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Jean Magloire, a health activist, faultsmany Haitians for squandering time and money playing dominoes and the Haitianlottery instead of saving up for or digging latrines themselves. Ivers, though,feels conflicted. She supports the mantra of responsibility. But when sherelayed that line at a community meeting, she says people laughed: “They askedme, ‘How do we even get started?’ ” Half of all Haitians live on less than $1per day, and goods, even food, are surprisingly expensive. Saving even $100seems daunting. Campa says PIH will make exceptions and build latrines forwidows, people with AIDS, and other vulnerable groups. But for the most part itrespects the government’s wishes and focuses instead on clinics, hygienecampaigns, and delivering cholera vaccines.
PLANS TO IMPROVE WATER and sanitation faceother hurdles. Few aid groups— PIH being an exception—focus on much beyondrelieving immediate needs. And while aid money is still flowing to Haiti, fundshave a history of disappearing there. After the earthquake, the United Statesgave Haiti $2.25 billion in aid. But no one knows how $1.5 billion of that wasspent, says Vij Ramachandran, a fellow at the Center for Global Development inWashington, D.C. Given Haiti’s history of corruption, she adds, at least some wasprobably stolen. “Unless aid is invested in building local institutions andstrengthening the government,” Ramachandran says, “you will not see any realchange.” Cultural habits can also slow efforts to improve public health. Womentraditionally gather drinking water in Haiti, but because it’s women’s work,such chores often take low priority. At one fountain near Mirebalais, despitethe quickly setting sun, women waited around with a dozen empty jugs whileteenage boys washed their motorcycles. Bad hygiene habits also persist. ManyHaitians say that cholera convinced them to start washing their hands afterdefecating and stop drinking irrigation water in the fields. But others admitthey still don’t bother with such niceties. Rejouit, the health commissioner,insists that Haiti can eradicate cholera. Other doctors remain pessimistic,especially near St. Marc and other hard-hit districts. Still others say theyare hopeful, but they realize that hope is about all Haiti has ever had. One ofthem, Patrick Ulysse, a health coordinator for PIH, nodded at the prospect of acholera-free Haiti. “I’m optimistic,” he said. He then paused and half-smiled: “I have tobe.” ■
China has long had a love affair with salt.Since about 2200 B.C.E., when the country first produced it, salt has been animportant preservative for vegetables and meats. Entire regional cuisines aredescribed simply as “salty,” and individual dishes have monikers like“salt-and-pepper pork.” In Tibet, locals drink a salty yak butter tea in place ofwater. All told, the average rural Chinese citizen consumes 12 grams of saltdaily, according to the 2010 Global Burden of Disease study; the averageAmerican takes in 9 grams, while the daily maximum recommended by the WorldHealth Organization (WHO) is 5 grams. “High salt intake is part of Chinese foodculture,” says Wu Yangfeng, a cardiovascular specialist at the PekingUniversity Clinical Research Institute who heads the George Institute forGlobal Health, China, in Beijing. It is also an acute health problem—but onethat researchers believe can be tackled. Salt is a major contributor to analarming rise in hypertension in China’s rapidly aging population. Some 54% ofChinese adults aged 45 and older now have hypertension, according to the ChinaHealth and Retirement Longitudinal Study, among the highest rates in the world.Hypertension is a risk factor for stroke—the leading cause of death in ruralChina in 2010—and other cardiovascular diseases. As the country develops,Chinese are also eating more meat and engaging in less physical activity, whichdrives the rise in hypertension and chronic disease. Those lifestyle factorsare hard to combat, especially in a people tasting modern life for the firsttime. Meanwhile China’s overburdened health care system is ill-equipped totreat hypertension directly, given the legions of patients. An estimated 40million Chinese aged 60 and over with the condition haven’t been diagnosed, andof those who have been, only a small proportion get their blood pressure undercontrol. But researchers say reducing China’s salt consumption is feasible—andcould have a major impact. In fact, the country is an ideal place to try anintervention, says Bruce Neal, an epidemiologist with the George Institute Chinaandthe University of Sydney in Australia. In developed countries, most salt isconsumed through processed food or in restaurants; efforts to fighthypertension have focused on pressuring the food industry to lower saltcontent—often unsuccessfully. In China, salt is primarily added to meals duringhome cooking or at the table, so prevention messages can target the individual.And the salt industry is controlled by a state monopoly, meaning that there areonly a few distributors. “That’s really important if we want to intervene,”Neal says. There is still debate about whether it’s useful to lower salt intakebelow 6 grams a day (Science, 24 May 2013, p. 908), but most scientists agreethat bringing down China’s very high levels is a relatively cheap, effectivepublic health intervention. Based on disease models from elsewhere, Wu andcolleagues estimate that reducing the average Chinese person’s intake by a meregram a day could save 125,000 lives a year. But whether such a behavioralintervention is feasible on a large scale—and to what degree it would actuallyreduce cardiovascular disease—hasn’t been carefully