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Reducing NCDs globally: the under-recognised role of environmental risk factors
by The Lancet Medical Journal
July 2018
This month, the World Health Organization Independent High-Level Commission on Non-Communicable Diseases (NCDs) published a set of recommendations to accelerate progress towards achieving the Sustainable Development Goals Target 3.4 for reducing NCDs by 2030.
Unfortunately, this globally important report had a major omission: recognising the detrimental role of environmental risk factors, beyond the conventional behavioural factors (tobacco and alcohol use, physical inactivity, and unhealthy diet), in enhancing global NCD burden and health inequality.
First, there was no mention of environmental toxic elements (such as arsenic, copper, lead, cadmium, and mercury). In recent decades, toxic element exposure has become a global public health concern as emerging evidence suggests that even at lower average exposure levels (which are common in many global regions including the west) these toxic elements may have a considerable detrimental effect on NCD outcomes.
For example, high levels of arsenic from contaminated drinking water and foods affects over 200 million people in 70 countries, and has been linked to a wide range of cardiovascular and neoplastic conditions. These effects are exerted via oxidative stress, inflammation, genotoxicity, epigenetic dysregulation, and perturbations in the gut microbiome.
Second, recent estimates show that over 5·5 million people die prematurely every year due to household and outdoor air pollution.
Whereas the main contributors to outdoor air pollution are anthropogenic emissions such as from traffic and industry, indoor air pollution—a major problem in the resource-poor countries—derives principally from combustion of unprocessed solid biomass for cooking in approximately 90% of households. The current report only briefly alludes to the outdoor air pollution.
Third, the current report appears to be somewhat inconsistent with an earlier report,10 in which WHO recognised that certain chemicals—such as arsenic, lead, and airborne particulate matter—as important risk factors for NCDs, estimating that 23% of global premature deaths could be prevented through healthier environments.
The current WHO report, therefore, would benefit greatly by explicitly recognising the importance of major environmental risk factors—such as toxic chemicals and indoor and outdoor air pollution—in reducing NCD burden, beyond the roles of conventional behavioural risk factors.
Such considerations are essential to gain wider sociopolitical support for promoting appropriate legislation to regulate water, food, and air quality; national and regional standards for environmental health protection; and adequate investments towards reducing NCDs attributed to these major global determinants.

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The conflict must end: Fighting threatens to drive up hunger in South Sudan’s lean season
by Stefanie Glinski
IRIN News, agencies
2 July 2018
On Saturday, a new ceasefire came into effect in South Sudan. But within hours it had been violated – terrible news for millions of South Sudanese in the midst of their “lean season”, when food stocks are low and heavy rains can arrive suddenly, washing out roads and links to lifesaving assistance.
July marks the peak of the hunger gap, when harvests are depleted just as new crops are planted. Without food distributed by aid groups, an estimated 7.1 million people – more than half the population – would go hungry. Continued conflict makes humanitarian access to many areas extremely difficult, as well as being deadly and disruptive for civilians.
“The conflict must end,” World Food Programme Country Representative Adnan Khan told IRIN. “It’s one of the main causes of hunger in South Sudan today, forcing millions of people to abandon their land, homes, and jobs, putting them at risk of hunger. We need both peace and sustained humanitarian access to succeed.”
The civil war, now in its fifth year, has claimed tens of thousands of lives, displaced more than four million people – either to other parts of South Sudan or to neighbouring countries – and, along with poor governance, done untold damage to the oil-rich country’s economy.
On 27 June, President Salva Kiir and his rival Riek Machar agreed that a "permanent" ceasefire would come into effect within 72 hours, and that humanitarian corridors would be opened up.
But, like numerous previous ceasefires, it was violated almost before the ink dried. The latest agreement builds on a flawed 2015 peace accord that has done nothing to end the conflict, and many analysts believe it is also destined to fail.
Without lasting peace, international aid organisations fear little progress can be made to help stem hunger in the world’s newest country, which has one of the world’s worst levels of food security (access to enough nutritious food for a healthy life).
“Food security goes beyond seasonality,” explains Alemu Manni, a project manager with the UN’s Food and Agriculture Organization. During conflict, “people are not able to cultivate their land and are forced to flee the country, disrupting their livelihoods.”
