged 40 to 49 say they experienced stress yesterday, compared with 63% of actively disengaged employees aged 20 to 29. ACTIVE DISENGAGEMENT COSTS ORGANIZATIONS As actively disengaged employees experience more unhealthy days than their peers, they end up costing their companies more in lost productivity. A Gallup analysis finds that an engaged worker aged 40 to 49 costs his or her employer $127.76 per month in lost productivity due to unhealthy days, while an actively disengaged worker in the same age range costs $236.20—an 85% increase. BOTTOM LINE Many factors can influence the health of employees, and in some cases, workers with pre-existing health issues may be more likely to miss work and be less engaged. A lack of engagement is not always responsible for a decline in physical or mental health; it is possible that poor health precedes poor engagement. The data in the current study do not determine the direction of causation. But a previous Gallup study shows that workplace engagement does affect employees’ physiological state to some degree. Researchers examined the daily mood and cortisol (stress hormone) levels of engaged and actively disengaged employees and discovered that engaged employees experience more moments of happiness and interest, and fewer moments of stress and sadness, during the course of their workday. The researchers found higher levels of morning cortisol for less engaged employees on workdays, with no difference on weekends. These findings suggest that an individual’s work situation affects his or her mood, which then connects to physiological stress. 30 | THE WORLD IN 2050

While the data from the present study are cross-sectional and not longitudinal, research that has looked at the relationship between workplace engagement and health issues over time has found substantial connections between employee perceptions of the work environment and various health problems such as coronary heart disease, inflammation and depression. As organizations continue to seek ways to reduce healthcare costs, they often turn to wellness programs or incentives to help employees better manage health issues. But they should not discount the role of employee engagement in creating a healthier workforce. Gallup research shows that engaged employees are more likely than actively disengaged employees to participate in wellness programs offered by their organizations. Engagement is a catalyst for higher well-being -- it helps put employees in a mindset that encourages them to make healthy decisions. To achieve the greatest amount of change, leaders should look for ways to integrate purpose, social, financial, community and physical well-being principles through company-sponsored benefits and manager education programs. High engagement and high well-being have an “additive effect,” and when employees achieve both, their organizations benefit immensely. These employees miss fewer days due to illness, are less likely to leave their companies and are more likely to say they are adaptable to change and are performing at an “excellent” level. Editor’s Note: Sangeeta Agrawal contributed to the research of this article. Originally published by Gallup, this piece has been republished by Diplomatic Courier with permission.

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COMPANIES’ ROLE IN IMPROVING EMPLOYEE AND COMMUNITY HEALTH AND WELLBEING BY NEBEYOU ABEBE

he prevalence of chronic disease continues to grow in staggering numbers across the U.S. The Centers for Disease Control and Prevention (CDC) reports that as of 2012, about half of all adults (or 117 million people) have one or more chronic health conditions and 25 percent have two or more chronic health conditions. The Robert Wood Johnson Foundation recently noted that 48 percent of all health care spending in 2006 was for the 50 percent of the population who have one or more chronic medical conditions. Similarly, the American Heart Association estimates the total cost of diagnosed diabetes in 2012 was $245 billion, including $176 billion in direct medical costs and $69 billion in decreased productivity. We are at a turning point in this country. The health of our nation and vitality of our communities depends on companies stepping up to the plate and solving for this very public epidemic, not only because it is the right thing to do, but also because it can have a significant impact on the overall performance of the organization. In addition to the obvious –healthier, happier employees–organizations can save millions on health care and disability costs, increase workforce productivity, reduce employee absenteeism and decrease rates of illness and injuries. Furthermore, corporate-sponsored health and wellness programs are an essential element to competitive employee compensation and benefit packages which attract and retain the best talent. In the past, employers have worked to help improve employee health by providing resources—from free and discounted gym memberships and fitness programs, healthy options in employer-provided dining rooms and THE FUTURE OF WELLBEING | 33

cafeterias, reimbursements for preventive care through managed healthcare, and even nutrition and diet counseling. But despite their best efforts, low engagement and lack of employee compliance has yielded minimal tangible returns. This can largely be attributed to lack of education, lack of trust of the current screening systems, concern for privacy breaches of personal health information (PHI), as well as an overall lack of time, motivation and money. The complexities of these issues have been expounded upon in the work done by Dr. Soeren Mattke from RAND Health, whose studies in worksite wellness has shown mixed results in the actual engagement of employees in direct solutions or interventions to improve their health. Companies need to seek approaches that reach into the community, improve support for individuals both at their worksite and at home, engage the entire family unit to support healthy habits and behavioral changes, and ultimately increase engagement and compliance rates into evidence-based programs for chronic disease prevention and intervention, particularly for moderate and high risk employees. With an eye on addressing the current achievement gap in employer wellness programs, Sodexo and the YMCA of Central Florida have formed a unique partnership resulting in a new comprehensive approach to health and well-being that focuses on expanding the value, availability, access and effectiveness of workplace wellness programs. The groundbreaking 3-year pilot program, entitled Communities for Health, is currently underway and aimed at combating preventable chronic illnesses that escalate healthcare expenditures, which accounts for 18 percent of the GDP and is projected to rise sharply. The initiative is designed to enhance traditional, and mostly underutilized, employee wellness programs through a comprehensive, system-based approach that engages employees at work and at home, increasing the likelihood of success and yielding a more significant impact than traditional workplace wellness initiatives. The program triages participants for their level of risk and readiness for change, connects employees with a lifestyle coach, embraces a peer-topeer approach, encourages a â&#x20AC;&#x153;buddy systemâ&#x20AC;? that extends into the community, leverages technology, and strategically uses incentives throughout. Communities for Health aims to achieve five specific objectives: 1. Engage individuals to participate in a robust health and wellness program through their employer; by building a network of support, both in the workplace, the community, and at home; 2. Leverage community health partners, local and national merchants, and integrated technology systems to support health management and incentive-based rewards for healthy behaviors; 34 | THE WORLD IN 2050

3. Strategically segment the workforce to connect participants to the appropriate evidence-based program, based on risk level and readiness to change; 4. Reduce employee and family health risks by encouraging healthy behaviors that will positively impact performance and reduce healthcare costs; and 5. Leverage healthier behaviors of the employee to change the behaviors of their neighboring community.

Phases of the Communities for Health Pilot

At Sodexo, we consider health and wellbeing programs to be a critical component of improved performance for individual employees, organizations and the community at large. As the 18th largest employer in the world, serving 80 million consumers daily, we believe that we have an opportunity and a responsibility to help improve our nationâ&#x20AC;&#x2122;s health and well-being. By taking a systems-based approach to employee health management that leverages community-based organizations (including both the public and private sector), employers, healthcare providers and family/community relationships we can improve engagement in and compliance to evidence-based prevention and chronic disease management programs. Our collaborative approach is intended to address the challenges facing employers, providers, insurers and individuals, but also to leverage the collective assets of these sectors to drive employee and family engagement. Using the power of peer to peer engagement, the strength of evidence-based programs, the impact of behavioral modification in lifestyle management, and the influence of friends, family and other communitybased support; we are positioning ourselves to tackle the barriers that plague most wellness programs. About the author: Nebeyou Abebe is Senior Director, Health & Wellbeing in Sodexo North Americaâ&#x20AC;&#x2122;s Office of Sustainability & Corporate Social Responsibility. THE FUTURE OF WELLBEING | 35

HOW MOBILE TECHNOLOGY CAN IMPROVE EMPLOYEES’ WELL-BEING BY DAN WITTERS AND SANGEETA AGRAWAL

eople are increasingly using mobile technology to improve their well-being. This isn’t surprising, given that mobile technology is becoming more integral to people’s lives. In the U.S., the Centers for Disease Control and Prevention report that 39% of American adults now use only mobile phones, which outweighs the 7% who use only landline phones by a 5-to-1 ratio. Gallup research shows that about two-thirds (65%) of American adults have a smartphone. About half of these smartphone users—or 34% of all adults—have downloaded at least one app that is meant to support healthy living, and 19% of all adults have downloaded and routinely used at least one such app. This means that one out of every five people are regularly using mobile technology to improve their chances of a life welllived. Among full-time workers, this percentage climbs to 23%. Out of 11 popular types of apps on the market, usage varies. Across all adults, the most common use is for calorie counting: 18% report having downloaded an app for that purpose. Of these, one-third—or 6%—routinely use the app. Health recipes and food/exercise diaries are the next most common type of apps used.

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MOBILE APPS AND HEALTH: WHERE TECHNOLOGY AND WELL-BEING CONVERGE Gallup and Healthways define well-being based on five essential elements: purpose, social, financial, community and physical. Taken together, these elements provide key insights into whether people find daily life and work experiences fulfilling, have strong and supportive relationships, are financially secure, are proud of and actively involved with their community, and are physically healthy and making smart choices about their health. THE GALLUP-HEALTHWAYS WELL-BEING 5 Gallup and Healthways have developed a comprehensive, definitive source of well-being measurement, the Gallup-Healthways Well-Being 5. This scientific survey instrument and reporting experience measures, tracks, and reports on the well-being of individuals and organizations. The five essential elements of well-being are: •

Purpose: liking what you do each day and being motivated to achieve your goals

•

Social: having supportive relationships and love in your life

•

Financial: managing your economic life to reduce stress and increase security

•

Community: liking where you live, feeling safe, and having pride in your community

•

Physical: having good health and enough energy to get things done daily

Respondents can be classified as thriving, struggling or suffering on each element according to how they rate that particular facet of wellbeing in their lives: •

Thriving: Well-being that is strong, consistent and progressing in a particular element.

•

Struggling: Well-being that is moderate or inconsistent in a particular element.

•

Suffering: Well-being that is low and at high risk in a particular element.

Across the U.S., 28% of American adults are not thriving in any of the five elements, while just 7% are thriving in all five. But those who download and routinely use health-related apps do better in well-being. After 38 | THE WORLD IN 2050

controlling for all demographics and for previously existing chronic conditions, these regular users are thriving in at least three of the elements 33% of the time, compared with 27% among all others. When we look closely at app use and well-being at the individual element level, however, the strength of the relationship varies. We find little difference in financial well-being between those who routinely use health apps and all others. But when it comes to physical and social well-being, routine users of health apps are more than 20% more likely to be thriving than those who donâ&#x20AC;&#x2122;t routinely use such apps. This highlights the dual nature of health-related apps in promoting better physical health and increased social engagement. These results donâ&#x20AC;&#x2122;t prove that using apps will lead to better well-being outcomes; adults with high well-being might be more predisposed to download and use healthrelated apps. But finding these results after controlling for all demographics and chronic conditions suggests that catalyzing use of health-related apps is a good way to increase well-being. And some types of apps are more closely related to high well-being outcomes than others. While use of running map apps and apps for healthy restaurant menu options are mutually highly linked to both social and physical well-being, other apps are more uniquely aligned. Apps for water intake and healthy recipes are strongly linked to social well-being benefits, while running maps and personal training apps are strongly associated with physical well-being. Editorâ&#x20AC;&#x2122;s Note: Originally published by Gallup, this piece has been republished by Diplomatic Courier with permission.

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SMART THINKING FOR HEALTHY LIFESTYLES BY MARIO OTTIGLIO

ince the start of this millennium, we have witnessed many success stories in global health. Death from infectious diseases like malaria and tuberculosis have been cut in half. A child is twice as likely to survive past their fifth birthday than he or she was fifteen year ago. Hunger and malnutrition remain, but affect a smaller percentage of the world’s population than ever before. Yet there is an area where the trends are not in our favor. Non-communicable diseases (NCDs), including cardiovascular diseases, respiratory diseases, cancer and diabetes, are the world’s leading cause of poor health, and growing in prevalence. In low-and middle-income countries (LMICs), where health systems are often strained, under-equipped and under-staffed, NCDs lead to the premature death of over 13 million people each year. Faced with such a momentous challenge, governments struggle to address NCDs “on a budget”. This will hamper attempts to put in place effective Universal Health Coverage, a key component of the Health Sustainable Development Goal for 2030 (SDG 3). When we look to the world in 2030 or beyond to 2050, will we be able to say enough was done today to stem the rising tide of NCDs? I am hopeful that the answer will be yes,

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thanks in part to ongoing multi-sectoral efforts to reach the widest audience possible with information that could save their life. HEALTH AND WELLNESS IN THE COMMUNITY Many NCDs require treatment for years on end, even over the course of a lifetime. The health consequences can be crippling for an individual. The economic consequences are twofold: the cost to patients and their healthcare systems, and the loss of productivity in a country where too many people are not well enough to work. A Harvard University study estimates a loss in economic output of USD 7 trillion in developing countries due to NCDs from 2011 to 2025. But there are solutions: according to the World Health Organization (WHO), the majority of the world’s NCDs could be prevented through behavioral change. As stated by WHO Director General Margaret Chan, “The worldwide increase of non-communicable diseases is a slow-motion disaster, as most of these diseases develop over time. But unhealthy lifestyles that fuel these diseases are spreading with a stunning speed and sweep.” We like to call them the “4 Healthy Habits”, and they go a long way for a person’s wellness: cutting out tobacco and overconsumption of alcohol, while eating healthy and being physically active. Equipped with this knowledge, my organization, the International Federation of Pharmaceutical Manufactures and Associations (IFPMA), works with the International Federation of Red Cross and Red Crescent Societies (IFRC) to produce toolkits to help community volunteers assess a person’s risk of developing an NCD, provide guidance on preventative steps they should be taking, and refer at-risk individuals to clinical assessment. Thus far, the tools have been translated into 10 languages including Arabic, Russian, French and Indonesian. Long-term public health strategies in LMICs call for more doctors and nurses on the ground to care for people with NCDs—today many countries in sub-Saharan Africa have less than one doctor per 10,000 people, compared to 20 or 30 doctors in high-income countries. As governments work to this objective, multi-sectoral partnerships like 4 Healthy Habits reduce the burden upon health systems, sharing messages about NCD prevention at community level in order to reach as wide an audience as possible. HEALTH AND WELLNESS AT YOUR FINGERTIPS If you want to get important information out to the many, it is impossible to ignore the value of the cell phone. 42 | THE WORLD IN 2050

There are over 7 billion cellular subscriptions in the world, the large majority in LMICs. Mobile technology is transforming the way that we approach the dissemination of health information. Widely available, affordable, and portable, cell phones can take key health messages and put them directly into people’s hands—at very low cost. To unlock this potential, IFPMA has teamed up with WHO, the International Telecommunications Union (ITU) and other partners in Be He@ lthy, Be Mobile. This partnership provides governments with best practices for mhealth interventions, based on existing clinical evidence from trials around the world. For example, the mDiabetes initiative in Senegal is working to reach the country’s estimated 400,000 undiagnosed diabetes patients and provide them with care before the disease progresses to the need for hospitalization. Health partnerships like 4 Healthy Habits and Be He@lthy, Be Mobile promote the good behaviors to stop NCDs in their tracks, providing governments in low-resource settings a leg-up in achieving the Sustainable Development Agenda of the United Nations. Alongside the pursuit of new, more effective treatments for NCDs and support for capacity building of healthcare and regulatory professionals in LMICs, preventative action is a critical element of my industry’s framework for action on NCDs and the SDGs more generally. We do our best to walk the talk. A survey from across our industry demonstrated nearly 100% of IFPMA member companies had well-established workplace wellness programs in place, to the benefit of over 1.1 million employees. After all, today or in 2050, and no matter how impressive modern medicine, it is better that someone remains healthy in the first place. About the author: Mario Ottiglio is Director of Public Affairs, Communications & Global Health Policy at IFPMA. He joined IFPMA in 2007 and held different positions of increasing responsibility. Mario develops and leads the implementation of global health policies as well as designs public affairs and communication strategies. He represents IFPMA in discussions with international organizations, governments and other nongovernmental organizations building consensus on policy decisions and partnerships.

