A planetary health innovation for disease, food and water challenges in Africa.

Many communities in low- and middle-income countries globally lack sustainable, cost-effective and mutually beneficial solutions for infectious disease, food, water and poverty challenges, despite their inherent interdependence1-7. Here we provide support for the hypothesis that agricultural development and fertilizer use in West Africa increase the burden of the parasitic disease schistosomiasis by fuelling the growth of submerged aquatic vegetation that chokes out water access points and serves as habitat for freshwater snails that transmit Schistosoma parasites to more than 200 million people globally8-10. In a cluster randomized controlled trial (ClinicalTrials.gov: NCT03187366) in which we removed invasive submerged vegetation from water points at 8 of 16 villages (that is, clusters), control sites had 1.46 times higher intestinal Schistosoma infection rates in schoolchildren and lower open water access than removal sites. Vegetation removal did not have any detectable long-term adverse effects on local water quality or freshwater biodiversity. In feeding trials, the removed vegetation was as effective as traditional livestock feed but 41 to 179 times cheaper and converting the vegetation to compost provided private crop production and total (public health plus crop production benefits) benefit-to-cost ratios as high as 4.0 and 8.8, respectively. Thus, the approach yielded an economic incentive-with important public health co-benefits-to maintain cleared waterways and return nutrients captured in aquatic plants back to agriculture with promise of breaking poverty-disease traps. To facilitate targeting and scaling of the intervention, we lay the foundation for using remote sensing technology to detect snail habitats. By offering a rare, profitable, win-win approach to addressing food and water access, poverty alleviation, infectious disease control and environmental sustainability, we hope to inspire the interdisciplinary search for planetary health solutions11 to the many and formidable, co-dependent global grand challenges of the twenty-first century.

Ending extreme poverty has a negligible impact on global greenhouse gas emissions.

Growing consumption is both necessary to end extreme poverty1and one of the main drivers of greenhouse gas emissions2, creating a potential tension between alleviating poverty and limiting global warming. Most poverty reduction has historically occurred because of economic growth3-6, which means that reducing poverty entails increasing not only the consumption of people living in poverty but also the consumption of people with a higher income. Here we estimate the emissions associated with the economic growth needed to alleviate extreme poverty using the international poverty line of US $2.15 per day (ref. 7). Even with historical energy- and carbon-intensity patterns, the global emissions increase associated with alleviating extreme poverty is modest, at 2.37 gigatonnes of carbon dioxide equivalent per year or 4.9% of 2019 global emissions. Lower inequality, higher energy efficiency and decarbonization of energy can ease this tension further: assuming the best historical performance, the emissions for poverty alleviation in 2050 will be reduced by 90%. More ambitious poverty lines require more economic growth in more countries, which leads to notably higher emissions. The challenge to align the development and climate objectives of the world is not in reconciling extreme poverty alleviation with climate objectives but in providing sustainable middle-income standards of living.

The effects of cash transfers on adult and child mortality in low- and middle-income countries.

Poverty is an important social determinant of health that is associated with increased risk of death1-5. Cash transfer programmes provide non-contributory monetary transfers to individuals or households, with or without behavioural conditions such as children's school attendance6,7. Over recent decades, cash transfer programmes have emerged as central components of poverty reduction strategies of many governments in low- and middle-income countries6,7. The effects of these programmes on adult and child mortality rates remains an important gap in the literature, however, with existing evidence limited to a few specific conditional cash transfer programmes, primarily in Latin America8-14. Here we evaluated the effects of large-scale, government-led cash transfer programmes on all-cause adult and child mortality using individual-level longitudinal mortality datasets from many low- and middle-income countries. We found that cash transfer programmes were associated with significant reductions in mortality among children under five years of age and women. Secondary heterogeneity analyses suggested similar effects for conditional and unconditional programmes, and larger effects for programmes that covered a larger share of the population and provided larger transfer amounts, and in countries with lower health expenditures, lower baseline life expectancy, and higher perceived regulatory quality. Our findings support the use of anti-poverty programmes such as cash transfers, which many countries have introduced or expanded during the COVID-19 pandemic, to improve population health.

Tackling psychosocial and capital constraints to alleviate poverty.

