Treatment of multidrug resistant tuberculosis (MDR-TB) is lengthy, toxic, expensive, and has generally poor outcomes. We undertook an individual patient data meta-analysis to assess the impact on outcomes of the type, number, and duration of drugs used to treat MDR-TB.
Methods and Findings
Three recent systematic reviews were used to identify studies reporting treatment outcomes of microbiologically confirmed MDR-TB. Study authors were contacted to solicit individual patient data including clinical characteristics, treatment given, and outcomes. Random effects multivariable logistic meta-regression was used to estimate adjusted odds of treatment success. Adequate treatment and outcome data were provided for 9,153 patients with MDR-TB from 32 observational studies. Treatment success, compared to failure/relapse, was associated with use of: later generation quinolones, (adjusted odds ratio [aOR]: 2.5 [95% CI 1.1–6.0]), ofloxacin (aOR: 2.5 [1.6–3.9]), ethionamide or prothionamide (aOR: 1.7 [1.3–2.3]), use of four or more likely effective drugs in the initial intensive phase (aOR: 2.3 [1.3–3.9]), and three or more likely effective drugs in the continuation phase (aOR: 2.7 [1.7–4.1]). Similar results were seen for the association of treatment success compared to failure/relapse or death: later generation quinolones, (aOR: 2.7 [1.7–4.3]), ofloxacin (aOR: 2.3 [1.3–3.8]), ethionamide or prothionamide (aOR: 1.7 [1.4–2.1]), use of four or more likely effective drugs in the initial intensive phase (aOR: 2.7 [1.9–3.9]), and three or more likely effective drugs in the continuation phase (aOR: 4.5 [3.4–6.0]).
In this individual patient data meta-analysis of observational data, improved MDR-TB treatment success and survival were associated with use of certain fluoroquinolones, ethionamide, or prothionamide, and greater total number of effective drugs. However, randomized trials are urgently needed to optimize MDR-TB treatment.
Low birth weight and prematurity are amongst the strongest predictors of neonatal death. However, the extent to which they act independently is poorly understood. Our objective was to estimate the neonatal mortality risk associated with preterm birth when stratified by weight for gestational age in the high mortality setting of East Africa.
Methods and Findings
Members and collaborators of the Malaria and the MARCH Centers, at the London School of Hygiene & Tropical Medicine, were contacted and protocols reviewed for East African studies that measured (1) birth weight, (2) gestational age at birth using antenatal ultrasound or neonatal assessment, and (3) neonatal mortality. Ten datasets were identified and four met the inclusion criteria. The four datasets (from Uganda, Kenya, and two from Tanzania) contained 5,727 births recorded between 1999–2010. 4,843 births had complete outcome data and were included in an individual participant level meta-analysis. 99% of 445 low birth weight (<2,500 g) babies were either preterm (<37 weeks gestation) or small for gestational age (below tenth percentile of weight for gestational age). 52% of 87 neonatal deaths occurred in preterm or small for gestational age babies. Babies born <34 weeks gestation had the highest odds of death compared to term babies (odds ratio [OR] 58.7 [95% CI 28.4–121.4]), with little difference when stratified by weight for gestational age. Babies born 34–36 weeks gestation with appropriate weight for gestational age had just three times the likelihood of neonatal death compared to babies born term, (OR 3.2 [95% CI 1.0–10.7]), but the likelihood for babies born 34–36 weeks who were also small for gestational age was 20 times higher (OR 19.8 [95% CI 8.3–47.4]). Only 1% of babies were born moderately premature and small for gestational age, but this group suffered 8% of deaths. Individual level data on newborns are scarce in East Africa; potential biases arising due to the non-systematic selection of the individual studies, or due to the methods applied for estimating gestational age, are discussed.
Moderately preterm babies who are also small for gestational age experience a considerably increased likelihood of neonatal death in East Africa.
The World Health Organization is currently developing guidelines on screening for tuberculosis disease to inform national screening strategies. This process is complicated by significant gaps in knowledge regarding mass screening. This study aimed to assess feasibility, uptake, yield, treatment outcomes, and costs of adding an active tuberculosis case-finding program to an existing mobile HIV testing service.
Methods and Findings
The study was conducted at a mobile HIV testing service operating in deprived communities in Cape Town, South Africa. All HIV-negative individuals with symptoms suggestive of tuberculosis, and all HIV-positive individuals regardless of symptoms were eligible for participation and referred for sputum induction. Samples were examined by microscopy and culture. Active tuberculosis case finding was conducted on 181 days at 58 different sites. Of the 6,309 adults who accessed the mobile clinic, 1,385 were eligible and 1,130 (81.6%) were enrolled. The prevalence of smear-positive tuberculosis was 2.2% (95% CI 1.1–4.0), 3.3% (95% CI 1.4–6.4), and 0.4% (95% CI 1.4 015–6.4) in HIV-negative individuals, individuals newly diagnosed with HIV, and known HIV, respectively. The corresponding prevalence of culture-positive tuberculosis was 5.3% (95% CI 3.5–7.7), 7.4% (95% CI 4.5–11.5), 4.3% (95% CI 2.3–7.4), respectively. Of the 56 new tuberculosis cases detected, 42 started tuberculosis treatment and 34 (81.0%) completed treatment. The cost of the intervention was US$1,117 per tuberculosis case detected and US$2,458 per tuberculosis case cured. The generalisability of the study is limited to similar settings with comparable levels of deprivation and TB and HIV prevalence.
Mobile active tuberculosis case finding in deprived populations with a high burden of HIV and tuberculosis is feasible, has a high uptake, yield, and treatment success. Further work is now required to examine cost-effectiveness and affordability and whether and how the same results may be achieved at scale.
Choosing an optimal first line antiretroviral therapy (ART) in resource-limited settings (RLS) involves a careful balancing act. On the one hand, we would want to ensure that patients receive the most efficacious therapy available. On the other hand, the most efficacious regimens may be too costly for countries afflicted by the dual burdens of very high HIV prevalence and of resource scarcity. This dilemma is compounded by the recent emergence of good quality evidence to start ART earlier (i.e., at higher CD4 counts), which can improve life expectancy , reduce the risk of tuberculosis acquisition , and reduce the transmission of HIV . These considerations will mean that about 9 million extra people will need to be placed on ART by 2015 —all in the context of a decline in global funding for AIDS during 2009 and 2010 .
The World Health Organization (WHO) has thus advised that countries should consider a number of factors in addition to clinical efficacy when considering choice of ART. These include in-country ART costs, numbers of current and future individuals needing to start ART, and the country’s national prevalence of chronic hepatitis B, tuberculosis, and anemia .
PEARLS Contributions Top
In a new study published in this week’s PLoS Medicine, Thomas Campbell and colleagues compared the efficacy and safety of three ART regimens for treatment naïve patients in the Prospective Evaluation of Antiretroviral Therapy in Resource-Limited Settings (PEARLS) trial . They conducted a randomized controlled trial to compare the efficacy and safety of open-label ART with efavirenz plus lamivudine-zidovudine (EFV+3TC-ZDV), atazanavir plus didanosine-EC plus emtricitabine (ATV+DDI+FTC), or efavirenz plus emtricitabine-tenofovir-DF (EFV+FTC-TDF). Of note, their study population was considerably more representative of the global population of people with HIV than many other studies. The study population of 1,571 individuals with HIV-1 was drawn from nine countries (including eight low- and middle-income countries) in four continents. Forty-seven percent were women.
The trial found that ATV+DDI+FTC was inferior to EFV+3TC-ZDV in terms of treatment efficacy (21% and 15% treatment failures, respectively). EFV+3TC-ZDV and EFV+FTC-TDF were equally efficacious (19% and 18% treatment failures, respectively). This is in contrast to the only other randomized controlled trial to have evaluated the relative efficacy of these two regimens (GS-01-934), which found EFV+FTC-TDF to be more efficacious than EFV+3TC-ZDV . In common with other trials, PEARLS found that the EFV+ZDV-3TC regimen was associated with more side effects requiring drug substitution than the EFV+FTC-TDF regimen.