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FIGHTING LYMPHEDEMIC CANCER AND BEYOND WILLIAM REPICCI, EPAMEINONDAS GOUSOPOULOS, AND KATHY BATES

our doctor enters your hospital room. First, the good news is delivered. The treatment was a success. You beat cancer. As your heart soars at the news, there is a muted warning that follows. You have a significant chance of now developing a disease called lymphedema, which you will have for the rest of your life. “Never you mind, though,” the doctor says. “Chin-up. After all, your life was saved. How can one complain about a little inconvenience in exchange for your life?” However, ask anyone with lymphedema what it is like to have this disease and you are likely to hear her or him say, “Lymphedema is worse than cancer. They cured my cancer. Lymphedema is forever.” Lymphedema is fairly straightforward. It is a swelling resulting from the accumulation of lymph fluid when the lymphatic system is damaged or fails to function as it is meant to do. It most often affects one’s extremities. There are no cures and few treatments. Up to 150 million people across the globe suffer from it—many as a result of cancer treatment, others as one of the symptoms associated with filariasis, and still others will find that they have a genetic link to the disease that can lead to the onset of symptoms at birth or even much later in life. So, how does lymphedema fit into a conversation about “well-being,” a term that asks us to quantify just how well our life is going. General wellbeing measures might include physical health and the absence of pain, the ability to perform those tasks that one loves and a sense that one is valued within their community. Without those basic qualities of life the physical limitations of lymphedema wear away at one’s joy. Patients feel 44 | THE WORLD IN 2050

further isolated from well-meaning friends who can’t comprehend what sufferers are going through. A life with lymphedema means daily treatments that can last for hours. It means wearing expensive compression garments, often not covered by insurance, uncomfortable in warm weather and unfashionable all year round. It could mean one needs to use a pneumatic pump to reduce swelling and that a therapist will be needed to maintain health through manual lymph drainage. It means accepting the fact that the slightest cut on the skin might result in a bacterial infection called cellulitis, which may require occasional trips to the emergency room to avoid going into toxic shock. Aside from ongoing pain, clothes will no longer fit, one’s romantic life will be turned upside down and because high altitudes exacerbate the swelling, the adventure of air travel now raises only the fear of further physical trauma. Many sufferers report constant pain. All know ongoing discomfort as they carry extreme excess weight on one side of the body that isn’t symmetrical with the other limb. Routine joys like sports, gardening, going for walks, and even the wearing of one’s wedding ring, may have to be abandoned altogether. Along with the physical ramifications of lymphatic disease and lymphedema, those with this disease report suffering the daily psychosocial trauma from a society that simply doesn’t understand the nature of disease. Feeling mocked and ostracized, a high incidence of patients report self-loathing, depression and suicidal thoughts. In the United States alone, up to 10 million people suffer from lymphedema. This represents more patients in that country than those that suffer from Multiple Sclerosis, Muscular Dystrophy, AIDS, Parkinson’s disease and ALS—combined. Yet most people have never heard of it and little is invested in its cure. Too often presented to patients as simply an unfortunate side-affect of cancer, those who need to be the advocates of change have remained mostly muted. However, this is changing. With NGOs such as Lymphatic Education & Research Network, patient advocates are making their voices heard—and both politicians and funding agencies are listening. The road to well-being for those with lymphedema must include new treatments and cures that relieve the suffering. In this regard, the National Institutes of Health has revealed a heightened interest in lymphatic research. There must also be insurance for the treatments that currently exist in order to relieve patients from the crushing financial burden they now shoulder themselves. And finally, a worldwide campaign is needed to educate the public and thereby reduce the current emotional suffering caused by misunderstanding of the disease. THE FUTURE OF WELLBEING | 45

A strong component of oneâ&#x20AC;&#x2122;s well-being is feeling a psychological sense of community. This leads to a state of empowerment, which inspires the action that leads to change. The days of suffering in silence are coming to an end. With the United States Senate and other countries establishing March 6th as World Lymphedema Day, a global movement is afoot and revolutionary change in the quality of life of lymphedema patients will inevitably follow. About the authors: William Repicci is the Executive Director of the Lymphatic Education and Research Network (LE&RN), Epameinondas Gousopoulos is an MD/PhD researcher at the Swiss Federal Institute of Technology Zurich working on lymphedema treatment and Chair of LE&RN Europe Chapter, and Kathy Bates is an Academy-Award-winning actress, lymphedema patient and spokesperson for LE&RN.

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WE ARE ALL IN THIS TOGETHER BY MARIA DE LOS ANGELES CRUMMETT AND JUDY GIBSON

cross the globe, one medical condition is certain: regardless of geography, language, politics or economic development, we will all get older. While we hope new technologies and medical advances will improve the care and treatment of age-related diseases, aging presents a range of issues that cannot be addressed in the lab. The aging population impacts all societal needs: health care, the workplace, housing, family relationships, and the role of the government in providing services. It requires the best minds from around the world to join together and share innovations, best practices and new paradigms across borders and cultures. Age-related health and wellness is the kind of 21st century global challenge that our nationâ&#x20AC;&#x2122;s flexible and dynamic public diplomacy initiatives such as the Fulbright and Humphrey Programs are particularly well-suited to address. Americaâ&#x20AC;&#x2122;s 65-and-over population is projected to nearly double over the next three decades, from 48 million to 88 million by 2050, according to a new report commissioned by the National Institute on Aging. Global life expectancy is projected to climb from 68.6 years in 2015 to 76.2 years in 2050, while the global population aged 80 and older is expected to more than triple from 126.5 million to 446.6 million, and is predicted to quadruple in some Asian and Latin American countries by 2050. Without a doubt, we are all in this together, and we all have much to learn.

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Because there is such a strong cultural component to how a society treats its aging population, it is especially important to have individuals who can share their experiences and knowledge in a way that is both culturally sensitive and attuned to a country’s changing needs. As the Institute of International Education nears its centennial in 2019, we have a unique vantage point to see the power of connecting people across countries and cultures to address shared global problems. In our experience administering the Fulbright Scholar Program and the Hubert H. Humphrey Fellowship Program on behalf of the programs’ sponsor, the U.S. Department of State, we have seen how effective this kind of international exchange can be in bringing together doctors, hospitals, universities, governments and private sector resources. We would like to share just a few examples to inspire others in all fields. These individuals demonstrate how important it is not only to immerse yourself in and learn from another country’s practices, but also to bring them back and share with colleagues and students at home. Peggy McFarland, a professor of social work and Director of Field Instruction at Elizabethtown College, spent a year as a Fulbright U.S. Scholar in Vietnam, teaching at the Vietnam National University in Ho Chi Minh City and helping the country’s Ministry of Health and community agencies examine the problems of a rapidly increasing elderly population. She brought a wealth of experience through her research on Alzheimer’s and as cofounder of a firm that provides eldercare management. But equally important was her prior experience travelling with students to assist in orphanages throughout Vietnam. Her role as a Fulbrighter and cultural ambassador positioned her well to advise Vietnam’s health providers on creating new services, and specifically to allow social workers to work in the hospitals – a recommendation which is now starting to be implemented. “Building relationships is people to people,” she noted, as she worked not only to teach, but to “make a cultural connection and form a relationship between countries.” She has brought these lessons back to students and faculty at her university and to her continued work in meeting the needs of the elderly at home in Pennsylvania. While not everyone can spend a year abroad, the Fulbright Specialist Program provides flexible, short-term opportunities for professors and professionals to go on timely assignments to complete specific collaborative projects at the request of an institution in the host country. Lisa M. Brown, the Director of the Trauma Program at Palo Alto University, served as a Fulbright Specialist with the University of the West Indies, in Mona, Jamaica. Her extensive clinical and research experience on aging, health, vulnerable populations, disasters, and long-term care was integral to helping the university develop a new masters of public health in gerontology. Her work in shaping the curriculum will have important and lasting impact on how aging persons are treated at the national and community level. 48 | THE WORLD IN 2050

Danni Xiang was the Vice-Chief Physician for the Department of Geriatric Medicine at Huadong Hospital in Shanghai when she came to the United States on a Humphrey Fellowship, which is part of the Fulbright family of programs. The Humphrey Program provides opportunities for accomplished mid-career professionals from designated developing countries of Africa, East Asia and the Pacific, Europe and Eurasia, the Near East, South and Central Asia, and the Western Hemisphere to the United States for one year of non-degree graduate study and practical professional experience. Their experiences studying and working alongside U.S. counterparts and Fellows from other countries prepare them for leadership and promotes global connections in critical fields such as public health. At Emory University’s Rollins School of Public Health, Dr. Xiang shared her perspectives on her work and acquired new skills and knowledge in epidemiology, health policy and management and data management related to aging. When her Fellowship ended, she applied for a Humphrey Alumni Impact Award to expand the impact of the knowledge and skills gained during her Humphrey Fellowship. Jointly-funded by the State Department’s Bureau of Educational and Cultural Affairs and by IIE through its Fulbright Legacy Fund, the award enabled her to return to Shanghai with her advisor, Dr. Ted Johnson, Chief of the Division of General Medicine and Geriatrics at Emory, to train community doctors in techniques such as Comprehensive Geriatric Assessment and how to work with a multidisciplinary team, including geriatricians, physical therapists, pharmacists, geriatric nurses, neurologists, and nutritionists. Her training helped family doctors learn to identify potential problems, integrate treatment of diseases, promote functional status, prevent life-threatening injuries, reduce hospitalization rates and keep patients living in the community longer. She expects the knowledge she shared to create a new model for managing the older patients in the future. These are only a few examples of how we can learn from professionals and educators in other countries and cultures, and return home to share and magnify the impact of that knowledge. The bonds that are formed through this kind of exchange will serve our societies on many levels. The Fulbright Program, funded by an annual appropriation from the U.S. Congress with generous contributions from and partnerships with foreign governments, universities and private sector partners, is the best investment we can make in improving the world we share. About the authors: María de los Ángeles Crummett is Deputy Vice President for Scholar Exchanges and Executive Director, CIES at the Institute of International Education (IIE) and Judith S. Gibson is Director of Global Professional Exchanges at IIE, the leader in developing and implementing cross-border strategies and programs that harness the power of international education. THE FUTURE OF WELLBEING | 49

MIGRATION AND WOMEN’S HEALTH A NEGLECTED ISSUE IN NEED OF ACTION BY ELIZABETH MACLEAN

here is a current tendency to think of migrants as young men. Although in some cases this stereotype still holds true, patterns of migration are rapidly changing and more must be done to ensure that vulnerable female migrants are protected, particularly in terms of their health.

Although earlier in the European “migrant crisis” the vast majority of those arriving were men (over 70% of irregular migrants into Greece and Italy in June 2015 were adult men), this gender gap has gradually decreased over the past year and the UN High Commissioner for Refugees (UNHCR) estimates that men now make up only around 40% of migrants arriving in the Mediterranean. Forced movements in particular seem to affect higher numbers of women and children. Indeed, over three quarters of Syrian refugees registered by UNHCR are either women or children under the age of 18. Women are also participating to a greater extent in economic migration; for example in some in South Asian countries, such as the Philippines, a significant portion of national GDP now comes from remittances sent home by female migrants working abroad. With levels of migration increasing across the globe it is essential that migrant women’s health and access to care is high on the political agenda.

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Although in some cases - especially within cultures where women are marginalized - migration can help to improve women’s professional opportunities and access to education/care; the health of female migrants, however, is often negatively affected. Migrant health is a complex issue involving many different determinants. Several models have shown the dynamics between health statuses and systems in countries of origins and host countries, as well as the stresses involved in the process of migration itself. In the context of migration, the rights of women can be especially precarious and opportunities for their protection are often limited by the social, political and economic environments which they have migrated from and to. With female migrants from cultures where women are traditionally given little autonomy over their healthcare decisions, these traditions/ideologies can persist even after migrants are settled in their host countries. This in turn affects their ability to seek and access quality healthcare. Limited knowledge about the available health services that are accessible in their host country is also a major barrier. Health care needs and expectations of female migrants obviously differ from those of men and must be taken into account. However it has been repeatedly reported that women’s reproductive health needs are often overlooked even within well structured refugee camps. For example, due to the poor levels of hygiene in migrant reception facilities migrant women are at heightened risk of severe gynecological problems. Such problems could easily be prevented by assessing health requirements of women on arrival and providing clean sanitary pads and other such products. Pregnant women are also among those arriving at migration hubs such as Lampedusa in Greece. Pregnancy is always a sensitive and vulnerable time for women, the dangers of which can be further augmented by the process of migration. Asylum-seeking women can have high-risk pregnancies due to the severe physical and emotional strain of their journeys and due to previous treatment in their countries of origin; many having suffered sexual violence or genital mutilation (which can cause major birthing complications). Evidence shows that migrant mothers are more likely to suffer from pregnancy complications, including preterm delivery and postpartum depression compared to national women. A review also showed that migrant women settling in Western Europe had poorer maternal health indicators, including perinatal mortality compared to native women. It is therefore important for sufficient provision to be made for the reception of pregnant women at known immigration landing points. The vulnerability of women to exploitation and violence has also been consistently raised, especially within asylum seeker settings. All too often women are placed in cells alongside hundreds of men and are not provided with safe, well-lit bathrooms. Médecins Sans Frontières (Doctors 52 | THE WORLD IN 2050

Without Borders) as well as UNHCR and the United Nations Population Fund (UNFPA) have repeatedly urged for improvements to refugee holding centers to help protect women from sexual harassment and abuse, yet in many areas the risks of sexual abuse remain very real. Furthermore, the vast majority of victims of human trafficking are women and girls (79%). The most common form of human trafficking (79%) is into the sex trade, where rape and sexual violence are common. Sexual violence can not only affect the psychological health of female migrants but can also be a major cause of infectious diseases such as HIV and other STIs. This vulnerability to sexual abuse is exacerbated by a lack of appropriate policies and programs designed to protect female migrantsâ&#x20AC;&#x2122; health. As we move into an era of increasing female mobility both internationally and domestically, attention must be focused on making migration safer and healthier. In the area of womenâ&#x20AC;&#x2122;s health, much remains to be done if the wellbeing of women and girls is to be protected. About the author: Elizabeth Maclean is a Research Officer at the International Centre for Migration Health and Development in Geneva, Switzerland.

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THE PARADOX OF EMPOWERMENT BY AUGUSTA SMALLWOOD

he looming pressure of high uncertainty and volatility associated with the water-food-energy-climate-health nexus in addition to the well-documented gender inequalities across all sectors in development are among many factors defining the imminence and urgency of sustainable health impact and outcomes. Gender equality is at the core of sustainable health outcomes, as gender plays a critical role in the ability to improve and protect health, which is increasingly imperative to a population that is both growing and aging. The crux of the problem is that despite progress bridging gender gaps over the last two decades, gender disparities are widespread and persist with high variability in health impact and outcomes by geographic region and populations. So, in an effort to address these variations, public policy and the development community have introduced a new phrase, the classic “female empowerment,” into their game of strategic-approach-buzzword-bingo. According to the United States Agency for International Development’s USAID’s Policy on Gender Equality and Female Empowerment, female empowerment “often comes from within and individuals empower themselves” and “cultures, societies, and institutions create conditions that facilitate or undermine the possibilities for empowerment.” Trust me, I understand if you’re wondering how female empowerment could possibly be problematic, as I’ve hypocritically used this phrase time and time again before only recently realizing its paradoxical implications

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after feeling irked by its ambiguity and overuse in the development arena. Other than those who believe empowerment is a zero sum game, with whom I vehemently disagree with, where female empowerment results in men’s disempowerment, I’ve only understood female empowerment to have a positive connotation. As I’ve now come to realize the contradictory implications of female empowerment extend beyond semantics, I believe its seemingly positive notion is precisely what distracts our ability to see this rhetoric for what it is – a concept masquerading by proxy of a positive connotation to undermine gender equality. Let’s be clear: I am the utmost supporter of female empowerment in the context of a measure of progress in gender equality; however, I believe the use of female empowerment as a strategic approach is not only a paradox, but also reinforces societal norms that disempower females. While I too initially considered the possibility that I was quibbling over semantics, I now see my reluctance as a testament to this discursive barrier’s strength. Here’s why: Despite the implied meaning of the development community that power can be bestowed upon you, by definition empowerment comes from within. Consequently, a strategic focus that involves “female empowerment,” not only places an undue burden on females never experienced by their male counterparts that is inherently unequal, but also perpetuates a fallacious understanding that empowerment automatically translates into opportunity. Anecdotal evidence: how many times can you recall seeing the phrase “male empowerment?” Based upon my experience, disadvantaged females require “empowerment” and disadvantaged males require “enablement.” If the goal is gender equality, why are we perpetuating gendered rhetoric? Furthermore, even if seizing or realizing the full extent of your power translated as de facto opportunities, why is the development community fixated on the individual efforts of women and disregarding those social, economic, cultural, and political determinants that disempower? In effort to transcend the misnomer of gender equality in terms of parity or numbers and to ensure impact beyond what’s superficial, the development community needs to clearly articulate and ensure that the underlying issue is being addressed rather than its symptoms. When I read “female empowerment,” my first thought is “How?” To effectively address gender inequality and ensure sustainable outcomes, we not only need to understand how it’s proposing to be done, but also what the end goal is. In other words, what does the empowered female look like? If I, as a Western woman, am the ideal of an empowered woman, why do gender gaps in pay and labor persist? What are the shortcomings of strategies focused on female empowerment?