Many policies attempt to help extremely poor households build sustainable sources of income. Although economic interventions have predominated historically1,2, psychosocial support has attracted substantial interest3-5, particularly for its potential cost-effectiveness. Recent evidence has shown that multi-faceted 'graduation' programmes can succeed in generating sustained changes6,7. Here we show that a multi-faceted intervention can open pathways out of extreme poverty by relaxing capital and psychosocial constraints. We conducted a four-arm randomized evaluation among extremely poor female beneficiaries already enrolled in a national cash transfer government programme in Niger. The three treatment arms included group savings promotion, coaching and entrepreneurship training, and then added either a lump-sum cash grant, psychosocial interventions, or both the cash grant and psychosocial interventions. All three arms generated positive effects on economic outcomes and psychosocial well-being, but there were notable differences in the pathways and the timing of effects. Overall, the arms with psychosocial interventions were the most cost-effective, highlighting the value of including well-designed psychosocial components in government-led multi-faceted interventions for the extreme poor.

Realizing the values of natural capital for inclusive, sustainable development: Informing China's new ecological development strategy.

A major challenge in transforming development to inclusive, sustainable pathways is the pervasive and persistent trade-off between provisioning services (e.g., agricultural production) on the one hand and regulating services (e.g., water purification, flood control) and biodiversity conservation on the other. We report on an application of China's new Ecological Development Strategy, now being formally tested and refined for subsequent scaling nationwide, which aims to mitigate and even eliminate these trade-offs. Our focus is the Ecosystem Function Conservation Area of Hainan Island, a rural, tropical region where expansion of rubber plantations has driven extensive loss of natural forest and its vital benefits to people. We explored both the biophysical and the socioeconomic options for achieving simultaneous improvements in product provision, regulating services, biodiversity, and livelihoods. We quantified historic trade-offs between rubber production and vital regulating services, finding that, over the past 20 y (1998-2017), there was a 72.2% increase in rubber plantation area, leading to decreases in soil retention (17.8%), water purification [reduced retention of nitrogen (56.3%) and phosphorus (27.4%)], flood mitigation (21.9%), carbon sequestration (1.7%), and habitat for biodiversity (6.9%). Using scenario analyses, we identified a two-pronged strategy that would significantly reduce these trade-offs, enhancing regulating services and biodiversity, while simultaneously diversifying and increasing product provision and improving livelihoods. This general approach to analyzing product provision, regulating services, biodiversity, and livelihoods has applicability in rural landscapes across China, South and Southeast Asia, and beyond.

An integrated bioeconomic local economy-wide assessment of the environmental impacts of poverty programs.

A new generation of poverty programs around the globe provides cash payments to poor and vulnerable households. Studies show that these social cash transfer programs create income and welfare benefits for poor households and the local economies where they live. However, this may come at the cost of damaging local environments if cash payments stimulate food production that conflicts with natural resource conservation. Evaluations of the economic impacts of poverty programs do not account for the welfare consequences of environmental impacts, which are potentially large for poor communities closely tied to natural resources. We use an ex-ante policy simulation tool, a bioeconomic local computable general equilibrium model parameterized with microsurvey data, to analyze the expected welfare consequences of environmental degradation caused by a cash transfer program. For a Philippine fishing community that is a net importer of fish, we show that a government cash transfer program initially increases real incomes for all households. However, increased demand for fish leads to a decline in the local fish stock that reduces program benefits. Household groups experience declines in real income benefits of 2-63%, with fishing households suffering the largest declines. Impacts on local fish stocks depend on the extent to which markets link fishing communities to outside regions through trade. Greater market integration can mitigate the fish stock decline, but this reduces the local income benefits of cash transfers.

Impact of poverty reduction on access to water and sanitation in low- and lower-middle-income countries: country-specific Bayesian projections to 2030.