How do we explain the discrepant findings between PEARLS and GS-01-934? The authors of PEARLS provide a plausible explanation relating to differences in how the primary efficacy endpoints were defined. GS-01-934 used as primary endpoint the US Food and Drug Administration (FDA) time to loss of virologic response (TLOVR). This includes all antiretroviral (ARV) substitutions as endpoints (failures). The ZDV containing arm had more adverse events than the TDF arm (22 versus 9), and this was the main determinant of the difference in primary endpoint between the two arms. Their explanation is given further credence by a reanalysis of PEARLS using the FDA-recommended TLOVR as the primary outcome. This transformed the PEARLS outcomes to concur with those of GS-01-934—the TDF regimen was superior.
In our opinion, a cogent case can be made that including protocol-pre-specified drug substitutions in an efficacy endpoint that is labeled as virological suppression is misleading. Both the rates of virological suppression and drug side effects are important endpoints, but it is unhelpful and misleading to conflate the two into one category and then label this as virological suppression. Of further note, the analytical approach taken in GS-01-934 favoured the commercial funder of the trial, Gilead Sciences. Six of the 12 authors of GS-01-934 were employees of Gilead, who manufacture TDF, and according to the authors of GS-01-934, “the study was designed by and the data were analyzed at Gilead Sciences” .
Practical Implications Top
The PEARLS study provides further evidence to back up the first two of four ART regimens listed by the WHO guidelines as acceptable first line ART regimens: AZT +3TC+EFV, TDF+3TC (or FTC)+EFV, AZT+3TC+NVP, and TDF+3TC (or FTC)+NVP .
PEARLS confirms the widely held view that TDF/FTC/EFV is an excellent first line ART regimen for use in RLS . Its advantages include daily dosing, availability in a fixed dose combination, compatibility with tuberculosis treatment, effect on hepatitis B, low rates of side effects, and more recently the fact that the cheapest generic price for TDF is lower than that of the equivalent for ZDV . The ability of RLS to access the cheapest ARVs varies dramatically ,. The evidence from PEARLS that ZDV has equivalent virological suppression to TDF could be used by these countries and others to further link ZDV and TDF in competitive price reductions.
One of the most useful contributions that PEARLS makes to our knowledge of ART is the lack of heterogeneity of efficacy or toxicity of ART according to country, continent, race, and/or ethnicity. There have been numerous concerns raised in the literature that there may be increased risks of drug toxicity from particular ARVs in specific populations. It has been argued that there is a risk that both TDF  and EFV  would have greater side effect rates in African populations. Reassuringly, PEARLS found no evidence of differential efficacy or toxicity by country, continent, race, or ethnicity.
Future Studies Top
Nevertheless, there are a number of limitations with the PEARLS trial that point the way for future research. One of these is the choice of protease inhibitor (PI)-based ART—unboosted ATV/DDI/FTC. A number of trials have shown the superiority of boosted- over unboosted-ATV, and this is now widely regarded as best practice . A further problem is the inclusion of DDI, a drug whose toxicity and complexity in dosing has led to its exclusion from numerous guidelines for first line ART. It was thus not surprising that this regimen was less efficacious than EFV+3TC/ZDV. Given the suboptimal nature of this regimen, one certainly cannot generalize the findings to other PI-based ART. PI-based ART may be a good option for first line ART in RLS in persons who have been exposed to ARVs in the form of the prevention of mother-to-child transmission or pre-exposure prophylaxis . Other first line regimens in need of further research in RLS are regimens including nevirapine 400 mg daily and rilpivirine (which has less neuropsychiatric side effects than EFV, and could possibly be produced for as little as US$10 per patient per year but is somewhat less effective in patients with high baseline viral loads ). New ARVs that may become options for the future include an alternative pro-drug version of tenofovir, GS-7340, which requires a lower dose and could be considerably cheaper than TDF . PEARLS has provided policy makers and clinicians in RLS with reassurance of the equivalence, as far as virological suppression is concerned, of EFV+3TC-ZDV and EFV+FTC-TDF. For the reasons mentioned above, TDF containing ART will remain the optimal first line ART in RLS. Unfortunately, we remain a long way from ensuring that all ART-requiring patients in RLS receive optimal ART rather than more toxic regimens, or no ART at all.
Author Contributions Top
Conceived and designed the experiments: Wrote the first draft of the manuscript: CRK. Contributed to the writing of the manuscript: RC. ICMJE criteria for authorship read and met: CRK RC. Agree with manuscript results and conclusions: CRK RC.
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- In developing countries, extractive industries (including ore mineral mining and oil extraction) have far reaching consequences on health through environmental pollution, some communicable diseases, violence, destitution, and compromised food security.
- The rapid expansion of extractive industries and the increasing frequency of environmental disasters are bound to engage medical humanitarian organisations in developing novel types of expertise.
- While humanitarian organisations might be called to intervene in areas occupied by the extractive sector, in this Essay I argue that oil and mineral exploitation reveals a fundamental clash of values between humanitarianism, the for-profit sector, and privatised global philanthropy.
- Specific medical humanitarian organisations can respond to these challenges in different ways, based on their position between pragmatic or principled approaches, and their willingness to develop new technical capacities.
Since 2010, Zamfara State in northern Nigeria has been the theatre of what some reports have called “the worst lead poisoning epidemic in modern history” . At least 43 villages have been affected during the outbreak period  and more than 400 children have died since March 2010 . Contamination has been the result of small-scale artisanal mining and domestic processing of lead-heavy gold ore. An epidemiological survey conducted in May 2010 in two of the most affected villages  recorded a daily under-5 mortality rate (U5MR) more than six times the United Nations High Commissioner for Refugees (UNHCR) emergency benchmark of >2.0/10,000/day, with those aged less than 24 months being particularly at risk. The survey concluded that 25% of children aged <5 years had died in the past year and blood sampling indicated that most of the surviving children had critical blood lead levels that required chelation therapy. The long-term neurological and cognitive effects among survivors of this outbreak are still unknown.
A protracted public health crisis of such a magnitude, affecting predominantly young children in impoverished communities, has much in common with classical humanitarian crises created by famine, natural disasters, infectious diseases, or conflicts. However, acute lead poisoning is a medical condition about which team members of Médecins Sans Frontières (MSF) were not exactly familiar when they were initially called to investigate the Zamfara outbreak in March 2010. The organisation responded to this unusual situation by developing a novel field of expertise, notably in providing clinical care to the many children in need of chelation therapy . MSF’s continuing intervention in Zamfara is only part of a broader multisectoral public health intervention, including environmental remediation and the institution of safer mining techniques .
This context is not foreign to the usual terrain of medical humanitarianism, which combines clinical care, public health interventions, and advocacy for vulnerable populations. But at the same time, the Zamfara outbreak was a landmark in MSF’s history, expanding the scope of medical humanitarian action to environmental emergencies. Indeed, the rapid expansion of mainstream development agendas will inevitably lead many relief organisations to confront the longer-term consequences of “extractive industries,” as it is becoming more and more known how chronic the adverse effects of such industries can have on health and societies. In this Essay I describe the broader health effects of extractive industries, to which relief organisations like MSF could be called to respond. In the last two sections, I will reflect upon the risks for these organisations in becoming engaged with corporate extractive industries.
Extractive Industries and the Resource Curse Top
Extractive industries, or mining, deal with two categories of resources: (i) fossil fuels (coal, oil, or gas), and (ii) mineral ore. The exploitation of these resources can take variable dimensions, from large mining sites (generally run by multinational companies) to small-scale artisanal mining (as in the case of Zamfara). Unfortunately, for the majority of populations living in areas occupied by extractive industries destitution is often the norm, rather than the improved livelihoods that many hope would result from increased resource activity. This phenomenon has been variably called the “paradox of plenty” or the “resource curse.” It is typically, but not exclusively, observed in sub-Saharan Africa, where considerable reserves of oil and mineral resources are increasingly being exploited. The resource curse was initially defined as the apparent macro-economic observation that dependence on exports of natural resources slows down economic growth. Exact mechanisms are still disputed, but resource curse theories have been expanded to include broader observations than just macro-economic trends (Box 1).