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Rather than burdening females with the individualized responsibility to pull themselves up by the bootstraps and become empowered, the development lexicon should address the structural disadvantages females encounter that disempower. For those questioning the importance in analyzing discursive implications, I urge you to consider empowermentâ&#x20AC;&#x2122;s implicit notion of male dominance and its effect on the distribution of power. Perhaps, a discursive approach to deconstructing gender roles would be more effective in creating the social transformation necessary to achieve gender equality. This means unlinking gender from societal norms by reframing the structural differences in opportunities, such as comparing the differences in how females actively participate to men. About the author: Augusta Smallwood is a graduate of George Mason Universityâ&#x20AC;&#x2122;s MHA program in Health Systems Management and The College of William & Mary where she studied Gender and Healthcare. Her work as a Consultant at LMI focuses primarily on global health issues and health supply chains.

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THE FUTURE OF PREVENTIVE HEALTH AND WELLBEING BY FOLUSO ISHOLA

good percentage of the global population is aging rapidly and comorbidities will continue to rise largely as a result of lifestyles associated with economic development such as smoking, obesity, harmful consumption of alcohol, unhealthy diet and sedentary lifestyle. Chronic diseases related to diet and nutrition presents one of the greatest public health burdens in terms of direct and indirect cost to the society and the government. The economic case for investing in preventive health is stronger than it has ever been. According to the World Health Report 2002- Reducing Risks, Promoting Healthy Life, chronic diseases account for almost 60% of all deaths and 43% of the global burden of disease. By 2020, these figures are expected to rise to 73% and 60% respectively, yet the main risk factors associated with chronic diseases are largely preventable. Primary prevention is considered to be most cost effective and sustainable course of action in building stronger and healthier communities. As such, a paradigm shift from disease care to preventive health care is an urgent need. With innovative approaches and rapid technological advancement, opportunities exist to promote healthy living and reduce disease risk. Such innovative approaches are bound to be disruptive to the current health care environment by responding to an increased demand for faster, easier, self-service ways to manage and improve health, making behav-

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ior and consumption choices healthier and optimizing opportunities for good health. These actions will need to be well integrated into routine service provision and healthcare processes to support the promotion of well-being and health rather than management of disease and may exist well beyond the boundaries of the health sector. Mobile health or mHealth is a rising area in preventive healthcare. According to a report from Research2Guidance, there are more than 100,000 apps falling into the health, fitness, or medical categories. Mobile health apps will have the one of biggest impact on healthcare system providing faster, easier and affordable access to health information and services while helping to reduce noncompliance and improve patient outcomes. Services such as nutrition, fitness, medical reference, wellness, medical condition management, diagnostics, compliance, reminders, emergency response and management and remote monitoring will be available to consumers at their convenience. Providing an evidence base on what works, in different contexts, and at what cost, is a key element in future of preventive health. Some researchers have attempted to promote evidence based strategies on mHealth targeted at behavior change, health promotion and disease prevention. A study on the development of a mHealth behavior change system to facilitate learning, utilization, engagement, and motivation concluded that integration of behavior change best practices, mHealth technologies and flexible learning design process is necessary to improve patientâ&#x20AC;&#x2122;s behavior. Another study on the development of a mHealth app that would provide consumers with quick and easy-to-understand nutrition information and support the selection of healthier choices suggested that the huge volume of crowdsourced data provided a novel means for low-cost, realtime tracking of the nutritional composition of foods. There is also a growing body of evidence on mHealth interventions in low and middle-income countries (LMIC), particularly in improving adherence, appointment compliance, data gathering, and developing support networks. Despite the undeniable benefits mHealth provides, data privacy is a major concern. A technical analysis of the data practices and privacy risks of many mHealth apps which involved reviewing mobile application privacy policies, analyzing the data apps store and the network communication between apps and the internet revealed that many apps compromise the privacy of users by sending unencrypted data disclosing personal information to app developersâ&#x20AC;&#x2122; websites and third-party sites for analytic and advertising purposes. These potential tradeoffs need to be considered and more efforts will be needed in improving the privacy policies of apps to generate a wider market. To manage data privacy risk, there must be a handle on the data thatâ&#x20AC;&#x2122;s collected, the security of data transfer, and all third parties accessing the mobile application. 60 | THE WORLD IN 2050

The use of genetic data to monitor individualsâ&#x20AC;&#x2122; risk factors and predict the onset of chronic disease is another key element in the future of preventive health. Technological advances have been made in the determination of genetic predisposition to disease with growing interest in the application of genetic tests in predicting risk for disease. This prediction is expected to delay or prevent the onset of disease by encouraging individuals to get screened earlier and more frequently or undergo preventive surgery. However, a major limitation is the potential of genetic tests that are not valid or useful to cause harm by prompting inappropriate changes in medical care based on incomplete or incorrect information. Promoting personalized preventive strategies may be the standard in coming years given the need to enhance health for a reduced cost. While some have made the economic argument for preventive care by highlighting the possibility of reducing healthcare spending and its appeal to both the public and policy makers, others have critiqued its cost effectiveness stating that it is inherently no better than disease care. While the health value for preventive care may be apparent, it still faces unique challenges in demonstrating its economic value. Behavior change is a difficult process, and once modified, may take a while to demonstrate health and economic benefits. In addition, the large number of people who may need to receive preventive care so a few can be spared of disease may limit economic savings. Nevertheless, preventive healthcare strategies hold the key to improved health outcomes. Short term cost may rise with initial investment; however, long term savings are undeniable. Shifting the paradigm to preventive health will require a new mindset, one in which measurements are taken to define the status of a personâ&#x20AC;&#x2122;s health and not to establish a diagnosis. Innovative ideas, cross sector partnership and multi-disciplinary research will be critical in moving towards an effective, efficient and evidence based system that promotes preventive health and wellbeing of populations, reduces health inequalities, strengthens public health and ensures sustainable health systems. About the author: Foluso Ishola has a medical degree from Obafemi Awolowo University, Nigeria and Masterâ&#x20AC;&#x2122;s Degree in Public Health from London School of Hygiene and Tropical Medicine. She is the Co-Founder of Global Youth Coalition against Cancer, an Emerging Global Leader Initiative-Atlas Corps Fellow and Program Fellow at Susan G Komen.

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RELATIONSHIPS MATTER MOST BY JENNIFER B. RHODES

e are more than a month out from the publication of Rebecca Traisterâ&#x20AC;&#x2122;s new book chronicling the recent rise of single women as a political force. Now more than ever American women are choosing to opt out of marriage in favor of their own careers. What looks on the surface as a progressive shift in American culture really may be, in my opinion, a misunderstanding of the vital importance that relationships of all types have on our overall well being and financial success. American values have always promoted independence over interdependence. This, in combination with buying into the notion that success and happiness requires status and working long hours, few young Americans realize the sacrifices they are making with regard to their future well-being and happiness when they completely neglect their personal lives. While some will eventually find the balance they desire, a growing population of adults will struggle to surround themselves with healthy individuals. The cost regarding productivity is high when one chooses unsupportive relationships or simply lives in an environment without access to such relationships. We have long known the impact negative experiences have on an adultâ&#x20AC;&#x2122;s well being. In 1998, Drs. Felitti and Anda published a groundbreaking article attributing early death and major medical challenges to adult experiences with adversity in childhood. The Adverse Childhood Experiences (ACE) Study has shown that trauma, abuse, and the lack of supportive relationships is tied to a multitude of substance abuse, mental health, and medical problems. The more risk factors an adult experiences 62 | THE WORLD IN 2050

the more likely he or she is to have multiple diseases and face an early death. This cycle continues generation after generation with little incentive and money to support moving the cycle in a healthier direction. Despite ongoing research indicating that over two-thirds of the American population has suffered from at least one ACE event, prevention programs are not always widely supported. There is strong data supporting programs like the Nurse-Family Partnership, which helps families learn better parenting skills through the use of highly trained home visitors. Why is this important? Early intervention can teach parents how to have a meaningful and emotionally available relationship with their child. This relationship promotes healthy brain development and often leads to better overall well being for both the parent and the child. Not only do these programs stop the cycle of intergenerational trauma, they intervene and change the pattern leading to a significantly lower cost in the need for adult social services, including incarceration. The programs are economically advantageous and yet the United States falls way behind other countries in its support of early intervention programs. We have known for years that the right relationship has profound neurobiological benefits on children. Many, however, do not realize that the right adult relationship can also play a role in how we regulate our emotions and can either support or inhibit healthy adult development. Dating, cohabitation and possibly marriage, therefore, become equally important developmental milestones for adults and leave room to question why we do not value romantic relationships and friendships as much as the parent-child relationship from a policy perspective. Shouldnâ&#x20AC;&#x2122;t we be supporting all healthy relationships? Healthy living and the overall happiness of our adult population rests on the premise that our citizens can access and profit from healthy relationships. We would be wise to listen to our researchers and clinicians about the prevalence rates of relational trauma that occur and fund programs that aim to change these dynamics from birth. Familiesâ&#x20AC;&#x2122; need paid family leave and reliable day care. Relational violence needs to be decreased. Single adults need to be supported in their search for a partner who is kind, supportive and adds value to their lives. Work-life balance should not be a luxury. It should be made a priority so that we can nurture and respect the very people who are capable of providing the emotional support needed for all of us to thrive. Doing so would not only make us happier but would support a more productive and healthy lifestyle for everyone. About the author: Jennifer B. Rhodes, PsyD is a licensed clinical psychologist and the founder of the bi-costal relationship consultancy, Rapport Relationships. Dr. Rhodes completed her doctorate degree at Yeshiva University and her post-graduate training at Tulane University Medical Center and the Institute for Abuse, Violence, and Trauma. Dr. Rhodes is member of Ladies America, a Thought Partner for the World in 2050 series. THE FUTURE OF WELLBEING | 63

FINANCE AND AGING BY GWENDOLYN BECK

e work hard all our lives and, as the years fly by, age keeps sneaking up on us. Most of us try to ignore it, but we all want to retire, or slow down, and lead the life of our dreams eventually. Who are we going to rely on when the time comes to retire? Ourselves? Our company? Pensions? The government? Are you self-sufficient enough? Have you saved enough? And, what about our parents? We have seen unprecedented global aging over the last half-century, as many nations have plummeting fertility rates, and mounting life expectancies. In the USA, 20% of the population will be over 65 years old by the end of this decade. But, there are ways to lead a happy, long retired life! Longevity and successful aging can be achieved by everyone, we just have to assess our situation, plan, and focus on the goal. How is your health? New technologies provide great data about your everyday health. Any wearable device for tracking your fitness like FitBit, Microsoft Band, or iWatch are great products to track your movement, and more importantly, your sleep. Are you getting enough exercise? Thin people live longer – proven fact (but, you don’t want to be too thin). Are you getting enough sleep? Research is showing that sleep is extremely important to staving off neurodegenerative diseases (dementia, etc.). Are you dreaming nightly? New research shows this is how the brain cleans out debris and replaces it with ‘good’ cells. Note the amount of calories you burn while sleeping compared to half an hour on a treadmill. Are you hydrated? As you age, you naturally lose your desire for thirst. Keep your brain hydrated by drinking two 8oz. glasses of water within 15 minutes of waking – preferably with a squeeze of lemon or lime. 64 | THE WORLD IN 2050

How is your posture? If you stand up straight, you look younger and healthier. This also keeps you’re your internal organs in the proper place. Check yourself against a wall and/or in the mirror. Are you eating correctly? Take a one-month a year break from white sugar, red meat and alcohol, and you’ll be surprised at the difference it makes in your overall health and outlook. It’s important to give your liver, kidneys and heart a chance to repair from the everyday stress and strain of today’s diets. Money – is there enough for you to live the life you’ve dreamt of? If not, what to do? Take a look every other year at what you’re saving and what you’re spending. Where are you investing your money and do you have a good advisor? Is your stock/bond portfolio solid? A home is usually a great investment, however a boat or car is usually not. Would a reverse-mortgage work for you? Is it offered in your country? Are there other financial vehicles you would be able to take advantage of? Do you have insurance for long-term care, disability and health if your country does not offer it free? Where you live can be a big factor in how you are treated and what services are offered to seniors. Can we save money by retiring in a different country? Many countries compete for retirees, and offer tax, health and banking incentives. Hungry won’t tax your retirement if you are part of the EU. Mexico and Costa Rica have huge ex-pat communities of American citizens, and your dollar/euro will go further. Do you have Advance Directives? If these are not in place, someone else will make decisions for you, especially regarding your money. Wills, trusts, power of attorney, health care surrogate and anything else you wish must be completed and filed BEFORE something happens. If you get dementia, it’s too late. And, please, write down everything you can think of – I’ve seen people locked away in apartments because the person they left in charge doesn’t want to be bothered with keeping them in the lifestyle they had. Watch out for Financial Scams! Seniors are a weak link in the fight against cybercrime. Be sure you, your parents, loved ones and neighbors are vigilant against scammers attempting to break into their nest egg. This is a worldwide problem and gets worse by the year. Is there enough Fun and Laughter in your life? It’s very important to enjoy the ride to Club 99 (for those of us who make it to 99 years old). Make sure you surround yourself with others who enjoy the same things you do – whether it’s laughter, dancing, astronomy, walking on the beach, politics or gardening. By focusing on keeping your brain strong, your body will follow and reap the rewards of successful aging! About the author: Gwendolyn Beck has a background in finance with Credit Suisse and Morgan Stanley. She has a Master’s in Gerontology from George Mason University, and is founder of ‘Club 99’ www.clubninetynine.com. Beck is member of Ladies America, a Thought Partner for the World in 2050 series. THE FUTURE OF WELLBEING | 65

WHO ARE THE HAPPIEST PEOPLE IN THE WORLD? BY WINONA ROYLANCE

n celebration of the International Day of Happiness on March 20th, Gallup recently released their 2016 Global Emotions Report detailing the emotional status of countries around the world. Based on nearly 147,000 interviews with adults in 140 different countries in 2015, the report measures happiness in terms of how often people experience happiness â&#x20AC;&#x201C; through laughter, smiling, and enjoyment â&#x20AC;&#x201C; rather than the standard format of asking people how they perceive their own happiness. The report found that in terms of positive emotions, 71% of people worldwide reported having positive experiences on the day before the survey. This criteria was based on whether or not the participant: felt well-rested, was treated with respect, had smiled or laughed a lot, learned or did something interesting, and/or experienced enjoyment at any point during the day before the survey. Astonishingly, 7 out of the top 10 countries with the highest Positive Experience Index were from Latin America, with Paraguay coming in at number one with 84%. On the other end of the spectrum, Syria ranked last for the fourth year in a row with 36%. Despite this wide gap, majorities in nearly all countries surveyed say they smiled or laughed a lot the day before the interview. Unfortunately, the Negative Experience Index also saw an increase in the past year. More than 1/3 of people reported experiencing a lot of 66 | THE WORLD IN 2050

worry or stress, with 28% experiencing physical pain, 21% reporting sadness, and 20% experiencing anger the day before the survey. Iraq ranked number one on this year’s Negative Experience Index at 58%, with Iran coming in second place at 50%. Both countries have been at the top of the list for the last five years. Despite an increasing Negative Experience Index, the global happiness average of 71% has remained surprisingly consistent since 2006. Similarly, 72% of people reported smiling or laughing a lot the day before the interview, with only seven countries–Iraq, Nepal, Serbia, Syria, Turkey, Turkmenistan, and Ukraine–reporting less than 50% on the laughter and smiling scale. People around the world tend to be happy, and Gallup’s report reveals this by providing a unique index that measures the experience of happiness, rather than the perception of happiness. It’s good to know that on this year’s International Day of Happiness, we truly do have something to celebrate. About the author: Winona Roylance is a Correspondent with Diplomatic Courier Magazine.