studied. A study by theGeorge Institute published in 2007 found that introducing a low-sodium saltsubstitute lowered blood pressure in 608 high-risk adults in northern China,but it didn’t look at outcomes like stroke. A study in Taiwan did measure suchhealth effects, but it involved just a few thousand men living in oneretirement home and didn’t control well for errors, Neal says. Neal and Wu arethe lead investigators of a huge randomized controlled trial to test the healthimpact of salt reduction among a broader group of people who live and cook athome. The China Salt Substitute and Stroke Study has recruited 21,000participants with a history of hypertension or stroke in more than 600 villagesin northern China and Tibet. Since early July, participants in some villageshave received a salt substitute in which sodium chloride is partially replacedwith potassium chloride, which has been shown to lower blood pressure; thesepeople also receive regular advice on lowering salt intake. Patients in controlvillages use normal table salt and receive advice only at the start of thestudy. Over the next 5 years, investigators will record stroke and othercardiovascular events, while urine samples will reveal changes in sodium andpotassium intake. The study comes at a time when hypertension andcardiovascular disease are already firmly on the Chinese government’s agenda. Aspate of health care reforms introduced in 2009 (Science, 1 February 2013, p.505) includes free blood pressure checks and partially subsidized drugs forhypertension patients. The country has set a target of reducing saltconsumption to 9 grams per person by 2015. If the study shows that using thesalt substitute can bring down disease, Wu and Neal plan to lobby governmentleaders to introduce a substitute nationwide and subsidize its manufacture.(Now, producing the new substance can cost up to twice as much as regularsalt.) In their vision, shops would offer a subsidized salt substitutealongside regular salt. Of course, people would actually have to buy and usethe substitute. Neal says that an alternative strategy would be to convince thesalt industry to gradually reduce sodium content in China’s entire saltsupply—a goal that may be possible because of the salt monopoly. Othercountries should pay attention, says Feng He, an epidemiologist at Queen MaryUniversity of London’s Wolfson Institute of Preventive Medicine. WHO estimatesthat 80% of cardiovascular deaths occur in low- and middle-income countries; inmany of them, hypertension patients can’t afford treatment, so prevention isparamount. Salt substitutes may prove particularly useful elsewhere in Centraland East Asia, where sodium intake is among the highest in the world—and where,like in China, consumers add much of it to their diets themselves. It may be atradition that’s well worth breaking. ■
Jean Magloire, a health activist, faultsmany Haitians for squandering time and money playing dominoes and the Haitianlottery instead of saving up for or digging latrines themselves. Ivers, though,feels conflicted. She supports the mantra of responsibility. But when sherelayed that line at a community meeting, she says people laughed: “They askedme, ‘How do we even get started?’ ” Half of all Haitians live on less than $1per day, and goods, even food, are surprisingly expensive. Saving even $100seems daunting. Campa says PIH will make exceptions and build latrines forwidows, people with AIDS, and other vulnerable groups. But for the most part itrespects the government’s wishes and focuses instead on clinics, hygienecampaigns, and delivering cholera vaccines.
PLANS TO IMPROVE WATER and sanitation faceother hurdles. Few aid groups— PIH being an exception—focus on much beyondrelieving immediate needs. And while aid money is still flowing to Haiti, fundshave a history of disappearing there. After the earthquake, the United Statesgave Haiti $2.25 billion in aid. But no one knows how $1.5 billion of that wasspent, says Vij Ramachandran, a fellow at the Center for Global Development inWashington, D.C. Given Haiti’s history of corruption, she adds, at least some wasprobably stolen. “Unless aid is invested in building local institutions andstrengthening the government,” Ramachandran says, “you will not see any realchange.” Cultural habits can also slow efforts to improve public health. Womentraditionally gather drinking water in Haiti, but because it’s women’s work,such chores often take low priority. At one fountain near Mirebalais, despitethe quickly setting sun, women waited around with a dozen empty jugs whileteenage boys washed their motorcycles. Bad hygiene habits also persist. ManyHaitians say that cholera convinced them to start washing their hands afterdefecating and stop drinking irrigation water in the fields. But others admitthey still don’t bother with such niceties. Rejouit, the health commissioner,insists that Haiti can eradicate cholera. Other doctors remain pessimistic,especially near St. Marc and other hard-hit districts. Still others say theyare hopeful, but they realize that hope is about all Haiti has ever had. One ofthem, Patrick Ulysse, a health coordinator for PIH, nodded at the prospect of acholera-free Haiti. “I’m optimistic,” he said. He then paused and half-smiled: “I have tobe.” ■