Box 1. Common Features of Environments Occupied by Extractive Industries and Typically Subject to a “Resource Curse” Phenomenon*
- Slow macro-economic growth
Classical Explanatory Observations (Macro Level)
- Crowding out of productive economic sectors (agriculture and manufacturing)
- Authoritarian regimes
- Civil war
- Lower spending on health care and education
Additional Observations (Micro Level)
- Environmental destruction, including decreased access to clean water
- Dysfunctional and inequitable health systems
- Higher child mortality
- Higher rates of chronic malnutrition
- Lower life expectancy
- Violence and related health effects
* Adapted from reference .
The Niger Delta in Nigeria is a classical example of a resource curse environment based on oil extraction , but most oil-rich areas of sub-Saharan countries also feature unmistakable elements of a resource curse, for example southern Chad and South Sudan . In a similar way, with their important deposits of gold and other valuable metals, the provinces of eastern Democratic Republic of Congo (DRC) have been held as a paradigm of destitution and transnational exploitation in the face of mineral wealth . The resource curse also concerns countries outside of sub-Saharan Africa, including Mongolia, Timor-Leste, and Papua New Guinea.
Aside from macro-economic considerations, the enormous social, health, and environmental costs of extractive industries need to be put in the perspective of any real or alleged gains. Extractive resources are limited by definition. There is some consensus that the peak of world oil production is inevitable, if not yet past . Over the last century, the global extraction of ores and minerals has increased by a factor of 27 . This is not only due to the expansion of the world population, but also to an increase of average resource use per capita, mostly in industrialised countries. Even by the most conservative estimates, this situation is unsustainable. Furthermore, extracted resources should be seen through the lens of their genuine use value, instead of their exchange value or symbolic fallacies attached to it. For example, it is relevant to ask if the possession or consumption of an extra ounce of gold or another carat of gems is worth the human price exacted at their sites of exploitation. Humanitarian considerations can offer some illuminating perspectives on such questions.
Health Hazards Top
Mining in general, and resource curse environments in particular, have been a source of increased health hazards for resident populations and workers alike. To the extent that safer environments, better education, better access to health care, and decreased poverty are important determinants of health, it is easy to see possible links between extractive industries, the resource curse, and poor health. In addition, a number of specific medical conditions have been documented as resulting from the activities of extractive industries, including oil exploitation.
For example, occupational and environmental hazards include exposure to pollution generated by mining and ore processing, pulmonary diseases due to dust inhalation (silicosis), respiratory diseases and cancer linked to gas flaring , and a number of communicable diseases such as tuberculosis and HIV/AIDS. The Blacksmith Institute, an international environmental nongovernmental organisation (NGO), lists mercury and lead pollution from mining or ore processing among the top ten worst toxic pollution problems in the world , and ranks as number one mercury pollution from artisanal gold mining. Mineral mining in southern Africa has been shown to be associated with extremely high incidence rates of tuberculosis , and in the same context, migration to and from mines contributes to HIV and tuberculosis spread in the general population. Mining towns also feature complex social environments open to risky sexual behaviours, with the resulting increase in sexually transmitted infections ,. More sporadic diseases can result from artisanal gold mining, like the protracted outbreak of Marburg hemorrhagic fever of Durba in northeastern DRC  that was apparently due to exposure to cave-dwelling bats . The list of specific hazards also includes exposure to radionuclide mining and extraction. For example, concerns are being voiced over environmental contamination of soil, drinking water, inhaled dust, and urban constructions around uranium mines in northern Niger .
More general effects of extractive industries are likely to occur through impacts on arable land and water resources . In DRC, chronic childhood malnutrition (stunting) is unequally distributed geographically between provinces. Rates of stunting remain very high in the Kasai and Katanga regions that rely on the mining industry, comparable to the level seen in eastern provinces that are at war . Mining thus appears to be an independent social determinant of chronic malnutrition in DRC.
Finally, oil and mineral extraction often generate contexts of chronic violence, civil war, and human rights abuses, which are classical features of the resource curse. Mental health consequences of chronic violence and insecurity in the Niger Delta have been documented, including a high prevalence of post-traumatic stress disorder . In eastern DRC, a complex pattern of socio-cultural disarray generates different forms of violence , and currently there is an endemic situation of “rape with extreme violence” across mining zones in South Kivu .
Differing Values between Humanitarian Organisations and Extractive Industries Top
The overview presented above shows that there is much scope for medical humanitarian organisations, through their logistic resources, technical expertise, and means of advocacy, to help improve the health situation of populations impacted by extractive industries. This can be the case, for example, in response to acute environmental emergencies. Humanitarian actions can also offer temporary contributions to health care provision in endemic contexts of violence and destitution. With the consumption of oil and minerals increasing worldwide, humanitarian organisations will very likely be expected to play an even more important and frequent role in the mitigation of the health impacts of extractive industries. By doing so, however, humanitarian organisations will inevitably be brought to confront the root causes and mechanisms of such adverse impacts, and the conflicts of values that they represent. Three examples come to mind: the globalisation of economic forces, corporate governance, and global philanthropy.
Firstly, with regard to the informal sort of economy grounded in artisanal or illegal mining, it is important to examine the deeper social and political causes of destitution that lead to a shift in local livelihoods from agriculture to mineral extraction. For example, the recent gold rush in Zamfara and its dire public health consequences ultimately reflect a volatile global economy artificially driving the value of gold . Secondly, in the case of extractive industries controlled by the more formal corporate sector, it is important to recognise the clash of values between humanitarian action and for-profit industries. For example, the presence of medical NGOs could be misconceived as contributing to the “social license to operate” of extractive industries, particularly when paralleled by local corporate initiatives undertaken under motives of “corporate social responsibility” . In addition, humanitarian NGOs can be directly engaged as actors of privatisation and outsourcing of health services, particularly in conflict settings , again representing a conflict of values. Thirdly, at a higher level of management, NGOs can become directly or indirectly the beneficiaries of philanthropy exercised by private foundations with financial interests in the extractive sector. Stuckler and colleagues  have shown how the financing of global health philanthropy is prone to conflict of interests, through investments in corporate sectors that can contribute to adverse effects on health and social welfare. In 2010, for example, the Bill & Melinda Gates Foundation had more than 5% of stock investments in transnational oil companies (Text S4 in ), some of them operating in the Niger Delta. From the Foundation’s perspective, the separation between grant-making and investing functions  accommodates such a contradiction, but from the perspective of local populations, this could be seen as an example of disregard for the root causes of their ill health brought about by mainstream development programs relying on the rapid extraction of natural resources.
A New Agenda for Medical Humanitarian Organisations? Top
The health community has been accused of failing to do its share to address the kind of social injustice epitomised by the condition of residents of the Niger Delta . As they witness resource curse contexts and contribute to some local relief, medical humanitarian organisations will inevitably be called forth to add their voice to broader debates on the adverse health consequences of extractive industries. In case of environmental emergencies, this moral imperative could be fulfilled by advocating for more fundamental and collective remediation measures. For example, MSF recently lambasted Nigerian authorities for delaying the urgently needed release of funds earmarked for environmental remediation and safer mining . While advocacy and expansion of their operational expertise are obvious paths for NGOs, a more complex and ideologically loaded question to solve is about what type of relationships humanitarian organisations should entertain with the corporate sector. At the institutional level, three options can be envisaged.