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THE PERFECT LAWN: CLIMATE CHANGE, NATIONAL SECURITY, AND DEATH BY KATHRYN H. FLOYD

n spring of 2015, a number of satirical articles and polls were coming about the moment when Americans would really start to care about climate change. No, we would not care when reading horrifying statistics about carbon dioxide levels in the atmosphere. We would not care when hearing about melting ice in the Arctic. However, we are going to care when we step outside our front doors into our beautiful, lovely, and…oh…completely dead lawn. Yellow grass is immediate, tangible, and an affront to the American Dream of a picture perfect little life. Our love affair with the perfect lawn has several roots (pun intended). The early idealization hails from England, where the lush greenery comes natural and large manor houses with idyllic gardens are a status symbol. Crossing the ocean, the recreation of this painting posed several problems. First, America’s soil has a significantly different composition. Those of us on the East coast would shudder with dread and whisper “clay.” The British air can best be described as moist, whereas we fluctuate between humid and bone dry based on the time of year. Much like we will never be Kate Middleton, our lawns will never attain such status. But, we try. In the post-World War II era, Americans aimed for cookie cutter houses with matching yards. We were going to win the Cold War, not least with perfectly manicured lawns that showed the world our strength and success. America would defeat the Soviets because of superior nuclear

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strength and amazing grass. My 4500 sq ft plot of land has a similar history to what I have described so far. The land beneath my feet was once Fort Lyon, part of the Union defenses of Washington, DC during the Civil War. Fast forward to 1947, the land was divided up into near identical duplexes to house many of the veterans returning from Europe and the Pacific. Had the Cuban Missile Crisis resulted in nuclear warfare, my house would have been toast. While the walls of my house are built to withstand the test of time, my soil is—as you would guess—clay. Occasionally, I find odd things in the clay that were either intentionally buried to break down and add iron or are perhaps artifacts. Digging is always an adventure. The quest for superiority, in national security and lawn care, was attained by pursuing bigger, better, and faster tactics. On one hand, we had an arms race and missile defense program that darn near bankrupt the Soviets. On the other, chemicals and industrial mowers created the illusion of a lawn, albeit one that required constant care and vast amounts of water. Justifying the win out-shadowed major concerns, like a lack of a coherent strategy in Vietnam. Still today, we apply nasty chemicals that are known to be linked to cancer because these make the yard greener. Mission accomplished? In October 2015, Montgomery County became the first locality to ban cosmetic pesticides on private lawns, which is astonishing on many levels. According to NASA, there are some 101,788 sq miles of lawn in the continental United States, which is three times bigger than the land used to irrigate crops. Watering this requires as much as 180 to 240 gallons of water per person per day. In most places, the home owner has the right to use chemicals that can kill. These chemicals enter our collective ground water and run into our streets, touching the paws of animals and the hands of children. With water crises like Flint, Michigan and elsewhere, it is unconscionable that we would so vainly waste and intentionally poison water. As a practitioner and lecturer on security issues, I found myself intoxicated by the thrill of the green yard as a retreat from studying war and violence. Uneducated, I was part of the problem and took whatever the hardware store handed me. I applied fertilizer, weed preventer, bug killer, and anything else that seemed like it would help me create my private oasis. Then two things happened. First, these products did not work well. My lawn struggled and I still had weeds. It was becoming addicted to chemicals and required constant feeding, like the user who needs the next hit of heroin to function. My lawn was mutually assured destruction where whatever product I tried required another and then another to keep things stable. Then, the voice in the back of my head chimed in: “what is in these products?” Also, as I own the most adorable French Bulldog on the planet: “why does a pet-safe product require my dog to stay off the lawn for hours?” So I shut down my chemical rotation, just as the US had to pull the plug on Star Wars, and switched to only organic products. For 70 | THE WORLD IN 2050

the climate and national security, organic lawn care is mission critical. In-between teaching William & Mary students about national security, I follow a relatively easy (and cheaper) rotation of all-natural products that, however unpleasant these may taste, I could eat. Sitting on the front stoop reading about terrorism, I call out to a neighbor that their puppy is welcome and safe on my yard. The products that I apply improve my soil and our planet. When necessary, I water from the rain barrel or hose once a week for only an hour to encourage my grass to grow deep, self-sustaining roots. For any who is still holding onto their â&#x20AC;&#x153;rightâ&#x20AC;? to use chemicals, I leave you with one closing argument. My yard is nicer, greener, and more environmentally friendly than yours, and not killing you. About the author: Kathryn H. Floyd lectures on security topics for the College of William & Mary and is the Vice President of Medauras Global. As her next career, she just may start an organic lawn care company. Floyd can be reached at @khfloyd, where she may or may not tell you her secrets to a beautiful lawn.

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EGYPT’S HEALTHCARE REVIVAL

BY DR. PAUL NASH

n the ancient world, it is said, there was no better place to receive medical care than Egypt. Whether you suffered from kidney stones or an eye infection, or had your leg shattered by a racing chariot, a treatment could be found in the “Land of Abundance.” Herodotus, the fourth-century BCE Greek historian, wrote that Egypt “is full of physicians: some treat the eye, some the teeth, some of what belongs to the abdomen, and others internal diseases.” Recently discovered evidence from mummified human remains and papyrus texts confirms this laudatory report. It shows that Egyptians as early as the third millennium BCE knew how to care for head wounds, set fractured bones, and even perform rudimentary (though successful) brain surgery. That knowledge eventually found its way to Greece and the Western world through physicians in Alexandria. Since the early modern era, advances in Western medicine have completely transformed how diseases are diagnosed and treated. Based on new chemical, anatomical, and physiological knowledge, and guided by novel clinical and experimental practices, modern medicine has saved millions from early death and improved the quality of life for countless others. But today even the most essential drugs and technologies are not available everywhere, to everyone. Each year people in underdeveloped countries suffer or perish from illnesses that could be easily treated through access to affordable interventions. According to the United Nations, about half the medical equipment in developing countries is non-functioning, either because it has broken 72 | THE WORLD IN 2050

down or there are simply too few properly trained technicians to operate it. That figure is much higher in Africa, where close 85 percent of hospitals report difficulty in finding qualified medical engineers. Pharmaceuticals, on the other hand, are in great supply. The problem, though, is that many are counterfeit—concocted to turn a quick profit with few or no active ingredients. Today, the global trade in counterfeit drugs is second only to the illicit arms trade. In Egypt the social price is enormous. And its impact is only deepening as the country’s demographics change. With more than 88 million people, Egypt is one of the most populous countries in North Africa and the Middle East. The UN estimates that by 2050 the country will be home to 140 million people. More than 40 percent will live in urban and overcrowded areas, and the population overall will be older since the proportion of dependent seniors is growing faster than the working-age cohort. While medical care in Egypt has gradually improved over the past thirty years, an expanding and aging population, coupled with deficiencies in the public healthcare system, presents enormous challenges. Costs are rising, and so too are non-communicable diseases, including cancer, diabetes, cardiovascular diseases, and chronic respiratory diseases. It is no surprise, then, that the country’s new government has moved healthcare to the top of its national, social, and economic development agenda. Multinational companies like Pfizer, Merck, and GE Healthcare see this as an opportunity to help make a difference. Pfizer, the world’s largest pharmaceuticals firm and one of the oldest in America, has a long history in Egypt. It entered the country over half a century ago, in 1961. Since then it has grown to become Egypt’s seventhlargest drug provider, employing more than 600 people between its corporate headquarters on the western bank of the Nile, across from downtown Cairo, and its high-tech manufacturing and packing plant in Almaza. Pfizer has a dual focus in Egypt. One is its anti-infectives portfolio, which includes antibiotics in multiple forms and antifungals. The other is its cardiovascular portfolio, which encompasses mature products for hypertension and dyslipidemia. These are just the start, for Pfizer is moving quickly into other product areas in high demand, such as biologics, vaccines, and targeted-therapy oncology medicines. The company is also working to reshape Egypt’s clinical research environment by promoting better investigative methods and compliance procedures. Its latest initiative applies a pioneering concept for R&D directive called INSPIRE, which stands for “Investigator Networks, Site Partnerships and Infrastructure for Research Excellence.” Through INSPIRE, Pfizer has set up strategic partnerships with the Ministry of Health and a number of THE FUTURE OF WELLBEING | 73

top Egyptian universities and hospitals. These are intended to focus clinical studies on areas where they can have the biggest impact. Merck is another multinational pharmaceutical giant operating the country. It arrived in the Egyptian market in 1965, shortly after Pfizer, and since then has introduced important new drugs, such as Rebif (Interferon beta 1a), one of the most effective treatments for certain forms of multiple sclerosis, which helps to decrease the frequency of relapses and delay the occurrence of some of the physical disability associated with the disease. Both companies have become active training partners in the country, providing ongoing medical education to local physicians, pharmacists, and paramedics, designed to close knowledge gaps and improve clinical competence. Still, Egypt’s public healthcare system faces huge obstacles. Many state-run hospitals and clinics are in disrepair, government doctors receive low wages, and the national medical insurance program covers only public workers and schoolchildren. Nearly three-quarters of all healthcare expenses are paid privately out-of-pocket. For many Egyptians, that means essential and even life-saving medicines remain out of reach. “The main challenges,” says Ashraf El-Khouly, Pfizer’s corporate affairs director for Egypt, “is the pricing of pharmaceutical products, taking into consideration the devaluation of the Egyptian pound, as well as intellectual property rights and data exclusivity.” El-Khouly believes these challenges can be overcome if the country is able to develop a well-sustained medical insurance program, along with stronger laws to clamp down on counterfeiters. Cairo must also introduce a shorter and more efficient registration process, he says. Improved medical technology and equipment is equally important. With spending on medical devices rising but local production still limited, the government is trying to make it easier for foreign manufacturers to offer their products for sale within Egypt’s borders. In 2013 the Central Administration for Pharmaceutical Affairs (CAPA) reformed its regulatory standards, streamlining the approval process for imports. GE Healthcare is at the forefront of that market. It already has more than 12,000 technologies deployed in hospitals across the country. The chief products are PET/CT scanners for disease detection, monitoring, and treatment planning, as well as mammography and ultrasound machines that can also detect blood-flow patterns, used to confirm findings and pinpoint lesions when screening results are inconclusive. GE Healthcare works closely with the Ministry of Health on several projects. One is a paperless and filmless image-reporting system called RIS 74 | THE WORLD IN 2050

PACS. The system allows radiologists at six key hospitals across Egypt to share x-ray images with a central lab in Cairo for remote assessment and storage, helping to speed up diagnoses. Other projects include installation of a PET/CT unit for the National Cancer Institute, together with a suite of imaging devices for women, capable of serving 12,000 patients a month. GE Healthcare has also helped to launch a mobile breast cancer-screening program, which aims to increase early detection, diagnosis, and treatment, as well as to promote general awareness of the disease. So far, the program, which has four units deployed across the country, has screened over 150,000 women. Most recently, GE Healthcare installed the country’s first new-generation cyclotron production facility in the Children’s Cancer Hospital Egypt, the largest pediatric oncology center of its kind in the Middle East and Africa. Like Pfizer, GE Healthcare advises the government on policy reforms and assists in the development of assessment programs and management services, with a focus on education and training for local skills development. In March it signed a partnership framework agreement to establish a Biomed Center of Excellence. This agreement, which is supported by the World Health Organization (WHO), is expected to improve the country’s medical technology management system and enhance biomedical services. Egypt spends less than five percent of its GDP on healthcare, well below the global average of nearly 10 percent. Per capita, that amounted to $151 (in U.S. dollars) in 2013, compared to the global average of $1,038, according to the latest figures from the WHO. With Egypt’s healthcare sector lagging so far behind many other countries, Western multinational companies see ample room for the market to grow, possibly even doubling over the next five years. Already, many are exploring new trade and investment opportunities. In May the U.S. Department of Commerce led a delegation of six U.S. healthcare companies to Egypt, the fourth such delegation in only six months. “Egypt is working to increase access to quality healthcare for it citizens through the Healthcare Reform Program,” said Ken Hyatt, U.S. Deputy Under Secretary of Commerce. “The companies on this trade mission can offer the latest in innovative healthcare technology and services.” American executives appear confident that expanded foreign trade and investment in Egypt’s healthcare sector will benefit Egyptians, hastening the revival through innovation, economic cooperation and commercial engagement, as well as providing additional pressure for quicker policy reforms and more public spending. About the author: Paul Nash is a Senior Editor with Diplomatic Courier. THE FUTURE OF WELLBEING | 75

THE FUTURE OF HUMAN LONGEVITY BY MADELINE BIELSKI

he Human Genome Project was completed back in 2003, but the scientific community is not done exploring human genes. Human Longevity Inc. (HLI) is looking to translate human biological information, so they can ultimately lengthen the human lifespan by addressing diseases associated with aging. HLI is looking to develop an “integrated health record” for individuals joining their database. This record would include a wide range of information from maternal and paternal nucleotides to MRI images. Once this data is collected, HLI is looking for a way to translate this information, so they can decipher a person’s health outcome. In a blog, Peter Diamandis, vice-chairman and co-founder of HLI, compared this translation process of this data to that of Google Translate (GT) an apt comparison considering they have tapped Franz Och, the man who built GT, to serve as HLI’s Chief Data Scientist. The idea behind GT is that the technology goes through a learning process to understand the rules of the language, rather than being taught every rule. Och is looking to build a team to work on the process of translating all of this biological information and ultimately HLI is looking to address age-related illnesses like dementia, cancer, and heart disease. The concept of being able to better address the health decline associated with aging is an appealing one. Of course people living longer and a 76 | THE WORLD IN 2050

healthier life is of great benefit, but there are also other societal impacts to consider. If doctors are better able to diagnose and treat illnesses, health care costs could decrease. As HLI notes, globally more than 7 million USD are spent on healthcare and around half of these costs are accumulated in the later years of a personâ&#x20AC;&#x2122;s life due to afflictions brought about by old age. HLIâ&#x20AC;&#x2122;s goal of increasing the human lifespan, as well as making it a healthier lifespan, would decrease these costs associated with treatment, because medicine could transition to being a more preventive practice. Another major consideration with this kind of technology should be access. Long, healthy lives should not be limited to just the developing world or one sector of society. If real gains are made in understanding human illnesses through this translation, these gains should be realized by all rather than a few. This of course is a larger issue with the global health industry, but it is something to consider when contemplating who will benefit from this kind of technology. Overall, this new endeavor is exciting. To see how quickly technology is advancing is impressive and it will be intriguing to see where the next development takes us: hopefully to a healthier a world. About the author: Madeline Bielski is a Correspondent with Diplomatic Courier Magazine.