During last year’s lean season, an estimated six million South Sudanese experienced severe food insecurity. According to the FAO, this number dropped to 4.8 million after crops were harvested, and the number of people living in conditions of famine fell from 40,000 to 25,000.
“All of our activities and lives revolve around food. It’s an all-consuming thought,” says Mary Amaik, a mother of six who has lived in Pibor for the past two years.
Pibor, a small town close to the Ethiopian border in eastern Boma State, lies on plains at the source of the Pibor River. It has a small market and an unpaved airstrip that fixed-wing aircraft can’t use during the rains because of the mud. So most aid is now flown in by helicopter, which is much more expensive.
South Sudan’s rains are dramatic. In just a few minutes, roads turn into streams thick with sticky mud, making it almost impossible for cars or trucks to pass. The rainy season runs roughly from May until October – just the time when people are hungriest.
Heavy raindrops hit the corrugated roof of Amaik’s home like a drum roll, the water washing off the dust and gushing into the thick, earthy soil. “During the rainy season, my garden floods and the majority of my crops are destroyed,” Amaik says. “Right now, it’s a challenge to get food.” During the wetter months, she explains, it’s impossible for traders to reach her town by road. “Even if we have money, there is no food in the market,” she says.
Agricultural yields have declined since the civil war broke out in December 2013. South Sudan is expected to produce a half a million fewer tonnes of cereal this year than its population requires, a shortfall similar to 2017.
Much of South Sudan’s food is now imported from Uganda, brought in along roads where armed attacks and looting are common. Yet even when supplies arrive, the prices keep them beyond the reach of many.
The bags of sorghum in Amaik’s house were distributed by aid agencies. Sorghum, the main crop eaten in South Sudan, has risen in price almost fourfold since 2016. During the height of the last lean season, the price peaked at 560 percent above the previous year.
Food insecurity is categorised into five “phases” of severity. The most extreme phase, “catastrophe/famine” was declared in the towns of Leer and Mayendit in northern Unity State in February 2017.
This year, limited access has made it impossible to gather the data needed to accurately assess the situation in some parts of southern Unity State. Recent fighting forced aid agencies to postpone deliveries of emergency food supplies to Unity.
“It was the hardest area to collect information from, but we know it’s an area of high concern,” says Philip Dau, director of monitoring and evaluation at the National Bureau of Statistics for South Sudan.
“We also saw indicators for food insecurity in Pibor, although these are not pointing to ‘catastrophe’. Sometimes, there are indicators – such as lack of food – but we find no evidence of crisis,” Dau explains.
Lack of access is a constant issue as the conflict fragments among more armed groups, according to Obia Achieng, chief of field operations for UNICEF in South Sudan.
“Nationally, we have conflict between the main parties,” Achieng explains. “Locally, there are dynamics between leaders, smaller conflicts linked to cattle raids, and communal conflicts which limit our access,” he says, adding that it’s difficult to deliver long-term assistance to children and women in south Unity. “But we are trying,” he adds.
In Pibor, as throughout South Sudan, women are largely responsible for planting and harvesting. “Men – even my husband – tell me that I am ‘just’ a woman and that I don’t have rights. We do all of the field work and the planting,” says Amaik. “I think that men are part of the problem when it comes to hunger. The situation is worse, because they don’t work much.”
Stefano Temporin, who heads the South Sudan office of German NGO Welthungerhilfe, says many young men are often away from their homes at cattle camps. They “only return to their families with the start of the rainy season. Others may have been drafted by the various armed groups,” he says.
Although aid agencies provide food, seeds, and farming tools, people here frequently eat only one meal a day, gathering fruit from the forest. Sometimes, they are forced to kill their scrawny cows – often a family’s only asset and also widely used as dowry payments – for what little meat they provide.
“People in some areas are employing harmful survival tactics to try to tide them through tough times, including eating less, rationing, and reducing the diversity of food,” says WFP’s Khan.
For Amaik and her family, sorghum and wild fruits are their mainstays. “During the rainy season, people migrate to Pibor from the villages, so they are not cut off from the market,” she says. “It’s better in Pibor.”
As for the people living in rural, secluded areas with little access to food, she notes: “I don’t know how they survive.”

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