Firstly, some NGOs enter into broad alliances with corporate industries, following expectations of mutual benefits, shared expertise, and a space for dialogue. For example, the Devonshire Initiative  was established under the auspices of the University of Ottawa and brings together prominent international humanitarian NGOs, Canadian mining companies, and Canadian development agencies as observers. Such alliances have been criticised as being improperly imposed upon NGOs by conservative governments, through conditional funding by their respective official development agencies . Secondly, some NGOs make conditional alliances with the corporate sector, based on common norms or endeavours, for example the respect of human rights or fair trade. Examples include the Kimberley Process  and the Alliance for Responsible Mining . Thirdly is lack of engagement with the corporate sector, which many mainstream medical humanitarian organisations would rather opt for due to questions of values and conflicts of interest. But there are additional operational reasons why medical humanitarianism may wish to remain independent from the corporate sector. In the frequent cases where resource curse situations fuel civil unrest, extractive industries are naturally perceived as parties in the conflict. A broad interpretation of the main Red Cross principles (neutrality, impartiality, and independence) would therefore suggest that organisations ascribing themselves to the Red Cross tradition ought to interact carefully with the corporate extractive sector, in the same way as they would avoid partnerships with military forces. More generally, a principled understanding of humanitarian medicine entails selfless moral commitments that are incompatible with the for-profit objectives of corporate industries. Accordingly, a pragmatic approach of engagement with the corporate sector for the delivery of aid, or an implicit support to mainstream development agendas could compromise the legitimacy of humanitarian medicine , particularly in the eyes of those populations suffering the most from the presence of extractive industries.
A fourth and additional line of engagement would be for NGOs to support the public sector in its specific endeavours to address the health effects of extractive industries. Along this line, a recent initiative is the declaration of political commitment to fight tuberculosis in the mining sector, soon to be ratified by the Southern African Development Community (SADC), a regional inter-governmental organisation .
With an essentially private, broad-based, and sustained funding flow, MSF has not yet been compelled to take any position over its relationship toward extractive industries, but it is currently opening an internal debate on pragmatist versus principled arguments. In the meantime, the Zamfara outbreak has called attention to a novel agenda for medical humanitarian organisations, including technical preparedness for environmental disasters, dialogue with international environmental organisations, and a better understanding of the exact role of resources extraction in perpetuating humanitarian crises.
Author Contributions Top
Wrote the first draft of the manuscript: PhC. Contributed to the writing of the manuscript: PhC. ICMJE criteria for authorship read and met: PhC. Agree with manuscript results and conclusions: PhC.
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- Pre-exposure prophylaxis (PrEP) with anti-retroviral (ARV) medications is partially efficacious for preventing HIV infection among men who have sex with men (MSM) and heterosexuals.
- As PrEP becomes available and prescribed for use among MSM a better understanding of willingness to use PrEP and avoidance of condom use are needed so that behavioral programs and counseling may be enhanced for maximum benefit.
- Targeted messaging will be needed about ARV prophylaxis for various at risk populations, but the general message should be that condoms continue to be the most effective way to prevent HIV transmission through sex and that PrEP is an additional biomedical intervention.
- As new effective biomedical intervention methods, such as PrEP, become available language about “protected” and “unprotected” sex, which used to exclusively mean condom use, will need to adapt.
Pre-exposure prophylaxis (PrEP) to prevent HIV infection with anti-retroviral (ARV) medications was found to be partially efficacious among men who have sex with men (MSM)  and heterosexuals ,. Other studies have provided information about potential uptake of PrEP among MSM, including factors associated with use and sharing of HIV medications before  and after  ARV efficacy was known. In a study of high-risk, substance-using MSM in four United States cities conducted prior to the release of efficacy trial results, black and Latino (versus white) MSM were more willing to use a less effective PrEP product in order to avoid condom use ; further, high-risk MSM with less education reported more non-prescribed, pre-efficacy ARV use (by HIV-negative men) and sharing of ARVs with sex partners (by HIV-positive men) to prevent HIV infection . In an Internet study of US MSM immediately following release of the efficacy trial results among MSM, black and Latino (versus white) MSM were more willing to use PrEP after efficacy was known .
Colleagues – have identified important challenges relating to the implementation of PrEP, including specialist and generalist physician willingness to prescribe PrEP based on trial results . These issues will become even more prominent due to the recent recommendation of the US Food and Drug Administration (FDA) Advisory Committee to approve emtricitabine/tenofovir disoproxil fumarate (TDF/FTC or Truvada) for use as PrEP among sexually active adult men and women. This essay addresses PrEP implementation challenges for MSM and their communities in the US.
PrEP implementation among MSM poses several challenges, including (a) understanding of PrEP use and use preferences; (b) PrEP implementation costs to individuals and the health care system, and the associated epidemiological impact; (c) effective messaging about PrEP to various MSM-related audiences; and (d) implications of PrEP on the dialogue and language for research and PrEP use in practice.
Understanding PrEP Use and Preferences among MSM
Prior to known efficacy, ARV use and sharing for HIV prophylaxis among MSM was minor . In a large sample of HIV-negative substance-using MSM  in four US cities (Chicago, Los Angeles, New York, San Diego), a group at substantial HIV risk, only 2% reported PrEP and 4% post-exposure prophylaxis (PEP) use at a time preceding known efficacy of ARV use for prophylaxis of HIV infection. Among HIV-positive MSM in the study, 2.5% and 4% reported sharing ARV drugs with partners for PrEP and PEP, respectively. In a separate analysis of the data and focusing on self-reported efficacy level needed in order to forego condom use, substantial proportions of the HIV-negative men  were willing to have anal sex without a condom while taking PrEP (28% for receptive and 51% for insertive), given an efficacy level at or below the range of efficacy trial findings among MSM (i.e., 44% efficacy overall for oral PrEP, up to a 73% efficacy with 90% adherence in the iPrEX trial ). In an Internet study of US MSM conducted in early 2011, soon after efficacy trial results among MSM were announced , 83% of the HIV-negative men reported that they were likely to use an oral PrEP product at 44% efficacy, the overall efficacy level found in the trial . The demand for PrEP could be relatively high, depending on access, eligibility, and cost coverage. Racial/ethnic minority MSM may be particularly willing to use PrEP, and could especially benefit from its use, given extremely high HIV prevalence and incidence levels among black and Latino MSM populations . As ARVs become increasingly available by prescription for HIV-negative and HIV-positive MSM, non-prescribed use of ARVs by HIV-negative men and sharing by men with HIV may increase.
More surveillance and assessment is needed to monitor and better understand, among other issues, reasons for differential willingness to use PrEP and avoidance of condom use among MSM—so that behavioral programs and counseling may be enhanced for maximum benefit for both ARV prophylaxis and condom use. Ongoing community-level behavioral and clinical research is needed to determine the prevalence and effectiveness of intermittent dosing; behavioral risk substitution for condom use, including use of seroadaptive behaviors (e.g., HIV serosorting, behavioral positioning as a lower risk insertive versus receptive partner); preferences about PrEP formulation (e.g., oral, topical); provider knowledge, perceptions, and clinical behavior; and PrEP costs and access through different service provision settings.
PrEP should be prescribed and clinically monitored by a health care professional to ensure appropriate use and effectiveness (; US Centers for Disease Control and Prevention [CDC] full guidelines forthcoming), which includes medication adherence and regular HIV testing. Trial data indicate that good adherence is critical for high PrEP efficacy  and innovative approaches to promote PrEP adherence that are easily implemented in clinical and community settings are needed , including alternatives to oral administration of medication (e.g., rectal gel). Concerns about acquisition and transmission of drug-resistant HIV strains have also been raised , particularly if PrEP is being applied after HIV infection but before detectable infection, when a more rigorous ARV treatment should be employed. Further, monitoring is needed to capture both prescribed and non-prescribed use of ARV for HIV prophylaxis to better understand community-level utilization of PrEP and PEP, and to address the clinical, behavioral, and epidemiological implications of ARV use to prevent HIV transmission in MSM populations.
PrEP Costs and the Related Epidemiological Impact
Issues of cost to the individual and the health care system are central to PrEP implementation ,. There continue to be waiting lists for ARV treatment in some communities due to limited funding; large segments of HIV-negative persons will not have insurance or the direct payment capability to pay for PrEP. Drug manufacturers, insurance companies, and federal agencies must work to close gaps in access, particularly among resource-poor MSM with limited access to HIV prevention and health care.