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GLOBAL HEALTH VIS-À-VIS DIPLOMACY BY DR. EPAMEINONDAS GOUSOPOULOS

lobal health diplomacy is the interdisciplinary field where health sciences, including medicine, meet policy-making. A simple definition would struggle to capture the broad spectrum covered by this emerging field, which exceeds the disciplinary boundaries of public policy and health sciences. The discipline relies on training, advanced research and critical exploration of cultural, social and political affairs and their relation to healthcare. Global Health Diplomacy Intertwines Policy and Healthcare Diplomatic and health care professionals aiming to improve health through foreign policy are global health diplomacy’s integral actors. In new global health organizations, the role of biosecurity, pharmaceutical research, and bio-clinical research are the foundation of global health diplomacy. Furthermore, global health diplomacy, whose policies affect massive amounts of people, is shaped by diplomatic, epidemiological, and ethical realities. These realities are determined by funding, policies, and technology—three factors that help identify upcoming trends. Global health diplomacy increasingly relies on interaction among health infrastructures and players within global health diplomacy. Accountability of players; including governments, non-governmental institutions, philanthropic institutions, and members of the private sector; is crucial. Health relies on international cooperation. As such, international THE FUTURE OF WELLBEING | 79

partners within healthcare exceed traditional sovereign states. With this understanding, health diplomats must understand global health diplomacy and its limitations, structures, approaches and potential relationship pitfalls. However, within global health diplomacy, a mass array of actors determine funding and set individual agendas in health policymaking. Institutions are Among Global Health Diplomacyâ&#x20AC;&#x2122;s Many Actors Included in these actors are large institutions. Large institutions, who pioneered healthcare intervention, play an influential role in he future of healthcare related policies that have concrete and measurable impact. The Rockefeller Foundation, Rotary International and the Bill and Melinda Gates Foundation are examples of philanthropic organizations that create new notions of civil society and public responsibility. Technology Furthers Global Health Diplomacy Another factor, technology, plays an immense role in global health diplomacy. Technology has always been regarded as a means towards advancement but not an actor itself. Technological innovations in healthcare have resulted in major changes in many disciplines, ranging from the development of new drugs to telemedicine or even drug logistics. In particular, the expansion of pharmaceutical and biomedical research may contribute to the eradication or limitation of certain diseases. Additionally, there is a new generation of drones that are being used to reach isolated communities or individuals who lack nearby healthcare facilities. Thus, technological developments and drug research are enabling healthcare professionals and political actors to target health in new, innovative ways. Time is not the Most Important Factor Posing a challenge, the importance of policies, initiatives or players often pales in comparison to the perceived importance of time. The amount of time taken to respond to a healthcare crisis undoubtedly relates to the effectiveness of the intervention (measured in terms of relieved pain and restored health) but is not the most important factor. Undoubtedly, HIV/AIDS, tuberculosis (TB), SARS, and Ebola were cases of stratified, successful contests against dreadful diseases. However, in these cases time was not been the most decisive factor. Although speed is preferable in medicine and healthcare, the therapeutic intervention pipeline is the bottleneck in the implementation of a curative approach. Exhibiting the importance of global health diplomacy, two of the eight Millennium Development Goals (MDGs) goals refer to health issues. These 80 | THE WORLD IN 2050

goals are to improve maternal health and to combat HIV/AIDS, malaria and other diseases. Illegal Immigration Compromises Health Although not included in the MDGs for combating the spread of diseases, immigration and migration pose major risks to global health. Illegal immigration results in inadequate living conditions, increased exposure to harmful factors, an absence of health insurance coverage and under-treatment of illnesses. Immigrants represent a vulnerable population with endangered human rights and fragile health. Within immigration and migration, global health diplomacy plays a pivotal role ensuring the healthcare sustainability of individuals, and providing preventive measures for the societal spread of disease. This aspect of global health diplomacy is delicate, but is also urgent. Thus, it requires solutions in real time and decisions that respect the balances of international diplomacy. Global Health Diplomacy Requires a Fluid, Creative Approach Global health diplomacy, like medicine, is more of an art than a science. It has to be executed in an ethical manner and with respect to the historical, political, social, cultural, and economic differences between each involved party. Health diplomats have the privilege to operate on the highest international level, while at the same time bearing the responsibility of serving more than just a nation. Healthâ&#x20AC;&#x2122;s inclusion in foreign policy does not and will not ensure worldwide health. However, its inclusion adds merit to the perspective that foreign policy advancements benefit everyone. Collectively, diplomats design and implement policies that change the demographic landscape of entire countries. Global health diplomacy is a philanthropic and profoundly political service, which places humans at the center of attention and uses all available means to sustain their health. About the author: Epameinondas Gousopoulos is MD/PhD researcher at the Swiss Federal Institute of Technology Zurich working on lymphedema treatment and Chair of LE&RN Europe Chapter.

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POLIO’S BACKDOOR INTO CHINA BY DR. PAUL NASH

he Karakoram Highway cuts a rugged path through the high black mountains that separate China from Pakistan, where mirror-like lakes reflect the snowy peaks and azure sky. The highway runs 800 miles, connecting the Gilgit-Baltistan region of Pakistani Kashmir with Kashgar, a city in the Xinjiang Uyghur Autonomous Region of China. It is the only land link between the two countries, and it follows an ancient caravan trail that was once part of the Silk Road. Today, the highway belongs to the China-Pakistan economic corridor. It is at the center of a multi-billion dollar project to join China with Pakistan’s other roadways leading to the Gwadar port, west of Karachi on the Arabian Sea, a future hub for the trans-shipment of critical oil and natural gas from the Persian Gulf. The Karakoram corridor represents the future of Sino-Pak trade, but it could also put China at risk. Pakistan’s recent failure to stem the spread of polio has reminded Beijing of the corridor’s potential to become a gateway for the importation of the crippling disease into a country that now prides itself on being polio-free. Global efforts to stamp out polio, a highly infectious and incurable viral infection, have been hampered for decades by the transmission of the poliovirus across international borders. The World Health Organization (WHO) estimates that 60 percent of polio cases around the world can be traced to travelers who have carried wild poliovirus from one country to another. THE FUTURE OF WELLBEING | 83

As recently as 1988, polio killed or paralyzed as many as 350,000 people worldwide every year. Spread through contact with saliva or feces, the poliovirus enters the body through the mouth, multiplies in the gastrointestinal tract and then moves into the bloodstream. It can invade the central nervous system, destroying the motor neuron cells and causing irreversible paralysis in one out of every 200 cases, usually in the legs. Among those paralyzed, five to 10 percent die when their respiratory muscles shut down. Over the past three decades, global immunization campaigns have saved five million people from being crippled by polio, according the UN Foundation’s Polio Eradication Initiative, and today the world is closer than ever to being polio-free. But the disease remains endemic in three countries: Nigeria, Afghanistan, and Pakistan. Pakistan reported 91 cases last year. During the first four months of 2014, it reported 59 of the world’s 79 cases—40 of those in the country’s northeastern region. The region’s proximity to China is cause for worry. Even though Pakistan’s health ministry has ordered immunization counters set up at airports and border crossings, the remote Karakoram corridor remains vulnerable. In 2011, China experienced its first polio outbreak in more than a decade—the result of wild poliovirus (type 1) being carried through the Karakoram corridor into southern Xinjiang. The virus paralyzed 21 people, including 10 young children, and caused two deaths. When the virus was first detected in Xinjiang in 2011, China’s health ministry coordinated a massive response to prevent it from spreading. It dispatched more than 500 experts to the region to train and direct 1,000 health specialists, and enlisted 500,000 volunteers, health workers and government officials. The outbreak was curbed in only four months, and over a seven-month period, more than 43 million doses of oral poliovirus vaccine (OPV) were administered to children and adults under 40. Pakistan’s inoculation campaigns have met with less success. In many areas, they have suffered from logistical challenges, as well as from attacks by Pakistani Taliban militants and other extreme Islamist groups who claim that Western countries use the vaccine to contaminate Muslims or make them infertile. More than 50 people, including health workers and their security escorts, have been killed in attacks in Pakistan since December 2012. When Pakistan began its latest inoculation drive in May, concentrating on the semi-autonomous tribal areas along the Afghan border, officials said that militancy and resistance to immunization would likely prevent the vaccine from reaching 369,039 children. Other challenges exist, as well. Some NGO workers allege that the government is deliberately dragging its heels so as to sustain the millions of dollars it receives each year from the World Bank and other international organizations. From 2012 to 2014, Pakistan 84 | THE WORLD IN 2050

drew $249.64 million in loans from the World Bank, Islamic Development Bank and other countries to help eradicate polio, with some of these funds said to be providing regular income to high officials, a claim Islamabad denies. Historically, poliovirus has been endemic in China, but gradually it has been brought under control by the introduction of OPV. China developed an effective OPV in the 1950s, and by 1963, the vaccine was being administered in mass inoculation campaigns each winter. It was included in the WHO’s newly-mandated Expanded Program on Immunizations in 1978. After a polio epidemic between 1989 and 1991, which paralyzed some 10,000 people, China finally saw its last indigenous case in 1994. The country was declared polio-free in 2000, 21 years after the United States. Today, OPV is manufactured in China in sufficient quantities each year to cover all newly born children. In 2013, 145 million doses were released. In accordance with the WHO’s global Polio Endgame Strategic Plan, China’s National Health and Family Planning Commission is now working to phase in the inactivated (killed) poliovirus vaccine (IPV). Unlike OPV, it does not pose a risk of paralysis, and it is expected to supplant OPV in the coming years. While imported IPV became available in China in 2009, its supply is limited and costly. Last year, only 8.3 million doses of IPV were released in the country. That prompted private pharmaceutical companies to apply for licenses to manufacture and distribute the vaccine domestically. Nevertheless, China’s anti-polio campaign still faces serious challenges, especially in Xinjiang, which is predominantly Muslim. Increasingly, the Taliban and other fundamentalist groups in Pakistan are leading Muslims to believe that polio vaccination is un-Islamic or haraam (forbidden). Some observers fear that such notions could easily take hold in Xinjiang, which for years has been undergoing an Islamic revival. And even if inoculation were to reach full coverage in the region, there is no guarantee that all children would acquire full immunity to the virus. As China expands its trade and investment ties with Pakistan—already it has pledged $52 billion to infrastructure and energy projects over the next five years—it will have to revisit the pledges it made last year to provide Pakistan with polio eradication assistance. Intercountry and interregional collaboration will play a crucial role in immunization and monitoring efforts. And health authorities will have to become move vigilant in tracking travelers passing through the Karakoram corridor as workers, technical consultants and business people move in ever greater numbers to and from regions most at risk of harboring the disease. About the author: Paul Nash is a Senior Editor with Diplomatic Courier. THE FUTURE OF WELLBEING | 85

TECHNOLOGY PIONEERS DISRUPTING HEALTH BY JORDAN ERNSTSEN

echnological innovation has a transformative potential for society and the global economy. In acknowledgement of the revolutionary power of such innovations, the World Economic Forum (WEF) annually recognizes companies from around the globe as Technology Pioneersâ&#x20AC;&#x201D;companies at the forefront of their respective industries and trailblazers in cutting-edge products, processes, and business models. The World Economic Forum has annually recognized Technology Pioneers since 2000, selecting them from a field of hundreds of notable candidates in an open nominations process. To facilitate the selection process, the WEF appoints an 82-member selection committee constituted of distinguished industry experts, academics, and venture capitalists. Committee members evaluate the innovative nature of the company, investigating for innovation in business model, process, or product. The potential impact of the innovation to pioneer or disrupt markets and improve society is also carefully considered. In their review, the selection committee further analyzes the growth and sustainability of the company, whether it is truly a viable long-term market competitor and leader. Although a number of the candidate companies are relatively young, only started a few years before, their concept must also already be market-proven and demonstrate practical application. Finally, potential recipients are examined for leadership, and the ability to drive the company and respective industry forward. Following are five of World Economic Forumâ&#x20AC;&#x2122;s tech pioneers currently disrupting healthcare.

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GUARDANT HEALTH (REDWOOD CITY, CALIFORNIA, USA) In one form or another, the pervasiveness of cancer leaves few unaffected; finding solutions and developing effective treatment options has become a global enterprise. In contribution, the scientists at Guardant Health have created a blood analysis technology that surveys a patient’s cancer genomics. After submitting just two tubes of blood, the innovative technology interrogates cancer related genes to identify the cancer’s progression, or lack thereof. The resulting analysis yields profound insight that is then leveraged to establish personalized treatment options. Guardant Health enables medical professionals to improve therapy decisions concerning a patient’s cancer; the prompt analytical report means that cancer developments and treatments are monitored in real-time. For patients, Guardant Health technology offers a cost effective and simple yet accurate method to track their cancer and whether treatments are working. Together, patients and medical professionals are equipped with in-depth information to understand the patient’s cancer and develop tailored treatment options. HEALTH CATALYST (SALT LAKE CITY, UTAH, USA) Founded in 2008 and headquartered in Salt Lake City, Utah, Health Catalyst has worked to develop a data warehousing platform and analytics application to transform healthcare. Previously, quality patient care has suffered from a lack of accurate information, but now the healthcare industry is saturated in data. Organizing, unifying, and utilizing this data is the primary aim of the technology developed by Health Catalyst. Using the data warehouse platform and analytic application facilitates quality patient care and is improving healthcare systems across the country. The technology was developed by a team of veteran healthcare providers who identified inefficiencies and problematic features of traditional data warehousing systems. To resolve these issues and reform the nation’s healthcare infrastructure, Health Catalyst created their pioneering data warehousing architecture and combined it with sophisticated analytics. The result is the present platform being implemented in hospitals today and quickly generating valuable and measurable improvements. LABCYTE (SUNNYVALE, CALIFORNIA, USA) Research and experimentation in life sciences, molecular medicine, drug discovery, and diagnostic testing includes varying degrees of human interaction with liquid. Rethinking this process, the innovators at Labcyte designed a transformative approach to liquid handling: using sound to transfer precise amounts of fluid without having to touch them. Implementing this technology in the fields of genomics, proteomics, cell based assays, and drug discovery has yielded several significant results. Among the benefits of Labcyte’s sound-based liquid handling technology are improved data and precision delivery, and reduction in handling costs and waste disposal. Furthermore, the technology preserves sample integrity through eliminat88 | THE WORLD IN 2050

ing cross-contamination. This precise and efficient delivery method using acoustic droplet ejection is proving itself as a viable and sustainable alternative to traditional methods of liquid handling. It is simple to operate and can handle high volume workloads while reliably generating fast and accurate results. Increasingly, Labcyte’s sound driven technology is removing traditional limitations on liquid handling and helping scientists across the world do more with less. ORGANOVO (SAN DIEGO, CALIFORNIA, USA) Organovo is pioneering groundbreaking technology designed to significantly improve medical science and disease treatment. The company uses a three-dimensional bioprinting technology to create functional human tissues. These manufactured tissues accurately represent human biology and are engineered to mimic and function as native tissue. Such technological innovation has a number of implications: the Organovo team employs the bioprinting technology to facilitate medical research and therapeutic applications, using great science to achieve greater advances in health. In collaboration with academic medical institutions and biopharmaceutical companies, Organovo creates human tissue for disease modeling. By giving researchers functional human tissue, they have the opportunity to test drugs before their administration to human subjects. This enables researchers to more fully understand the impact of experimental drugs and bridge the disparity between preclinical tests and clinical trials. Additionally, the capacity to create healthy, three dimensional tissue yields the possibility of repairing or replacing damaged and diseased tissues in the human body. Certainly, Organovo’s bioprinting technology lends itself to improving medical research, drug development, and disease treatment. VAXXAS (SYDNEY, AUSTRALIA) Vaxxas was nominated for its development of the Nanopatch, a revolutionary vaccine delivery system, in order to facilitate advancements in health care and disease treatment. The Nanopatch constitutes an amalgamation of thousands of “vaccine coated microprojections” that, when applied, penetrate the skin and release the vaccine to key immune cells immediately under the surface. In collaboration with vaccine companies, Vaxxas continues to develop safe and effective methods of vaccine delivery, targeting the performance of existing vaccines for diverse diseases and oncology. In addition to enhancing the “therapeutic and market potential of existing vaccines,” Vaxxas hopes to facilitate “unprecedented immunogenic response” to next generation therapeutics. These efforts demonstrate the Vaxxas commitment to enhanced health care, the mitigation and eradication of infectious diseases and the improvement of global health. About the author: Jordan Ernstsen is a Correspondent with Diplomatic Courier Magazine. THE FUTURE OF WELLBEING | 89

CHINA AND INDIA’S GROWING INEQUITIES IN ACCESS TO HEALTH CARE BY ABHIRUP BHUNIA

hina and India collectively represent more than 35 percent of humanity. Both countries have lifted hundreds of millions of people out of poverty in the last two decades. However, the developmental challenges that India and China have yet to surmount are mammoth. The public health sector is a crucial part of this challenge. India and China ranked 95th and 75th respectively in the Social Progress Index’s ‘Health and Wellness’ segment, while the corresponding rankings in the ‘Nutrition and Basic Medical Care’ were 97th and 68th; both figures are unflattering. In the more popular UN’s Human Development Index (HDI), which encompasses health, education, and income variables, India and China ranked a miserable 136th and 101st in 2013. Whichever way one looks at it, the indications betray an absolute health policy failure in two of the world’s most populous states. Both India and China share lacklustre state participation in the health sector. While public health expenditure as a percent of GDP in the U.S. is in excess of 7 percent and anywhere between 6 to 8 percent in EU countries, in India and China the corresponding figures were respectively a meagre 1.4 percent and 2.3 percent in 2012.