China has long had a love affair with salt.Since about 2200 B.C.E., when the country first produced it, salt has been animportant preservative for vegetables and meats. Entire regional cuisines aredescribed simply as “salty,” and individual dishes have monikers like“salt-and-pepper pork.” In Tibet, locals drink a salty yak butter tea in place ofwater. All told, the average rural Chinese citizen consumes 12 grams of saltdaily, according to the 2010 Global Burden of Disease study; the averageAmerican takes in 9 grams, while the daily maximum recommended by the WorldHealth Organization (WHO) is 5 grams. “High salt intake is part of Chinese foodculture,” says Wu Yangfeng, a cardiovascular specialist at the PekingUniversity Clinical Research Institute who heads the George Institute forGlobal Health, China, in Beijing. It is also an acute health problem—but onethat researchers believe can be tackled. Salt is a major contributor to analarming rise in hypertension in China’s rapidly aging population. Some 54% ofChinese adults aged 45 and older now have hypertension, according to the ChinaHealth and Retirement Longitudinal Study, among the highest rates in the world.Hypertension is a risk factor for stroke—the leading cause of death in ruralChina in 2010—and other cardiovascular diseases. As the country develops,Chinese are also eating more meat and engaging in less physical activity, whichdrives the rise in hypertension and chronic disease. Those lifestyle factorsare hard to combat, especially in a people tasting modern life for the firsttime. Meanwhile China’s overburdened health care system is ill-equipped totreat hypertension directly, given the legions of patients. An estimated 40million Chinese aged 60 and over with the condition haven’t been diagnosed, andof those who have been, only a small proportion get their blood pressure undercontrol. But researchers say reducing China’s salt consumption is feasible—andcould have a major impact. In fact, the country is an ideal place to try anintervention, says Bruce Neal, an epidemiologist with the George Institute Chinaandthe University of Sydney in Australia. In developed countries, most salt isconsumed through processed food or in restaurants; efforts to fighthypertension have focused on pressuring the food industry to lower saltcontent—often unsuccessfully. In China, salt is primarily added to meals duringhome cooking or at the table, so prevention messages can target the individual.And the salt industry is controlled by a state monopoly, meaning that there areonly a few distributors. “That’s really important if we want to intervene,”Neal says. There is still debate about whether it’s useful to lower salt intakebelow 6 grams a day (Science, 24 May 2013, p. 908), but most scientists agreethat bringing down China’s very high levels is a relatively cheap, effectivepublic health intervention. Based on disease models from elsewhere, Wu andcolleagues estimate that reducing the average Chinese person’s intake by a meregram a day could save 125,000 lives a year. But whether such a behavioralintervention is feasible on a large scale—and to what degree it would actuallyreduce cardiovascular disease—hasn’t been carefully studied. A study by theGeorge Institute published in 2007 found that introducing a low-sodium saltsubstitute lowered blood pressure in 608 high-risk adults in northern China,but it didn’t look at outcomes like stroke. A study in Taiwan did measure suchhealth effects, but it involved just a few thousand men living in oneretirement home and didn’t control well for errors, Neal says. Neal and Wu arethe lead investigators of a huge randomized controlled trial to test the healthimpact of salt reduction among a broader group of people who live and cook athome. The China Salt Substitute and Stroke Study has recruited 21,000participants with a history of hypertension or stroke in more than 600 villagesin northern China and Tibet. Since early July, participants in some villageshave received a salt substitute in which sodium chloride is partially replacedwith potassium chloride, which has been shown to lower blood pressure; thesepeople also receive regular advice on lowering salt intake. Patients in controlvillages use normal table salt and receive advice only at the start of thestudy. Over the next 5 years, investigators will record stroke and othercardiovascular events, while urine samples will reveal changes in sodium andpotassium intake. The study comes at a time when hypertension andcardiovascular disease are already firmly on the Chinese government’s agenda. Aspate of health care reforms introduced in 2009 (Science, 1 February 2013, p.505) includes free blood pressure checks and partially subsidized drugs forhypertension patients. The country has set a target of reducing saltconsumption to 9 grams per person by 2015. If the study shows that using thesalt substitute can bring down disease, Wu and Neal plan to lobby governmentleaders to introduce a substitute nationwide and subsidize its manufacture.(Now, producing the new substance can cost up to twice as much as regularsalt.) In their vision, shops would offer a subsidized salt substitutealongside regular salt. Of course, people would actually have to buy and usethe substitute. Neal says that an alternative strategy would be to convince thesalt industry to gradually reduce sodium content in China’s entire saltsupply—a goal that may be possible because of the salt monopoly. Othercountries should pay attention, says Feng He, an epidemiologist at Queen MaryUniversity of London’s Wolfson Institute of Preventive Medicine. WHO estimatesthat 80% of cardiovascular deaths occur in low- and middle-income countries; inmany of them, hypertension patients can’t afford treatment, so prevention isparamount. Salt substitutes may prove particularly useful elsewhere in Centraland East Asia, where sodium intake is among the highest in the world—and where,like in China, consumers add much of it to their diets themselves. It may be atradition that’s well worth breaking. ■
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