ARV coverage for HIV-negative and -positive individuals has serious implications for HIV epidemiology. Mathematical models generally focus on efficacy, coverage, and inadvertent taking of PrEP by newly HIV-infected persons before diagnosis, and have demonstrated that ARV resistance could be a concern if PrEP is not monitored for HIV infection systematically ,. Others have assessed potential cost-effectiveness of PrEP among high-risk groups such as MSM ; however, more cost analysis and epidemiological modeling is needed to determine implementation scenarios for optimal health benefit.
PrEP Information and Messaging for Various MSM-Related Audiences
Targeted educational messages will be needed about ARV prophylaxis for various populations (Table 1). The general message should be that condoms continue to be the most effective way to prevent HIV transmission and acquisition through sex and that PrEP is an additional biomedical intervention that can provide protection from HIV infection. Multi-level prevention messages will need to be developed in order to maximize overall protective effects addressing key audiences of HIV-negative MSM highly affected by HIV (e.g., black and Latino MSM), HIV-negative MSM not using other prevention methods (e.g., condoms), HIV-positive MSM on ARVs (because they might consider sharing ARVs), and health care providers. For MSM and their providers, clear information and guidelines are needed about PrEP efficacy, risks of side effects and other PrEP use complications, the need for ongoing HIV testing and PrEP monitoring by providers, and the importance of adherence to prescribed PrEP –. Critical distinctions between PrEP and PEP and the appropriate use of each should also be addressed. At broader MSM community levels and for providers, information regarding for whom PrEP is most suitable should be provided. Specific PrEP guidelines are being developed by CDC and interim guidelines currently exist ; however, determination of the appropriateness of PrEP will ultimately be a mutual decision made between the patient and provider. For all of the audiences noted above, information on the dangers of sharing PrEP with others should address the risk of medication ineffectiveness and complications when PrEP is not directly prescribed and monitored by a qualified health care provider ,. Lastly, nonjudgmental support from providers is needed for HIV-negative MSM on PrEP, and provider services to promote adherence and appropriate monitoring are needed for all MSM receiving ARVs.
Dialogue and Language Issues Associated with PrEP
As we transition from an era of one effective biomedical intervention method (i.e., condoms) to an era of multiple efficacious interventions (i.e., condoms, ARV prophylaxis, and ARV treatment as prevention ), language about “protected” and “unprotected” sex will need to adapt. Protection from HIV infection previously meant condom use; however, protection in the future could also include oral PrEP, PEP, topical agents, or other products. This is also an opportune time to have a more explicit discussion about the efficacy and effectiveness of both methods. The research literature suggests that condoms are generally in the range of 80%–87% effective in reducing HIV transmission in studies of vaginal use among heterosexuals ,. Given efficacy trial results among MSM, PrEP can be 44% efficacious among MSM and 73% efficacious with high (90%) adherence. However, other host and partner factors are critically important in the equation (e.g., viral load, immune system functioning, number and intensity of exposures, severity of PrEP side effects). Taken together, condom use continues to be strongly recommended for the prevention of sexual transmission of HIV for all MSM, and PrEP may provide additional protection for some very high-risk MSM, determined jointly by MSM and their health care providers. However, when researchers and practitioners discuss protective action and its effect on HIV transmission, we must be clear in assessing condom use, and PrEP uptake and adherence. For example, MSM studies will need to assess separately for sexual event-level condom use and adherence and PrEP use and adherence, and include or control for each other in analysis.
Language becomes complicated when capturing PrEP and PEP—and the potential use of both by some men—in practice. Taking ARVs for prophylaxis before sexual exposure is considered PrEP. However, if a high-risk HIV-negative person who has recently engaged in sexual risk behavior is prescribed and is adherent to PrEP, but still becomes infected with HIV, PrEP becomes a suboptimal form of treatment. Over time, success of ARV prophylaxis may be due to administration before and/or after sexual exposures. The choice of approach—PrEP as a continuous approach, or PEP as an episodic approach—is contingent upon close monitoring and open discussions between providers and patients. As PrEP and PEP use become more common in the future, distinguishing between PrEP and PEP could become complex for individuals, and thus for research based on behavioral self-report. Detailed assessments will be needed to measure the complexity of ARV use over time.
Next Steps Top
Although PrEP will likely be inaccessible to many US MSM in the near future because of prohibitive cost to individuals and the health care system, some HIV-negative MSM may be prescribed ARVs and other MSM may inappropriately obtain ARVs from friends or sex partners to prevent HIV infection. Over time, access to PrEP could become a reality for many MSM, particularly in high-income countries, as availability increases and costs decrease. Given the emergence of this prophylaxis option, public health officials and providers are challenged to address community-level monitoring of prescribed and non-prescribed PrEP use in addition to condom use; develop effective multiple messages about condom use and PrEP for MSM and for their health care providers; disseminate information about the hazards of sharing ARV medications; and develop language about HIV prevention and risk reduction that has historically focused almost exclusively on condom use for sexually active MSM. As other efficacious HIV prevention interventions become available (e.g., topical antiviral products) , lessons learned from PrEP implementation can be applied to roll out of those approaches as well.
Author Contributions Top
Wrote the first draft of the manuscript: GM. Contributed to the writing of the manuscript: GM BK PS. ICMJE criteria for authorship read and met: GM BK PS. Agree with manuscript results and conclusions: GM BK PS.
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More than half of the world’s population now live in cities , and while urbanization has the potential to allow greater access to health care for all, huge discrepancies in how resources are allocated within cities result in major inequities in health . Addressing these discrepancies and improving health require accurate assessment. To that point, earlier this month PLOS Medicine published a Policy Forum article by Jason Corburn and Alison Cohen that focused on the urbanizing planet and the need for health equity indicators to guide public health policy in cities and urban areas .
The major theme of Corburn and Cohen’s argument is that if societies are to ensure those living in the poorest urban slums have the same right to health as people living on the richest boulevards, health indicators must allow for the identification of where health inequities exist. For example, while indicators in Nairobi measure population access to communal toilet blocks, they give no information as to whether the toilet blocks are hygienic or safe to use and therefore mask inequity within the city. Such indicators, however, would have little value in cities like London or New York, which illustrates the need for context-specific measures.
There is a long history of public health interventions dramatically improving the health of a city. In London, both the Great Stink of 1858, caused by the River Thames becoming an open sewer , and the Great Smog of 1952, when London was shrouded in a dense smog for several days mostly due to burning coal as fuel , were tipping points that led to improved sewerage systems and clean air laws. These two examples were so extreme that it was not necessary to develop a metric to prompt action; the problems were there to be seen, breathed, and smelled. However, environmental problems should be tackled before they become overpowering; environmental hazards that are not obvious to residents still affect human health. Indeed, a recent study estimates that about 3,200 air-quality related deaths occur every year in greater London . These more subtle hazards require indicators to assess and track their impact and progress.
The remaining air quality problems in London are dwarfed by those in cities without strong environmental laws and accountable government. Last year, World Health Organization (WHO) figures on the air quality of nearly 1,100 cities across the globe  found the worst air particulate matter not to be in the world’s largest cities but from Iran (four cities), Mongolia, India (two cities), Pakistan (two cities), and Botswana—these ten cities have the highest mean annual levels of particulates sized 10 micrometers (µm) or less (PM10). For particulates of 2.5 µm or less (PM2.5), cities from Mongolia, Madagascar, Kuwait, Mexico, Ghana, Poland (two cities), Senegal, Italy, and Peru feature in the top ten.
WHO estimates that approximately 1.34 million premature deaths were attributable to outdoor air pollution in 2008 , with much of that burden falling within low- and middle-income countries. Examples of industrial exposure have demonstrated the devastating effect that prolonged exposure to high levels of respirable particulates can have on health  and, despite existing health and safety laws, occupational exposure to poor air quality remains a problem even in the richest countries . The majority of outdoor airborne particulates in cities come from burning fossil fuels, and in particular from traffic and industry, and the practice of burning solid fuels for cooking and heating. A substantial body of evidence has demonstrated an association between exposure to particulates within the atmosphere, especially PM2.5, and adverse effects on health, with cardiovascular disease being the leading cause of air pollution–mediated morbidity and mortality .