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INDIA: THE UNINSURED BILLION Out of pocket payments (OPP) refer to the direct cash outlays by patients/ individuals/families to the healthcare provider. In India, OPP comprise of more than 70 percent of total health-related spending, compared to less than 12 percent in the U.S. There is a near-complete absence of a wideranging state-sponsored insurance program in India, even as targeted health programs for the poor suffer from inefficiency, corruption, ill-equipped hospitals, and ill-trained professionals. India has opened up its health sector to the private insurance players, but the latter play an insignificant role in either the health insurance market or the larger healthcare sector. Whatever little of public health insurance exists is in the form of employer-contributed schemes. Naturally, these apply only to the marginal share of population engaged in the urban formal sector. The idea of a ‘Right to Health’ is now being discussed in India. Under this scheme, health sector spending is likely to be increased to 3 percent of GDP (still likely to be insufficient) and universal access to healthcare made a reality. But there is a proclivity among Indian policymakers to limit their commitments to mere promises. CHINA: SOARING HEALTH INEQUALITY Currently, about 50 percent of China’s population pays out of pocket for healthcare facilities. In absolute numbers, this amounts to more than 600 million people. But colossal as it might sound, this does not capture the essence of the Chinese problem fully. In 2005, 179 million rural Chinese had health insurance coverage, up from a mere 8 million in 2003. Officials proclaimed recently that 800 million individuals are now covered by the country’s New Rural Cooperative Medical Scheme (NCMS). Official data show that nearly 90 percent of the population in China are insured. But the problem lies with the hundreds of millions of (by some accounts 250 plus million) rural-to-urban migrants who are left in the lurch as neither urban insurance schemes nor rural insurance programs apply to them. As proof of identity/citizenship eludes these migrants, they are deprived of any state-sponsored healthcare. Also, city-based insurance programs apply only to formal sector workers, leaving dependents and informal sector workers to fend for themselves. Moreover, because urban and rural health insurance schemes are operated separately, there are significant differences in risk protection and premium collection (which are sometimes too high in urban areas). Premium collections have steadily risen over the years. The extent of income-related health inequality in China is very high. Studies have also found urban populations to be more vulnerable to diseases and this might have to do with absurd levels of pollution in China’s cities on the back of rapid industrialisation. If a health crisis in urban centers is to be avoided, focusing policy at92 | THE WORLD IN 2050

tention on the urban poor and migrants is the need of the hour. Out-of-pocket health spending among the poor increases poverty rates in developing countries, as a large portion of their lifetime savings is wiped out, thus pushing them back into the below-poverty zone. One has to bear in mind that even a 0.5 percent increase in poverty means 6.15 million people in India and 6.75 million people in China. These are big numbers. If development in the global south is truly to be achieved, health should take policy precedence. Malnutrition, poor hygiene, and lack of clean drinking water are critical areas of policy focus. Finally, the needs for SouthSouth cooperation in these areas by way of exchange of knowledge and experience are high and need to be tapped. These include sharing technical expertise and exploration of joint R&D prospects in the pharmaceutical sector and public health infrastructure. About the author: Abhirup Bhunia is research analyst with the Institute of Economic Growth, New Delhi and holds a Masterâ&#x20AC;&#x2122;s in International Political Economy from Sussex University, UK. His upcoming book is tentatively titled Sino-Nigerian Developmental Ties and Issues.

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PRIVATE SECTOR SOLUTIONS IN FOOD SECURITY AND NUTRITION BY PHILIP H. DE LEON

ur planet is under tremendous stress to meet the evergrowing demand of human activities. In 2015, the Earth “overshoot day” – the day each year when our demands on the planet outstrip its ability to regenerate – was reached on August 13, 2015. It is therefore critical to pause and think on how we are going to feed the world, taking into consideration that the world population will grow by an additional two billion people by 2050. In the 1970s after the first oil energy crisis, France started using the motto “We don’t have oil but we have ideas” in order to reduce the country’s energy consumption. We can’t reduce our food consumption but we can optimize its production and reduce waste. The FAO estimates that “one-third of food produced for human consumption is lost or wasted globally, which amounts to about 1.3 billion tons per year” and that “recovering just half of what is lost or wasted could feed the world alone. “ PRIVATE SECTOR SOLUTIONS This is where the private sector comes into the picture with solutions that notably can address the United Nations’ Sustainable Development Goals such as Zero Hunger and Responsible Consumption and Production. These solutions consist in software to hardware and in expertise to optimize

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planning, production, storage, transformation and distribution of food. Technology and innovation intersect with food security and proper nutrition and are revolutionizing agricultural activities. Mobile phone applications enable smallholder farmers in emerging countries to track the price of commodities, to identify potential buyers for their crops and to facilitate financial transactions in the absence of local bank branches. Precision farming assisted by GPS technology enables more affluent farmers to connect the entire crop cycle from enterprise planning to planting, crop care, harvesting and grain storage. It also enables them to monitor their usage of seeds, fertilizers, pesticides and water, optimizing land usage down to a precision of a few centimeters. Precision farming through data collection over several seasons helps adjust the use of expensive inputs based on the output and yields generated on clearly identified tracks of land. Better technology and the usage of it can also improve quality and security of the output: for instance, harvesting grain at higher moisture levels and drying it in dryers result in less damage which in turn reduces the risk of mycotoxins insurgence. The existence of storage, and more precisely proper hermetic storage, such as grain silos and cold storage, is critical to reduce waste, notably post harvest losses. Similarly, processing equipment for fruits, roots and vegetables can considerably reduce waste for products with a very short shelf life (such as tomatoes into cans, mangos into juices and cassava into flour). Besides the production and productivity gains, technology and innovation prevent pollution of underground and flowing waters by adjusting the usage of fertilizers and pesticides to the level really needed. More importantly they indirectly prevent deforestation and the destruction of natural habitats by boosting production and productivity and thus profitability, reducing the need to increase acreage to increase volumes. New tools and solutions are available to farmers to make agriculture â&#x20AC;&#x153;sexyâ&#x20AC;? and appealing to the youth. This can contribute to change the thinking, notably in emerging markets: agriculture can now be seen as an industry of its own and as source of profits just like energy, construction or telecommunications, not just as a subsistence mechanism. In a recent article, Akin Adesina, President of the African Development Bank and former Minister of Agriculture and Rural Development of Nigeria referred to agriculture as a business and elaborated on approaching agriculture as an investment opportunity. If agriculture can finally be seen as a business that can generate profits to be reinvested in the business but also in healthcare, better nutrition and education then maybe the number of smallholder farmers abandoning their farms in quest of a better life in urban areas could be reduced. Small tracks of land need to be aggregated for capacity building purposes and to enable the mechanization of agriculture but the ability for some to succeed in agriculture is not a fiction. 96 | THE WORLD IN 2050

If the solutions exist why are they not more widely used? Though the private sector has the solutions to solve rapidly food security and proper nutrition issues, multiple obstacles get in the way of rolling them out. Access to finance is probably the most recurring challenge but many more exist such as: corruption that prevent companies from operating and that diverts money from state coffers that would otherwise go to agriculture projects; red tape and overregulation that slow, impede or simply deter the conduct of business; lack of regional integration that increases the cost of doing business; lack of investments in education and training that prevent human capacity building; pushes to force foreign companies to localize manufacturing when it does not necessarily reduce costs; protectionism shielding national â&#x20AC;&#x153;championsâ&#x20AC;? that are not necessarily champions when confronted to the reality of an open market, etc. Furthermore, the private sector cannot work alone. There has to be a meeting of the minds and of the means to get things done and some political will in the target country: public-private partnerships is regularly quoted as a solution and it can be. What also needs to happen is better coordination between the different players: private sector companies, governments (federal, regional, local), financing institutions (private or public banks, international financing institutions, foundations), implementers (private or public, NGOs, educational programs) and most importantly the end-users. Another problem is the goodwill intentions plagued by missing parts in the development scheme: for instance allocating money to purchase tractors but none to train the end-users or to provide spare parts; or supporting increased production without thinking about how the additional output would be stored and transformed will result in failure. Ultimately, the private sector is ready to help but success will depend on the involvement of and collaboration between all the actors. Our planet can properly feed nine billion people in a sustainable manner but all the roadblocks need to be removed to unleash its amazing potential. About the author: Philip H. de Leon is based in Washington, DC and is the Director for Public Affairs and International Business Development at AGCO Corporation. Mr. de Leon is the AGCO Staff Representative on the Presidentâ&#x20AC;&#x2122;s Advisory Council on Doing Business in Africa (PAC-DBIA) and an executive board member of the Corporate Council on Africa.

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BUILDING NEW MODELS TO NOURISH 7 BILLION BY DR. KLAUS KRAEMER

n a world of seven billion people, we must challenge ourselves to think differently. Innovation and resourcefulness are essential. As global economies large and small struggle, it is important to use the resources at our disposal to shape new models for the future to create a better life for all. The good news is we have the knowledge to make this happen. For a stronger, healthier future, we must start with a solid foundation: one that enables us to grow, to learn, to contribute to our communities, develop our nations and thrive. We know that in order to build a better future, each one of us seven billion (and counting) deserves these opportunities. To achieve this, we must overcome many health and development challenges; so where to begin? We must focus on solutions that maximize limited resources through innovation, partnerships, and smart investments. This solid foundation can be built with the smallest of building blocksâ&#x20AC;&#x201D; the micronutrients, vitamins, and minerals needed to nourish our children and families. As a global community, we have a great opportunity to shape nutrition-centered development solutions to give children a healthy start at life and in turn, nourish future generations of innovators. It is proven that well-nourished children are more successful in school and are less likely to contract and die from diseases throughout their lives.

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As they grow, well-nourished children will be more productive, increasing their earning potential in adulthood, thus helping families break the vicious cycle of malnutrition and poverty, and furthering economic development of their nations. Nutrition has cross-sector impact on development targets for education, health, poverty alleviation, agriculture development, food security, and gender equality. Simply put, investment in nutrition is an investment in the future, and is essential to success in all areas of global development. Building better nutrition begins early. It is vital to deliver proper nutrition and provide the right micronutrients during the 1,000-day window of opportunity during a mother’s pregnancy until her child turns two years old. The negative effects of malnutrition during this critical period cannot be reversed and permanently stunt a child’s intellectual and physical development. There are things we can do immediately, at a relatively low cost, to begin to make a change, including promoting exclusive breastfeeding for the first six months of a child’s life; appropriate complementary feeding; ensuring adequate nutrition for women of child bearing age, as well as pregnant and lactating women; and, supporting interventions that provide optimal intake of vital micronutrients. It is imperative that we also find new and innovative solutions. Because all sectors are involved in nutrition, there is incredible opportunity for innovation. Consider the factors that affect a child’s nutritional status: her mother’s health and nutrition, the support available to enable her mother to breastfeed, the types of crops available, her parents’ ability to ensure that complementary foods meet her needs, her family’s ability to afford nutrient-rich foods or fortified foods, and the accessibility of these products. Compounding these factors are the effects of climate change on food availability and storage, access to clean water, access to basic healthcare, and the economics behind it all. These are just a few examples. The many influences on a child’s nutrition as also mean that there are many opportunities to improve the child’s nutrition. From farm to fortification, cross-sector collaboration between civil society, government, businesses, and others can create new tangible solutions and integrate nutrition improvements into broader efforts. One way to approach solutions is to think about a food and nutrition value chain and the opportunities it presents to engage partners at different stages of production, processing, delivery, and implementation— from small-scale farmers, to food companies, to consumers. Whether it is capitalizing on existing delivery and production mechanisms to improve the availability of micronutrient-rich products or facilitating access to the tools and knowledge to fortify foods, together we can find solutions that best use limited resources. A value chain approach in the areas of production, processing and deliv100 | THE WORLD IN 2050

ery, micronutrient fortification and supplementation has led to the creation of highly successful public-private sector partnerships. Working with Sight and Life, DSM has forged partnerships with the United Nations World Food Programme (WFP) and the United States Agency for International Development (USAID) to support nutrition in the developing world in practical and inexpensive, yet innovative ways. With its technical expertise, DSM provides inputs for various nutrition improvement programs including staple food fortification programs run by USAID through the Feed the Future initiative; and micronutrient powder MixMe(tm) sachets delivered via WFP channels to increase daily intake of vitamins and minerals through home fortification. By leveraging each of the partners’ unique expertise and resources, we can improve the effectiveness and efficiency of nutrition interventions and scale up to the best possible impact-helping both the most vulnerable and the broader population. If we work to identify nutritioncentered inputs at each level of the value chain, we can reduce rates of malnutrition and disease, and bolster achievement in poverty reduction and food security as well. We all have a role to play in shaping the opportunities available to integrate nutrition-centered interventions across all sectors. We can build new transformative approaches into existing systems that support the goal of better nutrition for all people globally. Building a strong future rests on our ability to lay the building blocks for a strong human foundation. In a world of seven billion people where resources are stretched and financial resources limited, nutrition is one of the smartest investments we can make to build a strong future. Proper nutrition—micronutrients, vitamins, and minerals— form the essential building blocks for our potential as humans. About the author: Dr. Klaus Kraemer is Director of Sight and Life, a humanitarian initiative of DSM, committed to fighting hidden hunger— malnutrition caused by micronutrient (vitamin and mineral) deficiencies. Dr. Kraemer has over 25 years of experience in research and advocacy in the field of health and safety of vitamins, minerals, carotenoids, and nutraceuticals.

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FEEDING THE PLANET, EMPOWERING WOMEN BY IRENE KHAN

f we want to end hunger then we must empower women. If we want to feed the planet then we must fight gender discrimination. Many of us get misty eyed about our favorite dish—“the way Mom made it”—but few of us give much thought to the relationship between food security and gender equality. From tilling the land to getting dinner ready for the family, women are instrumental in producing, preparing, and serving food. But the gap between their role and their concomitant rights is enormous. Women farm the land but often do not own it. They cook the food but are expected to eat last in many cultures. When food is in short supply in poor families, girls are married off young, women become victims of domestic violence, and sometimes barter their bodies to feed their children and themselves. It is no mere coincidence that countries ranking highest on the global hunger index are also those where gender injustices are most stark. If we want to end hunger then we must empower women. If we want to feed the planet then we must fight gender discrimination. Both gender equality and food security are prominent themes of the international negotiations that are underway at the United Nations to adopt a new Development Agenda that will set the framework for international development policy and aid for the next decade and more. But it will be no more than a paper promise if the economic right of women to own, use and inherit, and sell land on the same basis as men gets short-shrift in this new Agenda.

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Access to land is fundamental to women’s food security. It determines how much food women can produce, consume or sell—which in turn affects not only their own well-being but also that of their children. According to the Food and Agricultural Organization (FAO), almost half the world’s agricultural labor force is female. Among the world’s 600 million livestock keepers, women are a large majority. Reliable statistics are hard to find on how much land women own or lease. Data suggests that on average women hold only 15% of the land titles. Land is collateral for credit. How much land a woman owns often influences whether and how much she can borrow to invest in seeds, fertilizers, pesticides, and tools to improve productivity. The gender imbalance in land ownership reinforces the gender asset gap in agriculture. Experts have estimated that if women farmers could borrow money to invest in fertilizers, pesticides, seeds, and tools on the same basis as men, they could increase their food productivity by almost a third. Just imagine what that would mean for the numbers of malnourished children in the world. The barriers to women’s access to land are multiple. High on the list is laws, often based on religious or customary practices that govern marriage, divorce and inheritance and restrict women’s right to acquire, inherit, control, use or dispose of land. As recently as 2012, an international survey found that 86 out of 121 countries have discriminatory inheritance laws or practices. In my own country, Bangladesh, my entitlement to inherit land as a Muslim woman under Shari’a law is several times less than that of a brother, son, uncle or nephew. Even in countries where the laws guarantee gender equality on land rights, implementation challenges may reduce their beneficial impact. Land titling and registration systems may be too complicated or corrupt or poorly administered. Women may lack basic documents such as birth or marriage certificates which are needed for land registration. Many countries do not have compulsory registration of births, marriages or divorces. Many families do not pay as much attention to registering the birth of girls as they do of boys. Even when laws confer rights and are properly implemented, social pressure may force women, especially uneducated rural women, to cede their rights to brothers, sons or husbands. In India, where the 2005 Hindu Succession Act gives Hindu women equal right to their father’s property, women have been known to renounce their claims in favor of their brothers in order to maintain harmony in the family. Access to justice is critical for claiming rights. But courts are often too far away, complicated, expensive and unresponsive to the needs of poor rural women who have little money, or time to spare from farm work and child care. The risks are too great, the response too poor to make the legal 104 | THE WORLD IN 2050

remedy really meaningful. In Kenya, IDLO has documented cases where women who go to court to assert their right to land are shunned for having “insulted” their menfolk. If they win their case, they may be beaten up or even killed. In the Solomon Islands IDLO reviewed dozens of court records but could not find any women listed as parties or witnesses to timber rights cases. Women’s names were absent from the official documents and agreements produced by the state legal system. When asked by the researcher, the women said that when they tried to attend court hearings they were told, “There’s only room for men; there is no room for any women.” Traditional and customary laws and practices have a strong influence on how marriage, inheritance and land titling issues are addressed in many parts of the world, especially in rural areas. Legal pluralism is common in many countries with formal and informal legal systems being used simultaneously with the result that even when women have legal claims over land under the formal legal system, discriminatory customary practices, such as denying widows the right of inheritance, may continue to prevail. In Rwanda, where legal reforms have strengthened women’s statutory land rights, IDLO found that such entitlements had limited practical value in rural areas where customary law continued to dominate and women, particularly widows and divorced women, faced severe obstacles in protecting and upholding their interests in land. Gender inequality is fundamentally a patriarchal power game. That is why even where customary land titling practices favor women, these are being increasingly disregarded and “forgotten” as land becomes a scarce resource, and rules are “re-interpreted” to benefit men. The law sets the parameter of what is desirable and the boundaries of what is acceptable. As such, it influences and guides behavioral norms and social interaction between men and women. Ending legal discrimination on land ownership and inheritance for all women—married or unmarried, widowed or divorced—is therefore essential. But just as the guarantee of equal pay is meaningless to a woman who is prevented by her family from going out to seek work, a statute on equal inheritance is of little use to a widow who is hounded out of her late husband’s village. Fair laws need to be underpinned by institutions that implement them effectively and social policies and services that empower women to stand up for their rights, access the institutions and hold them to account. In concrete terms, it means simplifying the process of land registration and putting it in language that women can understand. It means ensuring that women can get easily, speedily and at low cost the documents they need to register their claims. It means making women aware of their rights and giving them practical support such as paralegal services and legal counseling to claim rights. THE FUTURE OF WELLBEING | 105