BACKGROUND: In 2017, 785 million people globally lacked access to basic services of drinking water and 2 billion people lived without basic sanitation services. Most of these people live in low- and lower-middle-income countries in South Asia, Southeast Asia and sub-Saharan Africa. To monitor the progress towards universal access to water and sanitation, this study aimed to predict the coverage of access to basic drinking water supply and sanitation (WSS) services as well as the reduction in the practice of open defecation by 2030, under two assumptions: following the current trends and accelerated poverty reduction. METHODS AND FINDINGS: Households reporting access to basic WSS services and those practising open defecation were extracted from 210 nationally representative Demographic Health Surveys and Multiple Cluster Indicator Surveys (1994-2016) from 51 countries. A Bayesian hierarchical mixed effect linear regression model was developed to predict the indicators in 2030 at national, urban-rural and wealth-specific levels. A Bayesian regression model with accelerated reduction in poverty by 2030 was applied to assess the impact of poverty reduction on these indicators. Out of 51 countries, only nine (Bangladesh, Bhutan, Ghana, India, Nepal, Pakistan, The Philippines, Togo and Vietnam) were predicted to reach over 90% coverage in access to basic services of drinking water by 2030. However, none of the countries were projected to achieve equivalent coverage for access to basic sanitation services. By 2030, 21 countries were projected to achieve the target of less than 10% households practising open defecation. Urban-rural and wealth-derived disparities in access to basic WSS services, especially sanitation, were more pronounced in sub-Saharan Africa than South Asia and Southeast Asia. Access to basic sanitation services was projected to benefit more from poverty reduction than access to basic drinking water services. Households residing in rural settings were predicted to receive greater benefit from poverty reduction than urban populations in access to both basic WSS services. CONCLUSION: Achieving poverty eradication targets may have a substantial positive impact on access to basic water supply and sanitation services. However, many low- and lower-middle-income countries will struggle to achieve the goal of universal access to basic services, especially in the sanitation sector.

Impact of a Family Economic Intervention (Bridges) on Health Functioning of Adolescents Orphaned by HIV/AIDS: A 5-Year (2012-2017) Cluster Randomized Controlled Trial in Uganda.

Objectives. To investigate the long-term impacts of a family economic intervention on physical, mental, and sexual health of adolescents orphaned by AIDS in Uganda.Methods. Students in grades 5 and 6 from 48 primary schools in Uganda were randomly assigned at the school level (cluster randomization) to 1 of 3 conditions: (1) control (n = 487; 16 schools), (2) Bridges (1:1 savings match rate; n = 396; 16 schools), or (3) Bridges PLUS (2:1 savings match rate; n = 500; 16 schools).Results. At 24 months, compared with participants in the control condition, Bridges and Bridges PLUS participants reported higher physical health scores, lower depressive symptoms, and higher self-concept and self-efficacy. During the same period, Bridges participants reported lower sexual risk-taking intentions compared with the other 2 study conditions. At 48 months, Bridges and Bridges PLUS participants reported better self-rated health, higher savings, and lower food insecurity. During the same period, Bridges PLUS participants reported reduced hopelessness, and greater self-concept and self-efficacy. At 24 and 48 months, Bridges PLUS participants reported higher savings than Bridges participants.Conclusions. Economic interventions targeting families raising adolescents orphaned by AIDS can contribute to long-term positive health and overall well-being of these families.Trial Registration. ClinicalTrials.gov registration no. NCT01447615.

The New Patterns study: coordinated measures to combat child poverty.

BACKGROUND: Child poverty rates are rising in Norway with potential negative consequences for children. Services for families with low income are often fragmented and poorly integrated, and few coordinated initiatives have been implemented and evaluated in Norway. AIMS: The aim of the current study is to evaluate how integrated and coordinated services provided over a prolonged period by a family coordinator are related to changes across a wide range of health, wellbeing and home environment indicators for the participants. METHODS: The study uses a mixed methods approach utilising survey and register data, as well as information from interviews and shadowing, to document and evaluate outcomes associated with the intervention and the process of implementation. Data are gathered at baseline and annually throughout the duration of the study. Participants are identified to facilitate longer-term follow-up using register data. CONCLUSIONS: This project will develop important knowledge about the implementation of coordinated services to families with a low income, and how this way of organizing services influences important outcomes for the family members in the short and long term.

Defamilisation/familisation measures and pensions in Hong Kong and Taiwan.

This article discusses the link between familisation measures (to lower the negative consequences of participating in the family as a care-provider) and defamilisation measures (to reduce individual responsibility for providing care in the family), and pensions for women. To enhance women's chance of having a secure retirement life, it makes two suggestions: government should provide defamilisation measures to assist women to accumulate pension income through work-based pension measures; and government should provide familisation measures extensively as an alternative to these measures. It also demonstrates how the case examples of Hong Kong and Taiwan provide support to these two suggestions.