The WHO figures show that only a few of the world’s cities currently meet WHO guideline values for PM2.5 and PM10. Although the reported average values are high, the data don’t include readings from industrial areas and other recognized “hot spots,” so the measurements are unlikely to be representative of the exposure endured by many individuals living in cities. Much of the data come from very few monitoring stations within a city and often from only one. Furthermore, although the data span 2003–2010, the great majority come from 2008–2009, making determination of trends difficult. Clearly there is a need for more air quality data from the world’s cities—and in particular from those in low- and middle-income countries—but if those at highest risk within cities are to be identified, better local assessment seems warranted. Perhaps more worrying than inadequate measurement is when data, such as air quality, are seen by local and national governments as an embarrassment to be hidden away. Earlier this year China announced it would start monitoring PM2.5 and ozone levels in 27 provincial capitals and other key regions with the aim of expanding this program to all cities at prefecture level or above in 2015 . While the statement, which set out the need for monitoring by stating, “we need firmer resolution and more effective measures, under higher standards, to remedy air pollution and steadily improve air quality,” is to be condoned, the reliability of the measures have been questioned . Particularly concerning is the lack of concordance between the US Embassy’s and the Ministry of Environmental Protection’s measurements for PM2.5 in Beijing, with the US figures often being substantially higher than the official Chinese figures .
As Corburn and Cohen note in their article, for indicators to be effective they must be context-specific and relevant, and be made available transparently so that they can be open to interpretation and reevaluation. Only by measuring and disseminating such data will the inequities in the world’s urban areas, and the steps necessary to address them, become clear.
Author Contributions Top
Wrote the first draft of the manuscript: PS. Contributed to the writing of the manuscript: VB JC PS LC EV MW. ICMJE criteria for authorship read and met: VB JC PS LC EV MW. Agree with manuscript results and conclusions: VB JC LC PS EV MW.
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5 to 8 times stronger than vitamin E and stronger than vitamin C, this ‘antioxidant breakthrough’ may help boost your immunity, maintain normal cholesterol levels, and put the brakes on aging.*
You may already know I place a strong emphasis on eating as much unprocessed, organically grown food as possible for optimal health.
One frequently overlooked way to enhance and optimize health with organically grown food is the use of herbs and spices – unprocessed and organic, of course.
One amazing benefit of these herbs is that they’re very low in calories, while being dense in vitamins and minerals.
In the same vein, they’re thermogenic, meaning they naturally boost your metabolism to help you burn calories.* You feel satisfied more easily, so you eat less.* Studies show that consuming certain herbs and spices before each meal can potentially reduce your caloric intake.*
Due to their nutrient-dense status, they promote your overall wellbeing with antioxidants more potent than many fruits and veggies.*
Herbs and spices promote health and wellbeing in your entire body, not just in a particular area.*
This “whole person” approach is why I believe these spices and herbs can benefit you so greatly.
But I consider one particular spice the “granddaddy” of them all, because its benefits are so amazing and far-reaching.
Don’t Waste Your Time and Health with
Synthetically Processed Herbs and Spices
Just as it’s important to select and consume wholesome, unprocessed organic foods, you should do the same with herbs and spices.
Avoid breezing down the spice aisle of your local grocery store to pick up any old herb or spice.
It is important to be very selective.
If the herb or spice you’re looking for is processed or not organically grown, you risk missing out on their most potent active ingredients, which provide you with optimal benefits.
If the herb or spice isn’t cultivated, harvested, produced, and packaged using certified organic processes, you could be robbed of its healthful active ingredients.
In fact, I recommend you totally avoid herbs and spices that aren’t 100% certified organic. Why waste your time — and risk potential health consequences from artificial ingredients and questionable chemical processes?
India is the home of Ayurveda, recognized as an authoritative source of knowledge and truth in natural health promotion — with herbs and spices lying at the very heart of Ayurvedic practice. So it would make perfect sense to consider using herbs that were grown in India if you are considering Ayurvedic herbs
That’s one of the reasons I traveled over 15,000 miles to India last year — to find a high quality source of these herbs. During my trip to India, I witnessed firsthand how the Ayurvedic holistic approach and organic processes work in unison.
And of the many herbs and spices I studied, the one in particular that caught my immediate attention was turmeric. It provides you with these whole-person benefits:
- Supports your healthy joint function*
- Promotes your radiant skin*
- Helps improve your digestion*
And so much more…
There’s some debate about the timing of turmeric’s first use as a healthy spice.
But one thing is certain. Thousands of years ago, people in India and China used the spice. In fact, some stories suggest usage dates back 10,000 years in India when they say Lord Rama walked the earth.
And the ancient Polynesians carried turmeric with them on their incredible voyage across the Pacific Ocean to Hawaii. Today, Hawaiians still use this spice — known to them as Olena.
While in China, Marco Polo in 1280 AD recorded information on turmeric in his diary:
“There is also a vegetable which has all the properties of true saffron, as well the smell and the color, and yet it is not really saffron.”
So, turmeric has been used as a substitute for saffron (an old world spice) in Europe for over 700 years.
One of the main healthful ingredients in turmeric is curcumin (a curcuminoid), which as I said, gives turmeric its yellow color.
Western scientists first isolated the curcumin molecule in 1815, obtained its crystalline form in 1870, and determined its overall structure in 1910.
Curcumin can potentially benefit you by:
Promoting your immune system against stress*
- Promoting your immune system*
- Helping you maintain your healthy digestive system*
- Supporting your healthy bones, joints, and overall skeletal system*
- Helping you maintain cholesterol levels that are already within the normal range*
- Promoting your healthy blood and liver functions*
How Turmeric and Curcumin Provide Antioxidant Nutrients*
You probably know that antioxidants are important for your health.
I believe antioxidants are your body’s #1 way to neutralize free radicals and help you potentially slow down the signs of normal aging.*
Oxidation by free radicals can damage cells and organs — and thus impact your aging process* — something I’m sure you’d rather put the brakes on.
Antioxidants are also key nutrients in:
- Supporting your memory function*
- Promoting your heart health*
- Boosting your immune system*
Turmeric’s antioxidants help protect your cells from free radical damage.*
The antioxidant content within turmeric comes from active compounds called curcuminoids.
These curcuminoids deliver antioxidants that may be:
- 5 to 8 times stronger than vitamin E — and also stronger than vitamin C
- 3 times more powerful than grape seed or pine bark extract
- Strong enough to scavenge the hydroxyl radical — considered by many to be the most reactive of all oxidants*
How Turmeric Enhances Your Outer Beauty*
Speaking of antioxidant nutrients and their potential to impact the aging process, some of the first aging signs you may see as you get older are changes to your skin.
Believe it or not, the organic ingredients found in turmeric can help promote your healthy skin.*
How, you ask?
Curcuminoids support important blood and liver functions, healthy joints, and your overall well-being,* which in turn helps promote radiant, supple skin.*
Turmeric has been considered to be ‘skin food’ for thousands of years in India and other cultures.*
- Cleanse your skin and maintain its elasticity*
- Provide nourishment to your skin*
- Balance the effects of skin flora*
So, turmeric can act as your one-two punch against normal aging with its skin promotion and antioxidant capabilities — outer beauty plus inner purity.*
Your Triple-Action Cellular Booster and Adaptogen*
Another potential advantage from turmeric usage involves the smallest living things within you — your cells.
Turmeric can assist your cells in three ways, by:
- Helping neutralize substances that can cause cellular stress*
- Maintaining your cells’ integrity when threatened by occasional environmental stressors*
- Providing the antioxidants you need to help support your cells against excessive oxidation and free radicals*
Turmeric is also recognized as an adaptogen — helping to support your body against stress and providing immune system support.*
How this Ancient Spice has Become
Embedded in India’s Ayurvedic Practice
Turmeric, like other herbs and spices, is a principle herb in Ayurveda — India’s ancient holistic health system. Ayurveda means “knowledge of life” — with herbs lying at the very heart of Ayurvedic practice.