Indonesia provides an interesting example where, in order to access rice subsidies women need to provide evidence that they are in fact the head of their household. But in many cases the women could not obtain divorce certificates, mostly from religious courts, because of the costs, the inaccessibility of courts or simply not knowing how to go about the process. A legal empowerment initiative, using paralegals, legal literacy training and advocacy, helped to sensitize the local government institutions about the women’s problems. It also led to policy changes, including more circuit courts in rural areas and waiver of court fees. Any reform initiative must be conscious of the realities within which women live their lives in traditional rural societies where women cannot travel freely and are not encouraged to speak up in male-dominated environments. That might mean making agricultural extension services more gender-sensitive by taking them to where the women are, or bundling legal aid and empowerment initiatives with the social services and economic support that women need, as well as protection from gender-based violence. Good practice underlines the need for holistic support—legal as well as non-legal. Far too often, policy makers and development experts focus on changing laws without understanding the gender politics that exclude and marginalize women. That is dangerous because experience shows that when initiatives to reform laws are carried out in isolation from the cultural context, without a proper understanding of the male-dominated community structures and the male-female power dynamic, they not only fail to bring about positive change, they actually set back progress. Formal titling that ignores the informal system, far from correcting historic wrongs, may further entrench discriminatory land rights. Nor is reform likely to succeed if it fails to engage customary, informal systems or gender relations in traditional societies. Attempts in Kenya to transform customary procedures relating to land titling so that women’s access to land would be widened had the opposite effect of not only cementing male ownership, but also precluding women’s access and use of land under custom. In the Solomon Islands men have traditionally had a prominent role in land dealings because they can speak and write in English and because of the custom of women “no save tok”—that is, may not talk about land—and should “stand behind” men. When the 1996 Land and Titles Act 1996 came in, it benefitted a small number of landholders, mostly men, who, exercising their traditional right to “talk” about land, effectively stepped forward and registered themselves as trustees. IDLO’s extensive work with women and informal justice systems have thrown up interesting findings on how change comes about, what works 106 | THE WORLD IN 2050

and what does not. A comparative study of Tanzania and Mozambique found that women are better able to claim their rights when they have information and expert help, and can mobilize themselves to work collectively. A case study in Namibia found that customary rules are more amenable to change when male community leaders can be mobilized alongside women to advocate for positive transformation. A core principle of the rule of law is that we are all equalâ&#x20AC;&#x201D;equally protected by the law and equally accountable to it. Not so it seems for womenâ&#x20AC;&#x201D;especially in the context of food, land and law. Think of that the next time you see a poor woman with a hoe in the field or stirring a pot in her kitchen. Feeding the Planet is about equality for women. About the author: Irene Khan is the Director General of International Development Law Organization (IDLO).

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A SURPRISE LEADER IN FIGHTING HUNGER BY MOHAMMAD ZIAUDDIN

angladesh was long associated with hunger and malnutrition, but that image no longer applies. The country has been transformed from one of chronic food shortages and poverty to an international food basket. Food production in Bangladesh has quadrupled in the past 40 years. It might be surprising to learn that Bangladesh now exports food to other nations. In an era when the lack of food security can lead to political upheaval and population displacement, Bangladesh has pioneered methods that can and should be duplicated in other developing nations. Bangladeshâ&#x20AC;&#x2122;s independence in 1971 freed the nation from economic strangulation and consequent high levels of poverty and extreme hunger. Regular devastating floods also swallowed up the otherwise fertile farmland and left its toll on the hapless people. The world still remembers the ravages of the natural disasters and food shortages, hunger, starvation and death. The new nation lacked resources and received inadequate aid needed for food production. Today, Bangladesh is a model for hunger reduction. It has made remarkable strides in reducing malnutrition. A recent United Nations report on global hunger highlights Bangladesh as one of the bright spots in the global effort to end hunger by 2030. The report says that Bangladesh has cut chronic hunger by more than half since 2000. Between 1990 and 2011, it proudly reduced the number of underweight children by 25 percent and infant mortality by 50 percent, achievements matched by only five other countries.

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Bangladesh began its transition from being a hungry nation to a country that exports rice by promoting both economic and food security. In the late 1990s, a revolution of rice production—fueled by improved varieties of rice—helped make Bangladesh a self-sufficient country. In addition, Bangladesh became a hot spot for aquaculture, turning 150,000 shallow ponds into sustainable fish farms. The growing levels of food production not only decreased hunger and bolstered nutrition, they also improved economic security for the nation’s poor by providing them with more income each year. Among the most notable ways that Bangladesh has decreased hunger is through improved health services for children and increased employment for women. Government programs encouraged the participation of women in the garment and aquaculture industries. Today, more than 60 percent of the nation’s fish farmers are women. Their involvement has helped expand these industries and has provided a second source of income for many previously impoverished families. USAID has been an active partner of Bangladesh in this effort. The American agency has trained some 67,000 women in aquaculture techniques. One of these women is Parveen Begum, wife of a poor farmer and a mother of three. With her husband she invested about $15 worth of carp in a small pond that her family owned. By the end of the year she had earned a substantial sum of $156 by selling fish at the market. So impressive was her return that Parveen’s neighbors sought her advice on improving their yields. In addition, the government worked with the World Food Program to provide hot meals to schoolchildren. The food was purchased from local female farmers, reducing child hunger while providing local jobs. Social safety-net programs also proliferated. These included the “Food for Education “program developed in the late 1990s with funds from the U.S. State Department. It provided cash for food vouchers for impoverished families that pledged to send their children to school. It fed hungry families while at the same time helping to educate the next generation. This initiative has spread around the world and was touted in the United Nations’ hunger report as a key to reducing global malnutrition. Microfinance programs have also been contributing to combat hunger. Bangladesh is where the global microfinance movement was founded to help the poor, especially women. The small loans loaned in such programs have enabled small businesses to start and flourish, producing income that has bolstered the prospects for countless families all over the country. Bangladesh’s efforts to end hunger within its borders have succeeded in meeting one of the eight U.N. Millennium Development Goals for de110 | THE WORLD IN 2050

veloping nations. The U.N. aims to achieve these goals by the end of this year. All of them will not be achieved globally, but Bangladesh has eradicated extreme under well ahead of the target. Bangladeshâ&#x20AC;&#x2122;s example provides hope that hunger can someday be eradicated everywhere. Its success demonstrates that countries that take advantage of scientific advances in agriculture and aquaculture and can empower families with the chance to create ongoing businesses. This protects the most vulnerable members of the societies. Experts believe that the next phase in reducing world hunger will focus on establishing ways to protect people from short-term food insecurity that results from natural disasters. Bangladesh again is a role model because of its regular encounters with floods, especially in its widespread lowlands. When the world looks for ways to move from hunger to plenty while fighting against the odds, it should first look to Bangladesh. About the author: Mohammad Ziauddin is Bangladeshâ&#x20AC;&#x2122;s ambassador to the United States.

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FISHING FOR THE FUTURE BY MADELINE BIELSKI

hen considering job creation and economic growth, fish don’t usually come to mind. However, Egypt’s aquaculture might just be a sector to look at to help address the country’s high rates of unemployment and poverty.

Egyptian aquaculture has seen major growth over the past few decades, increasing from producing 61.9 thousand tonnes of fish in 1990 to 705.5 thousand tonnes in 2009. The aquaculture sector overtook capture fishing in the volume of fish production in 2003. Aquaculture also had an estimated total market value in Egypt of over 1,354.646 million USD in 2009, making it a significant economic industry for the state. According to the Food and Agriculture Organization of the United Nations (FAO), Egyptian aquaculture accounts for 65 percent of the fish produced in the state and 75 percent of the aquaculture occurring in Africa. Aquaculture directly employs around 100,000 Egyptians, meaning they are engaged in either the farming, wholesale or retail sectors of the aquaculture value-chain. In terms of production and job creation, it is estimated that for every 100 tonnes of fish produced there are 14 full-time equivalent jobs. Beyond direct employment, aquaculture also stimulates many indirect jobs in industries like transportation, feed mills, and hatcheries, which support the work of those farming and selling fish. Notably, around half of those employed in the aquaculture valuechain are Egyptian youth. Specifically in the farming sub-sector, the

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employment is evenly distributed between those over and under the age of 30. Aquaculture’s relatively high youth employment is significant seeing as the unemployment for Egyptian youth was 38.9 percent in 2013 according to the World Bank in comparison with the overall 12.7 percent unemployment rate. Aquaculture is a sector with easier access for youth, especially since more formal jobs are scarce. The aquaculture sector’s growth rate and ability to create jobs is impressive, but these benefits are threatened by the rise in input costs. The Improving Employment and Incomes through Development of Egypt’s Aquaculture Sector (IEIDEAS) project, sponsored by the Swiss Agency for Development and Cooperation and managed by CARE Egypt and WorldFish from 2011 to late 2014, looked to sustain the aquaculture sector’s growth. The project was run in five key governorates in Egypt and set out to increase both productivity and profitability of aquaculture. Explicitly, the project aimed to create 10,000 new jobs in aquaculture and increase the net income brought in by the sector. The endeavors pursued by IEIDEAS focused on improving the efficiency and quality of the fish produced by Egyptian farmers. For instance, the program introduced a new breed of tilapia to several Egyptian fish hatcheries that boasts a faster growth rate. This new breed, which was slowly integrated into fish farms, promised to increase the efficiency. To further the mission to increase farmer productivity, WorldFish released a series of videos in Arabic on YouTube covering topics ranging from fish feeding to water management to be utilized by farmers. The hope is that by educating farmers on best practices, their profitability will increase as they are creating a more quality product, more efficiently. IEIDEAS also zeroed on an important sector of aquaculture that often goes unnoticed: women. The retail sector employs around 32,000 people, 30 percent of which are women. While it is significant that women are present in the workforce, especially considering Egypt’s strict gender roles, they still face many challenges when working in fish retail. Fish vending exists in Egypt’s informal economy. While informal jobs are important to diversify citizens’ income streams when formal jobs are scarce, these jobs lack security. Fish retailers are typically unregistered and as a result do not have legal or social protection. For women this often leads to manipulation and intimidation by men when they are trying too sell their fish. In order to combat this issue, IEIDEAS introduced a theater program for female fish retailers. The program simulates confrontations women might encounter when vending. The goal is to empower women and 114 | THE WORLD IN 2050

show them how to effectively deal with the challenges they may face. This program also serves as a uniting experience for women, helping them create a supportive community of female fish vendors to look out for one another and gain protection. Beyond employment, aquaculture also is an important sector in the context of Egypt’s looming food security issue. Fish accounts for 38 percent of the animal protein consumed by the Egyptian people and aquaculture is responsible for 65 percent of fish production in Egypt. In regards to poverty, 25 percent of the Egyptian population is impoverished and, according to the World Bank, live below national poverty lines. Because of their limited income, affordable and nutritious food like fish constitutes an essential part of their diet. As Egypt tackles its economic and social issues, the aquaculture industry should not be forgotten. Aquaculture holds great promise for job creation for the state’s unemployed labor force, as well as an opportunity to provide for Egypt’s poor. While Egypt is a nation more known for its deserts than its bodies of water, its aquatic potential is something to be recognized. About the author: Madeline Bielski is a Correspondent for Diplomatic Courier Magazine.

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RETHINKING EGYPT’S WHEAT BARNS BY DR. PAUL NASH

n Egypt the cost of food touches politics like nothing else can. Between the two there exists a basic and sometimes fateful link. The Pharaohs, who once lorded over the fertile Nile valley with god-like authority, were reminded of this, from time to time, whenever food supplies ran short and their temple and tomb masons put down their tools in quiet protest. Those who would rule modern Egypt ignore food prices at their own peril. The country’s 89 million people consume more than 200 million loaves of bread every day. About three-quarters of those depend on government food subsidies, which were introduced by socialist President Gamal Abdel Nasser in the 1950s. For decades, Egypt’s dictators have used bread subsidies to help keep their subjects quiet and themselves in power. But when disruptions in the wheat supply system caused prices to soar over 300 percent in 2011, Egyptians poured into the streets by the hundreds of thousands, calling for an end to President Hosni Murbarak’s 30-year rule. They demanded freedom and justice, but what they also wanted, perhaps above all else, was aish, a word that in Arabic means both bread and life. It wasn’t the first time in recent memory that rising food prices have sparked mass political revolt. In 1977 the Bread Riots erupted after Anwar Sadat’s government, looking to mollify foreign creditors who felt public spending had slipped out of control, decided to kill subsidies for basic foodstuffs like flour, rice, and cooking oil. Two days of violent rioting followed, leaving seventy-nine people dead and another 566 injured.