Turmeric has multiple uses within Ayurveda, including blood cleansing and maintaining healthy skin.*
In Ayurvedic terminology, turmeric includes the following:
- Verdana sthapana — promotes your healthy nervous system and helps you with occasional discomfort*
- Sangrahani — supports your absorption of vitamins and minerals*
- Anulomana — helps you in purging out wastes and building healthy blood*
- Rakta stambhaka — promotes the wellness of your circulatory system*
And this is just the tip of the iceberg when it comes to Ayurvedic turmeric uses.
What does this mean to you?
Simply, turmeric has been used in Indian culture for thousands of years for a multitude of health-promoting reasons.* An estimated 500 million Indians still use the spice today.
What Are Your Best Sources for Turmeric?
So by now, you might be wondering about potential sources of turmeric.
Well, you may already know you can find it in the spice aisle of your local grocery store. But as mentioned earlier, I don’t recommend using your local grocery store, due to the quality of their herbs and spices.
Even though there may be some good spices available there, it’s very difficult to verify their purity and potency.
Also, the turmeric powder you buy in your store is a spice. It doesn’t necessarily come from high-quality organic herbs — and is not produced using certified organic processes, causing you to risk missing its healthful benefits.
What’s more… with store-bought turmeric powder, you’ll probably just use it once in a while to cook with — not on a daily basis to consistently take advantage of the benefits it offers.
So, what other options do you have?
I recommend searching for a high-quality, 100% organic-based turmeric supplement.
But there are some things you should watch for when choosing a turmeric supplement.
Avoid Unnecessary Fillers, Additives, and Excipients
When I did my own research on available turmeric supplements, I found a surprising array of choices.
Besides, curcumin and curcuminoid ingredients, I found products with questionable ingredients like fillers, additives, and excipients. An excipient is a substance added to the supplement as a processing or stability aid.
One ingredient, magnesium stearate (also known as stearic acid), is a potentially toxic metal additive from pill production.
Another ingredient I found in many turmeric supplements, Dibasic Calcium Phosphate (DCP), may even inhibit the absorption of essential minerals within your system.
There are others you may find as well, but the bottom line is… you don’t want or need these ingredients in your turmeric supplement. Some pose potential health risks — and all are unnecessary.
Make Sure Your Herbal Supplement Comes from a
Certified Organic Producer Committed to Quality Processes
The key to delivering an organic-based turmeric supplement rests in the manufacturer’s commitment to quality and excellence.
In fact, I believe that without these quality processes in place, it really doesn’t matter what organic herbs are harvested. You simply won’t end up with a top-notch consistent organic formula. In turn, you won’t receive the maximum potential value of the herb.
So, it’s important to highly scrutinize and research the manufacturer’s credentials.
In fact, you may not be able to stop with the manufacturer alone. Keep in mind, the total organic process involves planting, cultivation, selective harvesting, and then producing and packaging the final formula.
Here’s the type of certifications I recommend you look for:
- Hazards and Critical Control Points (HACCP) — International food safety certification that World Health Organization (WHO) standards are met
- Safe Quality Food (SQF) — HACCP-based food safety and risk management system covering the identification of food safety, quality risks, and the validation and monitoring of control measures
- Good Manufacturing Practices (GMP) — International certification verifies all required practices necessary for an effective food safety program are followed
- International Organization for Standardization (ISO) 9001:2000 — International standard for quality, safety, ecology, economy, reliability, compatibility, inter-operability, efficiency, and effectiveness
- Orthodox Union (OU) Kosher — Certifies compliance for Kosher observers and followers
- International organic certifications such as: USDA, EU, and NSOP (India)
Use This Checklist to Find Your Highest Quality Turmeric
To take advantage of all the great benefits turmeric has to offer you, I created a checklist on what you should look for in a turmeric supplement.
Whatever you do, don’t settle for second best.
Here’s my checklist to help you find the best turmeric source:
- Contains only 100% certified organic ingredients — Turmeric extract with at least 95% curcuminoids
- Comes in supplement form — Don’t rely on your typically low quality and unpredictable local grocery store spice. Additionally when you heat the spice during cooking many of the beneficial properties are lost.
- Avoids fillers, additives, and excipients — No need for questionable “other ingredients” in the formula
- Provides a vegetable capsule — Avoid gelatin-based capsules whenever possible
- Is produced by a certified organic manufacturer with high-quality organic and safe production practices — Don’t settle for second best here!
13 Ways this Ancient Herb Can Help You
Spice Up Your Life (and Your Health*)
Let me summarize thirteen ways this 100% certified organic-based Turmeric can spice up your whole person:
- Boosts your antioxidant protection against free radicals*
- Helps promote your healthy skin*
- Supports your overall eye health*
- Provides you immune system support*
- Aids your skeletal system and joint health*
- Encourages your healthy liver function*
- Helps you maintain healthy cells with support against free radicals*
- Balances the health of your digestive system*
- Aids you in support of healthy blood and your circulatory system*
- Helps you maintain normal cholesterol levels to support your cardiovascular system*
- Assists your neurological system’s healthy response to stress*
- Promotes a healthy female reproductive system*
- Helps you maintain blood sugar levels already within the normal range*
Millions of people use turmeric on a daily basis in their lives today. In India alone, up to 500 million people use it in one form or another every day.
Isn’t it time you gave your body what it deserves?
My Recommendation for a Turmeric Supplement
My time researching and studying herbs and spices here in India convinced me there’s only one turmeric supplement I can recommend — my USDA Certified Organic Turmeric.
Let me explain why I consider this a bonus.
During my travels to India, I witnessed firsthand many of Organic India’s cultivation and production processes. And to say I was impressed doesn’t do them justice.
Organic India goes far beyond producing the highest quality organic turmeric by:
- Helping preserve and enrich the environment — As a result, this manufacturer received exclusive rights to harvest certified organic crops from central and northern India.
- Adhering to and setting new standards of certification — As the manufacturer of the Turmeric, Organic India seriously commits to follow the highest quality standards for producing organic products.
- Committing to holistic quality and environmentally responsible business practices — From preservation of seed and enrichment of soil… through cultivation, harvesting, manufacturing, and packaging, all phases of the production cycle reflect the quality commitment.
- Educating and certifying organic growers and farmers — Organic farmers receive training and education in all aspects of sustainable organic farming methods. A 3rd party international agency certifies farmers as “certified organic.”
- Respecting and honoring the organic farmers — By honoring the well-being and dignity of local farmers, a win-win scenario continues to evolve for everyone involved.
Organic India is among the few herbal companies in India to receive the following certifications:
- SQF — Safe Quality Food (certified by SGS India Pvt. Lmt.)
- HACCP — Hazards and Critical Control Points (by SGS)
- GMP — Good Manufacturing Practices (by SGS)
- ISO 9001:2000 — International standard for quality and safety
- OU Kosher — Certifies compliance for Kosher observers and followers
- Organic certifications from: Skal International, Ecocert International, USDA, EU, and NSOP (India)
So, not only is the Turmeric formula of the highest quality, the producer is totally committed to protecting the environment and the organic farmers.
I think you’ll agree this is a win-win scenario for all.
Try this 100% Certified Organic-based
Herbal Supplement Risk-Free
So, don’t you think it makes sense for you to try the Turmeric? I believe you’ll agree it’s certainly an impressive formula.
Order this supplement now and you’ll get my 100% lifetime guarantee.
I’m so convinced this is a great product to help you enhance your overall health* — you can try it risk-free.
That’s right — I’ll take all the risk on this one.
If for any reason you’re not satisfied (and I know you will be satisfied), you can return the product for a full refund (minus shipping and handling).
Now that’s confidence in a great product — Turmeric.
Soure: Dr. Mercola
Per capita soft drink consumption has increased nearly 500 percent over the past five decades,1 and children, unfortunately, are a major reason for this staggering increase.