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And it happened again thirty years later. In 2007 and 2008 disruptions in flour supply created widespread panic, which quickly morphed into deadly protests against official graft and corruption. Along the Nile, urban sprawl has gradually squeezed traditional farmlands, and the agricultural supply chain has been left in desperate need of modernization. As a result, the country has become the world’s largest importer of wheat to feed its rapidly growing population, which has one of the highest per capita wheat consumption rates in the world. Each year the government is forced to purchase on international markets nearly three times the amount of wheat it buys from its own domestic farmers. That represents about 10 million tons – a major drain on the country’s foreign reserves and more wheat than China, India, Japan, and Venezuela combined import. Deposed President Mohamed Mursi, during his short year in power, called for an Egyptian solution to the problem and promptly slashed imports, believing that alone would lead Egypt on a path to self-sufficiency. Abdel Fattah el-Sisi, the country’s current president, says that simply cutting imports is not enough. The solution, he thinks, lies in controlling high levels of consumer food waste and post-harvest losses, which also use up other resources such as water, energy, and labor. To deal with food waste, el-Sisi’s administration has introduced a nationwide smartcard system to ration bread. Plastic cards are issued to households, allowing each to buy five loaves per family member per day. If a family uses less than its full daily allowance, it accumulates points on the card, which can be used to purchase other staples in governmentregistered stores. The government reckons the program will curb enough waste to enable the country to bring down imports by 30 percent. On the supply side, officials are working on ways to trim post-harvest losses. About 40 percent of all food grown in Egypt never makes it to market. Most is lost to spoilage due to heat and humidity, or to insects, rodents, and human theft. That spoilage occurs mainly in the country’s traditional shouna or open-air, dirt-floored storage barns, protected only by barbed-wire fencing. Last year, el-Sisi’s government hired Blumberg Grain, a division of Miami-based investment firm Blumberg Partners, to build the largest integrated grain-storage network in the Middle East and North Africa. Blumberg Grain works with countries in Africa and around the world to modernize agricultural supply chains, with a focus on reducing postharvest losses to 5 percent or less. In Egypt, that could translate into savings of more than $600 million (U.S.) a year. The Shouna Development Project, as it is called, is planned in two 118 | THE WORLD IN 2050

phases. The first will see Blumberg Grain equip 93 shouna with modern warehousing units for initial processing and storage of locally harvested wheat. Blumberg says it can drastically lower spoilage simply by moving the grain into a temperature-controlled environment, out of the sun and humidity. Inside, the grain can be cleaned, dried, and graded before being stored, where it could remain preserved for years on end. The average warehouse can hold about 8,000 metric tons of grain and process about 20 metric tons per hour but the system’s modular design is a fully scalable. Being bolted together, rather than welded, it can be quickly constructed without specialized skilled labor. The Egyptian Army has already agreed to help put up the steel warehouse, as well as assist with project management and logistics. Light steel and concrete are only the start. The warehouses, more importantly, will be connected remotely to a central management station in Cairo – Blumberg likens it to a military command center – which allows the Supply Ministry to monitor inventory levels and site security in real-time across the country. Environmental sensors placed throughout the storage units routinely measure air humidity and temperature. An automated system makes needed adjustments to air flows to maintain the right moisture levels, preventing mold growth, rot, sprouting, and insect infestation. The power to run all these systems is drawn from the units’ own generators, and Blumberg offers the option of rooftop solar cells and wind turbines, making them completely energy self-sufficient. Egypt’s Minister of Supply and Internal Trade, Dr. Khaled Hanafy, who recently toured the first site in Alexandria, said that President el-Sisi is expanding the project to see another 201 shouna modernized, for a total of 294 sites in all. With this second phase completed the project will enable processing capacity of 11.7 million metric tons of wheat a year, and create 2.35 million metric tons of new storage capacity in 11.4 million square feet of storage space. James L. Jones, former Supreme Allied Commander of NATO and U.S. National Security Advisor, said he was pleased to see an American company “play a critical role in bolstering Egypt’s food security while also fostering U.S.-Egyptian business-to-business ties.” Jones, together with the U.S. Chamber of Commerce, the world’s largest business federation, assisted in expediting the project. Blumberg Grain is now also working with the Ministry of Supply to build cold chain logistics centers for perishable produce in each of the governorates across Egypt. In addition, the company is setting its sights further afield. It wants THE FUTURE OF WELLBEING | 119

to establish a manufacturing plant in Egypt, from which it can build, on an annual basis, food security systems capable of storing 3.6 million metric tons, and distribute them across the broader region. According to company estimates, 432 million metric tons of storage capacity is needed in North Africa and the Middle East. Accounting and professional services firm KPMG says a manufacturing and export hub in Egypt would create more than 1,000 jobs for Egyptians and contribute $1 billion (U.S) to the countryâ&#x20AC;&#x2122;s economy during its first year of operation alone. Blumberg Grain has previously installed similar storage facilities in other African countries, including Senegal, Nigeria, and the Democratic Republic of Congo, where post-harvest losses account for more than the total in food aid given to the countries. Outside the region, the company recently announced plans to invest $250 million (U.S.) in India over the next five years to set up facilities to manufacture storage units for fruit and vegetables in states such as Punjab, Gujarat, Uttar Pradesh, Haryana, and Karnataka. About the author: Paul Nash is a Senior Editor for Diplomatic Courier.

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UNIVERSITY-BUSINESS COLLABORATIONS KEY TO GLOBAL FOOD SECURITY BY DR. ROGER BEACHY

nch by inch, the proverbial ivory towers at research institutions around the world are being remodeled to make way for a new era of university-business partnerships.

Given that world population is expected to top 9 billion by the year 2050, the change comes none too soon in the food and agriculture arena, where broad, integrated systems must be created to feed that burgeoning global family. In the 20th century the federally established “land-grant” universities brought science into agriculture in the United States, and in the 1940s through the 1960s, researchers around the world joined forces in the “Green Revolution” and saved millions from hunger by introducing new crop varieties and techniques. Since the 1990s, many advances in agriculture production have been based on academic research that was translated to products in the private sector. Most products were developed to increase production of commodity crops, including corn, cotton, soy and canola, and served large- and smallholder farmers alike. With greater focus now on food and nutrition and sustainable practices, including reducing the use of agrichemicals and producing highvalue, nutrition-rich crops, other changes are needed.

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Now it is time to reach across academic disciplines and bridge the gaps between university scientists, farmers and businesses to work collaboratively to feed the world. LEARNING TO BUILD PARTNERSHIPS Universities and businesses have tremendous opportunities to achieve long-term successes for food and nutrition security around the world. But both partners must first learn a bit about each other’s culture and focus on building action-oriented collaborations. For example, universities and research organizations need to create more portals through which industry can engage the finest research minds and find common ground for melding academia’s intellectual capacity and research infrastructure with the financial resources of industry. At the University of California, Davis, one of the most successful industry-engagement portals is Seed Central, a vibrant networking initiative established in 2010 to better connect the university’s plant scientists, related campus researchers and students with California’s thriving seed industry. Seed Central’s ultimate goal is to help solve real-world food and agriculture problems by speeding up the transfer of scientific discoveries to practical applications in industry. But its founders wisely recognized that just as a successful harvest begins with preparing the soil, so sound relationships are key to growing research collaborations. Seed Central now includes, 31 industry members, four educational partners outside of UC Davis and 12 regional government-related partners. More than 600 individuals from industry have attended Seed Central’s monthly events, along with more than 500 UC Davis faculty, students and staff. And plans have been initiated to construct on campus a “collaborative research laboratory” that would provide research space for seed industry partners as well as UC Davis scientists and students. As such collaborative relationships grow, universities need to develop their entrepreneurial strengths. That includes structuring research agreements to accommodate the eventual transfer of ideas and technology from the beginning – not as an afterthought. Academia also should keep in mind that the agriculture and food industry operates on relatively narrow profit margins and potential partners will be looking to the university to provide streamlined systems and tech-transfer-savvy personnel to ensure the efficient flow of discoveries from lab to marketplace. The Innovation Institute for Food and Health, a new initiative admin122 | THE WORLD IN 2050

istered through the World Food Center at UC Davis and launched in partnership with Mars Inc. is working to promote just such an environment that encourages innovation and entrepreneurship among faculty, while addressing grand challenges in agriculture and food. The Innovation Institute plans to provide funding for projects judged most likely to bring societal benefits, and anticipates that other companies will join in the initiative. EXPECT A LEARNING CURVE On the industry side, private firms need to develop a better understanding of academia’s realities, including how university research is funded. For example, in the U.S. it’s important for firms that partner with universities on research agreements support the “indirect costs” of research as well as direct costs, providing funds to literally keep the lab’s lights on and the water running. They’ll also be expected to pay for library services and salaries for graduate students and post-doctoral staff, who are the workhorses of academic research. Both sides of such collaborations should anticipate a learning curve and a few bumps along the way. Yet, the potential rewards for industry, academia and society will far outweigh the difficulties. Especially in food and agriculture, university-business partnerships hold vast opportunities that the world cannot afford to let lie fallow. About the author: Roger Beachy is an acclaimed plant biologist and executive director of the World Food Center at UC Davis, established in 2013 to increase the economic benefit from campus research; influence policy; and convene teams of scientists to tackle food-related challenges in California and around the world.

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UPROOTED

THE FUTURE OF VERTICAL FARMS BY ELLESSE BALLI AND MOLLY WHEELER

he next leap in urban design may very well be greenhouses. These are not the quaint and cluttered backyard hothouses with which you are familiar. Rather, these are veritable green compounds—more reminiscent of Star Trek than anything your eccentric neighbor owns. Take for example, the University of Arizona’s $450,000 greenhouse at the South Pole. Suddenly, the most extreme environment on earth can be depended upon to provide year-round produce. Gene Giacomelli, a contributing researcher on the project, declares unhesitatingly that greenhouses “can grow any crop anywhere at any time.” Traditionally, the appeal of greenhouses has been their ability to support non-native plant species. However, recent scientific developments have endowed greenhouses with a new benefit—efficiency bordering on the absurd. According to Theodore Caplow, executive director of the engineering firm New York Sun Works, well-designed greenhouses use as little as 10% of the water and 5% of the area required by farm fields. The revolutionizing technologies are hydroponics and aeroponics, systems that cultivate plants in nutrient liquids and nutrient spray, respectively, rather than in soil. Caplow’s firm is taking this advanced agriculture to the city. It has long been speculated that if greenhouses were erected on the all rooftops in New York City, they could supply double the amount of produce the city consumes annually. While converting every last urban rooftop may seem outlandish, Caplow maintains that there is an easy way to have a similar impact—farming the facades of office buildings. Double-

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glass facades are already a popular method employed by architects to save energy; the design allows winter sun in while insulating against heat loss. Conversely, in the summer, most double facades have built-in shades to keep the interior at room temperature. Caplow asserts that hydroponic gardens could be the source of that shade while simultaneously growing produce. In his design, plants cycle within the light-abundant space on vertical conveyor belts. Eventually, the matured plants transition to the lower floors for harvesting. Caplow assures, “The systems we are designing are what we can actually do today.” Perhaps even more innovative is Columbia Professor Dickson Despommier’s design for a vertical farm. His blueprints reveal a full Manhattan block converted into a 30-story crop powerhouse. The skyscraper is designed to cultivate food through the use of grow lights and conveyor belts all powered by renewable energy sources. Approximately 100 kinds of fruits and vegetables would be grown on upper floors while the lower floors utilize the resulting plant waste to raise fish and poultry. Each floor would additionally employ sophisticated monitoring systems, including sensors for each plant that track its nutrient absorption, DNA chip technologies to detect the presence of plant pathogens, and a gas chromatograph to determine the maturity of the plant’s flavenoids. This may all seem wishful thinking, but like Caplow, Despommier maintains, “These are all right-off-the-shelf technologies. The ability to construct a vertical farm exists now.” The promise of the vertical farm is profound. It is estimated that the year-round hydroponic production would yield 4 to 30 times that of farmland, depending upon the crop. There would be no weather-induced crop failure; no need for herbicides, pesticides, or fertilizers; and no infectious disease acquired at the agricultural interface. What’s more, vertical farms would revitalize the environment by eliminating agricultural runoff by recycling black water, adding energy back to the grid via methane generation from composting non-edible parts of plants, dramatically reduce fossil fuel use, and return current farmland to nature. Indeed, the Food and Agricultural Organization emphasizes that the best way to sequester carbon is to allow for the regrowth of cleared forest. Admittedly, urban farms are not without some drawbacks. Caplow suggests that cultivating wheat, corn, rice, or orchard fruit indoors is not nearly as efficient as most fruits and vegetables. And of course there is the matter of price. Initially, at least, urban produce will likely be more expensive than that grown at farms. But as time passes urban greenhouses are becoming a more viable solution. As Giacomelli aptly asserts, “All our cheap food is based on cheap transportation.” Furthermore, the strain of a swelling urban population—it’s estimated that by 2050 we’ll reach 9 billion, with 85 percent living in cities—may make vertical farming a godsend. 126 | THE WORLD IN 2050

Despommier’s skyscraper farm has aroused global interest. Some of the most promising clients are governments lacking sufficient arable land. Indeed, Jordan, India, and China have already begun pursuing greenhouse economics. Ultimately, figures for the vertical farm suggest it could produce enough food for 50,000 people. The professor notes that with merely 160 of these buildings, “You could feed all of New York.” Perhaps even more impressively, the Dutch-based PlantLab’s new Plant Production Units (PPUs) could supply one person with all their produce with ten square feet of space. To feed 100,000 people would only require the equivalent of two adjacent soccer fields stacked 10 levels high. Aside from the traditional agriculture requiring vastly more resources than vertical farming, it also has a significantly larger amount of waste. Indeed, PlantLab reports that more than 40% of food is wasted in the traditional supply chain from standard farms, collections and processing, distribution, wholesale, and market. PlantLab’s projected supply chain directly transports the food from the plant production unit to the market, significantly cutting down the time from harvest to table and the amount of food waste destined for the dumpster. Additionally, PlantLab’s design is entirely scalable. Their grow houses could be placed in any locality with PPUs ranging in size from microwaves to skyscrapers. Ultimately, as the global population grapples with the scarcity of resources like potable water and arable land, major concerns around food security are increasingly prevalent. These innovative agricultural systems can do more than ensure the growth of off-season plants and more effective water and land use. They could be the answer to ensuring the global population has access to healthy, locally-sourced food. About the authors: Ellesse Balli and Molly Wheeler work at the Hinckley Institute of Politics at the University of Utah and are Contributors to Diplomatic Courier.

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FEEDING THE FUTURE BY LINDA P.B. KATEHI

hen we talk about how to feed and nourish a world projected to add about two billion people over the next generation, we are really facing a multitude of unprecedented challenges.

If all we had to do was produce more food, the problem would be difficult enough. But we need to do so while dealing with serious restraints caused by climate change, shrinking agricultural land, drought and environmental degradation so extensive that in China – the world’s most populous nation – nearly a fifth of farmland is dangerously polluted. Much of the world also has pressing needs for modernizing food production, storage, packaging, processing and transportation. Meeting this signature challenge of our age will take diverse teams of experts across a variety of disciplines and specialties all working together. We will need the best, most innovative minds in the private and public sectors working more collaboratively, on a larger scale, than we have ever seen. At the University of California, Davis – listed number one in the world for agriculture and forestry the past two years by QS World University Rankings – we recently collaborated with a longtime industry partner to form the Innovation Institute for Food and Health. When people think of Mars, Incorporated, they usually picture M&M’s and Milky Ways. But since its founding in 1911, Mars has grown into

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one of the largest privately owned food companies in the world. It has more than $33 billion in annual revenues and brands that sell everything from rice to pet food and chewing gum. Mars also has a strong record in innovation and sustainability. It has been a research partner with UC Davis for nearly four decades. Together, we have worked on ground breaking research projects that have helped define nutrition requirements for pets, discover the benefits of cocoa flavanols for human health and map the genomes of Theobroma cacao (cacao) and Arachis hypogaea (peanut). We are also collaborating to establish plant breeding centers in Africa that will enable African scientists to translate the knowledge gained from the Mars-lead effort to sequence 101 food crop genomes indigenous to Africa (the African Orphan Crops Consortium) – to develop crops with improved nutrition, yield and drought tolerance. In creating our new Innovation Institute, the university was drawn to Mars for the breadth of its scientific research, its commitment to sustainability and its skill at translating scientific research into commercial products and applications, which is a central part of the Institute’s mission. As Harold Schmitz, the company’s chief scientist, has written, Mars wanted to collaborate with UC Davis on the Innovation Institute for Food and Health because of our agricultural expertise and our proficiency in management, economics, law, engineering and “many other areas vital for companies such as Mars to innovate successfully.” Interdisciplinary collaboration is a cornerstone of UC Davis research. We know that the old ways of doing research in isolated silos rarely produces the kinds of breakthroughs and innovations the world needs. That’s why in 2010, UC Davis allocated $18 million to launch new, globally competitive large-scale interdisciplinary research projects for which we hope to attract additional outside funding. We believe these projects can lead to transformative knowledge and technologies that will aid in solving major problems facing our state, nation and the world. So far in the RISE program—Research Investments in the Sciences and Engineering—we have funded 13 research teams involving more than 90 faculty from nine academic disciplines. Projects that these new research teams are working on include the development of new tools to understand, monitor and overcome plant stress; technologies to quickly, efficiently and cheaply identify pathogens of plants and people based on genetic markers to streamline disease identification; and ways to strengthen plant resistance to fungal, bacterial and viral pathogens. 130 | THE WORLD IN 2050

Another important way that land-grant universities like UC Davis have an impact on agricultural efficiency and productivity is through our Cooperative Extension programs. Although chronically underfunded, these programs provide an amazing group of cooperative specialists who work closely with faculty in our College of Agriculture and Environmental Sciences and School of Veterinary Medicine. Working together, we help farmers in their businesses, strengthen agricultural markets, help the balance of trade, address environmental issues, promote plant health and provide farmers and consumers with research-tested techniques to enhance food safety. To cite just one example, UC Davis researchers have worked through our extension programs to help California almond growers cut their water usage by a third in recent years. California and the federal government need to reinvest in our Cooperative Extension programs so we can take more of our cutting-edge research and translate it from theory into practice. Also, these programs need to stay in close proximity to our outstanding Colleges of Agriculture and Veterinary Medicine to provide the necessary translation of great science to the products and services that benefit our agricultural industry. As we work to meet the tremendous food-related challenges facing our planet, we must continue to develop and implement even more of the kind of uncommon collaborations and partnerships highlighted here in order to get the job done. About the author: Linda P.B. Katehi has served as the sixth chancellor of the University of California, Davis since 2009.

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