Kids are introduced to soda at very young ages and consumption only increases as they get older.
An estimated 56 percent of 8-year-olds drink soda daily, and once the teenage years come, some kids drink at least three cans of soda each day.2
Regular soda is, of course, a significant source of sugar (mostly in the form of fructose), with each can containing about 10 teaspoons of sugar, but due to artificial sweeteners’ health effects, diet sodas may have far more serious health effects.
Consumption of sugar-sweetened soda and other beverages has been linked to the rising obesity epidemic, along with other health issues, among kids.
Likely as a result, a campaign has begun to get kids to stop drinking so many sugar-sweetened beverages… unfortunately, rather than replacing them with water or other healthy beverages it appears many kids are simply chugging down diet sodas instead – an absolutely terrible choice for kids’ health.
Diet Beverage Consumption Doubles Among U.S. Kids
Researchers at Emory University in Atlanta have found that more kids than ever in the United States are downing diet drinks – approximately double the number that were drinking them a decade ago. The study looked at data from a federal health survey, which ended with the year 2008 and showed that 12.5 percent of children were drinking artificially sweetened beverages.3
On the surface this may appear to be a positive switch if it means kids are consuming less sugar as a result, but diet sodas are actually worse for your health than regular soda, due to the artificial sweeteners they contain. As senior research of the study, Dr. Miriam Vos, noted:4
“We do want children to drink less sugar. But the challenge is that there are no studies that have looked at the long-term health effects of artificial sweeteners in growing children.”
Diet Drinks May Actually Make Kids Gain Weight
U.S. kids are having a hard time keeping their weight under control. And one of the glaring issues surrounding diet drinks is that the artificial sweeteners they contain are linked to weight gain. If kids are getting hooked on diet drinks (and I do mean hooked, as these substances are very addictive, which I’ll explain shortly), it could set them up for a lifetime of weight struggles.
Take, for instance, a study by researchers at the University of Texas Health Science Center at San Antonio.5 After following 474 diet soda drinkers for nearly 10 years, they found that their waists grew 70 percent more than the waists of non-diet soda drinkers. Further, those who drank two or more diet sodas a day had a 500 percent greater increase in waist size!
As you may know, your waist size is not only a matter of aesthetics, but also one of the most powerful predictors of lean body mass and your risk of serious degenerative disease. Your waist size is a far more accurate predictor of your heart risks than your body mass index (BMI), so any habit that has the potential to increase your waist size by 500 percent more than someone who does not have that habit is one worth breaking.
Worse still, no one knows what impact these substance will have on kids who start drinking them at young ages and continue on for decades throughout their lives.
Case in point, a second study by some of the same researchers also revealed that mice eating food laced with the artificial sweetener aspartame had higher blood sugar levels than mice eating food without it, which suggests it may increase your risk of diabetes and metabolic syndrome.6 One study even found drinking a diet soda daily may increase your risk of type 2 diabetes by 67 percent.7
Furthermore, research by Sharon P. Fowler, MPH, who was also involved in the studies noted above, and her colleagues found that your risk of obesity increases by 41 percent for each can of diet soda you drink in a day!8
Diet Soda May Increase Your Risk of Having a Stroke
Also concerning, if you’re considering letting your child drink diet drinks, is that researchers found people who drank diet soft drinks daily were 43 percent more likely to have suffered a vascular event, including a stroke.9 This significant association persisted even after controlling for other factors that could increase the risk, such as smoking, physical activity levels, alcohol consumption, diabetes, heart disease, dietary factors and more.
According to the authors:
“This study suggests that diet soda is not an optimal substitute for sugar-sweetened beverages, and may be associated with a greater risk of stroke, myocardial infarction, or vascular death than regular soda.”
In other words, if you’re letting your child consume diet drinks in lieu of sugary drinks, you aren’t doing their health any favors. Instead, you’re simply swapping the health risks of sugar for the health risks of artificial sweeteners, which include a significant increase in the risk of stroke.
Your Child May Have a Hard Time Giving Up Diet Drinks Once They Start
As I mentioned earlier, it’s easy to become addicted to diet drinks, and experts note that you can become both psychologically and physically dependent on them.
One of the problems is that artificial sweeteners tend to trigger enhanced activity within your brain’s pleasure centers, yet at the same time provide less actual satisfaction. This separation of the taste of sweetness from caloric content means that when you consume artificial sweeteners, your brain actually craves more of it because your body receives no satisfaction on a cellular level by the sugar imposter. This can actually contribute to overeating and weight gain as well.
In other words, as far as “sweetness satisfaction” in the human brain is concerned, your brain can tell the difference between a real sugar and an artificial one, even if your conscious mind cannot. So you continue to crave more and more sweetness, in the form of diet drinks, sugar or whatever sweet treats you can find. As stated in the journal Nursing:10
“Artificial sweeteners are 200 to 13,000 times as sweet as sugar, and this enhanced sweetness is mildly addictive. Sweet taste triggers the dopamine signal, the same pathway triggered by drugs of abuse such as cocaine. If artificially sweetened sodas increase cravings, a person may need more sweets to feel satisfied, leading to excessive calorie consumption and weight gain.”
Beware of Diet Waters
The market has been flooded with “functional waters,” fortified (supposedly) with everything from vitamins and minerals to electrolytes, oxygen, fiber, and even protein. Supermarket beverage aisles can entice you along a virtual sea of beverage choices – energy drinks, vitamin waters, fitness waters, and sports/electrolyte concoctions in every imaginable color and flavor.
Flashy labels, pretty colors, and seductive scents are not always harmless to your health – but they are incredibly alluring, especially to kids.
But if you take a closer look at the labels, you’ll discover they’re spiking these waters with a lot of unsavory ingredients, many capable of wreaking havoc on your metabolism, hormones, and other physiological processes. Many of these so-called “functional waters” contain one, two or more artificial sweeteners, even though the water may not be advertised as “diet” or “low-calorie.” Some even contain sugar, corn syrup and artificial sweeteners like acesulfame potassium (ace-K) or sucralose (Splenda).
The only way you can learn that the artificial sweeteners are there is if you read the tiny 4-point font on the label… so don’t just assume that if your child is drinking a supposedly “healthy” flavored water that this is better than diet soda. Be sure to check the labels very carefully for harmful additives like artificial sweeteners.
Is Your Child a Soda or Diet-Soda Junkie?
If you or your children drink diet beverages or eat diet foods, I suggest you read through my book Sweet Deception. This book will explain how you’ve been deceived about artificial sweeteners like aspartame and sucralose – for greed, for profits… and at the expense of your own, and your children’s, health.
Complete avoidance of sweets, including diet drinks, is often necessary to break the addictive cycle if your child is already hooked. However, you can also try swapping their diet drink for a “natural soda” made from the herb stevia and carbonated water (my favorites are the liquid stevias that come in flavors like English Toffee and French Vanilla).
If your child is unable to resist the diet drinks, the emotional connection to cravings might be an important factor. One of the most profound methods I know of for diminishing the effects of food cravings is the Emotional Freedom Technique (EFT). EFT is the psychological acupressure technique routinely used in my practice to help people reduce their cravings, and it works well for kids. Turbo tapping, in particular, is very useful for soda addiction.
Make no mistake, though – food advertisers are doing all they can to lure your child in, just as Big Tobacco did generations ago.
So you need to first educate yourself about proper nutrition and the dangers of junk food, diet foods and processed foods in order to change the food culture of your entire family. To give your child the best start at life, and help instill healthy habits that will last a lifetime, you must lead by example. Children will simply not know which foods and drinks are healthy unless you, as a parent, teach it and role model it to them first.
My nutrition plan offers a step-by-step guide to feed your family right, and I encourage you to read through it now to learn how to make healthy eating decisions for you and your children. Each stage (beginner, intermediate and advanced) offers a separate section on beverages as well, which I suggest you share with your children to help them learn how to make healthier drink choices.
Soure: Dr. Mercola